Successful five-item triage for the broad spectrum of mental disorders in pregnancy – a validation study
Quispel et al. BMC Pregnancy and Childbirth
Successful five-item triage for the broad spectrum of mental disorders in pregnancy - a validation study
Chantal Quispel 0 1
Tom AJ Schneider 0
Witte JG Hoogendijk 1
Gouke J Bonsel 0 2
Mijke P Lambregtse-van den Berg 1 3
0 Department of Obstetrics and Gynaecology, Division of Obstetrics & Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam , Rotterdam , the Netherlands
1 Department of Psychiatry, Erasmus MC, University Medical Center Rotterdam , Rotterdam , the Netherlands
2 Department of Public Health, Erasmus MC, University Medical Center Rotterdam , Rotterdam , the Netherlands
3 Department of Child and Adolescent Psychiatry, Erasmus MC, University Medical Center Rotterdam , Rotterdam , the Netherlands
Background: Mental disorders are prevalent during pregnancy, affecting 10% of women worldwide. To improve triage of a broad spectrum of mental disorders, we investigated the decision impact validity of: 1) a short set of currently used psychiatric triage items, 2) this set with the inclusion of some more specific psychiatric items (intermediate set), 3) this new set with the addition of the 10-item Edinburgh Depression Scale (extended set), and 4) the final set with the addition of common psychosocial co-predictors (comprehensive set). Methods: This was a validation study including 330 urban pregnant women. Women completed a questionnaire including 20 psychiatric and 10 psychosocial items. Psychiatric diagnosis (gold standard) was obtained through Structured Clinical Interviews of DSM-IV axis I and II disorders (SCID-I and II). The outcome measure of our analysis was presence (yes/no) of any current mental disorder. The performance of the short, intermediate, extended, and comprehensive triage models was evaluated by multiple logistic regression analysis, by analysis of the area under the ROC curve (AUC) and through associated performance measures, including, for example, sensitivity, specificity and the number of missed cases. Results: Diagnostic performance of the short triage model (1) was acceptable (Nagelkerke's R2=0.276, AUC=0.740, 48 out of 131 cases were missed). The intermediate model (2) performed better (R2=0.547, AUC=0.883, 22 cases were missed) including the five items: ever experienced a traumatic event, ever had feelings of a depressed mood, ever had a panic attack, current psychiatric symptoms and current severe depressive or anxious symptoms. Addition of the 10-item Edinburgh Depression Scale or the three psychosocial items unplanned pregnancy, alcohol consumption and sexual/physical abuse (models 3 and 4) further increased R2 and AUC (>0.900), with 23 cases missed. Missed cases included pregnant women with a current eating disorder, psychotic disorder and the first onset of anxiety disorders. Conclusions: For a valid detection of the full spectrum of common mental disorders during pregnancy, at least the intermediate set of five psychiatric items should be implemented in routine obstetric care. For a brief yet comprehensive triage, three high impact psychosocial items should be added as independent contributors.
Mental disorders; Personality disorders; Pregnancy; Psychosocial problems; Triage; Validation
Pregnancy and childbirth are sensitive periods in which
mental disorders can arise or relapse . The
occurrence of mental disorders during pregnancy varies
across studies. Prevalence rates of 13% for major
depressive disorder, 1% for bipolar mood disorders, 1%
for substance use disorder, 2% for panic disorders, 4%
for post-traumatic stress disorder, 9% for generalized
anxiety disorder, 1% for obsessive-compulsive disorder,
4% for eating disorder, and 6% for personality disorders
have been reported in several recent studies from
Western countries, mainly using self-report questionnaires
[1,2]. Despite the high prevalence and subsequent
short- and long-term adverse health outcomes for both
mother and child [3-5], mental health is not always part
of routine prenatal care . Consequently, detection
and treatment rates of pregnant women with mental
disorders are low. Reasons include professionals lack of
expertise and education, reluctance to take
responsibility for case management, and avoidance of
stigmatisation of both women and professionals. If not asked
specifically, women are not inclined to report mental
health symptoms spontaneously [6,7].
