PERINATAL CLINICAL PRACTICE GUIDELINES EXECUTIVE SUMMARY. A guide for primary care health professionals

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1 PERINATAL CLINICAL PRACTICE GUIDELINES EXECUTIVE SUMMARY A guide for primary care health professionals

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3 Contents Overview of mental health care in the perinatal period 1 Background 2 1. Overview of effective perinatal mental health care 1.1 Providing mental health care in the perinatal period Practice guide effective care in the perinatal period 3 2. Psychosocial assessment 4 7. Pharmacological treatments Decision-making about pharmacological treatments Pharmacological treatments in the antenatal period Pharmacological treatments in the postnatal period Practice guide pharmacological treatments Mental health questionnaires 16 Clinical guidance, other resources and support for consumers Key considerations before psychosocial assessment Assessing psychosocial risk factors Example questions to identify psychosocial risk factors Using the EPDS Practice guide psychosocial assessment 6 3. Assessing risk of harm, psychosis and mother infant interaction Assessing risk of harm, psychosis and mother infant interaction Practice guide assessing for risk of harm, psychosis and mother infant interaction Acting on assessments Decision-making following psychosocial assessments Practice guide acting on assessments Psychosocial support Providing psychosocial support Practice guide psychosocial support Psychological therapies Providing psychological therapies Practice guide psychological therapies 13 This publication is funded by the Australian Government.

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5 Overview of mental health care in the perinatal period Contact and communication with woman in the perinatal period Communicate and provide care in a culturally sensitive, non-directive and woman-centred way ROUTINE PSYCHOSOCIAL ASSESSMENT (CHAPTERS 2 AND 3) Assess psychosocial risk factors ask about past or family history of mental health disorder, past or current abuse, emotional and practical support, drugs and alcohol, major stressors Assess symptoms of depression administer EPDS Assess symptoms of anxiety EPDS Q3 5 and psychosocial worry question Assess suicide risk as appropriate (Section 3.1) EPDS Q10 Assess for more severe disorders and determine if support and/or referral needed (Chapter 4) Base decisions on psychosocial assessment, further assessments as appropriate (e.g. assessment of mother infant interaction or for puerperal psychosis), woman s preferences and clinical judgement No psychosocial factors or symptoms Psychosocial factors and/or mild symptoms PROVIDE PSYCHOSOCIAL SUPPORT (CHAPTER 5) Lifestyle advice Early postnatal care Mild to moderate symptoms consider mental health assessment PROVIDE PSYCHOSOCIAL SUPPORT (CHAPTER 5) Non-directive counselling Peer support Severe symptoms mental health assessment ONGOING MONITORING OF MOTHER AND INFANT WELLBEING PSYCHOLOGICAL THERAPIES (CHAPTER 6) KEY Cognitive behavioural therapy Interpersonal psychotherapy Psychodynamic therapy Mother infant psychotherapy Evidence-based recommendation Good practice point PHARMACOLOGICAL TREATMENT (CHAPTER 7) Consider potential risks and benefits to the woman and fetus/infant of treatment versus non-treatment The full recommendations and good practice points are listed in the Clinical Practice Guidelines. 1

