Matrix Framework of PERINATAL DEPRESSION and RELATED DISORDERS

Aim of the framework:

· Provide guidelines on the core skills required by health professionals predominantly involved in screening women for depression and related disorders in the perinatal period:

- Specifically skills in using the Edinburgh Postnatal Depression Scale (EPDS) and a psychosocial assessment, and, as appropriate, conducting or referring on for a comprehensive assessment and diagnosis for women and their families.

· Provide different levels of skills for the management of women and their families who are experiencing depression and related disorders in the perinatal period:

- Including awareness, understanding management from distress through to disorders and treatment options.

· Ensure uniform standards of comprehensive clinical care informed by clinical practice guidelines.

- With a focus on:

· Prevention through early intervention, and treatment

· Optimizing the infant’s environment.

· Inform organisations currently providing or developing professional development courses.

· Promote best practice across Australia for perinatal mental health training, informed by clinical practice guidelines.

· The framework can be used to: Systemise existing training to see what is already available and where the gaps lie.

This matrix aims to define different levels of: training, content areas to be covered, and which professionals could be the target of training.

SKILLS TRAINING

	Awareness/Health Promotion/ Prevention	Basic Skills		Basic Skills Plus		Intermediate Skills		Advanced Assessment and Intervention Modules
Who for	· General community · Parents · Significant others · Health professionals · All Perinatal health professionals · Indigenous health professionals · General health workers · Childcare workers · NGOs · Health promotion/ Health Education Officers	· Midwives · M&CHC workers · GPs · Allied health · All Perinatal health professionals · Indigenous health professionals · General health workers · Childcare workers · Obstetricians/ Paediatricians		This module is designed for health professionals who have completed the ‘Basic’ Skills Online Training Package and are thus equipped to screen perinatal women for depression and anxiety. It is specifically targeted at health professionals who want to support women with mild levels of perinatal depression and/or anxiety; and is also helpful for those who will have some continued contact with the women across the perinatal period even if they are not the primary professional managing the depressive episode. Thus, they will need some basic understanding of how to effectively work and support a woman who is experiencing mild depressive and anxiety symptoms at the present time, or who has been referred to an appropriate health professional for further assessment and treatment. This may include: · Midwives · Child and Family Health Nurses/Maternal and Child Health Nurses · Social Workers · GPs · Obstetricians		“Intermediate” skills are relevant to health professionals who will be facilitating the treatment of mild to moderate anxiety and depression symptoms. For more severe or complex cases, specialist providers may be referred to and can be considered to have ‘advanced’ skills. The skills below can be developed through didactic information, workshops as well as case presentations but importantly need to be consolidated through supervised practice. Below is an outline of skills considered to fall in the “intermediate” category and are designed for various professional groups who have sufficient background (e.g. counselling skills) to manage mild and moderate mental health problems. This may include: · GPs · Child and Family Health Nurses, M&CHNs · Psychologists · Mental Health nurses · Midwives (with sufficient background/ specialist training) · Social Workers, Occupational Therapists and other Allied Health professionals with relevant mental health expertise · Health workers with mental health expertise e.g. indigenous · Mental Health Clinicians		This level of training is designed for health professionals who already have extensive mental health training and are thus assumed to already have the knowledge covered in the Basic Skills Online Training Package, as well as the skills outlined in the Basic Plus and Intermediate Skills Section. This section provides an overview of the essential skills that health professionals with a mental health background ought to have, specific to the perinatal field. It is specifically targeted at health professionals who will be actively treating perinatal depression and/or anxiety, while also managing other co-morbid mental health issues and psychosocial factors that may be present. This may include: · Psychiatrists · Psychologists · GPs · Mental Health nurses · Mental Health Clinicians · Enhanced MCH workers · Appropriate professional staff in Parenting Centres · Appropriate professional staff in Residential Units · Social Workers, Occupational Therapists and other Allied Health professionals with relevant mental health expertise.
