SCREENING TOOLS
Below is a list of the tools that are research-validated and easily accessible by health care professionals.
Research validity in surveys relates to the extent at which the survey measures what it intends to measure. In this case, a survey is “validated” as detecting likely maternal mental health disorders
We also list below questionnaires that are helpful in detecting risk for MMH disorders and one that assesses for support.
Primary Clinical Screening Tools
Depression
Edinburgh Postnatal Depression Screen (EPDS) (10 questions)
(This screener is validated for use in pregnancy and in the postpartum period.)
EPDS Total Score Severity Ranges:
none (0)
minimal depression (1–6),
mild depression (7–13),
moderate depression (14–19), and severe depression (19–30)
Cut off: 11 maximizes combined sensitivity and specificity*
Patient Health Questionnaire PHQ-2 (2 questions) or the PHQ-9 (9 questions)
(This screener is also validated for use in the general population, including the perinatal period.)
PHQ-9 Total Score Severity Ranges:
Some, including the UK’s National Health System, suggest scores could represent potential depression severity:
0-5 = none or mild
6-10 = moderate
11-15 = moderately severe
16-20 = severe
Cut off: 12 maximizes combined sensitivity and specificity*
Anxiety and Anxiety-Related Disorders
Perinatal Anxiety Screening Scale (PASS) (31 questions)
Anxiety
Edinburgh Postnatal/Perinatal Depression Screen (EPDS) (1 question, Q4)
(This screener is validated for use in pregnancy and in the postpartum period.)
Cut off: The EPDS includes one question (Q4. “I have been anxious or worried for no good reason”) which two studies found detected roughly two-thirds of those with identified anxiety disorders.
Generalized Anxiety Disorder GAD-2 (2 questions) or GAD-7 (7 questions)
(These screeners are validated for use in the general population.)
Some, including the UK’s National Health System, suggest scores could represent potential anxiety severity: 0-5 = none or mild
6-10 = moderate
11-15 = moderately severe
16-21 = severe
Perceived Prenatal Maternal Stress Scale (PPNMSS)
The PPNMSS is efficient to measure prenatal maternal stress (PNMS), which facilitates an early detection of stress and depression among pregnant women.
Psychosis
Because psychosis involves a break in reality, a person experiencing psychosis may be incapable of completing a symptom screening questionnaire directly; therefore family and those who are in close contact are often the first to notice behavior changes. The following psychosis symptom checklist (PSC) and overview can be used by providers and family members or close contacts to determine if a psychosis may exist.
Policy Center for Maternal Mental Health's Psychosis Symptom Checklist (PSC)
Substance Use Disorder
National Institutes of Health Screening and Assessment Tools Chart
Secondary Clinical Screening Tools
Pittsburgh Sleep Quality Index
Pittsburgh Sleep Quality Index (10 questions)
Obsessive Compulsive Disorder / Intrusive Thoughts
Obsessive Compulsive Inventory (OCI-4) (4 questions)
Obsessive Compulsive Inventory (OCI-12) (12 questions this screener includes one question that screens for intrusive thoughts.)
(This screener is validated for use in the general population, not just the perinatal period.)
Post-Traumatic Stress Disorder (PTSD)
Primary Care -PTSD-5 (PC-PTSD-5) (5 questions)
Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)
The CAPS is the gold standard in PTSD assessment. The CAPS-5 is a 30-item structured interview that can be used to:
Make current (past month) diagnosis of PTSD
Make lifetime diagnosis of PTSD
Assess PTSD symptoms over the past week
The CAPS was designed to be administered by clinicians and clinical researchers who have a working knowledge of PTSD but can also be administered by appropriately trained paraprofessionals. The full interview takes 45-60 minutes to administer.
Clinicians can request access to the assessment tool here.
PTSD Checklist for DSM-5 (PCL-5)
The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 has a variety of purposes, including:
Monitoring symptom change during and after treatment
Screening individuals for PTSD
Making a provisional PTSD diagnosis
The gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS-5). When necessary, the PCL-5 can be scored to provide a provisional PTSD diagnosis.
Traumatic Birth-related PTSD
City University - “City Birth” Trauma Scale (10 questions)
(This tool also includes a secondary section to screen for general PTSD.)
Bipolar Disorder
Mood Disorder Questionnaire (MDQ) (17 questions)
Suicide Ideation, Behaviors, Protective Factors & Access to Deadly Tools
There are two prominent evidence-based screening tools and risk assessments for suicide that can be used in the perinatal period. The NIMH “ASQ” or the Columbia screener (both which were developed with support from NIMH).
NIMH Ask Suicide Screening Questions (ASQ) (5 questions, if positive the safety assessment below should be utilized)
NIMH Suicide Safety Assessment Outpatient Provider Guide
-or-
Columbia Suicide Severity Rating Scale (5 questions) + SAFE-T Suicide Assessment
Note: A patient with suicidal thoughts should also be screened for OCD to understand if these thoughts are intrusive/unwanted ego-dystonic thoughts -incongruent with the person’s interests/intent.
Before sending a patient to the ER or admitting a patient with suicidal thoughts, these tools are critical for proper assessment and triage.
*More about Cut-Off Score “Sensitivity and Specificity”:
Mental Health screening tool cut-off scores are developed by researchers based on two factors, sensitivity and specificity:
Sensitivity refers to a test's ability to designate an individual with a disease as positive. A highly sensitive test means that there are few false-negative results, and thus fewer cases of disease are missed.
The specificity of a test is its ability to designate an individual who does not have a disease as negative.
More Resources For Screening and Assessment
The Handbook of Assessment and Treatment of Psychological Disorders
Center for Women's Mental Health at Massachusetts General Hospital
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