Psychiatric Symptoms and Disorders Associated with Reproductive Cyclicity in Women: Advances in Screening Tools

Abstract

Female-specific psychiatric illness including premenstrual dysphoria, perinatal depression, and psychopathology related to the perimenopausal period are often underdiagnosed and treated. These conditions can negatively affect the quality of life for women and their families. The development of screening tools has helped guide our understanding of these conditions. There is a wide disparity in the methods, definitions, and tools used in studies relevant to female-specific psychiatric illness. As a result, there is no consensus on one tool that is most appropriate for use in a research or clinical setting. In reviewing this topic, we hope to highlight the evolution of various tools as they have built on preexisting instruments and to identify the psychometric properties and clinical applicability of available tools. It would be valuable for researchers to reach a consensus on a core set of screening instruments specific to female psychopathology to gain consistency within and between clinical settings.

Keywords

anxiety depression diagnosis diagnostic instrument diagnostic tool menopause postpartum depression premenstrual dysphoric disorder rating scale screening

Background

There appears to be a subgroup of females who demonstrate vulnerability to normal physiological fluctuations in gonadal hormones [1]. This leads to psychopathology at various stages of the reproductive cycle, including with menses, ante- and postpartum, and in the perimenopausal transition. It has become increasingly clear that it is important to identify, diagnose, and treat this subgroup of women given the negative impact that these female-specific conditions can have on quality of life. The development of screening tools has helped to shape the diagnostic framework for female-specific psychiatric conditions like premenstrual dysphoric disorder (PMDD), and to better understand psychiatric symptoms and/or illness that may occur as related to a reproductive stage such as menopause. It is essential that screening tools have sound psychometric properties and are efficient for use in busy clinical settings. With this literature review, we attempt to highlight the various tools that have been in use over the years, specific to premenstrual symptoms, the ante- and postpartum period, and the perimenopausal transition.

The PubMed and Ovid search engines were used. Within Ovid, the search databases used were EMBASE (1974–March 2014), MEDLINE (1996–March 2014) and PsycINFO (1987–March 2014). A combination of the keywords ‘screening/diagnostic tool/instrument’, ‘diagnosis’, ‘rating scale’ and those related to various female-specific psychiatric conditions (e.g., ‘postpartum depression (PPD)’, ‘PMDD’, ‘menopause + anxiety/depression’) were used. Reference sections of relevant articles were manually searched to retrieve further studies. Our search was limited to the English language. For details on psychometric properties for the tools discussed, please see accompanying tables.

Premenstrual symptoms

Diagnostic information

As many as 75% of females experience symptoms of the premenstrual syndrome that can include psychological and physical symptoms that occur in the late luteal phase of the menstrual cycle [2]. A subgroup of these females experience more severe premenstrual symptoms that interfere with day-to-day functioning and may be diagnosed with PMDD. This more severe and debilitating form of premenstrual syndrome was initially formally recognized by the American Psychiatric Association (APA) in Appendix A of the Diagnostic and Statistical Manual of Mental Disorders (DSM) III-R [3] and was called Late Luteal Phase Dysphoric Disorder. The disorder was later renamed PMDD and included in DSM-IV-TR Appendix B as an area for future study [4]. The most recent version of the DSM (DSM 5) has seen this disorder move to a diagnostic category of its own, located within depressive disorders [5,6]. Prevalence rates for PMDD are fairly consistent in adults and adolescents and range between 3 and 8% [7 –9]. However, in addition to this baseline prevalence of PMDD, it is important to note that upward of an additional 20% of women may have sub-threshold PMDD and may require further monitoring and treatment [7]. For further review see [2,10 –15].

An individual must have five (or more) of eleven symptoms present during the late luteal phase with symptom improvement within a few days of the onset of menses to establish the ‘on–offness’ of symptoms. Studies have shown that the most commonly reported psychological symptoms and those that show most stability across cycles include mood lability and irritability [8,16–17]. The symptoms most commonly reported in adolescent populations include anger and irritability followed by tearfulness and an increased sensitivity to rejection [8]. A DSM diagnostic requirement is that the symptoms experienced are confirmed by prospective daily ratings during at least two symptomatic cycles [5].

There are advantages and disadvantages to both prospective and retrospective rating of premenstrual symptoms. It has been shown that retrospective reporting may produce biased results in that individuals have a tendency to report greater symptomatology compared with daily rating [18]. This may relate to sociocultural biases and either exaggerated or minimized symptoms, based on memory [19]. However, retrospective symptom reporting can be more time efficient and potentially expedite diagnosis and treatment initiation. Prospective charting can be burdensome to some patients and healthcare providers, leading to noncompletion of this diagnostic requirement [20].

There are currently no hormonal or biochemical markers to aid with the diagnosis of PMDD. Therefore, clinicians need to rely on clinical assessment and the use of subjective tools to screen for and diagnose this condition [21]. It has been estimated that there have existed at least 65 different scales used to classify premenstrual symptoms and assess study entry eligibility and treatment outcomes [22]. Generally, a change in symptom severity of 30–50% between the luteal and follicular phases indicates a probable diagnosis of PMDD [23]. Table 1 highlights some of the more commonly used tools that include retrospective questionnaires and prospective daily symptom rating.