Learning Objectives	Overall Objective: To promote and educate women in the perinatal period, their families, other health professionals and the wider community on perinatal mental health, the issues and factors that contribute to both positive and negative outcomes; how to best support families during the perinatal period, and the importance of decreasing stigma associated with perinatal depression and/or anxiety. In summary, some of the key objectives include: · Raising community awareness of the high prevalence rates of antenatal and postnatal depression and anxiety in the perinatal period and the associated consequences. · Understanding: - What perinatal mental health is, including the types and prevalence of perinatal mental health disorders, as well as the most common signs and symptoms - The risk factors that contribute to perinatal mental health disorders - The impact of untreated PND and anxiety on women, infants, partners and their family - Perinatal mental health in men - The protective factors that can facilitate positive wellbeing during the perinatal period and/or improve recovery - The importance of seeking help early · Understanding the importance of screening and assessment of perinatal mental health disorders; and applying consistent screening and assessment practices. · Understanding where to access support & help for women and their families, including information on appropriate: - Information and support lines - Educational and support materials, including how to provide appropriate reassurance and information - Support groups - Treatment options - Providers · Accessing and understanding the results of perinatal mental health research (including results from surveys and focus groups) and using the information to create and promote community awareness campaigns. · Recognising the importance of reducing stigma associated with mental health issues, both at the individual and community level and promoting positive practices regarding this issue (i.e. increasing community awareness campaigns, adapting assessment processes so that screening for perinatal depression and anxiety is seen as ‘the norm’, rather than an ‘unusual’ practice).	· To be aware of the key features and prevalence rates of the most common perinatal mental health disorders; knowing how to differentiate between the various disorders; and understanding the impact on infant health and wellbeing. · Understand the background, purpose and importance of screening, its application and limitations · Implement screening (using the EPDS) · Understand the importance of conducting a broader psychosocial assessment, including risk assessment, for comprehensive clinical care · Interpret the EPDS scores and integrate with other assessment material as well as communicate these results to women using basic counselling skills and client centred communication · Have awareness of evidence-based interventions for anxiety, depression and related disorders in the perinatal period. · Understand the importance of knowing where and how to refer to relevant referral pathways and existing treatments, interventions and support · Have awareness of early intervention and management strategies of acute situations · Ensure knowledge of relevant legislation · Understand professional boundaries in relation to distress and disorders in the perinatal period · Understand scope of practice · Have knowledge of Clinical Practice Guidelines for mental health disorders in the perinatal period.		Knowledge and skills covered in the “basic skills” are pre-requisites. This module aims to provide: · Knowledge on how to manage women with mild depressive and anxiety symptoms during routine care consultations who either do not require onward referral or are waiting for treatment, through the use of counselling skills that can promote a positive and supportive relationship with the woman (e.g. active listening, empathy, problem solving), with a particular focus on how to integrate these skills in discussions regarding the woman’s mental health and overall wellbeing. · Knowledge of perinatal mental health disorders and information particularly relevant to the subgroup of women who initially present with mild depression and anxiety – i.e. what are some key indicators that a woman may require some additional support or that her symptoms are escalating? · How to encourage women to follow-up with any referrals made to other mental health professionals and engage other services · The importance of managing one’s own emotions and reactions when addressing mental health issues and psychosocial risk factors with women.		Knowledge and skills described in the “basic skills” section of the matrix is a pre-requisite. This module aims to provide: · Knowledge of how to conduct in-depth assessment of perinatal mental health difficulties and develop a detailed management plan · Skills in management of mild-moderate perinatal mental health disorders · Comprehensive knowledge of pathways to care · A basic knowledge of therapeutic interventions for mother, infant and father and significant other/partner · Understanding the importance and role of supervision for health professionals.		Knowledge and core competencies covered in the Basic and Intermediate skills are assumed knowledge. This section aims to provide: · Further training in specialist management of moderate to severe perinatal mental health disorders · Comprehensive knowledge of: - evidence based treatment options for moderate/ severe perinatal mental health disorders - management of complex cases including infant and partner issues. Advanced Assessment and Intervention Modules Managing moderate to severe perinatal mental health disorders and in depth treatments. Choice of Modules: (It is likely that health professionals from various backgrounds, will be more familiar with some of the following areas/topics than others; thus rather than a ‘complete package’ the following overview can be used as a guide which clinicians can use to select the areas most relevant to their specific line of work and current gaps in knowledge base).
