The CPMHC issued the following press release and launched the #ITSNOTOK campaign asking the public to write to the CTFPHC and demand a retraction: https://canadiantaskforce.ca/contact/
Version française ici: https://cpmhc.ca/press-releases/
July 29, 2022 — The Canadian Perinatal Mental Health Collaborative (CPMHC) believes the recommendation by the Canadian Task Force on Preventive Health Care (CTFPHC) against perinatal mental health screening will do more harm than good and needs to be reconsidered in light of the current climate and evidence.
The recommendation was made public after it was published in the Canadian Medical Association Journal (CMAJ) on July 25th, 2022. The published article states that the recommendation was developed with scientific support from the Public Health Agency of Canada (PHAC).
The recommendation was categorized as a “conditional” recommendation meaning that the evidence is low and uncertainty exists. This comes almost a decade after their first recommendation against screening in 2013, at which time the recommendation was considered “weak.”
We Need More Than a Conversation
Instead of using validated screening tools such as the Edinburgh Postnatal Depression Scale (EPDS), the Generalized Anxiety Disorder-7 (GAD-7), and the Patient Health Questionnaire (PHQ-9), the CTFPHC is instead recommending that health care practitioners, many of which are not adequately trained or educated in perinatal mental health, simply ask pregnant and postpartum individuals about their mental health if they feel warranted to do so.
Screening tools can be an effective guide for health care practitioners who have not received training in perinatal mental health. If professionals are skilled, they can do an effective assessment without an instrument but this is not the majority of professionals caring for pregnant and postpartum individuals.
The recommendation against screening is based on the CTFPHC assumption that “usual care during pregnancy and postpartum includes inquiry and attention to mental health and well-being.” We know from the voices of countless people across Canada that they are not being assessed or asked about their perinatal mental health as confirmed by a 2020 study completed by top Canadian perinatal mental health researchers from the University of Calgary.
The CPMHC feels that due diligence was not observed in garnering the points of view of people with lived experience as only a small group (less than 30 individuals) of non-diverse, perinatal individuals were interviewed prior to the pandemic. Did the CTFPHC take into account the massive worldwide increases in depression, anxiety, intimate partner violence and substance use in pregnancy and the postpartum period during the COVID-19 pandemic?
The CPMHC feels this is a dangerous recommendation at a time when perinatal mental health challenges and concerns are on the rise. Pre-pandemic rates of perinatal mental illness are cited internationally as affecting 1 in 5 individuals. During the pandemic, rates of perinatal depression increased to 1 in 3, and rates of perinatal anxiety increased to 1 in 2 individuals.
It’s interesting that the CTFPHC uses low-rate prevalence statistics of 1-9% from well over a decade ago (14-17 years old) when Statistics Canada’s 2019 survey on Maternal Mental Health in Canada reported that “almost one-quarter (23%) of mothers who recently gave birth reported feelings consistent with postpartum depression or an anxiety disorder.” The survey was completed in collaboration with Health Canada and the Public Health Agency of Canada.
The CPMHC and multiple like-minded partners worry that this recommendation will push aside the importance of mental health assessments in favour of physical assessments, thereby further stigmatizing individuals struggling with their perinatal mental health.
The CPMHC is working with the federal government on fulfilling its mandate that promises to ensure “timely access to perinatal mental health services.” CPMHC Co-Executive Directors Patricia Tomasi and Jaime Charlebois met with Prime Minister Justin Trudeau and Minister of Mental Health and Addictions, Carolyn Bennett in May 2022. The PM and Minister Bennett both solidified their commitment in person, to fulfilling the mandate. The CPMHC feels as if the progress and momentum achieved to date could be jeopardized with the CTFPHC flawed recommendation given that universal screening goes hand-in-hand with timely access to perinatal mental health services.
Screening At Home and Abroad
Currently in Canada, almost all provinces and territories recommend universal perinatal mental health screening using a validated screening tool. The CPMHC report, Time for Action, contains a chart of each province and territories’ recommended screening practices (pg. 23-27). This screening is conducted either through public health nursing assessments or within the antenatal/perinatal record which is completed by obstetricians, family doctors, midwives, nurse practitioners, and nurses. Despite this recommendation, there continue to be barriers to the integration of this practice into routine care. Universal screening has never been fully implemented in Canada, so how can the CTFPHC make a judgment when there is no Canadian data to draw from?
In other countries, there is evidence that screening works and political leaders and health care providers are moving forward proactively with screening while this recommendation by the CTFPHC sends Canada in the opposite direction.
In 2016, based on the evidence of the benefits and harms of screening and the accuracy of screening instruments, the U.S. Preventative Task Force recommended screening for depression in the general adult population, including pregnant and postpartum women. They recommended screening be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. https://pubmed.ncbi.nlm.nih.gov/26813211/
A highly successful perinatal mental health access program in the U.S. is strongly reliant on screening tool results to guide treatment decisions Massachusetts Child Psychiatry Access Program (MCPAP for Moms), and certainly in Ontario, the Provincial Council for Maternal Child Health (PCMCH) guidance document and perinatal mental health care pathway includes a treatment stepped care approach in part based on symptom severity identified through the use of screening tools.