Table 1.

Screening tools for premenstrual dysphoric disorder.

Study (year)	Screening tool	Number of items and scale	Symptoms measured	Self-report or observer	Time to complete	Retrospective vs prospective	Psychometric properties	Ref.
Accortt et al. (2011)	Structured clinical interview for PMDD	Standard questions of 11 symptoms from DSM criterion A, follow-up questions on symptoms throughout menstrual cycle	Phys. and Psych.	Observer	Time intensive	Retro and current	Highly reliable and sensitive	[24]
Steiner et al. (2011)	PMTS rating scale – updated	PMTS-OR assesses 11 domains of symptoms, severity scale from 0 to 4 (0–2 for two domains). PMTS-VAS assesses severity of 12 symptoms (mirrors domains of PMTS-OR	Phys. and Psych.	Both	PMTS-OR is brief, easy to understand and administer. Average time to completion of PMTS-VAS is 68 sec	PMTS-O prospectively completed during follicular and luteal phase of cycle. PMTS-VAS retro	Valid, reliable and sensitive to change and severity of symptoms	[25 –27]
Steiner et al. (2011)	PSST-A	19 items – 14 symptoms and five functional items (wording of two changed from PSST to better represent adolescents), measured on four point scale of severity; screens for PMDD and PMS	Phys. and Psych.	Self-report	User friendly	Retro	Requires further validation by concurrent use alongside prospective daily charting of two menstrual cycles	[8]
Endicott et al. (1996) and Endicott et al. (2006)	DRSP	21 symptom items grouped within 11 domains + three items for impairment, rated on six point scale of severity	Phys. and Psych.	Self-report	User friendly	Pro	High reliability, validity, sensitivity	[28,29]
Steiner et al. (2005) (VAS revised) Rubinow et al. 1984, Casper and Powell (1986), O'Brien et al. (1979) (VAS: premenstrual mood index)	VAS	100 mm horizontal line with vertical line anchors (0 = ‘not at all’ and 100 = ‘extreme symptoms’)	Phys. and Psych.	Self-report	User friendly, time efficient	Either	High sensitivity, VAS-R high reliability and validity	[30 –33]
Steiner et al. (2003)	PSST	19 items – 14 symptoms and five functional items, measured on 4-point scale of severity, screens for PMDD and PMS	Phys. and Psych.	Self-report	User friendly	Retro	Validated	[7]
Freeman et al. (1996)	Penn Daily Symptom Report	17 items, 5-point scale of severity	Phys. and Psych.	Self-report	<2 min/day	Pro	Good reliability; validated	[34]
Mortola et al. (1990)	Calendar of Premenstrual Experiences	10 physical symptoms and 12 behavioral symptoms, four point scale of severity	Phys. and Psych.	Self-report	<2 min/day	Pro	High reliability, good predictive/concurrent validity	[35]
Rivera-Tovar and Ellen (1990)	Daily Assessment Form	33 item checklist, 6-point scale of severity	Phys., Psych., and lifestyle (e.g., alcohol intake)	Self-report	<5 min/day	Pro (two cycles)	Not well validated	[36]
Reid (1983)	Prospective Record of Impact and Severity of Menstruation	Variety of symptoms rated + neg/pos life events, concurrent medications and menstrual bleeding, eight point severity scale	Phys. and Psych.	Self-report	One page calendar	Pro	Validated	[37]
Halbreich et al. (1982)	PAF	95 item with 6-point severity scale	Phys. and Psych. during last three cycles	Self-report	Lengthy instructions and high number items may be less user friendly	Retro	High sensitivity, low specificity Reliable and validated tool	[38]
Steiner et al. (1980)	PMTS rating scale	PMTS-O assesses ten domains, 36 symptoms with severity ranging from 0 to 4 (0–2 for two domains). PMTS-SR is 36 items, yes/no	Phys. and Psych.	Both	PMTS-O is brief, easy to understand and administer. Average time to completion of PMTS-SR is 163 s.	PMTS-O prospectively completed during follicular and luteal phase of cycle. PMTS-SR retro/current	Validated, reliable and sensitive measure	[39]
Clare & Wiggins (1979)	Modified version of MDQ	35 items, rated on 4-point severity scale	Phys. and Psych.	Self-report	Less complicated and more user friendly than original. Adapted for British population	Retro	No tests of internal consistency or test-retest reliability Sensitivity 98.2% and specificity 66.1%.	[40]
Moos (1968)	Moos MDQ	47 items grouped into eight clusters, rated on 6-point scale	Phys. and Psych. for one cycle	Self-report	5 min to complete	Retro	No tests of internal consistency, validity inadequately addressed	[41]

DSM: Diagnostic and Statistical Manual of Mental Disorders; DRSP: Daily record of severity of problems; MDQ: Menstrual distress questionnaire; PAF: Premenstrual assessment form; Phys: Physical; PMDD: Premenstrual dysphoric disorder; PMS: Premenstrual syndrome; PMTS: Premenstrual tension syndrome; PSST: Premenstrual symptoms screening tool; PSST-A: Premenstrual symptoms screening tool for adolescents; Psych: Psychological; VAS: Visual analog scale.