In the city of Rotterdam, obstetricians and
psychiatrists agree on a structured triage for mental disorders
during pregnancy. Besides the general history, pregnant
women with mental disorders are guided to psychiatric
consultation on behalf of a short set of three psychiatric
triage items: previous hospital admission of the woman
for psychiatric disorder, previous hospital admission of a
first-degree relative for psychiatric disorder, or previous
psychotropic medication use. This selection was based
on prior studies that consistently showed that psychiatric
history is the strongest predictor for future psychiatric
disorders [1,8]. For triage purposes, we aim at the most
serious disorders, for which psychiatric admission or
medication use is needed. We additionally ask for
hospital admission of a first-degree relative as a general
marker for increased vulnerability for psychiatric
disorders, and more specifically because of the strongly
increased risk for postpartum psychosis in women with a
first-degree relative suffering from bipolar disorder .
To further facilitate obstetrical professionals in the
triage of mental disorders during pregnancy, several
screening instruments have been developed worldwide.
Most instruments show limitations in diagnostic
coverage. First, most instruments - such as the commonly
used Edinburgh Depression Scale - only focus on the
most common mental disorders such as depression and
anxiety [10-14]. Second, personality disorders are not
included despite the fact that these disorders are prevalent
during pregnancy and are known to worsen health
outcomes and complicate treatment in case of comorbid
conditions . Third, comorbid conditions such as
insufficient social support and substance use are claimed
to be strong independent co-predictors for mental
disorders [16,17] but are rarely incorporated in screening or
A trade-off exists between a) the comprehensiveness
of instruments, including mental disorders, and
comorbid psychosocial stressors or substance abuse, and b)
brevity, including a limited number of items, but with a
rather high correlation to the broad spectrum of mental
To improve the triage of the broad spectrum of
DSMIV axis I and II disorders during pregnancy, this paper
investigated the decision impact validity of: 1) the
currently used short set of three psychiatric items, 2) this
set after addition of seven specific psychiatric items
(intermediate set), 3) this set after the further addition of
the 10-item Edinburgh Depression Scale (extended set),
and 4) the final addition of common psychosocial
copredictors (comprehensive set). We hypothesized that
the addition of at least some specific psychiatric
screening items would be superior to the currently used short
set of screen items in order to predict psychiatric
disorders during pregnancy.
After complete description of the study to the subjects,
written informed consent was obtained. Data were
generated by the self-reported Mind2Care screen-and-advice
instrument (formerly known as GyPsy instrument) 
and a set of seven additional psychiatric self-reported
screening items. Mind2Care was primarily developed by
the Erasmus Medical Center as a tool for screening and
subsequent treatment allocation for psychiatric and
psychosocial risk factors during pregnancy. Mind2Care
includes a short set of currently used psychiatric triage
items (previous hospital admission of the woman for
mental disorder, previous hospital admission of first-degree
relative for mental disorder, previous psychotropic
medication use). Additional psychiatric triage items were
suggested by clinicians who screened more than 2300
pregnant women for mental disorders. Based on these
suggestions and comprehensive literature sources [1,16,19-23]
seven additional items were selected to be validated in
combination with the short set of items (which together
form the intermediate set): previous professional
psychiatric treatment, previous traumatic experience, previous
feelings of a depressed mood, panic attack, current
psychiatric symptoms, current severe depressive or anxious
symptoms, current severe fear of childbirth (see Additional
file 1). Mind2Care also included the 10-item Edinburgh
Depression Scale (EDS)  (if added: the extended set),
and ten psychosocial stressors, including life events and
substance use (unplanned pregnancy, unwanted pregnancy,
insufficient social support, relational problems, financial
debts, unstable housing, sexual or physical abuse,
smoking, alcohol consumption and illicit drug use)
(comprehensive set), and a set of characteristics (maternal
age, ethnicity, socioeconomic status, educational level,
marital status, gestational age, gravidity, and parity) .
All women filled out the Mind2Care and the seven
additional psychiatric triage items independently.
Outcome measure was defined as any current mental
disorder diagnosed using the Structured Clinical
Interview for the DSM-IV axis I and axis II disorders (SCID-I
and SCID-II) [20,21]. SCID-I assesses major mental
disorders of the DSM-IV axis I divided into seven primary
classes: mood, psychotic, substance, anxiety, somatic
symptom disorder, eating, and adjustment disorders.