6 Background WHO IS AT RISK OF PERINATAL DEPRESSION AND RELATED DISORDERS? The perinatal period (including pregnancy and the following year) is a time of great change in a woman s life, and it is common for women to experience a wide range of emotions. For many women, feelings of worry and stress resolve by themselves, but for some women, pregnancy and early parenthood can trigger symptoms of more serious mental health problems. The likelihood is greater for women who have had mental health problems before, who do not have enough support, or who have been through difficult times (e.g. family problems, abuse or loss). For women who feel isolated either by distance, culture or both (e.g. those from Indigenous and/or culturally and linguistically diverse communities), the likelihood may also be greater. HOW COMMON ARE PERINATAL DEPRESSION AND RELATED DISORDERS? Australian research indicates that up to one in ten (9 per cent) women will experience depression during pregnancy this increases to one in seven (16 per cent) in the year following birth. Anxiety is likely to be as, or more, common. Severe mental health disorders such as puerperal psychosis occur much less often, affecting around one or two in 1,000 women. Bipolar disorder can also arise or reoccur. All mental health disorders affect the wellbeing of the woman, her baby, her significant other(s) (e.g. partner) and family, during a time that is critical to the future health and wellbeing of children. WHO IS THIS GUIDE FOR? This Guide is derived from Clinical Practice Guidelines developed by beyondblue to assist primary care and other health professionals to provide effective mental health care to women during the perinatal period. This includes general practitioners (GPs), midwives, maternal and child health nurses, obstetricians, allied health professionals and Aboriginal and Torres Strait Islander health workers. Advice is based on the best available current evidence where this exists, and, where it does not, on lower quality evidence and clinical expertise. The full guidelines can be found at WHAT IS IN THE GUIDE? The Guide describes an approach to care based on routine assessment of emotional health and wellbeing during pregnancy and the following year, which can be integrated into women s regular health checks. Routine psychosocial assessment This includes questions about psychosocial risk factors that may increase a woman s likelihood of mental health problems, and also asks about any symptoms of depression or anxiety experienced in the previous week, using the Edinburgh Postnatal Depression Scale (EPDS) 1. If a woman has psychosocial risk factors and/or symptoms, the health professional uses clinical judgement to decide whether she would benefit from follow-up assessment and care. In the early postnatal period, it is also important to start assessing the relationship between mother and baby, and also to be aware if there are any signs of puerperal psychosis or bipolar disorder, particularly in women who have had these disorders before. Pathway to care Follow-up requires a pathway or map through which the woman and her family can access the most appropriate care and support. The pathway to care will depend on how severe the woman s risk or symptoms are, together with her preferences and social context. Women with psychosocial risk factors or mild symptoms may benefit from psychosocial support, monitoring and a later repeat assessment. Women with mild to moderate symptoms may benefit from psychological therapy. Women with diagnosed severe symptoms are likely to require a care plan that integrates these approaches, and they may need to consider also taking medication. In some instances, the woman may require hospitalisation, in which case mother and baby should be kept together whenever possible. Whatever the setting and circumstances, perinatal mental health care should be culturally responsive and family-centred. It should involve collaborative decision-making with the woman and her significant other(s), which includes full discussion of the potential risks and benefits of any treatments offered. 1 Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression: development of the 10-item Edinburgh postnatal depression scale. Brit J Psychiatry 150: Developed as the Edinburgh Postnatal Depression Scale and validated for use in both pregnancy and the postnatal period to assess for possible depression and anxiety. 2

7 1 Overview of effective perinatal mental health care Key elements of effective mental health care during pregnancy and early parenthood include considering each woman s context, maintaining a therapeutic relationship, supporting the woman s emotional health, and monitoring mother and infant wellbeing. In some situations, more intensive care such as psychological therapy or pharmacological treatment may be needed. These may require referral to mental health services. 1.1 PROVIDING MENTAL HEALTH CARE IN THE PERINATAL PERIOD Culturally responsive care The Australian population as a whole is diverse and the cultures of groups within this are dynamic and heterogeneous. Women are likely to feel safer in healthcare interactions when mental, social, spiritual and cultural, as well as physical aspects are considered. Woman s context While many Australian women experience high levels of economic prosperity, education and good health, many live in poverty and experience poor health outcomes. Gender inequalities persist, with women economically less secure and maintaining the primary carer role. Some women are subject to physical and psychological abuse. Taking these factors into account leads to a fuller understanding of an individual woman s situation. Family-centred approach Significant other(s) are usually a vital part of a woman s care and play a role in whether or not she accesses services. While some women seek support only from their significant other (e.g. father of the infant), some may wish to involve a wider family or social network and others may not want anyone else involved. Therapeutic relationship Key aspects of the therapeutic relationship include an open, collaborative process, active listening, and development of trust, confidence, mutual respect and empowerment. Psychoeducation Discussion of emotional health and wellbeing, reinforced by relevant and culturally sensitive written information, is an important aspect of care. Providing information continues at every point of contact with all health professionals during the perinatal period and considers the family s changing information needs. Follow-up Assertive follow-up of women with psychosocial risk factors and/or symptoms maximises opportunities to provide support this involves seeing women regularly, giving them outof-hours contact details, arranging their next appointment at the end of a session, and ensuring that the interval between appointments is based on clinical need. 1.2 PRACTICE GUIDE EFFECTIVE CARE IN THE PERINATAL PERIOD DO ensure that communication with women is empathetic and non-directive, and that discussions are womancentred. manage mother and infant together whenever possible. consider the risk of harm to a woman or infant at all points of contact with women in the perinatal period. give women and involved family members information about mental health in the perinatal period. identify health professionals and resources that may assist you, women and their significant others with specialist advice and support. explore options for case planning by a multidisciplinary team for women with a co-occurring mental health or physical condition or ongoing psychosocial factors. aim for continuity of care whenever possible (e.g. through sharing of information, collaborative development of management plans and networks of health professionals). DON T involve members of a woman s support network in her care without her consent. 3