Tools

The Menstrual Distress Questionnaire [41] was one of the first diagnostic tools used to assess premenstrual symptoms. It predated the inclusion of Late Luteal Phase Dysphoric Disorder in the DSM and had limited psychometric properties. The main advantage of this tool is that it provided the foundation for the development of future diagnostic scales used today. A modified version simplified the original 47 items and made the tool more user friendly and acceptable to a British patient base [40]. Notably, the major disadvantage of this tool is that it does not align with current diagnostic criteria for PMDD, and is therefore no longer a clinically relevant tool.

Using the symptom items from the Menstrual Distress Questionnaire, the Premenstrual Tension Syndrome (PMTS) rating scale was developed in 1980 [39]. A main advantage of this scale is that is consists of an observer and a self-report scale (PMTS-O and PMTS-SR, respectively), used in conjunction to identify symptom severity both prospectively and retrospectively. More recently, an updated version was created with a change in symptoms measured by the PMTS-O to more accurately reflect the DSM-IV criteria [25]. Furthermore, the original PMTS-SR was replaced with a Visual Analog Scale (VAS) as this method of symptom assessment, when coupled with the PMTS-O, has high validity, reliability, and sensitivity and is low in burden to the patient [26,27]. The PMTS-O scores were also comparable to VAS scores regardless of whether they were measured retrospectively or prospectively [30]. VASs have been used for many years and have extensive validation assessing subjective symptoms in many different fields. They have also proven to be sensitive to changes in symptom severity over time and with treatment [31 –33,42].

The Premenstrual Assessment Form (PAF) provides a retrospective review of the previous three menstrual cycles. Its main disadvantage is that with 95 items has been deemed tedious and less user friendly than other measures [38]. The PAF predates DSM diagnostic criteria but has been found to have high sensitivity and therefore its main advantage may be that it is useful in differentiating a clinically pathological population from control samples. Unfortunately, due to its discordance with the DSM, it does not provide information to confirm a diagnosis of PMDD [43]. Due to concerns related to the length of the original PAF, shortened versions have been created (see [44]). The Premenstrual Symptoms Screening Tool (PSST) is a 19 item retrospective tool that has recently been adapted into a measure of premenstrual symptoms in an adolescent population [7,8]. Its main advantage is that it is known to be a user-friendly tool that aligns with DSM diagnostic criteria and considers an individual's level of functioning. Its main disadvantage is that it is a retrospective tool and therefore does not help fulfill the DSM criterion of confirming symptoms prospectively. However, the International Society for Premenstrual Disorders (ISPMD) concludes that the PSST has high potential utility as a retrospective screening tool in a clinical population.

Prospective calendar models can be helpful for diagnosis in a clinical setting as they help accommodate the DSM criteria of two cycles of prospective cycle rating. The most recently developed prospective tool is the 21-item DRSP [28,29]. The main advantage of the DRSP is that it was developed in alignment with the DSM criteria for PMDD while also providing information on the severity of symptoms and level of impairment at various phases of the menstrual cycle. This tool is recommended by the Royal College of Obstetricians and Gynecologists and used throughout the literature as an easily accessible and well validated scale [45,46]. Other prospective tools include the 33-item Daily Assessment Form [36], the 17-item Penn Daily Symptom Report [34], the Prospective Record of Impact and Severity of Menstruation [37] and the 22-item Calendar of Premenstrual Experiences [35]. All of these tools measure both psychological and physical symptoms. The main advantage of the Prospective Record of Impact and Severity of Menstruation is that it is a validated tool that requires notation on negative and positive life events, concurrent medications, and menstrual bleeding. The Calendar of Premenstrual Experiences has good reliability and concurrent as well as predictive validity. Although more onerous than a screening tool, the use of specific questions as part of a structured clinical interview specific to PMDD is a highly reliable and sensitive means of confirming diagnosis [24].

Although there is still no consensus as to the best or most appropriate instrument for confirming the diagnosis of PMDD or to assess eligibility and treatment effect in clinical trials, recommendations from the ISPMD favor the DRSP as the accepted quantification technique. The ISPMD recommendations also support use of retrospective screening tools, such as the PSST, to avoid delaying entry into treatment.

