Perinatal anxiety and depression screening and psychiatric care linkage in a regional Korean obstetric setting.

Pregnancy is a transformative period characterized by physical and emotional changes, including hormonal, physiological, and psychological changes [ 1 ]. These changes render women particularly susceptible to mental health challenges, with anxiety and depression being the most prevalent conditions [ 2 - 4 ]. Maternal mental health affects the well-being of mothers and has long-term consequences for their children, including adverse birth outcomes, delayed developmental milestones, and behavioral problems [ 3 - 7 ]. Perinatal women experience various mental health problems. Anxiety and depression are among the most common mental health conditions during the perinatal period. Postpartum depression, in particular, is a well-known mental health disorder. In 1987, the Edinburgh Postnatal Depression Scale (EPDS) was developed as a screening tool for postpartum depression; consequently, most early research primarily focused on postpartum depression [ 8 ]. Since then, anxiety has emerged as an equally important mental health concern; hence, there has been increased attention on postpartum anxiety [ 3 , 7 ]. Although most early studies investigated anxiety and depression separately, recent studies have emphasized the close correlation between these two conditions, thereby encouraging a more integrated approach to understanding maternal mental health [ 1 , 6 , 9 , 10 ]. However, current research on maternal mental health screening remains limited. Relatively few studies have simultaneously evaluated anxiety and depression and antenatal screening has been investigated less frequently than postpartum mental health [ 7 , 10 , 11 ]. Although several anxiety and depression screening tools have been translated and validated in Korea [ 12 - 17 ], relatively few have been specifically adopted for perinatal populations, and routine screening for antenatal anxiety remains limited in real-world obstetric practice [ 18 ]. Furthermore, substantial gaps remain in psychiatric care linkages following perinatal mental health screening. Even when anxiety and depression screening is performed, psychiatric referral uptake and service utilization vary considerably according to the study population and healthcare setting, and fewer than half of women identified as high-risk ultimately receive psychiatric evaluation or treatment [ 19 , 20 ]. However, real-world data on psychiatric referral uptake and service utilization in the Korean perinatal population remain extremely limited. To address these research gaps, this retrospective single-center study aimed to describe opportunistic anxiety and depression screening practices, screening positivity, and psychiatric care linkages during pregnancy and the postpartum period in a regional obstetric setting in Korea.

A total of 565 women underwent at least one anxiety and depression screening assessment during the study period. After applying the predefined exclusion criteria, 445 women were included in the final analysis ( Fig. 1 ). The mean age at delivery was 35.2 years (range, 21-49). Among the total study population, 235 women (52.8%) completed at least one screening assessment during pregnancy. Among these participants, 24, 190, and 90 completed the screening assessments during the first, second, and third trimesters, respectively. All 445 participants completed a postpartum screening assessment. All participants who underwent repeated assessments completed a postpartum assessment together with one or more antenatal assessments. Only 12 participants completed the screening assessments at all four time points. The mean GA at testing was 11 +5 weeks for the first trimester, 22 +2 weeks for the second trimester, 34 +1 weeks for the third trimester, and 5 +5 weeks postpartum. Table 1 summarizes the mean BAI and EPDS scores and the proportion of participants with positive screening results. Among women who underwent at least one screening assessment during pregnancy, 78/235 (33.2%) screened positive for anxiety on BAI and 42/235 (17.9%) screened positive for depression on EPDS. Clinical characteristics were compared between the screening-positive and screening-negative groups separately within each gestational stage and postpartum period. In the second trimester, antiemetic drug use was more common in both the anxiety- and depression-positive groups. Unemployment and conception following fertility treatment were more common in the anxiety-positive group, whereas thyroid disease diagnosed during pregnancy was more common in the depression-positive group ( Table 2 ). During the postpartum period, a history of miscarriage, PPROM in the current pregnancy, and NICU admission were more common in both the anxietyand depression-positive groups. In addition, a history of PTB, PTB in the current pregnancy, neonatal birth weight <1.5 kg, and a low 1-minute Apgar score were more common in the depression-positive group, whereas cesarean delivery was also more common in the anxiety-positive group ( Table 3 ). In the exploratory multivariable logistic regression analysis for positive postpartum EPDS screening results, a neonatal birth weight <1.5 kg was the only variable that remained statistically significant after adjustment ( Table 4 ). In contrast, the number of participants in the first-trimester group was insufficient, restricting the ability to perform meaningful analyses of the clinical characteristics and exploratory factors. In the third-trimester group, no notable differences were observed in the unadjusted analyses between the positive and negative screening groups. Among the 12 participants who completed all four assessments, the least-squares mean anxiety and depression scores tended to decline across subsequent gestational stages and the postpartum period ( Table 5 , Fig. 2 ). Among the study participants, 37 women had moderate- to-severe anxiety on BAI and 121 had positive EPDS screening results. Based on the screening results and clinical judgment, 66 women were referred to the Department of Psychiatry at our hospital. Of these, seven (10.6%) attended an initial psychiatric consultation based on electronic medical records.