Content	· What is perinatal mental health? · The types of perinatal mental health disorders · The prevalence of perinatal mental health disorders · Signs & symptoms of perinatal mental health disorders · Normalisation of negative thoughts · Risk factors that contribute to perinatal mental health disorders · Awareness about screening and assessment of perinatal mental health disorders · Impact of untreated PND and anxiety on women, infants and their family · How to support/help, including providing information on appropriate: - Infolines - Educational and support materials - Support groups · Referrals to Primary Health Care (e.g. to GPs) · Using results of surveys to create community awareness campaigns · Appropriate reassurance / info about consequences of disclosure · Psychoeducation	1) Overview of ‘Perinatal’ Mental Health · Baby blues · Antenatal Depression (symptoms and prevalence) · Postnatal Depression · Antenatal and Postnatal Anxiety (the importance of anxiety as a target for support) · Related Disorders: Psychoses, Personality Disorders · Understanding risk factors of depression and anxiety · Short and longer-term impact of perinatal disorders on mothers, fathers and babies (including attachment and effects on both short and long term development of the child) 2) Context and background to the National Perinatal Depression Initiative (NPDI) · Prevalence of perinatal disorders and its impact · Difficulties in help-seeking beliefs and behaviours of women and their families · Why screen for depression? - Purpose of screening · Psychological and social assessment for comprehensive clinical care – understanding the woman’s current and past context including risk factors. · Brief historical milestones (National Postnatal Depression Program, NHMRC guidelines, national implementation). 3) How to talk to women about screening and further assessment · Basic client centred communication skills and motivational interviewing skills to engage women · How to raise screening with the EPDS · Focussing on the whole woman and her life situation (broader psychosocial assessment) · Integrating assessment in routine consultations · Exploring women’s responses to screening (include consumer perspective – i.e. “What was it like being screened?”) · 4) Depression screening using the Edinburgh Postnatal Depression Scale (EPDS) · What is the EPDS? What does is measure? What doesn’t it measure? (include a copy of EPDS) · Limitations · Acceptability · EPDS as current best practice Tool - (beyondblue/NHMRC guidelines and recommendations) · EPDS in other languages		Supportive Care: · Content covered under Basic Skills module is assumed Screening, Basic Psychosocial Assessment, understanding onward referral and Pathways to Care. 1) Basic management skills · Counselling Skills (active listening, empathy, reflecting; problem solving) to manage mild depression and anxiety and support women who may be waiting for treatment. 2) Comorbid and differential diagnoses · Knowledge of perinatal mental health disorders, with a particular focus on understanding signs and symptoms suggesting increasing severity of mood disorders, differential diagnoses, and the co-morbid issues that are often present (e.g. other mental health disorders; substance abuse, interpersonal and psychosocial difficulties). 3) How to encourage women to follow-up with any referrals made to other mental health professionals and engage other services · Introduction to Motivational Interviewing Skills - how can we encourage women to engage with services/ health professionals if they are reluctant, particularly in the presence of a positive EPDS 4) The importance of managing one’s own emotions · Dealing with one’s own reactions when addressing mental health issues and psychosocial risk factors with women; seeking support when needed.		1) Didactic Content: [to be supported by supervision] Managing mild to moderate perinatal mental health disorders · Content covered under Basic Skills module is assumed screening, basic psychosocial assessment, understanding onward referral and Pathways to Care 2) Assessment · Introduction to in depth psychosocial assessment for mothers, fathers, partners, infants, couples, families and significant others - see Attachment 1 example of some competencies expected to be achieved. 3) Diagnosis · How to differentiate between different mental health problems such as adjustment disorder, depressive episodes and related disorders including co-morbidity · How to identify aetiological factors important for management focus (formulation skills) 4) Treatment · Introduction to treatment, including: - Motivational interviewing - Consolidating Counselling skills - Psychological interventions (Individual & Group skills) - Managing family violence substance abuse and other psychosocial difficulties - Medication · Introduction to treatment options for: - Women - Parent-Infant relationship - Couples - Fathers/partners/significant others		1) Overview [to be supported by supervision] · Content covered under Basic, Basic Plus & Intermediate Skills modules 2) Assessment & Diagnosis · Specialised assessment for mothers, fathers, infants, also covering: - Parent-Infant Relationships – Assessing if the parent-infant relationship has been adversely affected by perinatal depression and/or anxiety. e.g. observing and