Ante- & postpartum

Diagnostic information

Following childbirth, upward of 85% of females will experience a mild and transitory state called the postpartum blues consisting of emotional lability with frequent crying episodes. These symptoms typically remit within 2 weeks of delivery but may have biological links to the development of significant mood changes later in the postpartum period [47]. A more serious and prolonged condition is PPD, which affects 10–15% of females within the first 4–6 weeks after childbirth [48]. PPD is a specifier to a Major Depressive Episode in the DSM 5 [5]. In addition to the negative impact on the new mother, there are many sequelae to PPD including marital distress and potential deleterious effects on the child [49]. These include poor mother–infant interaction and attachment and adverse effects on the development and cognition of the child [50,51]. Because the consequences of this illness can be so devastating, it is important for health care providers to screen for and identify women at risk for developing PPD. Despite multiple contacts with health care providers in the first year postpartum, many women go without much needed treatment because they are not asked the right questions [52]. Screening is ideal after 2 weeks postpartum given the somatic changes immediately following childbirth and the presence of transient baby blues that can lead to significantly reduced testing sensitivity [53].

There are a number of review papers that address screening tools in the antepartum [54,55]. Table 2 highlights some of the more commonly used screening tools for PPD. The table includes subsections for screening tools specific to depressive symptomatology in pregnant or postpartum women and general mood screening tools that have been used in a postpartum population.

Table 2.

Screening tools for ante- and postpartum.

Study (year)	Screening tool	Number of items and scale	Symptoms measured and when	Self-report or observer	Time to complete	Retrospective vs prospective	Psychometric properties	Ref.
Allison et al. (2011)	Postpartum Distress Measure	Ten items, scale for general distress and for obsessive–compulsive symptoms	Psych.	Self-report	<5 min to complete	Retro	Reliable with good convergent and divergent validity	[56]
Davis et al. (2008)	Postpartum Adjustment Questionnaire	15 item PPD risk assessment questionnaire (>6/15 = high risk for PPD)	Psych and social	Self-report	<5 min to complete	Retro and Current	Significant modest correlation with total PDSS scores	[57]
Beck and Gable (2000)	PDSS	35 items on seven symptom subscales, scale of 1–5 for agreement or disagreement with each item (score range 35–175 with cut-off of 80 for MDD)	Phys. and Psych.	Self-report	5–10 min to complete, written at seventh grade level	Retro	Good construct/content validity, reliability; sensitivity 91–94% and specificity 72–98%; checks for inconsistent response patterns	[58]
Beck (1998)	PDPI	Clinical checklist	Psych. + stress, social supports, marital satisfaction	Observer	Useful to initiate discussion, user friendly	Current	No psychometric properties	[59]
Stamp et al. (1996)	Modified Antenatal Screening Questionnaire	Three point scale of severity; given during pregnancy to predict depression at 6 weeks PP	Psych. and social (e.g., relationship and problem-solving style)	Self-report	5–10 min to complete	Current	Sensitivity 73% and specificity 43% (for major depression) and sensitivity 81% and specificity 48% (for minor depression)	[60]
Lovibond and Lovibond (1995b)	DASS	42 items on three subscales (depression, anxiety, and stress), four point scale of severity	Phys. and Psych.	Self-report	5–10 min to complete	Retro	Excellent internal consistency, good convergent and discriminant validity. Postpartum – strong support for reliability and validity of DASS	[61]
Cox et al. (1987)	EPDS	Ten items, 4-point scale of severity	Psych. (emotional and cognitive) + one item on sleep	Self-report	<5 min to complete	Retro	Moderate-to-good reliability; sensitivity 59–100%, specificity 49–100%, PPV 73%	[62]
Kumar et al. (1984)	Maternal Adjustment and Maternal Attitudes scale	60 item questionnaire, 4-point scale of severity	Phys. and Psych. + marital relationship and attitudes toward sex/pregnancy/infant	Self-report	User friendly, <10 min to complete	Retro	Reliable, good criterion related validity	[63]

DASS: Depression anxiety stress scales; EPDS: Edinburgh postnatal depression scale; MDD: Menstrual dysphoric disorder; PDPI: Postpartum depression predictive inventory; PDSS: Postpartum depression screening scale; Phys: Physical; PPD: Postpartum depression; PPV: Positive predictive value; Psych: Psychological.

Tools

The Maternal Adjustment and Maternal Attitudes scale was developed specifically to look at patterns of change in maternal adjustment, the marital relationship, and attitudes toward the infant [63]. Thus, one of the main advantages of this 60-item questionnaire considers interpersonal functioning and changes in maternal adjustment as well as depressive symptomatology. However, it is not in mainstream use given the availability of other less time intensive tools like the ten-item Edinburgh Postnatal Depression Scale (EPDS).

The main advantage of the EPDS [62] is that it was designed specifically for a postpartum population with a focus on psychological symptoms to reduce false positive screens based on somatic symptoms. The EPDS has been translated into as many as 36 languages, with varying degrees of validity, and used throughout the world [64,65]. Furthermore, it has been found to be an acceptable mood screening tool for a nonpostpartum female population [66] as well as for postpartum adolescents [67] and fathers in the postpartum period [68]. Although thought to be a one-dimensional screening tool for depression, an anxiety subscale within the EPDS has been confirmed and validated [69]. This is an important point given the likelihood that anxiety is a key component of PPD [70]. A possible disadvantage of the EPDS is that it originally had two items of irritability in the initial version that were subsequently removed. However, irritability is a prominent symptom in the spectrum of female-specific mood disorders including ante- and PPD. The Born-Steiner Irritability Scale consists of a 14-item self-rating scale and a five-item observer scale to assess the core items of irritability and should be considered for use as a supplemental tool when irritability is a key component of the presentation [71].