This study described opportunistic anxiety and depression screening practices, screening positivity, and psychiatric care linkages during routine antenatal and postpartum care. Positive screening results for anxiety and depression were identified in both antenatal and postpartum assessments. Several clinical characteristics differed between the screening-positive and screening-negative groups during the selected assessment periods. However, attendance at an initial psychiatric consultation among women referred for psychiatric evaluation was notably low, highlighting the substantial gap between perinatal mental health screening and subsequent psychiatric care linkage in routine obstetric practice. We also explored several clinical characteristics based on positive screening results and some findings were generally consistent with those of previous studies. During the second trimester, antiemetic drug use was more frequent in women with positive screening results for anxiety and depression. As antiemetic medications are commonly prescribed for severe nausea and vomiting during pregnancy, this finding may reflect the psychological burden associated with pregnancy-related physical discomfort and serve as a surrogate marker of symptom severity rather than a direct medication effect [ 25 ]. Unemployment was more common in the anxiety-positive group, consistent with previous studies reporting an association between socioeconomic instability and perinatal mental health difficulties [ 1 , 26 , 27 ]. Although studies specifically examining the relationship between fertility treatment and antenatal anxiety remain limited, infertility evaluation and treatment may be accompanied by considerable psychological stress, and anxiety may persist in pregnancies conceived following fertility treatment [ 28 , 29 ]. Moreover, thyroid disease diagnosed during pregnancy was associated with depressive symptoms, which is consistent with previous research reporting possible links between thyroid dysfunction and mood disorders [ 30 ]. During the postpartum period, a history of miscarriage, PPROM during the current pregnancy, and NICU admission were more commonly observed among women with both positive anxiety and depression screening results. In addition, neonatal birth weight <1.5 kg remained associated with positive postpartum EPDS screening results in the exploratory multivariable analysis. These findings may reflect increased psychological stress related to adverse pregnancy experiences, concerns regarding neonatal outcomes, maternal-infant separation, and uncertainty surrounding neonatal prognosis [ 10 , 31 , 32 ]. Furthermore, in a small longitudinal subgroup of 12 participants who completed assessments at all four time points, anxiety and depression scores tended to decline across the assessment periods. Given the small sample size, these exploratory longitudinal findings should be interpreted with caution and require confirmation through larger prospective studies. Only 10.6% of the women who were referred to the Department of Psychiatry attended an initial psychiatric consultation. Similarly, previous studies and international guidelines have acknowledged the persistent gaps between perinatal mental health screening and actual treatment utilization [ 33 , 34 ]. The proposed barriers include limited mental health literacy; insufficient provider training; unclear referral pathways; long wait times; and structural difficulties such as transportation, childcare, and accessibility to mental health services [ 19 , 20 ]. In particular, stigma and negative perceptions surrounding mental illness remain barriers to seeking psychiatric care in Korea and may discourage individuals from seeking professional mental health care despite experiencing mental health problems [ 35 ]. These sociocultural factors may have contributed to the low psychiatric service utilization observed in our cohort. We used the BAI and EPDS because both instruments have been validated in the Korean population and are commonly used in clinical settings [ 12 , 16 ]. The BAI was originally developed to distinguish anxiety from depressive symptoms, which are considered relevant because anxiety and depression frequently coexist