assessing the interactions between parent and infant; how do you know if interaction difficulties are present? How do you assess a mother’s responsiveness to her baby’s cues and make a clinical judgement if appropriate or not? How do you assess whether issues such as abuse or neglect are present? - Co-morbidity – Advanced knowledge of the various co-morbid issues that may be present when a mother is severely depressed/anxious including other mental health disorders as well as psychosocial factors (e.g. drug & alcohol issues; relationship difficulties; DV; financial/housing issues; infant sleep/settling/feeding difficulties, personality disorders, trauma, refugee, migration stress etc). · How to diagnose moderate to severe perinatal mental health disorders – Knowledge of what needs to be covered in a diagnostic interview, including administration of standardised measures, in order for a formal diagnosis to be made. 3) Treatment/ Referrals/ Management · Specialised treatment electives/ units available for: - Medication – Knowledge of common medications prescribed, typical doses, side-effects etc. When is medication warranted and who is responsible for managing this side of treatment? What do you need to know either as a) the health professional prescribing the medication or b) as a non-medical health professional that is seeing a woman currently on medication? - Specialised psychological treatments for ante and postnatal depression in women, including inpatient care – Detailed training in specialised psychological treatments for perinatal depression and anxiety (e.g. CBT; IPT). Understanding what the local inpatient care units are and when a referral to a residential/inpatient unit is warranted; and who is responsible for managing the mother once discharged, continuity of care and multidisciplinary care planning, working with area mental health services; non voluntary care.
Content		5) How to administer The EPDS and how to score it · Recap how to introduce the EPDS to women; Importance of basic communication in regards to introducing screening tools · Instructions for completion · When to administer (single time versus repeated measures) · What do scores mean? · Key cut-off scores (threshold ≥13) · Thoughts of self harm e.g. Question 10 · Having a conversation with women about their responses on the EPDS · Importance of basic client centred communication/counselling skills in regards to feedback around screening and assessment results with women · beyondblue fact sheet for further information 6) Further Assessment (if needed) · Risk assessment - Safety plan - Knowledge of appropriate Referral Pathway for crisis management (internal/external) · Psychosocial assessment - Understanding the psychosocial context and tools that can be administered e.g. PRAM · Integrating EPDS scores and other assessment material and formulating a management plan - Deciding on the need for diagnostic assessment - Recap: Importance of basic client centred communication/counselling 7) Awareness of appropriate evidence-based treatment options. · Treatment options for: Women, Couples, Fathers, Partners, Significant Others · Awareness of parent-infant interventions with evidence base and relevant theories (e.g. attachment, developmental) · Medication · Individual and Group Treatment Models · Self-care strategies						- Fathers – Understanding and recognising the occurrence of depression in new fathers; appropriate treatment options for fathers with depression and/or anxiety during the perinatal period. - Partners – Understanding the issues present for partners of women with perinatal depression and/or anxiety; and available support services. - Couples – Knowledge of and/or training in appropriate treatment options and services available for Couples – i.e. Couples Counselling with a focus on the perinatal period - Significant others – Knowledge of and/or training in the issues; treatment options and support services relevant for significant others - e.g. if a woman’s mother has a significant role in providing practical/emotional support to her daughter who is experiencing PND/Anxiety, it is important to be aware of the issues and difficulties she may be experiencing herself and what support may be beneficial for her. - Infants - Understanding what Parent-Infant Therapy is, when it is indicated and who can provide this treatment effectively and appropriately. Knowledge of treatment options and support services available for vulnerable infants and families (e.g. Circle of Security; HUGS). - Group treatments – Knowledge and/or training in group treatment programs available and the associated benefits for severely depressed/anxious mothers. Knowledge about key factors that may be counter-productive in group treatment (i.e. if a women has recently been discharged from an inpatient mother-baby service and is still severely anxious, would a referral to a group program be appropriate? Should group therapy occur at the same time as other therapies? - Motivational interviewing – Knowledge about skills and strategies that can be useful in encouraging women to engage in treatment and access support services, especially when severely depressed. - Co-morbidity – Managing co-morbid issues that may be present when a woman presents as severely depressed/anxious (e.g. drug & alcohol issues; DV; financial/housing issues; infant sleep/settling/feeding difficulties; refugee status etc). Providing low and high intensity care. Working with other agencies to provide a comprehensive management plan. Case management.