SCID-II assesses the eleven DSM-IV personality
disorders divided into cluster A, B and C personality
disorders. SCID responses include a 3-point rating with 1
indicating no, 2 indicating yes, sub-threshold, and 3
indicating yes, supra-threshold. Psychiatric diagnoses
are based on the underlying SCID algorithm and
scoring system. The 18 SCID classifications presented
here cover all of the information available from SCID-I
SCID interviews were conducted by a formally trained,
certificated researcher (C.Q.) in private rooms at the
outpatient departments of the participating hospitals or
at the womens homes. The interviewer was blinded to
all previous reported data. Due to the design of the
SCID, the interviews lasted from 15 minutes for women
without any mental disorder to 3 hours for women with
mental disorders. Outcomes measures were equal for
To include a reliable heterogeneous sample of pregnant
women with psychiatric disorders and women without
psychiatric disorders, we first approached a preselected
sample of 188 pregnant women at high risk for mental
disorders from a tertiary hospital. This sample included
pregnant women who were referred to this tertiary
hospital for psychiatric symptoms by their general
practitioner or midwife, and women with a history of
psychiatric symptoms, from September 2011 to July
2013. From May 2012 to July 2012 we approached an
unselected sample of 512 pregnant women at low risk
for mental disorders from a midwifery practice and an
obstetric outpatient department of a general hospital to
participate in this study. All practices were located in
Rotterdam, the second largest city in the Netherlands.
Exclusion criteria included having a miscarriage at the
time of screening, being non-Dutch speaking, and having
insufficient mental capability to complete the Mind2Care
independently. In total, 538 pregnant women fulfilled the
inclusion criteria. As 206 women refused participation
and two women had too many missing data points, 330
women were included (Figure 1). Women did not
receive a reward for participation. An a priori sample size
calculation defined that a sample of at least 120 women
with a mental disorder was needed to conduct
statistical analysis with a power of 0.8 and a 95% confidence
Figure 1 Study profile.
Table 1 Psychiatric diagnosis of study participants
established by SCID I and SCID II1 (n = 330)
Current mental disorder (axis I or II)
Current mental disorder on DSM-IV axis I
Participants (n = 330)
This study was approved by the institutional review
board of the Erasmus University Medical Center
Frequency tables, chi-squared tests and MannWhitney
U tests were used to describe and compare the study
groups. The proportion of characteristics, psychiatric
and psychosocial triage items according to the presence
of mental disorders were examined for comparative
reasons only. To investigate the model fitness of the
short, intermediate, extended, and comprehensive set
of triage items, first multiple logistic regression modelling
was applied with current psychiatric disorder (yes/no) as a
binary outcome measure. The short set of three
clinicallyused psychiatric items were entered into model 1. Then
the performance of the intermediate set of psychiatric items
in model 2 was tested, applying stepwise backwards
regression. The Edinburgh Depression Scale was added in model
3 (extended set). Finally we tested the additive value of
psychosocial items, including life events and substance
use (model 4, comprehensive set of items). At this stage,
we deliberately did not adjust for womens characteristics,
as we focused on the performance of different sets of items
in a heterogeneous group of pregnant women. Womens
characteristics were, however, entered in a fifth model to
explore the sensitivity of the triage models. Sensitivity was
explored to ensure validity under routine care conditions,
without the exceptions of any subgroup, for example lowly
educated women. Model fitting was assessed by
chisquared and Nagelkerke's R-squared statistics, and Hosmer
Lemeshow statistics reflecting classification power of a
group of variables.
Discriminant validity of the four triage models was
examined with the area under the Receiver Operator
Characteristics (ROC) Curve. The Area Under the Curve
(AUC) was calculated for all four models, with a value of
0.70 representing acceptable discrimination, 0.80
representing excellent discrimination, and 0.90 representing
outstanding discrimination. Test performances in terms
of sensitivity, specificity, positive predictive value (PPV)
and negative predictive value (NPV) were calculated
using a cut-off point of 0.4. The cut-off of 0.4 was
chosen as it reflects the proportion of mental disorders
in our sample.
All analyses were performed using the Statistical
Package for Social Science, version 20.0.
Table 1 reports the proportion of current mental
disorders of the DSM-IV axis I and axis II in the study
groups. Forty per cent of women had a current mental
Bipolar disorder type I or II
Major depressive disorder
Substance related disorder
Post-traumatic stress disorder
Generalized anxiety disorder
Current mental disorder on DSM-IV axis II
Cluster A personality disorder
Cluster B personality disorder
Cluster C personality disorder
1Diagnosis based on Structured Clinicial Interview of DSM-IV disorders axis I
and II (SCID I and SCID II).