during the perinatal period. In addition, compared with longer instruments such as the State-Trait Anxiety Inventory, the BAI may be feasible for use in routine outpatient obstetric practice. Although the generalized anxiety disorder-7 is also widely used, the reported optimal cut-off values in pregnant populations vary considerably across studies, ranging from 7 to 13 points [ 17 , 36 - 38 ]. Therefore, we selected the BAI as a practical instrument for anxiety screening in real-world clinical settings. However, the BAI includes several somatic symptoms, such as dizziness, palpitations, and shortness of breath, which may overlap with normal physiological changes during pregnancy and the postpartum period. Therefore, caution is required when interpreting anxiety screening results using the BAI in perinatal populations. Although the Patient Health Questionnaire-9 [ 14 ] and Beck Depression Inventory-II [ 13 ] are sometimes used to evaluate antenatal depression, we selected the EPDS to ensure consistency from the antenatal to postnatal period, because it has also been validated for detecting depressive symptoms during pregnancy despite being developed for screening postpartum depression [ 8 , 23 ]. This study has several strengths. First, it provided real-world data on the implementation of concurrent anxiety and depression screening during routine antenatal and postpartum care. Second, it offers practical insights into psychiatric care linkages following perinatal mental health screening, including the gap between positive screening results and actual psychiatric service utilization. However, several limitations must be considered. First, this retrospective, single-center study was predominantly cross-sectional, with only a small number of participants completing the assessments at all time points. The small and disproportionate first-trimester sample further limits the interpretation of trimester-specific findings. Second, socioeconomic and psychosocial factors, including household income, family relationships, and social support, were not comprehensively assessed. Third, because very low neonatal birth weight is closely associated with other adverse neonatal outcomes, residual confounding and potential multicollinearity among related perinatal variables cannot be excluded despite the multivariable adjustment; therefore, the multivariable findings should be interpreted as exploratory. Fourth, the BAI includes somatic symptoms that may overlap with normal physiological changes during pregnancy and the postpartum period, thus requiring cautious interpretation in perinatal populations. More broadly, the screening tools assessed the severity of anxiety and depressive symptoms but did not establish clinical psychiatric diagnoses. Finally, psychiatric attendance was ascertained only from electronic medical records at our hospital; thus, the care received at other institutions could not be identified, and psychiatric service utilization may have been underestimated. Moreover, only the initial psychiatric consultation was evaluated without the assessment of subsequent treatment or long-term follow-up. Future studies should adopt a large-scale, multicenter, prospective, longitudinal design to better understand the temporal course and outcomes of perinatal mental health symptoms. Crucially, establishing standardized guidelines that ensure seamless psychiatric referral and linkage to care is essential, similar to proven international models [ 23 , 33 , 34 ]. Our findings underscore that timely screening must be coupled with integrated mental health support and accessible clinical pathways to improve maternal wellbeing during the perinatal period. In conclusion, this retrospective, single-center study described opportunistic anxiety, depression screening, and psychiatric care linkages during routine perinatal care. Positive screening results were identified; however, psychiatric service utilization remained low, highlighting the gap between screening and subsequent care linkage. These findings support the development of integrated perinatal mental health referral systems through multidisciplinary collaborations among obstetricians, psychiatrists, nurses, and social workers.