In the U.K., the National Institute for Health and Care Excellence (NICE) guidelines first recommended screening in 2014 and was last updated in 2020 following a discussion with primary health care providers.
By 2016 in Australia, screening was already successfully instituted in most public obstetric settings with 70% of individuals screened during pregnancy and 90% in the postpartum period. Launched in May, 2022, iCOPE, a new federally funded digital screening platform based on the EPDS and Antenatal Risk Questionnaire is being provided to every hospital and obstetrical care provider in Australia. The tool provides individuals greater privacy and evidence-based assessment with results and referrals.
While these countries are progressively transforming their health care systems, the CTFPHC’s recommendation is deprioritizing the perinatal mental health needs of women and families.
Equity, Diversity and Inclusion Considerations
Here in Canada, health care practitioners believe perinatal mental health care is currently insufficient (95.8%), and 87% report that persons from diverse backgrounds encounter language, cultural, and cost barriers to perinatal mental health services as cited in CPMHC’s report listed above.
It is evident from CPMHC’s health care provider survey as well as the review done by Life With a Baby that Canadian mothers and individuals are falling through the cracks. Will equitable access to perinatal mental health care across Canada be created? How will those who live outside urban areas with access to little or no services be supported? What strategies will be put in place to eliminate the stigma that both providers as well as childbearing families experience related to discussing perinatal mental health and well-being?
In the CMAJ article, the only acknowledgment of equity, diversity, and inclusion is that the “impact on equity of a recommendation against screening is unknown” and that “some marginalized individuals report barriers to disclosing depressive symptoms or concerns with their health care provider (e.g., being unsure how to bring up the topic of depression, concerns about stigma, aversion to antidepressant medications or psychotherapy), in which case a recommendation against screening may result in some individuals with depression not being identified.” It is shocking that a qualitative systematic review was not incorporated in this research and the results of the knowledge translation (KT) activities were not prioritized.
Voices Heard – Are They Listening?
The following are direct quotes from the findings from the CTFPHC own participant focus groups:
- “Participants expressed concerns that without screening, they may not be capable of identifying symptoms of depression, or may not take initiative to seek input from a primary care provider, especially considering all of the stresses and changes one goes through as a new parent.”
- “There was a very strong preference to be screened for depression among participants (median score to the question: “…how much would you want to be screened during pregnancy or the postpartum period” was ‘9 = Very Much’);” and,
- “Many believed that screening at several times during pregnancy/postpartum period, and by several health care providers (e.g., midwives, doulas, nurse practitioners, pediatricians), would be beneficial.”
The fact that the CTFPHC went ahead with a recommendation considering their above statements and findings is hugely problematic and will result in more harm, especially within marginalized populations, who experience high rates of perinatal mental health challenges.
The CTFPHC acknowledges in their article that their recommendation goes “against current practice and policy in some jurisdictions” and that “some providers may feel discomfort about de-implementing screening” which the CPMHC views as unethical and astounding.
The CTFPHC’s main arguments against screening are that it is:
- Inaccurate and that false positives will further burden an overwhelmed health care system;
- Not beneficial due to a lack of evidence;
- Better for health care practitioners to have a conversation about mental health if they feel it’s warranted instead of using a validated tool;
- Not necessary because health care practitioners are trained to ask about perinatal mental health; and
- Screening wastes the time of the patient and practitioner.
The CTFPHC’s rationale for making the recommendation against screening is weak and flawed. In a 2022 study published in BMC Psychiatry (BioMed Central), a series of meta-analyses revealed a reduction in perinatal depression and anxiety among perinatal women undergoing screening programs.
The evidence selected by the CTFPHC to develop this recommendation does not take into account qualitative research studies and/or patient-directed research. Findings from Marsay, Manderson, and Subramaney (2018) reassured health care practitioners that patients are ok with being asked about their mental well-being. Findings also indicated that patients prefer that health care practitioners raise the topic as due to stigma, they don’t feel comfortable raising the issue themselves. This study also revealed that screening appeared to improve outcomes as participants described positive experiences such as gaining self-awareness and knowledge, validation from a health care provider, and self-agency to seek out support from others.
The CPMHC is currently strongly advocating for a national perinatal mental health strategy including standards of care. We need more strategies to identify individuals who would benefit from services and supports, not fewer. To assume that perinatal people are regularly asked about their mental health and well-being and make a recommendation based on that false assumption is dangerous. We are gravely concerned that this recommendation will place Canadian families and future generations at risk of mental health problems thereby further exacerbating the strain on the economy and health care system.
Jaime Charlebois (705-345-9049)
or Patricia Tomasi (705-715-3141)
Canadian Perinatal Mental Health Collaborative