Perinatal Mental Health Guideline: Summary for obstetricians
Routine screening for depression and anxiety and assessing psychosocial risk factors are integral parts of antenatal care that should be offered to all women. It is also important that women receive evidence-based advice on emotional and mental health, treatments and the risk of relapse if medications for mental health conditions and are discontinued.
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 pregnancy.
Providing woman-centred care
- Give all women information about common mental health conditions and the risk factors that may increase the likelihood of experiencing them during pregnancy (see Resources section below).
- Explain that depression and anxiety are common in pregnancy and that screening and assessment is part of usual pregnancy 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.
- 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 five experience anxiety in late pregnancy. Anxiety disorders frequently occur with depression.
- When — Conduct screening as early as practical in pregnancy and at least once later in pregnancy, or 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 (see 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 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 (i.e. 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.
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 any identified 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 documented to meet auditing requirements.
Prevention and treatment of mental health conditions
Supporting emotional health and wellbeing
- At every antenatal visit, enquire about women’s emotional wellbeing and provide access to information about emotional and mental health during pregnancy (see screening and assessment tools).
- 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. 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.
Herbal medicines during pregnancy
- 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.
- 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.
Medications in the perinatal period
- 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 psychiatrist.
- Women with severe mental illness may benefit from referral for review of their medications.
This is an adapted Summary of the 2017 Guideline for obstetricians.
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 obstetricians (ten hours CPD).