Perinatal Mental Health Guideline: Summary for general practitioners
Screening for depression and anxiety and assessing psychosocial risk factors are integral parts of antenatal and postnatal care that should be offered to all women. It is also important that women receive psychosocial support and evidence-based advice on psychosocial treatments and medications for mental health conditions.
Screening and assessment
Before screening and assessment
- Make sure that appropriate follow-up care is available, if required, including for situations where there are concerns for the safety of the woman, the baby or other children in the woman’s care.
- Identify health professionals from whom you can seek advice, clinical supervision or support regarding mental health care in the perinatal period.
Providing woman-centred care
- Give all women information about the risk factors that increase the likelihood of experiencing a mental health condition. This can be accessed through the free Ready to COPe Guide (see Resources section below).
- Explain that depression and anxiety are common in pregnancy and that screening and assessment is part of usual care. Results will remain confidential, unless there is a perceived risk of harm to the woman or her baby, as there is a duty of care for this to be communicated.
- Consider who should be present so that the woman feels safe during screening and assessment. While the presence of significant other(s) is often helpful, be sensitive about whether it is appropriate to continue with psychosocial assessment while they are in the room.
- Only screen for family violence when alone with the woman.
Screening for depression and anxiety
- Why — In Australia, one in ten women experience depression during pregnancy and one in six during the first postnatal year. Perinatal anxiety is experienced by around one in five women in late pregnancy and one in six in the early postnatal period. Anxiety disorders frequently occur with depression.
- When — Antenatal screening should be conducted as early as practical in pregnancy and at least once later in pregnancy. Postnatal screening should be conducted at 6-12 weeks after birth and at least once in the first postnatal year. Repeat screening at at any time if clinically indicated.
- How — The Edinburgh Postnatal Depression Scale (EPDS) is the recommended tool for screening for depression. It is usually completed by the woman, preferably without consulting others. The EPDS may also be administered verbally. As part of clinical assessment, use anxiety items from existing screening tools (e.g. EPDS Items 3, 4 and 5, Depression Anxiety Stress Scale (DASS) anxiety items and K-10 Items 2, 3, 5 and 6) and relevant items in structured psychosocial assessment tools (e.g. the Antenatal (Psychosocial) Risk Questionnaire (ANRQ)).
- Cultural considerations — When screening Aboriginal and Torres Strait Islander women, consider use of translations and adaptations of the EPDS developed in consultation with women from Aboriginal communities. If use of the EPDS is considered inappropriate, involve Aboriginal health workers where possible. For migrant and refugee women, use appropriately translated versions of the EPDS with culturally relevant cut-off scores.
- Responding to EPDS scores
- Arrange further assessment of a woman with an EPDS total score of 13 or more.
- For a woman with an EPDS score of 10 to 12, monitor and repeat the EPDS in 4–6 weeks.
- For a woman with a positive score on Question 10 of the EPDS, undertake or arrange immediate further assessment and, if there is any disclosure of suicidal thoughts, take urgent action in accordance with local protocol/policy.
Assessing psychosocial factors that affect mental health
- Why — Psychosocial assessment allows identification of circumstances (past and present) that affect a woman’s mental health. The number and type of factors identified influences the care pathway.
- When — Undertake psychosocial assessment in conjunction with screening for depression and anxiety.
- How — Psychosocial assessment can be undertaken as part of the clinical interview and/or using a structured psychosocial assessment tool. If using a tool to assess psychosocial risk, administer the ANRQ together with questions exploring the presence of family violence and drug and alcohol use.
- Cultural considerations — Consider a more conversational approach when assessing psychosocial risk among Aboriginal and Torres Strait Islander or migrant and refugee women, with involvement of Aboriginal and Torres Strait Islander health workers or multicultural health workers, where possible. Consider psychosocial risk factors that may be relevant to specific groups (e.g. lack of secure housing, experience of trauma).
- Responding to assessment — Discuss with the woman the possible impact of psychosocial risk factors (she has endorsed) on her mental health and provide information about available assistance.
Administration of screening tools
- Screening and assessment can be undertaken using digital and or pen-and-paper approaches (see Resources section below).
- When claiming Medicare Benefits Schedule (MBS) items, use of the EPDS and ANRQ is recommended. Screening and assessment needs to be offered and evidence of this must be documented.
Prevention and treatment of mental health conditions
Supporting emotional health and wellbeing
- At every antenatal visit, enquire about the woman’s emotional wellbeing and provide access to information about emotional and mental health during pregnancy and the early postpartum period (see Resources section below).
- Provide the woman with advice on lifestyle issues and sleep, as well as assistance in planning how this advice can be incorporated into their daily activities during pregnancy (see Resources section below).
- If a woman agrees, provide information to and involve her significant other(s) in discussions about her emotional wellbeing and care.
Herbal medicines during the perinatal period
- Advise women that omega-3 fatty acid supplementation does not appear to improve depression symptoms but is not harmful to the foetus when taken during pregnancy or breastfeeding.
- Advise pregnant women that the evidence on potential harms to the foetus from St John’s Wort or Gingko biloba is limited and that use of these treatments during pregnancy is not recommended.
Psychological approaches in the perinatal period
- Individual structured psychological interventions (cognitive behavioural therapy (CBT) or interpersonal psychotherapy (IPT) are the recommended therapies for women with mild to moderate depression in the perinatal period.
- Women with symptoms of depression in the perinatal period may benefit from facilitated self-help or directive counselling.
- Women with diagnosed post-traumatic stress disorder who are experiencing depressive symptoms may benefit from post-traumatic birth counselling.
- Women who have or are recovering from depression and are experiencing mother-infant relationship difficulties may benefit from individual mother-infant relationship interventions.
Medications during the perinatal period
- Selective serotonin reuptake inhibitors (SSRIs) are the first-line medication for women with moderate to severe depression or anxiety. Short-term use of benzodiazepines may be used treating moderate to severe anxiety while awaiting onset of action of an SSRI.
- Advise women that, while it is not usually necessary to discontinue the use of antidepressants during pregnancy or breastfeeding, any medications should be discussed with the prescribing doctor.
- Women with severe mental illness will likely be under the care of a psychiatrist and may benefit from a referral for review of their medications. This is of particular importance for women taking clozapine or sodium valproate, which should not be used during pregnancy.
- Ensure that women who are on medications for mental health conditions are aware of the risks of relapse associated with stopping medication and that, if a medication is ceased, this needs to be done gradually and with advice from a mental health professional.
- Women on antipsychotics are at a higher risk of weight gain and gestational diabetes.
- When exposure to psychoactive medications has occurred in the first trimester, especially with anticonvulsants, pay particular attention to the 18–20 week ultrasound, due to the increased risk of major malformation.
This is an adapted Summary of the 2017 Guideline for general practitioners.
To access the full 2017 National Guideline – click here
Resources for women and their families
COPE website – The COPE website contains extensive information, fact sheets on perinatal mental health disorders, and links to support services for women and their families.
Ready to COPE – A free fortnightly email provides information about emotional health and wellbeing across the perinatal period.
PANDA Helpline – Women can access telephone support for perinatal depression and anxiety on 1300 726 306 Monday to Friday 9.00am to 7.30pm (AEST/AEDT).
Resources for health professionals
COPE website – The COPE website contains extensive information, screening tools, online training programs and fact sheets specifically for health professionals.