By Nicole Letourneau
Recently the Canadian Task Force on Preventive Health Care was widely rebuked over their recommendation against breast cancer screening in women under 50. The Task Force is an advisory body established by the Public Health Agency of Canada (PHAC) to create clinical guidelines for healthcare providers across the country.
In response to public backlash, the Honorable Minister of Health, Mark Holland opened an external review of the Task Force. But this is not the first time that the Task Force has faced substantial criticism.
Mental health experts concerned about perinatal depression in expectant and new mothers have repeatedly critiqued the 2013 and updated 2022 Task Force guidelines on “Depression During Pregnancy and the Postpartum Period.” Shockingly, the Task Force recommends against universal screening for depression during and after pregnancy using the global gold standard screening tool.
Experts from research, clinical practice, and policy have all expressed alarm. They caution that this flawed recommendation is based on limited information, placing many women in danger and potentially harming children’s healthy development.
There is now a pending review of the Task Force guidelines — which should be embraced by the federal Minister of Health and PHAC — as a potent opportunity to address Canadian experts’ concerns and consider alignment with provincial and international standards.
In Canada, depression is a serious mental health problem affecting 23 per cent — nearly one quarter — of expectant and new mothers. It is the leading cause of death by suicide in new mothers, and depression during pregnancy is a powerful predictor.
The symptoms of depression such as low mood and fatigue undermine mothers’ abilities to be sensitive and responsive to their growing infants’ needs. These children are at risk for language and learning delays, behavioural and mental health problems and health problems linked to asthma and allergies.
Typically, mothers’ depression also precedes fathers’ depression, affecting 22 per cent of Canadian men. When both parents are depressed, children are in double jeopardy.
Two letters have been published in the Canadian Medical Association Journal (CMAJ) from researchers and clinicians expressing dismay at the recently updated recommendations on perinatal depression.
The British Columbia Reproductive Mental Health Program and Perinatal Services BC also disagree with the Task Force recommendations, as does the Province of Alberta’s Health Services. Both provinces engage in screening for perinatal depression, despite the Task Force recommendations.
Also, in December 2023, a group of eighteen researchers, clinicians and policy makers penned a letter to the Honourable Ya’ara Saks, federal Minister of Mental Health and Addictions. Many had provided feedback to the Task Force before the publication of the 2022 recommendations and were dismayed when the input was discounted.
The group argued that the Task Force recommendations for perinatal depressing screening were flawed for many reasons.
First, the guidelines are based on inappropriately limited, restricted evidence, with an overreliance on data from randomized controlled trials of screening programs. Clinicians and researchers have advocated that observational and non-randomized trial data be considered – including important Canadian data.
A Canadian pragmatic trial using longitudinal follow-up and health records showed that women screened at high risk of depression were nearly four times more likely to be diagnosed with depression than unscreened mothers.
Second, the guidelines do not adequately acknowledge the complexity of historical inequities in healthcare for women and failed to address stakeholder input. Past-President of the Canadian Psychiatric Association advised that the guidelines need to be informed by expert judgement by clinicians including physicians.
Third, the guidelines do not acknowledge the impact of stigma that undermines women’s likelihood of sharing their symptoms. Clinicians are convinced that women are unlikely to be forthcoming about their symptoms. Research suggests women would be willing, or even relieved to be screened, especially if there was a universal program.
Finally, adherence to the guidelines will promote the negative, ironically preventable, lifelong effects of depression on women and their children’s health and development.
As the Coalition for Responsible Healthcare Guidelines indicates, Canada is going against the recommendations for perinatal depression of essentially all other countries who take a position on screening — including the U.S., the UK, Denmark and Australia. For example, the U.S. Task Force recommended depression screening of adults, including pregnant and postpartum women, in June 2023.
Screening for depression is essential to ensure mothers and their families receive adequate support. This will reduce serious mother and child harms that result from untreated depression.
It’s long past time for the Task Force to revisit the perinatal depression screening guidelines and listen to Canadian expert opinion and international evidence.
Nicole Letourneau is a Professor and Research Excellence Chair in Parent and Child Health at the University of Calgary in the Faculty of Nursing and Cumming School of Medicine.