Perinatal Mental Health Guideline: Summary for mental health nurses
It is important that women receive psychosocial support, advice and access to evidence-based treatments for mental health conditions throughout the perinatal period. This Guide also includes information on screening for depression and anxiety and assessing psychosocial risk factors, which are integral parts of maternity care that should be offered to all women.
- Assess for postnatal psychosis and refer immediately to a general practitioner, perinatal psychiatrist or emergency department at the closest hospital. This is a psychiatric emergency.
- Asses for risk of harm to self or infant as part of initial assessment.
Prevention and treatment of mental health conditions
Supporting emotional health and wellbeing
- Mental health nurses are well positioned to provide mental health support through the provision of guided self-help or brief psychological interventions, as appropriate.
- Provide women 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).
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 guided self-help, in which a therapist or computer-based system assists women to work through written materials that are based on cognitive behavioural principles, 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.
- For women with borderline personality disorder, structured psychological therapies that are specifically designed for this condition (e.g. dialectical behaviour therapy) are the recommended therapy.
Medications in the perinatal period
- Selective serotonin reuptake inhibitors (SSRIs) are the first-line medication for women with moderate to severe depression or anxiety.
- It is not usually necessary for women to discontinue the use of antidepressants during pregnancy or breastfeeding but any medications should be discussed with the prescribing doctor.
- There is a high risk of relapse if medications for mental health conditions are ceased. If a medication is ceased, this needs to be done gradually and with the advice of a health professional.
- Doxylamine, a Category A drug in pregnancy, may be considered for use as a first-line hypnotic in pregnant women who are experiencing moderate to severe insomnia.
- Women with severe mental illness (bipolar disorder, schizophrenia) may benefit from referral for review of their medications.
Screening and assessment
Before screening and assessment
- Undertake training in screening and assessment, trauma-informed care and cultural competency/safety training , if you work with Aboriginal and Torres Strait Islander or migrant and refugee women.
- 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, supervision or support regarding mental health care in pregnancy and the postnatal period.
- If you and the woman do not speak the same language, involve an interpreter.
Providing woman-centred care
- Provide a safe and secure environment that fosters effective communication and promotes a trusting relationship.
- Give all women information about the different risk factors that may increase the likelihood of experiencing a mental health condition during pregnancy and/or the postnatal period.
- Explain that depression and anxiety are common in pregnancy and the postnatal period, and that screening and assessment is part of usual care and results will remain confidential, unless there is a perceived or actual risk of harm to the woman or her baby, as there is a duty of care for this to be communicated.
- Ask the woman if the presence of significant other(s) during screening is preferable and be sensitive about whether it is appropriate to continue with psychosocial assessment while others 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 year following birth. 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 the birth and at least once in the first year following birth. Repeat screening 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 on her own, preferably without consulting others. The EPDS may also be administered verbally. As part of clinical assessment, use anxiety items from existing screening tools (i.e. EPDS Items 3, 4 and 5) and relevant items in structured psychosocial assessment tools (see Resources section below).
- 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. If you and the woman do not speak the same language, involve an interpreter.
- Responding to EPDS scores
- Arrange further assessment of 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 score greater than zero 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.
- If a woman has high scores on Items 3, 4 and 5, she may be experiencing anxiety even if her total score is lower than 10.
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 (with the woman on her own) 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
A score of 23 or more suggests the high presence of risk factors, placing a woman at significantly increased risk of perinatal mental health problems.
Discuss with the woman the possible impact of psychosocial risk factors (she has endorsed) on her mental health and provide information about available assistance.
- As well as being used in screening, the EPDS and ANRQ can be used to monitor a woman’s symptoms and level of psychosocial risk over time.
- Provide a 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. This can be achieved by encouraging women to sign-up to the free Ready to COPE e-Guide to pregnancy and early parenthood.
- If a woman agrees, provide information to and involve her significant other(s) in discussions about her emotional wellbeing and care.
This is an adapted Summary of the 2017 Guideline for mental health nurses.
To access the full 2017 National Guideline – click here
Resources for women and their families
COPE website – The COPE website contains extensive information and 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.
COPE online training – This free accredited online training is available for midwives (ten hours CPD).
Information resources and screening tools: The COPE website contains specialist information, fact sheets, and screening tools to support health professionals in assessing the presence of risk factors and common mental health symptoms of depression and anxiety. There is also an information summary for assessing mother-infant interaction and maternal safety.
Online training program: Free, accredited online training is available for mental health nurses to provide knowledge skills and confidence in screening, assessment and referral for perinatal mental health. The program is accredited for 10 hours of CPD points with the Australian College of Mental Health Nurses.
Resources for women and their families
Ready to COPE – is a free fortnightly email that provides information about emotional health and wellbeing across the perinatal period. You can direct women to sign up here. You can also download and display antenatal posters and postnatal posters in your healthcare setting to ensure women have access to quality information throughout pregnancy and their first year of motherhood.