The 42-item Depression Anxiety Stress Scale was originally designed to cover a full range of core anxiety and depressive symptoms with a high level of discrimination between the scales, making this a clear advantage of this tool [61]. It has been found to have excellent internal consistency and good convergent and discriminant validity. It was more recently tested on an inpatient postpartum unit and found to be a useful instrument with sound psychometric properties that is able to screen for both anxiety and depression in the postpartum population [72]. A potential disadvantage is the length of time to complete, with 42 items compared with some of the shorter ten item tools. The Modified Antenatal Screening Questionnaire was developed to screen women antenatally to identify individuals at higher risk for PPD. It was found to predict minor depression with good sensitivity and fair specificity but a main disadvantage is that it has not been used extensively throughout the literature [60].

The Postpartum Depression Predictive Inventory (PDPI) is a different type of screening tool that consists of a clinical checklist derived from a metaanalysis of the literature that determined the eight most common predictors of PPD, including prenatal depression, life stress, and lack of social support, among others [59]. This inventory was not intended to be a formal instrument with tested psychometric properties but rather a tool to initiate discussion between patient and health care provider in the prenatal and postpartum period. However, in a prospective cohort study, the PDPI was found to be an appropriate self-report checklist, completed by the patient with follow up discussion with the clinician [73].

Beck conducted a phenomenological study to better understand and describe the lived experience of PPD [74]. Eleven themes emerged that the participants shared including but not limited to unbearable loneliness, insecurity, and the loss of all positive emotions. The 35-item Postpartum Depression Screening Scale (PDSS) was developed using direct quotes from this phenomenological study and has proven to have very good psychometric properties including good construct and content validity [58]. The main advantage of this tool is that it was derived directly from patient informed data. In a comparison study of the PDSS, the EPDS and the Beck Depression Inventory II, the PDSS was able to detect high levels of sleep disturbance, anxiety, and cognitive impairment leading to additional correct diagnoses of PDD that were not identified with the other screening tools [75].

A more recent screening tool was adapted by a research team from the risk factors identified in Boyer's metaanalysis on predictive factors of PPD [57,76]. This 15-item tool called the Postpartum Adjustment Questionnaire is a risk assessment questionnaire that was found to have modest correlation with PDSS scores although its main disadvantage is that it has a relatively low positive predictive value of 36–38%. The authors state that the answer to a single question about depression during pregnancy had the equivalent sensitivity and predictive power to the total Postpartum Adjustment Questionnaire score. This finding could have implications for the development of future screening tools and may indicate that the same information can be learned from fewer questionnaire items.

The ten-item Postpartum Distress Measure was developed to capture additional features of the postpartum experience such as generalized anxiety and obsessive–compulsive symptoms [56]. A significant number of postpartum women will experience distressing obsessive–compulsive symptoms and the authors note that the screening methods to date have mainly focused on depressive symptomatology, thus overlooking other important components of postpartum distress [77]. With reasonable psychometric properties including good convergent and divergent validity, the main advantage of this screening tool is that it may be very helpful in identifying a broader range of postpartum distress. A potential disadvantage is the lack of items focusing on physical symptoms or social stressors in the postpartum period. The Perinatal Obsessive–Compulsive Scale was developed specifically to screen for obsessive–compulsive symptoms in the prenatal and postpartum period. It is a self-report questionnaire with strong psychometric properties that measures both symptom severity and how much reported symptoms interfere with daily life [78].

Direct comparison of tools

There have been a few studies that have directly compared female-specific screening tools. Hanusa et al. [79] compared the EPDS and the PDSS-short form with a general mood and anxiety screening tool, the Patient Health Questionnaire 9. Not surprisingly, they found that the EPDS and PDSS-short form were significantly more accurate at identifying women at risk of PPD and concluded that the EPDS was a particularly efficient and accurate way to identify high risk women, even when administered by phone. Hanna et al. [80] compared the PDPI, PDSS, and EPDS and found a statistically significant correlation between the total scores of the PDSS and EPDS meaning that both tools accurately identified positive cases of PPD. However, the authors note that the PDSS is a long questionnaire and time consuming to both complete and score.

General mood & anxiety scales

Various other mood and anxiety scales exist and have been well validated in the general population including the Profile of Mood States [81], the Center for Epidemiological Studies Depression scale [82,83], the Beck Depression Inventory [84,85] and the Zung self-rating scale [86] (see Table 3). The Hospital Anxiety and Depression Scale [87] was designed for use in a physically ill population and therefore does have some applicability to the postpartum population as it mostly excludes somatic and neurovegetative symptoms of depression. The above scales have been used to varying degrees in the peripartum literature; however, most include somatic symptoms that are considered to be normal physiological changes in the puerperium (e.g., sleep disturbance). As a result, the psychometric properties are limited and these tools may produce higher scores and false positives compared with instruments designed for a postpartum population.