8 2 Psychosocial assessment Psychosocial assessment: aims to identify women at risk of experiencing mental health disorders in the perinatal period, to enable continued monitoring or referral for appropriate assessment, support and treatment involves asking questions about psychosocial risk factors known to be associated with an increased likelihood of mental health disorders in the perinatal period, and use of the EPDS to detect possible symptoms of depression and/or anxiety should take place as early as practical in pregnancy and 6 12 weeks after the birth, at least once, preferably twice, in both the antenatal and postnatal periods can be readily integrated into existing antenatal and postnatal care, and may therefore be undertaken by a range of health professionals including midwives, maternal and child health nurses, GPs, obstetricians, Aboriginal and Torres Strait Islander health workers, mental health nurses, practice nurses and allied health professionals. Psychosocial assessment is not diagnostic. It aims to ensure that women who would like help with their distress or symptoms, or who experience depression or a related disorder, receive the care they need. 2.1 KEY CONSIDERATIONS BEFORE PSYCHOSOCIAL ASSESSMENT Integrating psychosocial assessment into routine care This will depend on the setting and circumstances. If it is not feasible to conduct the assessments during the first visit (e.g. due to time constraints), explain the importance and purpose of the assessments and set aside time in a follow-up appointment. Key considerations include who will conduct the assessments and when, whether appropriate care pathways are available within the service (for women experiencing mild depression through to those with complex comorbidities), mechanisms for follow-up and referral, and how information can be shared to improve continuity of care. Availability of appropriate follow-up care Obtaining consent Before psychosocial assessment, explain the purpose of the assessment, including that it is part of normal care and that the woman s information will not be shared without her permission unless there is a concern that she may harm herself or another person. Consent for psychosocial assessment can be integrated with consent processes for other routine care. If the woman does not consent, document this and offer assessment during later consultations. Involving family members in assessment Women need to feel safe during the assessment. While the presence of significant others is often helpful, be sensitive about whether it is appropriate to continue with the assessment while they are in the room (e.g. if domestic violence is suspected). Planning for women who do not need or decline further care Not all women will want or need further monitoring or mental health assessment. Provide information and encourage continuing contact with an appropriate health professional, to support women to seek assistance if needed. Planning for who will provide ongoing care Ongoing mental health care in the perinatal period can be provided by a GP who has training in mental health care. However, not all women have access to or choose this type of care. Assist women to find a health professional with the skills, knowledge and cultural competence to provide appropriate continuing care. Ensuring continuity of care Many women see a number of health professionals during pregnancy and early parenthood. Promote continuity of care by documenting assessments and, with the woman s permission, sharing relevant information with the next health professional providing care (e.g. if she is referred to a psychologist). Before psychosocial assessment, make sure that appropriate health professionals are available to provide follow-up care if required and to assist if there are concerns for the safety of the woman, the fetus/infant or other children in the woman s care (notifying the relevant child protection agency may be a consideration in some cases). 4