2Including 44 women of the unselected cohort (low a priori risk for mental
disorders) and 87 women of the preselected cohort (high a priori risk for
disorder, with mood, anxiety and personality disorders
being the most prevalent.
Table 2 shows the characteristics and triage items for
the total group of women, and separately for women
with and women without a current mental disorder.
Women with mental disorders were more often of
non-Western ethnicity (44% versus 32%), less often
highly educated (27% versus 41%), and more often single
as compared to women without mental disorders (8%
versus 3%, all p < 0.05). All psychosocial and psychiatric triage
items were more common among women with a current
mental disorder, except for unstable housing and previous
hospital admission of a first-degree relative for mental
Table 3 shows the multivariate logistic regression
results for the prediction of mental disorders. All models
appeared to be statistically sufficiently valid, with an
increasing goodness of fit depending on the number of
items included, as we would expect.
Gestational age (weeks)2
Smoking during pregnancy5
Hospital admission for mental
disorder ever (woman herself)
Hospital admission of a first-degree
relative for mental disorder ever
Psychotropic medication use ever
Insufficient social support
Traumatic experience ever
Feelings of a depressed mood ever
Panic attac ever
Current psychiatric symptoms
Current severe depressive or
Current severe fear of childbirth
Edinburgh Depression Scale score2
Alcohol consumption during pregnancy6
(0.52 - 2.89)
(0.50 - 2.19)
(4.59 - 13.80)
(1.58 - 5.70)**
(1.36 - 5.64)**
(1.00 - 5.76)
(0.91 - 3.90)
(1.74 - 7.39)**
(1.75 - 7.28)**
(1.80 - 11.53)**
(0.95 - 5.98)
(1.88 - 18.27)**
Table 3 Multivariate logistic regression analysis for four triage models for mental disorders during pregnancy
Model 1 represents the short set of three psychiatric
items with a Nagelkerke's R2 of 0.276 and Hosmer and
Lemeshows statistic = 6.312. The AUC was 0.740 (95% CI:
0.683-0.797), representing an acceptable discrimination
(Figure 2). The test performance of the model at the
cutoff point of 0.4 showed a high specificity and NPV (0.83
and 0.77), yet 48 out of 131 cases were missed and 34
non-cases were falsely identified as a case. Model 2
includes the intermediate set of five psychiatric items for the
detection of mental disorders during pregnancy, as
nominated through a backwards stepwise regression analysis
(see Additional file 2). Nagelkerke's R2 was 0.547, Hosmer
(1.52 - 5.90)**
and Lemeshow was 1.454, and the AUC showed an
excellent discrimination of 0.883 (95% CI: 0.846-0.921).
Sensitivity and NPV appeared high (0.83 and 0.88). Model 2
missed 22 cases and identified 45 non-cases as cases.
Addition of the 10-item Edinburgh Depression Scale
(model 3, extended set of 15 items), increased Nagelkerke's
R2 with 16% to 0.637, Hosmer and Lemeshows statistic to
6.432, and the AUC to 0.918 (95% CI: 0.887-0.949),
representing outstanding discrimination. Twenty-three cases
were missed and 25 non-cases were falsely identified as a
case. The three psychosocial items sexual or physical
abuse, alcohol consumption during pregnancy and
having an unplanned pregnancy were all identified as
significant predictors for mental disorders during
pregnancy. The addition of these psychosocial items to the five
psychiatric items of model 2, increased Nagelkerke's R2
with 12% from 0.547 for model 2 to 0.615 for model 4
(comprehensive set of items). Hosmer and Lemeshows
statistic increased to 14.566. The AUC slightly increased
as well from 0.883 to 0.909, representing an outstanding
discrimination, comparable to model 3. Similarly as
compared to the addition of the 10-item Edinburgh
Depression Scale (model 3), the addition of three
psychosocial items did not affect the sensitivity or
NPV, but further increased the specificity and PPV
to 0.86 and 0.80 respectively. Again, 23 cases were
undetected, and 2 more non-cases were falsely identified
(n = 27).
Finally, socio-demographic characteristics were added
to explore the influence of these characteristics on the
performance of the triage models. After applying
stepwise backwards regression analysis, none of the
characteristics contributed to further improvement of the
detection of mental disorders, suggesting indifference of
the screening performance tool for socio-demographics.