Table 3.

Screening tools for general mood and anxiety.

Study (year)	Screening tool (general mood	Number of items and scale	Symptoms measured	Self-report or observer	Time to complete	Retrospective vs prospective	Psychometric properties	Ref.
Radloff (1977) and Eaton (2004) (revised)	CES-D scale and CES-DR (revised)	20 items, 6-point scale of severity with score range of 0–60	Phys. and Psych.	Self-report	5–10 min to complete	Retro	Good internal consistency, sensitivity 60% and specificity 92%; limited psychometric data in peripartum	[82,83]
Zigmond & Snaith (1983)	The Hospital Anxiety and Depression Scale	14 items with seven to assess depressed mood, 4-point scale of severity	Other than one question excludes neurovegetative symptoms (designed for use in physically ill population	Self-report	Easy to understand instructions, <5 min to complete	Retro	Reliable and valid measure of severity of symptoms	[87]
McNair et al. (1981)	The POMS	POMS standard has 65 items; depression subscale is 15 items, 5-point scale of severity	Phys. and Psych.	Self-report	Easy to understand items, tool can be completed <10 min	Retro and current	Good predictive and construct validity; high level of internal consistency and test-retest reliability	[81]

CES-D: Center for epidemiologic studies depression; Phys: Physical; POMS: Profile of mood states; Psych: Psychological.

While screening in the postpartum period is common, there is little evidence to support routine prenatal screening due to low predictive values of available tools [88]. Antenatal screening excludes important postnatal events that may play a significant role in the development of psychopathology. Furthermore, it should be noted that the tools reviewed above are not diagnostic instruments and must be used in conjunction with a psychiatric assessment to diagnosis an ante- or PPD [89].

Menopause

Diagnostic information

The menopausal transition is a natural stage of life for women and is frequently accompanied by physical and emotional changes. These changes can include vasomotor symptoms, sleep and mood disturbance, and a change in sexual function. Large scale studies including the Study of Women Across the Nation (n = 3302) [90] and the Seattle Midlife Women's Health Study (n = 508) [91] have identified the menopausal transition as a high risk period for some women to develop depressive symptoms. Therefore, it is important to have screening tools available in primary care and specialty clinics so that women can be screened for both physical and psychological symptoms that may negatively affect their quality of life. While menopause itself is not a psychiatric condition, the transition can be accompanied with biological and psychosocial changes that can precipitate psychiatric illness. Assessing for depressive symptomatology and anxiety is important and menopause-specific screening tools should attempt to incorporate these psychological symptoms. Table 4 highlights some of the available screening tools for symptoms linked to the menopausal transition.

Table 4.

Screening tools for perimenopause and postmenopause.

Study (year)	Screening tool	Number of items and scale	Symptoms measured	Self-reportor observer	Time to complete	Retrospective vs prospective	Psychometric properties	Ref.
Pimenta et al. (2012)	MSSI-38	38 items, 12 sets of symptoms, frequency and severity of symptoms measured on 5-point scale	Psych. and Phys. including vasomotor	Self-report	~5 min to complete	Retro	Good construct/criterion/external validity, good reliability and sensitivity	[92]
Im (2006)	The Midlife Women's Symptom Index (MSI)	88 dichotomous yes/no symptoms, if yes, rank on 5-point severity scale	Psych. and Phys. including vasomotor	Self-report	Lengthy questionnaire	Retro	Good internal consistency reliability, convergent/construct validity	[93]
Hauser et al. (1994) (I) and Potthoff et al. (2000)	MRS I and II	11 symptoms, 5-point scale of severity (anxiety added to MRS II)	Psych., somato-vegetative and urogenital	Self-report	User friendly/easy to understand	Current	High reliability/validated	[94,95]
Hilditch et al. (1996)	Menopause-Specific Quality of Life	30 item questionnaire covering four domains, 7-point scale of severity + quality of life question	Psych. and Phys. including vasomotor/sexual	Self-report	Average of 7 min to complete	Retro	Good reliability and face/content validity	[96]
Avis et al. (1993)	Everyday Complaint Checklist	16 symptoms, menopausal symptoms, yes/no response	Psych. and Phys. including vasomotor	Self-report	Easy to complete, user friendly	Retro	Used in cross-cultural comparisons	[97]
Hunter (1992)	WHQ	36 items within nine domains, 4-point scale of severity	Psych. and Phys.	Self-report	Easy to complete, 5 min	Retro and current	High internal reliability; good concurrent validity and sensitive to detecting change	[98]
Greene (1976)	Greene Climacteric Scale	21 symptoms, 4-point scale of severity	Psych., somatic and vasomotor	Self-report	<5 min to complete	Current	Good reliability, content/construct validity	[99]
Neugarten & Kraines (1965)	The Menopausal Symptom Checklist	28 items, 5-point scale of severity	Psych, Psychosomatic and somatic	Self-report	<5 min to complete	Retro and current	Good reliability	[100]
Kupperman et al. (1953)	Kupperman Menopausal Index	11 symptoms, 4-point scale of severity	Psych. and Phys. including vasomotor	Self-report/rated by physician	Time intensive, index needs to be calculated	Retro and current	Satisfactory test–retest reliability	[101]

MRS: Menopause rating scale; MSI: Midlife women's symptom index; MSSI: Menopause symptom severity inventory; Phys: Physical; Psych: Psychological; WHQ: Women's health questionnaire.