9 2.2 ASSESSING PSYCHOSOCIAL RISK FACTORS Aim of assessing psychosocial risk factors Some women may be more vulnerable to mental health disorders in the perinatal period due to a combination of biological, genetic, physiological or social factors. Assessment aims to identify these women, so that psychological and/or social support can be provided. Context of enquiry Enquiry aims to identify psychosocial risk factors without detracting from the normal experiences of pregnancy and motherhood or highlighting the potential for depression and related disorders to occur in the perinatal period. Framework for enquiry The example questions below provide a basis for discussion and can be adapted to the individual situation. Discussion need not be restricted to the key questions and may include the woman s wider psychosocial context. Best practice is to use a range of styles of questioning (e.g. using a closed question to begin discussion about an area, then open-ended questions to seek further detail and explore the woman s perspective). 2.3 EXAMPLE QUESTIONS TO IDENTIFY PSYCHOSOCIAL RISK FACTORS While example questions are given below, their use will depend on the training and skills of the health professional. Best practice is to use a range of styles of questioning; for example, using a closed question to initiate discussion about an area, then open-ended questions to seek further detail and explore the woman s perspective. The example questions can be used to guide the discussion, with further enquiry made if the woman affirms the presence of a psychosocial risk factor. If a semi-structured questionnaire approach is preferred, the sample form in Chapter 8 can be used. Past or current mental health problems 1. Have you ever had a period of 2 weeks or more when you felt particularly low or down? 2. Do you sometimes worry so much that it affects your day-to-day life? 3. Have you ever needed treatment for a mental health condition such as depression, anxiety disorder, bipolar disorder or psychosis? 4. Has anyone in your immediate family (e.g. grandparents, parents, siblings) experienced severe mental health problems? Previous or current abuse 5. When you were growing up, did you always feel cared for and protected? 6. If you currently have a partner, do you feel safe in this relationship? Drugs and alcohol 7. Do you or others think that you (or your partner) may have a problem with drugs or alcohol? Recent life stressors 8. Have you had any major stressors, changes or losses in the last 12 months (e.g. moving house, financial worries, relationship problems, loss of someone close to you, illness, pregnancy loss, problems conceiving)? Practical and emotional support 9. When you were growing up, was your mother emotionally supportive of you? 10. If you found yourself struggling, what practical support would you have available? Who could help provide that? 11. If you found yourself struggling, what emotional support would you have available? Who could help provide that? 2.4 USING THE EPDS Identifying depressive symptoms in the antenatal period While the EPDS was developed for use in the postnatal period, antenatal use of the EPDS is generally associated with adequate sensitivity and specificity to detect possible major depression. Consider a score of 13 or more on the EPDS for detecting symptoms of depression in the antenatal period. Clinical judgement should always be used. Identifying depressive symptoms in the postnatal period Postnatal use of the EPDS is associated with a high sensitivity and specificity. An EPDS score of 13 or more is most commonly used to identify possible major depression in the postnatal period. 5

10 Identifying anxiety symptoms in the perinatal period Although the EPDS was developed to detect symptoms of depression, there is evidence to support its use in detecting symptoms of anxiety (Q3 5 of the EPDS). Aboriginal and Torres Strait Islander women Scores may be influenced by the woman s understanding of the language used, mistrust of mainstream services and/or fear of the consequences if depression/anxiety is identified. Translations of the EPDS developed in consultation with women from Aboriginal communities have been found to identify a slightly higher number of women experiencing symptoms of depression. Women from culturally and linguistically diverse backgrounds Cultural practices (such as attending the consultation with a family member), differences in emotional reserve and the perceived degree of stigma associated with depression may influence EPDS results. Translated versions of the EPDS have been validated in some languages. Need for clinical judgement In some cases, an EPDS score may not accurately represent a woman s mental health. For example, anxiety associated with the first 12 weeks of pregnancy (e.g. fear of miscarriage) may confound the detection of symptoms. Other issues, such as fatigue, are potential confounders in later trimesters and postnatally. On the other hand, a woman may have a low score, even though there is good reason to believe that she is experiencing distress or depressive symptoms. A very high EPDS score could suggest a crisis, other mental health issues or unresolved trauma and further assessment is required. The EPDS questionnaire and a guide for calculating scores are included in Chapter PRACTICE GUIDE PSYCHOSOCIAL ASSESSMENT Assessing psychosocial factors DO ask all women questions about psychosocial risk factors as early as practical in pregnancy and again 6 12 weeks after the birth, and offer help if any factors are present. ask questions about psychosocial risk factors once a system is in place to provide support if needed. Administering and interpreting the EPDS DO administer the EPDS to all women (if supports/pathways to care have been identified), at least once, preferably twice, in both the antenatal period and the postnatal period (ideally 6 12 weeks after the birth) and make use of planned contacts with the woman (e.g. as part of scheduled antenatal care visits and routine maternal and baby health checks). administer the EPDS as a self-report tool immediately before or during a consultation or, if there are difficulties with the written questionnaire (e.g. relating to language or literacy, cultural issues or disability) and ask the questions during the consultation. explain to each woman the aims and nature of the EPDS and highlight that a score suggesting she may benefit from follow-up care does not mean that she has/will develop depression. give information on how to complete the questionnaire and explain that the woman should select the responses that are closest to her feelings over the previous 7 days, not just on that day. repeat the EPDS in 2 4 weeks if a woman s score is 13 or more in the antenatal period in line with clinical judgement. If the second EPDS score is 13 or more, refer to an appropriate health professional ideally the woman s usual GP. arrange referral or ongoing care if a woman s score is 13 or more in the postnatal period in line with clinical judgement. consider whether a woman may be experiencing anxiety, taking into account her answers to Q3, Q4 and Q5 of the EPDS and her response to the psychosocial assessment question about worrying. ensure access to timely mental health assessment and management for women with a score of 15 or more. assess a woman s safety and that of children in her care if a woman scores 1, 2 or 3 on Q10 of the EPDS. Seek advice and/or arrange immediate mental health assessment according to clinical judgement. use clinical judgement in decision-making about further support and/or referral, as it informs the interpretation of answers to the psychosocial factor questions and EPDS scores. 6