The burden of a broad spectrum of mental disorders in
pregnancy is considerable, and a structured triage is
often lacking. Our study showed that the currently used
short set of three psychiatric items at least performs
acceptably for triage purposes. However, an intermediate
set including the five psychiatric items traumatic
experience ever, feelings of a depressed mood ever, panic
attack ever, current psychiatric symptoms and current
severe depressive or anxious symptoms, significantly
improves the sets performance. Further improvement can be
achieved by adding the 10-item Edinburgh Depression
Scale or at least adding three items on co-morbid
conditions: alcohol consumption, physical or sexual abuse, and
having an unplanned pregnancy. The addition of these
three psychosocial items provides a brief yet broad triage
(see Additional file 2).
Many research studies have addressed the validation of
questionnaires focusing on one specific topic such as
antenatal depression or anxiety [10-14]. To our
knowledge, we are the first to screen for the broad spectrum
of DSM-IV axis I and axis II disorders during pregnancy
instead of focusing on the most prevalent disorders only.
As personality disorders contribute to the burden of
mental disease, triage creates an opportunity for
identifying disorders that are otherwise left unnoticed in the
obstetric setting. The rather complex and long lasting
treatment of personality disorders is often not a primary
aim during pregnancy, however, the provision of some
kind of maternal support is desired. In addition, we are
the first to systematically investigate the independent
predictive role of psychosocial risk factors, following a
study of de Graaf et al. .
Unlike previous studies, which mostly assess psychiatric
diagnoses in screen positive participants [26-28], we
obtained psychiatric diagnosis for both low and high-risk
participants. This validity check across all participants
provides the best information on the test performance of the
triage models. At this stage a thorough verification
procedure, yielding false negative and false positive rates of the
screening, justifies the effort of a psychiatric assessment of
The purpose of this study was to validate a set of items
for the triage of a broad spectrum of mental disorders
during the antenatal phase. Clinical triage requires the
combination of a high sensitivity, specificity, positive and
negative predictive value. The emphasis is on high
sensitivity and high negative predictive value (resulting in low
rates of missed cases), assuming that false-positive
women are identified during an intentional subsequent
confirmation by a psychiatric professional. Despite the
excellent discrimination of the triage models, 23 women
with a current mental disorder were missed. These
women are likely to have limited insight into their
illness, because all 23 responded negatively to the question
about having current psychiatric symptoms. Interestingly
three out of five women with a current eating disorder,
and two out of eight women with a current psychotic
disorder were missed by the triage model, indicating a
low sensitivity for these types of disorders. Seven out of
the 23 missed cases included first onset of psychiatric
disorders in women of moderate to high education from
a Western origin, without a psychiatric history and
without any psychosocial stressors. Two of these women
reported fetal loss or previous miscarriages as reasons for
their anxiety disorder. This stresses the importance of
special awareness of the psychiatric consequence of
previous adverse pregnancy outcomes.
This study was subject to several limitations. Firstly,
psychiatric diagnosis addressed a current state of mental
disorders and not a future state throughout pregnancy
or postpartum. Repeated assessments during pregnancy
and postpartum would provide valuable information on
the onset of mental disorder during later pregnancy and
after delivery. Nevertheless, this study included pregnant
women with a mixture of gestational ages, representing
the whole antenatal period. As postpartum mental
disorders often already start during pregnancy, we focused on
the antenatal period only. Secondly, the response rate
was relatively low (38%). This was possibly due to the
duration of the interview, as women were informed on
the approximate length of the interview prior to the
study. Baseline characteristics of responders and
nonresponders were comparable, except for ethnicity.
Nonresponders were more often of non-Western ethnicity
(46% versus 37%, p = 0.008). As women of non-Western
ethnicity more often had psychiatric disorders in this
study, this could have led to the selection of a healthier
The findings in this study led to an important
recommendation. For a brief triage and a subsequent referral
to psychiatric care or provision of support for women
with mental disorders during pregnancy, the
implementation of a comprehensive set of at least five psychiatric
triage items is warranted. As the addition of three
psychosocial items significantly improves the performance
of the triage tool at low cost, we advocate the
implementation of this 8-item comprehensive set of items in
routine obstetric care (see Additional file 2). Nevertheless,
triage alone is not enough. All identified women
following triage need a psychiatric consultation for the
confirmation of the psychiatric disorder and subsequent
Additional file 1: Ten potential psychiatric items for the triage of
mental disorders of the DSM-IV axis I and II during pregnancy.