Tools

The first questionnaire to identify common symptoms during the perimenopausal transition was the Blatt–Kupperman Index, later modified to the 11-item Kupperman Menopausal Index [101–102]. This index was a combination of self-report and physician ratings and therefore relied on the physician's summary of the severity of climacteric complaints. The main advantage of this tool is that it was a necessary and very useful first step to identify symptoms of menopause, however its main disadvantages are that had limited psychometric properties and neglected important sexual and urogenital symptoms such as decreased libido and vaginal dryness [103]. The 28-item Menopause Symptom Checklist (MSC) was developed mainly for use within menopause research and was a more comprehensive extension of the Kupperman Menopausal Index [100]. Neither one of these tools is used extensively in research or clinical settings today; however, the symptoms within the MSC were used to derive the Greene Climacteric Scale (GCS) [99].

The GCS is a screening tool that consists of 21 items that include psychological, somatic, and vasomotor symptoms. The GCS has been extensively validated with good content and construct validity and remains a valuable clinical and research tool with some of its advantages being that it is easily administered and scored. Similarly, the 36-item Women's Health Questionnaire (WHQ) has been helpful in hormone replacement and psychological intervention clinical trials as it has high internal reliability and good concurrent validity and is sensitive to change over time [98,104]. Furthermore, a main advantage to this screening tool is that it includes questions specific to sexual interest and satisfaction, acknowledging the important changes to sexual functioning that occur with menopause.

The Menopause-Specific Quality of Life [96] is a 30-item retrospective tool that emphasizes the impact that menopausal symptoms have on quality of life. It has become increasingly recognized that assessment of quality of life should be an integral part of any attempt to understand the impact of symptoms on day-to-day life. Assessment of quality of life should consider physical, psychological, and social changes and the Menopause-Specific Quality of Life includes these domains within the questionnaire. Furthermore, with good reliability and face and content validity, a main advantage of this tool is that it is helpful in determining changes to quality of life over time, which can be particularly useful in clinical trials.

The Menopause Rating Scale (MRS) is an 11-item clinically practical screening tool that is completed and scored by the individual, as opposed to the clinician [94,95]. While previous tools such as the Kupperman Menopausal Index focused on symptom relief assessed by the physician, an advantage of the MRS is that it allows a female to assess her own perceived symptoms. It includes psychological, somatic, and urogenital symptom domains and has high reliability and applicability [105]. The MRS has gone through an extensive translation process and is now available in many languages including English, Spanish, and Portuguese [106].

The Midlife Women's Symptom Index (MSI) was developed in response to the lack of an instrument that captured the menopausal symptom experience for multiethnic groups of midlife women [93]. Although its main disadvantage is that it is a fairly lengthy questionnaire covering 88 symptoms, it has good psychometric properties with good internal consistency reliability and convergent and construct validity. The main advantage of this tool is that the broad range of symptoms may lead to a better chance of finding ethnic differences in symptom presentation. The MSI may be of use from a clinical perspective when dealing with multicultural populations, as it is able to identify ethnic differences in a greater number of menopausal symptoms compared with older tools such as the MSC. Moreover, the reliability and validity of this tool has been supported for both pen-and-pencil and online formats [107]. The MSI and the Everyday Complaint Checklist [97] have been used in cross-cultural comparisons. Ethnic and cultural differences exist in the symptoms experienced during the menopausal transition with Asian women having the lowest total number of reported symptoms [108]. The Everyday Complaint Checklist has been modified and used in part within large scale studies, including the Study of Women Across the Nation study. It has proven to be a practicable tool as it is not restricted to items with an association with menopause and can be embedded within other health related checklists.

The Menopause Symptom Severity Inventory (MSSI-38) [92] is a 38-item questionnaire that assesses the frequency and intensity of symptoms, acknowledging that these are both important components to determine symptom severity. With good psychometric properties including construct, criterion, and external validity, it has potential to be a valuable clinical tool, and the only noted disadvantage is that it likely requires further validation across cultures given that it was originally studied in a Portuguese population.

As with the premenstrual population, the VAS can be applied to the perimenopausal and postmenopausal population as a practical tool that is sensitive to changes in symptom severity over time [109]. The items assessed by the Menopause VAS (VMAS) were generated from the CGS and have been further subdivided into the VMAS-P for physical symptoms and the VMAS-M for mood symptoms. Preliminary results show that the VMAS is able to catch clinically subtle variations and that its subscales are significantly and positively correlated with the corresponding GCS subscale.