11 ACTING ON IDENTIFIED PSYCHOSOCIAL RISK FACTORS Conduct psychosocial assessment No psychosocial factors 1 or more psychosocial factors YES Ask the woman if she would like help with any of these issues and identify appropriate service ** YES Are any of these of a highly significant nature * NO No Care as usual ** YES Use clinical judgement to consider if a referral for a mental health assessment is required # and identify an appropriate health professional to provide this assessment/care ## Care as usual Check for new psychosocial factors Notes: * Past history of a mental health disorder, past or present abuse, drug and/or alcohol problems. ** Referral to self-help or other support groups as available and appropriate. # Referral and information exchange require consent from the woman. ## Ideally, referral will be to the woman s usual GP or health professional with mental health training and expertise. 7

12 APPROPRIATE RESPONSES TO VARIOUS EPDS SCORES Provide EPDS questionnaire or administer face-to-face Woman scores 1, 2 or 3 on Q10 YES No Woman scores 10, 11 or 12 Woman scores 13 or more Repeat EPDS within 2 4 weeks Depending on clinical judgement: Antenatal: Repeat EPDS within 2 4 weeks and if 13 or more refer to appropriate health professional * Postnatal: Refer to appropriate health professional * Assess current safety of woman, fetus or infant and other children in the woman s care ** Notes: * Ideally, referral will be to a woman s usual GP or health professional with mental health training and expertise; referral and information exchange require consent from the woman. ** See Sections 3.1 and 3.2. CONSIDERING POSSIBLE SYMPTOMS OF ANXIETY Review answers to EPDS scores and psychosocial questions Woman has a positive score on EPDS Q3, Q4 and/or Q5 YES Woman answers yes to psychosocial question about worrying YES Depending on clinical judgement repeat enquiry about worrying and/or EPDS within 2 4 weeks or refer to appropriate health professional* Notes: * Ideally, referral will be to the woman s usual GP or health professional with mental health training and expertise; referral and information exchange requires consent from the woman. 8

13 3 Assessing risk of harm, psychosis and mother-infant interaction Other mental health assessments may also be needed to ensure the wellbeing and safety of both mother and infant and identify whether follow-up care is required. In the early postnatal period, it is important to start assessing the relationship between mother and baby. It is also necessary to be aware if there are any signs of risk of harm to the infant or risk of suicide, or symptoms of puerperal psychosis or bipolar disorder, especially if the woman is experiencing psychosocial adversity, or has a history of mental health disorders. The assessments can be undertaken by health professionals caring for women in the perinatal period, including midwives, maternal and child health nurses, GPs, obstetricians, Aboriginal and Torres Strait Islander health workers, mental health nurses, practice nurses and allied health professionals. Depending on the skills of the health professional, immediate referral for follow-up care may be needed. 3.1 ASSESSING RISK OF HARM, PSYCHOSIS AND MOTHER INFANT INTERACTION Obtaining information about a woman from others A woman s significant other(s) and those involved in her care can be critical sources of information about her recent behaviour, usual coping capacity and available emotional and practical support. When there is concern that a woman may harm herself or her infant or be developing a severe mental health condition (e.g. psychosis), health professionals can contact others without her consent. Mother infant interaction It is important to see the mother and infant together, observe their interaction closely and watch for patterns of interaction especially whether the infant is able to use the mother as a secure base from which to explore, as well as how the mother responds when attachment behaviour is triggered by the infant (see the following table). Consider referral to a specialist with perinatal mental health training (e.g. enhanced child and family health nurse, psychologist, psychiatrist, mental health nurse). Risk to the infant Risk of harm to the infant can be related to suicide risk in the mother, but can also be a separate issue. Expressions of fear of harming the baby may be a sign of anxiety rather than intent, but require further assessment. Indications of risk include irritation with the infant, regrets about having the infant, and wanting to or actually harming the infant. Symptoms of puerperal psychosis The onset of puerperal psychosis is unexpected and rapid. It usually occurs within 48 hours to 2 weeks of giving birth, but may occur up to 12 weeks after the birth. The combination of psychosis and lapsed insight and judgement endangers the safety and wellbeing of the affected woman and her infant. Risk of suicide If indicated, enquiring about the risk of suicide is necessary to ensure the woman s safety and arrange appropriate follow-up care. Assessing risk involves asking whether the woman has suicidal thoughts and, if so, whether she has planned suicide, the lethality of the method she has chosen and whether she has the means to carry it out. Indications of difficulties in the mother infant interaction (not attributed to organic causes) Problems with: Infant Difficulties feeding, sleeping and settling Failing to gain weight or failure to thrive Developmental delay Excessive wariness or friendliness with strangers Appears frightened in mother s presence Mother Unable to respond to infant s cues appropriately Persistent or pronounced lack of maternal empathy Hostile, rejecting, intrusive, teases the infant Fails to ensure infant s safety Mother infant interaction Infant has difficulty signalling/communicating needs to mother Mother unreliable, inconsistent or inappropriate in responding to infant s cues Infant persistently avoids looking at mother (or vice versa) Infant appears fearful or apprehensive of mother Frightening or frightened mother behaviour Inappropriate mother representations (e.g. experiences infant as rejecting, manipulative or vindictive) 9