This retrospective single-center study examined pregnant and postpartum women who visited the Department of Obstetrics and Gynecology between December 29, 2021 and January 31, 2023. As part of routine perinatal care, anxiety and depression screening using the Korean versions of the Beck Anxiety Inventory (BAI) and EPDS was recommended for all women attending routine outpatient visits. At our hospital, antenatal screening was intended to be performed once during each trimester whenever possible. However, because screening was performed only during routine outpatient visits, not all women completed screening during every trimester. Screening was not completed at every gestational stage for several reasons, including missed screening opportunities during routine care, initiation of antenatal care after the first trimester, delivery before a scheduled screening visit, and failure to attend subsequent outpatient visits. In contrast, postpartum follow-ups involved only one or two routine visits and missed opportunities for postpartum screening were uncommon. The analysis included women who delivered at our hospital at ≥23 +0 weeks of gestation, which was considered the threshold of fetal viability in this study. Screening assessments were conducted only during outpatient visits and not during hospitalization. Women were excluded if they were non-Korean, had a previously diagnosed psychiatric disorder before pregnancy or multiple pregnancies, were lost to follow-up, delivered at another institution, transferred to another institution for continued care, or had incomplete screening assessments. Screening assessments were categorized according to gestational age (GA) at the time of screening as follows: first trimester (≤13 +6 weeks), second trimester (14 +0 -27 +6 weeks), third trimester (≥28 +0 weeks until delivery), and postpartum period (after delivery until routine postpartum follow-up). This study was approved by the Institutional Review Board of Jeju National University Hospital (approval number: 2022-11-011). The requirement for informed consent was waived due to the retrospective observational study design using existing clinical data. Two validated screening instruments were used to evaluate maternal anxiety and depressive symptoms. First, anxiety was evaluated using the BAI, a self-report questionnaire developed to reliably determine the severity of anxiety symptoms and specifically designed to distinguish anxiety from depressive symptoms. This inventory consists of 21 items designed to assess the severity of anxiety-related symptoms. The participants rated the severity of their symptoms over the past week. The total score was calculated by summing the item scores (possible score range: 0-63). A score of 0-7 was considered within the normal range, whereas scores of 8-15, 16-25, and 26-63 indicated mild, moderate, and severe anxiety, respectively [ 21 ]. In this study, a BAI score of ≥8 was considered positive for anxiety. Second, depression was evaluated using EPDS, a well-validated 10-item self-report screening assessment. Each item asked participants to report how they felt during the past week. The total score ranged from 0 to 30, with higher scores indicating more severe depressive symptoms. Previous studies and guidelines have supported the use of an EPDS cutoff score of ≥10 for depression screening during the perinatal period [ 12 , 22 , 23 ]. Therefore, in this study, a score of ≥10 was used to denote positivity for depression. Women with moderate-to-severe anxiety on the BAI or a positive EPDS screening result received counseling regarding perinatal mental health and were informed of psychiatric consultation. A referral to the Department of Psychiatry at our hospital was made when the attending obstetrician considered a psychiatric evaluation to be clinically indicated based on the screening results and clinical interview. Psychiatric attendance was ascertained by reviewing the electronic medical records at our hospital. Only the initial psychiatric consultation was evaluated; psychiatric care received at other institutions could not be identified. Fertility treatments included ovulation induction, intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection. Hypertensive disorders, diabetes mellitus, and thyroid disease were categorized based on whether they were diagnosed before or during pregnancy. Hypertensive disorders during pregnancy included gestational hypertension and pre-eclampsia. Thyroid diseases included all clinically diagnosed thyroid disorders such as subclinical hypothyroidism, Hashimoto thyroiditis, and Graves’ disease. Gynecological diseases included uterine myoma, adenomyosis, ovarian cysts, uterine anomalies, and polycystic ovary syndrome. Miscarriage was defined as the termination of pregnancy before 20 +0 weeks’ GA. Preterm premature rupture of membranes (PPROM) and preterm birth (PTB) were defined as those occurring between 23 +0 and 36 +6 weeks’ GA. Fetal growth restriction was defined as an estimated fetal weight below the 10th percentile for GA. The 1-minute and 5-minute Apgar scores were evaluated as components of neonatal outcomes. A low Apgar score was defined as a score of less than 7 [ 24 ]. Descriptive statistics were used to summarize the demographic and clinical characteristics of the study population. Continuous variables were compared using a two-sample t-test or Wilcoxon rank-sum test depending on the data distribution. Categorical variables were analyzed using the chisquare test or Fisher’s exact test, as appropriate. Due to the opportunistic screening process, markedly unequal sample sizes across gestational stages, and limited repeated measurements, the screening results were descriptively summarized separately at each gestational stage without formal comparisons across trimesters. By contrast, linear mixed models were applied only to the subset of participants who completed repeated assessments at all four time points. Therefore, this study was predominantly cross-sectional, with longitudinal data available for only a small subset of participants. Exploratory univariable and multivariable logistic regression analyses were performed for delivery- and neonatal outcome variables in relation to positive postpartum EPDS screening results. Variables with P <0.10 in the univariable analyses were entered into the multivariable logistic regression model. Adjusted odds ratios and 95% confidence intervals were calculated. There were no missing data for the variables included in the regression analyses and no imputation was performed. Statistical analyses were conducted using SAS software version 9.4 (SAS Institute Inc., Cary, NC, USA), with statistical significance set at P <0.05.