Content		8) Pathways to care: collaborative practice · Importance of Multidisciplinary Care/Collaboration between service providers · Knowledge of Local Referral pathways for mild, moderate and severe/complex mental health disorders (including mental Health Care Plans) · Knowledge of Local Referral pathways for women and families at different levels of risk · Awareness of local community support including child care options 9) Cultural & Familial Diversity: Adapting screening, assessment and referral pathways · Special needs groups i.e. CALD and aboriginal community · EPDS translations · Using an interpreter
Ethics, Duty of Care and Supervised Practice	Not applicable	Ethics, Duty of Care and Supervised Practice ·It is expected that all health professionals will conduct themselves in a manner that promotes and adheres to the professional code of ethics which is relevant to one’s own service provider group, and will be accountable for decisions made. · It is also expected that issues regarding appropriate supervised practice, including access to ongoing support and supervision for health professionals across all skill levels will be an integral part of each health professionals’ clinical practice.
		Duty of Care and Supervision: · Professional responsibilities and duty of care principles related to the screening and assessment process – e.g. ensuring that there is adequate time to complete the screening and assessment process with women; recognising the importance of having and building upon relevant skills, knowledge of referral pathways both within the organisation [depending on context] as well as externally within the community). · Front line health professionals will need to have the opportunity to access professional support for issues associated with the screening process, including time to discuss challenging clients and additional supports that may be required.	Duty of Care and Supervision: · Knowing how, where and when to refer elsewhere (i.e. knowing what to do when a woman who initially presented with only mild depressive and anxiety symptoms now appears to be experiencing moderate/severe symptoms and/or other difficulties). · Knowing how, where and where to access support for one’s self (i.e. recognising the importance and knowing how to manage your own emotions and ‘separate’ yourself from your client and their presenting problems. Being aware of the issues you need to be mindful of and what to do if you notice yourself becoming affected by the woman’s presentation and/or circumstances – e.g. you too have previously experienced domestic violence, numerous miscarriages etc. · As health professionals will be engaging in some management or ‘holding’ there is likely to be a need for increased access to professional support.		Duty of Care and Supervision: · Knowing how and where to refer elsewhere when the scope of the clients’ issues are outside of one’s skill range (this will vary depending on skill set of each health professional & the nature and severity of the diagnosed disorder and associated issues) – e.g. knowing what to do if a woman’s mental health has deteriorated even if she is already engaged in treatment with you – knowing what other referral pathways may be appropriate and necessary to refer to. · Health professionals who are actively involved in the management and treatment process, will once again require increased support for issues pertaining to the management of mental health issues, and ought to have access to appropriate supervision – e.g. access to individual or peer supervision that allows the health professionals to discuss treatment and management issues of mild or moderate depression and anxiety and associated challenges.		Duty of Care and Supervision: · Knowing how, where and when to refer elsewhere when the scope of the clients’ issues are outside of one’s skill range -this will once again vary depending on the skill set of each health professional & the nature and severity of the disorder being treated and other complicating factors that may be present. – e.g. what do you do when a woman who initially presented with severe depression and anxiety but low risk of harming herself or others is now reporting increased suicidal ideation and/or has attempted to harm herself and/or her baby? · Health professionals treating severe and complex mental health issues will require increased access to ongoing and specialised supervision. It is critical that some form of appropriate supervision is always accessible, is there is an increased risk of working with escalating circumstances and issues relating to safety. · It is also essential that when learning specialised treatments, e.g. parent-infant specialist therapies, information and skills related to these are initially consolidated through regular supervision. Continued peer supervision is encouraged whenever specialist treatments are being implemented, regardless of experience.
How to deliver*	· Broad/specific campaigns (beyondblue) · Ambassadors · blueVoices · Website · Media · beyondblue Resources/fact sheets · Conferences/seminars · DVDs · Websites	· Specialised training packages · Online · Face to face · Accreditation · Curriculum (under development) · DVDs · Case Presentations · Cross agency delivery/ local network workshops			· Manualised treatments for face-to-face work · Online treatments · Self-help books		· Workshops/Multi-disciplinary Group

* Also- Other methods as required