Description: Additional file 1 includes an overview of the ten potential
psychiatric items to be used for the triage of mental disorders during
Additional file 2: The comprehensive set of five psychiatric items
and three psychosocial items to be implemented in routine
obstetric care for the triage of mental disorders of the DSM-IV axis I
and II. Description: Additional file 2 includes an overview of the
comprehensive set of psychiatric and psychosocial items to be used for
the triage of mental disorders in routine obstetric care.
AUC: Area under the curve; EDS: Edinburgh depression scale; NPV: Negative
predictive value; PPV: Positive predictive value; ROC: Receiver operator
characteristics; SCID: Structured clinical interview of the DSM-IV disorders.
The authors declare that they have no competing interests.
All authors CQ, TAJS, WJGH, GJB and MPLvdB contributed to the study
concept and design. Data collection was conducted by CQ and TAJS. CQ
performed data analysis, primarily supervised by GJB and MPLvdB. Data
interpretation was conducted by all authors. CQ wrote the first draft of the
paper. All authors critically revised the article, approved the final version, and
agree to be accountable for all aspects of the work.
We acknowledge all obstetricians, all midwives and research assistants from
the participating midwifery practices and hospitals in Rotterdam who
provided the opportunity for this study.
Stichting Achmea Gezondheid is acknowledged for proving financial support
to this study [grant number z-282]. The funders did not participate in any
part of data collection, data analysis or interpretation of the data, nor in the
writing or approval of the manuscript.
1. O'Keane V , Marsh M , Seneviratne G . Psychiatric Disorders and Pregnancy . London: Taylor & Francis Group publishers; 2006 .
2. Gold KJ , Marcus SM . Effect of maternal mental health illness on pregnancy outcomes . Expert Rev of Obstet Gynaecol . 2008 ; 3 ( 3 ): 391 - 401 .
3. Chen YH , Lin HC , Lee HC . Pregnancy outcomes among women with panic disorder - do panic attacks during pregnancy matter ? J Affect Disord . 2010 ; 120 ( 1-3 ): 258 - 62 .
4. Jablensky AV , Morgan V , Zubrick SR , Bower C , Yellachich LA . Pregnancy, delivery, and neonatal complications in a population cohort of women with schizophrenia and major affective disorders . Am J Psychiatry . 2005 ; 162 ( 1 ): 79 - 91 .
5. Grote NK , Bridge JA , Gavin AR , Melville JL , Iyengar S , Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction . Arch Gen Psychiatry . 2010 ; 67 ( 10 ): 1012 - 24 .
6. McCauley K , Elsom S , Muir-Cochrane E , Lyneham J. Midwives and assessment of perinatal mental health . J Psychiatr Ment Health Nurs . 2011 ; 18 ( 9 ): 786 - 95 .
7. Dolman C , Jones I , Howard LM . Pre-conception to parenting: a systematic review and meta-synthesis of the qualitative literature on motherhood for women with severe mental illness . Arch Womens Ment Health . 2013 ; 16 ( 3 ): 173 - 96 .
8. National Collaborating Centre for Mental Health. Antenatal and postnatal mental health: the NICE guideline on clinical management and service guidance . London, Great Britain: The British Psychological Society and The Royal College of Psychiatrists ; 2007 .
9. Robinson GE , Stewart DE . Postpartum psychiatric disorders . CMAJ . 1986 ; 134 ( 1 ): 31 - 7 .
10. Cox JL , Holden JM , Sagovsky R. Detection of postnatal depression . Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry . 1987 ; 150 : 782 - 6 .
11. Altshuler LL , Cohen LS , Vitonis AF , Faraone SV , Harlow BL , Suri R , et al. The Pregnancy Depression Scale (PDS): a screening tool for depression in pregnancy . Arch Womens Ment Health . 2008 ; 11 ( 4 ): 277 - 85 .
12. Brunoni AR , Benute GR , Fraguas R , Santos NO , Francisco RP, de Lucia MC , et al. The self-rated Inventory of Depressive Symptomatology for screening prenatal depression . Int J Gynaecol Obstet . 2013 ; 121 ( 3 ): 243 - 6 .