14 General responses to identified risk of suicide ASK Suicidal thoughts Plan Lethality Means Consider risk to the infant at all times Fleeting thoughts of self-harm or suicide but no current plan or means Suicidal thoughts and intent but no current plan or immediate means Continual/specific suicidal thoughts, intent, plan and means LOW RISK Discuss available support and treatment options Arrange follow-up consultation (timing of this will be based on clinical judgement) Identify relevant community resources and provide contact details MEDIUM RISK Discuss available support and treatment options Organise re-assessment within 1 week Have contingency plan in place for rapid re-assessment if distress or symptoms escalate Develop a safety plan with the woman HIGH RISK Ensure that the woman is in an appropriately safe and secure environment Organise re-assessment within 24 hours and monitoring for this period Follow-up outcome of assessment Monitor risk to infant 3.2 PRACTICE GUIDE ASSESSING FOR RISK OF HARM, PSYCHOSIS AND MOTHER INFANT INTERACTION Information sharing DON T ask others about a woman s mental wellbeing without her consent, unless there is a concern that she may harm herself or others. DO be aware of the requirements of the relevant mental health act or child protection act when there is a risk that a woman may harm herself, the infant or other children in her care. Mother infant wellbeing DO assess the mother infant interaction as an integral part of care in the postnatal period. assess risk to the infant if significant difficulties are observed with the mother infant interaction and/or there is concern about the mother s mental health. Bipolar disorder DO consider the possibility of bipolar disorder in women with current or past symptoms of mania whether or not they have had a depressive episode, especially if the woman has a personal/family history of bipolar disorder. arrange comprehensive mental health assessment and involve a psychiatrist in the care of women experiencing symptoms of bipolar disorder. Puerperal psychosis DO consider the possibility of puerperal psychosis in women experiencing mood swings, confusion, strange beliefs and hallucinations in the early postnatal period. arrange comprehensive mental health assessment and involve a psychiatrist in the care of women with reported or observed marked changes in mood, thoughts, perceptions and behaviours. Suicide risk DO develop a system to assess a woman s risk of suicide and ensure immediate management as needed. If a woman has a positive score on Q10 of the EPDS on one occasion, repeat the assessment as often as clinically required, with a view to reassessing risk over time. ensure that you have discussed your concerns with key others when a woman is expressing suicidal thoughts. Both they and the woman need to identify early warning signs, and who to contact for help (e.g. family network, GP, psychiatrist) and to develop a safety plan based on this. 10