Conclusion

The development of screening tools has helped to shape the diagnostic framework for female-specific psychiatric conditions like PMDD, and to better understand psychiatric symptoms and/or illness that may occur as related to a reproductive stage such as menopause. Consensus groups, such as the ISPMD, can be particularly helpful in providing a unified approach to the recommendations of screening tools, among other elements of patient care. As such, the ISPMD suggests use of the DRSP as an appropriate quantification technique for the diagnosis of PMDD, and suggests that retrospective tools such as the PSST should be used to avoid delaying entry into treatment. Despite this, throughout the literature, there is still no clear consensus as to which screening tool is best for female-specific psychiatry illness or psychiatric symptoms and/or illness that may occur as related to a reproductive stage such as menopause.

One reason for the lack of consensus on a gold standard screening tool despite the significant number of screening tools that exist likely relates to the evolution of an improved conceptualization of female-specific psychiatric illness over time. Screening tools have changed over time as our understanding of the illnesses have changed as is evident when considering the historical timeline of many of the tools highlighted in this paper. As a result, this has made certain tools less relevant if they do not align with current diagnostic criteria as per the DSM. Of interest, some tools have stood the test of time, including scales such as the EPDS and GCS, both developed over 25 years ago but created for use in a specific population. In addition, with increased recognition of female-specific psychiatric illness or symptomatology, the patient volume has increased in many clinical settings. Therefore, more time efficient and user-friendly tools have likely been preferred. Furthermore, there are historical and geographical patterns of use related to where certain screening tools were developed, if they have been available in multiple languages, and the integrity of the psychometric properties.

For more thorough evaluation, health care practitioners should consider structured interviews that address the assessment needs of women. The Composite International Diagnostic Interview - Venus (CIDI-V) is the first structured clinical interview that includes specific questions related to menstrual, perinatal, and hormone therapy history [110]. It is another tool for clinician's to be aware of that prompts consideration of female-specific conditions and provides links to many of the screening tools outlined in this review, including the PSST, Perinatal Obsessive–Compulsive Scale, EPDS, GCS and VAS. Although this structured interview was developed for use in epidemiological studies, it is a valuable tool for clinical practice.

Future perspective

The benefits of international consistency in the use of screening tools for female-specific psychiatric illness include having a universal language that primary care clinicians and specialists alike can understand and use for accurate communication regarding patients. It allows for reliability in research and ensures that we are screening patients for diagnoses as they appear in standardized diagnostic manuals, such as the DSM. The future of female-specific screening tools should include elimination of tools that are overly burdensome or lengthy for both the patient and clinician. Furthermore, all attempts should be made to use tools that align with diagnostic criteria, should those criteria exist. International consensus gatherings can be very helpful to analyze psychometric properties and compare the usability and practicality of tools. In addition, further research that involves direct comparisons of various screening tools will be particularly helpful in highlighting which tools are most useful in a clinical or research setting. We anticipate that as our understanding of female-specific psychopathology continues to evolve, so will the screening tools used to detect illness.

Financial & competing interests disclosure

M Steiner has received research grants/funding from Canadian Institutes of Health Research, Ontario Mental Health Foundation, Natural Sciences and Engineering Research Council of Canada, Society for Women's Health Research, Pfizer, Eli Lilly, and Lundbeck; has served as a consultant for AstraZeneca, Bayer Canada, Servier, and Lundbeck; and has received honoraria from the Society for Women's Health Research and AstraZeneca. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Executive summary

The development of screening tools has helped guide our understanding of female-specific psychiatric illness and to better understand psychiatric symptoms and/or illness that may occur as related to a reproductive stage such as menopause.

Both prospective and retrospective screening tools have been developed for premenstrual dysphoric disorder. Conclusions from the International Society for Premenstrual Disorders support the use of the Daily Record of Severity of Symptoms as the most established and widely used prospective tool.

Although retrospective tools to screen for premenstrual dysphoric disorder are subject to recall bias, the International Society for Premenstrual Disorder concludes that the Premenstrual Symptoms Screening Tool is potentially useful in this context. Furthermore, it is the only tool to be adapted for use as a valid measure of premenstrual symptoms in an adolescent population.

Screening for postpartum depression (PPD) is ideal after 2 weeks postpartum given the somatic changes immediately following childbirth and the presence of transient baby blues.

There are a number of good screening tools for PPD including the Edinburgh Postnatal Depression Scale, which is used widely both in clinical and research settings and has shown to be particularly efficient and accurate when compared with other PPD tools.

Although menopause is a natural stage of life for women, this transition can be a high-risk time for some women to develop depression. Screening tools need to capture both physical and psychological changes that occur during this transition.

The Green Climacteric Scale is an extensively validated screening tool that considers psychological, somatic, and vasomotor symptoms.

For more thorough evaluation, clinicians can consider use of the Composite International Diagnostic Interview – Venus, a structured clinical interview with a focus on female-specific psychopathology.

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