13. Spielberg CD , Gorsuch RL , Lushene R , Vagg PR , Jacobs GA . Manual for the State-Trait Anxiety Inventory . Palo Alto, CA: Consulting Psychologists Press ; 1983 .
14. Holcomb Jr WL , Stone LS , Lustman PJ , Gavard JA , Mostello DJ . Screening for depression in pregnancy: characteristics of the Beck Depression Inventory . Obstet Gynecol . 1996 ; 88 ( 6 ): 1021 - 5 .
15. Tyrer P , Simmonds S. Treatment models for those with severe mental illness and comorbid personality disorder . Br J Psychiatry Suppl . 2003 ; 44 : S15 - 8 .
16. Lancaster CA , Gold KJ , Flynn HA , Yoo H , Marcus SM , Davis MM . Risk factors for depressive symptoms during pregnancy: a systematic review . Am J Obstet Gynecol . 2010 ; 202 ( 1 ): 5 - 14 .
17. Hauck Y , Rock D , Jackiewicz T , Jablensky A. Healthy babies for mothers with serious mental illness: a case management framework for mental health clinicians . Int J Ment Health Nurs . 2008 ; 17 ( 6 ): 383 - 91 .
18. Quispel C , Schneider TA , Bonsel GJ , Lambregtse-van den Berg MP . An innovative screen-and-advice model for psychopathology and psychosocial problems among urban pregnant women: an exploratory study . J Psychosom Obstet Gynaecol . 2012 ; 33 ( 1 ): 7 - 14 .
19. Breitkopf CR , Primeau LA , Levine RE , Olson GL , Wu ZH , Berenson AB . Anxiety symptoms during pregnancy and postpartum . J Psychosom Obstet Gynaecol . 2006 ; 27 ( 3 ): 157 - 62 .
20. First MB , Spitzer RL , Gibbon M , Williams JBW . Structured Clinical Interview for DSM-IV Axis I Disorders - Patient edition (SCID-I/P, Version 2 . 0 ) [In Dutch: Gestructureerd Klinisch Interview voor de vaststelling van DSM-IV As I Stoornissen - Patienten Editie] Dutch translation , H.C. Rmke Group . The Netherlands: Swets & Zietlinger B.V. Lisse ; 1999 .
21. First MB , Spitzer RL , Gibbon M , Williams JBW , Benjamin L. Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) [In Dutch: Gestructureerd Klinisch Interview voor DSM-IV As-II Persoonlijkheidsstoornissen] Dutch translation . Department of Medical Psychology , University of Maastricht. 1997 .
22. Koleva H , Stuart S , O'Hara MW , Bowman-Reif J. Risk factors for depressive symptoms during pregnancy . Arch Womens Ment Health . 2011 ; 14 ( 2 ): 99 - 105 .
23. Tam WH , Chung T. Psychosomatic disorders in pregnancy . Curr Opin Obstet Gynecol . 2007 ; 19 ( 2 ): 126 - 32 .
24. Bunevicius A , Kusminskas L , Pop VJ , Pedersen CA , Bunevicius R. Screening for antenatal depression with the Edinburgh Depression Scale . J Psychosom Obstet Gynaecol . 2009 ; 30 ( 4 ): 238 - 43 .
25. de Graaf JP , Steegers EAP , Bonsel GJ . Inequalities in perinatal and maternal health . Curr Opin Obstet Gynecol . 2013 ; 25 ( 2 ): 98 - 108 .
26. Austin MP , Hadzi-Pavlovic D , Saint K , Parker G . Antenatal screening for the prediction of postnatal depression: validation of a psychosocial Pregnancy Risk Questionnaire . Acta Psychiatr Scand . 2005 ; 112 ( 4 ): 310 - 7 .
27. O'Hara MW , Stuart S , Watson D , Dietz PM , Farr SL , D'Angelo D. Brief scales to detect postpartum depression and anxiety symptoms . J Womens Health (Larchmt) . 2012 ; 21 ( 12 ): 1237 - 43 .
28. Wisner KL , Sit DK , McShea MC , Rizzo DM , Zoretich RA , Hughes CL , et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings . JAMA Psychiatry . 2013 ; 70 ( 5 ): 490 - 8 .