15 4 Acting on assessments Decision-making following assessments is based on the number and type of psychosocial and other factors involved, the severity of symptoms and the preferences of the woman and her significant other(s). Setting, context and cultural background will also influence the approach taken. The process that is followed will depend on the health professional involved and the available local pathways to care. Health professionals in primary care can have an ongoing role in the psychosocial care of women in the perinatal period. However, the health professional s mental health expertise will determine his or her involvement in comprehensive mental health assessment and more intensive care such as psychological or pharmacological treatment. Specific mental health expertise is required to develop a management plan for women with more severe symptoms. 4.1 DECISION-MAKING FOLLOWING PSYCHOSOCIAL ASSESSMENTS Referral When the health professional who administered the psychosocial assessments does not have the appropriate knowledge and skills to manage the woman s care further, a mental health referral is required. The referral pathway will depend on the setting and the services available in the local area. Comprehensive mental health assessment Psychosocial assessments provide information about a woman s mental health and wellbeing, but not a diagnosis. Comprehensive mental health assessment allows a diagnosis to be made and a management plan developed. When a woman declines further care Some women may decline a comprehensive mental health assessment, others may want further care, but not actively seek it for a range of reasons (e.g. background of trauma, fear of authorities, lack of money, trust or knowledge), and others may feel ambivalent about taking up the referral. Maintaining a good therapeutic relationship, actively addressing any uncertainty about treatment, and discussing the benefits of assessment and the aspects of referral that are causing the woman concern may be of assistance. 4.2 PRACTICE GUIDE ACTING ON ASSESSMENTS DO consider comprehensive mental health assessment when there is a past history of mental health disorder, past or current abuse, alcohol or drug misuse, or observed difficulties in the mother infant interaction. arrange comprehensive mental health assessment for women with recurrent or new onset of severe mental health disorder, suicidal thoughts or if there is risk of harm to the woman, infant or other children in her care. with the woman s consent, inform her usual GP if a possible current mental health disorder is detected, even if no further assessment or referral is made. identify referral options for women requiring comprehensive mental health assessment and actively encourage and support women to use them. consider the urgency of referral, particularly when a woman has severe symptoms or suicidal thinking. consider referring women to other agencies (e.g. Alcohol and Drug Information Service, support groups) as necessary. initiate access to Medicare counselling items. First a GP needs to develop a mental health treatment plan with the woman. The GP then refers to a mental health care professional either through the Better Access or perinatal ATAPS Medicare programs (ATAPS is managed by the GP Networks). consider seeking advice from a mental health specialist, either directly or through a support line (e.g. beyondblue info line, PANDA or local mental health service). 11

16 5 Psychosocial support Given the degree of change encountered by many women during pregnancy and early parenthood, it is likely that most will benefit from appropriate psychosocial care in the perinatal period, whether or not they experience psychosocial problems or depressive symptoms. Early intervention for women experiencing distress or depressive symptoms may help to prevent more serious mental health problems from developing. Psychosocial support can be provided by health professionals caring for women in the perinatal period, including midwives, maternal and child health nurses, GPs, obstetricians, Aboriginal and Torres Strait Islander health workers, mental health nurses, practice nurses and allied health professionals. 5.1 PROVIDING PSYCHOSOCIAL SUPPORT Lifestyle advice Women in the perinatal period may benefit from reliable advice on lifestyle issues and sleep, as well as help in planning how this advice can be incorporated into their daily activities. Support in the early postnatal period Some women may experience distress or symptoms of depression if they feel overwhelmed and unable to manage. They may also experience disappointment and grief if something has gone wrong or their expectations of the pregnancy, birth or early motherhood are not realised. Support or specific care at this time can help women to adjust and prevent more serious mental health problems from developing. Peer support Telephone-based peer support may be useful in preventing and treating depression in women with psychosocial factors and/or symptoms, especially for women experiencing isolation (e.g. through geographic location, social isolation, disability). Non-directive counselling Empathetic woman-centred discussions with a focus on listening to the woman and encouraging her to make decisions based on her own judgement can help her to take a more positive view. Psychoeducation Discussion of emotional health and wellbeing, reinforced by relevant and culturally sensitive information, is an important aspect of care in the perinatal period. 5.2 PRACTICE GUIDE PSYCHOSOCIAL SUPPORT Women in the perinatal period DO provide women with advice on diet, physical activity, sleep, smoking and alcohol. encourage women to discuss any nutritional or other supplements they are taking. support women in talking about their experiences and needs, using active listening techniques. provide detailed verbal and written information on depression or anxiety at this time and the benefits of support. Women with psychosocial factors and/or symptoms DO support women with a history of mental health disorders by planning more intensive antenatal and postnatal support (e.g. offering early assessment, identification and referral to specialist services). ask the woman if she would like anyone from her support network to be involved in ongoing care. inform women about psychosocial support options in their community. consider the full family context and facilitate support for other family members, including the infant and other children, if required. provide psychoeducation (e.g. assisting women to maintain regular sleep patterns, balancing possible harm of sleep deprivation against the benefits of breastfeeding, and supporting the mother infant interaction). 12

17 6 Psychological therapies Cognitive behavioural therapy (CBT), interpersonal psychotherapy (IPT) and psychodynamic therapy have been shown to improve depressive symptoms in the postnatal period. Psychotherapy involving the mother and the infant may improve mother infant interaction. Psychological therapies should be provided by registered practitioners with accredited training in the relevant therapy. Government funding to receive treatment from psychiatrists, psychologists, appropriately trained GPs, social workers, occupational therapists and nurses can be accessed through initiatives including Access to Allied Health Care (ATAPS), Better Access initiative (Medicare items), Better Outcomes in Mental Health Care, the Mental Health Nurse Incentive Program, and Non-Directive Pregnancy (Perinatal) Support Counselling (Medicare items). 6.1 PROVIDING PSYCHOLOGICAL THERAPIES Selecting an appropriate therapy Choice of therapy involves consideration of psychological and physical comorbidities, barriers to help-seeking and the likely impact on the woman, infant and family of not treating the condition. Therapies offered should be appropriate to the woman s age, education level, intellectual capacity, language and/or cultural factors and motivation (these will have a variable impact on the woman s suitability to engage in psychological interventions). Severity of disorder For women with moderate to severe symptoms, pharmacological treatment needs to be considered initially. Psychological interventions can be introduced once the more severe symptoms have resolved and the woman is able to engage in therapy. Informed decision-making To make an informed decision about psychological therapies, a woman needs relevant and culturally appropriate information about the nature of therapies. Discussing the suitability and acceptability of therapies with the woman and her significant other(s) is also necessary. Involvement of significant other(s) Including the woman s significant other(s) in psychological interventions may make it easier for her to apply the principles/skills learned into her daily life. Mother and infant psychotherapy This term describes a treatment approach where the mother and infant are seen together and the therapy focuses on the mother infant relationship and maternal sensitivity. Specifically trained health professionals provide the therapy. 6.2 PRACTICE GUIDE PSYCHOLOGICAL THERAPIES DO consider cognitive behavioural therapy, interpersonal psychotherapy or psychodynamic therapy for women with diagnosed mild to moderate depression in the postnatal period. if psychological therapy is indicated, discuss with the woman and her significant other(s) the most appropriate type of therapy to be used, based on her preferences and the availability of therapists and other providers in the community. if mother infant relationship difficulties do not improve with routine primary care interventions, refer the woman to a perinatal and infant mental health specialist or service. make referral to a mental health care professional either through the Better Access or perinatal ATAPS Medicare programs (ATAPS is managed by the GP Networks). DON T administer therapies in which you are not trained. 13

18 7 Pharmacological treatments Pharmacological treatment of depression and related disorders during the perinatal period is not likely to differ from approaches at other times. However, the potential for harm to the fetus and the breastfed infant must be carefully balanced against the likelihood of harm to mother and infant if the mother remains untreated. Due to the overall paucity of evidence, no absolute assurance can be given about any medication used during pregnancy or breastfeeding. Medications should only be prescribed after careful deliberation with the woman (and her significant other[s]), when she is planning a pregnancy, is pregnant or breastfeeding. When symptoms are severe, involving a psychiatrist is advisable. Please refer to the most recent TGA Therapeutic Guidelines and Medications Handbook for current advice for use of medication in the general population. 7.1 DECISION-MAKING ABOUT PHARMACOLOGICAL TREATMENTS Risks and benefits While there are risks associated with using medications in the perinatal period, it should not be assumed that it is always better to avoid medication. Untreated mental health disorders in this period can significantly affect the physical and/or mental wellbeing of the woman, the fetus/infant, significant other(s) and family. Discussing risks and benefits When considering treatment choices for mental health disorders during pregnancy and breastfeeding, or when a pregnancy is planned, it is important to place risks from pharmacological treatment in the context of the individual woman s condition. It should also be noted that the background risk of birth defects in the general population is between 2 per cent and 4 per cent. 7.2 PHARMACOLOGICAL TREATMENTS IN THE ANTENATAL PERIOD Depression Based on the quantity of evidence available, the preferred antidepressants are selective serotonin reuptake inhibitors (SSRIs). Current evidence shows no consistent pattern of additional risk of birth defects from early pregnancy exposure above the general population risk. In later pregnancy, the main risk from SSRIs is poor neonatal adaptation, resulting in withdrawal syndromes in babies including mild breathing problems, irritability and difficulty in settling. Less is known about the safety of tricyclic antidepressants (TCAs) but they can also be considered, especially if they have been effective previously. Anxiety Benzodiazepines can be used to treat panic attacks and severe anxiety disorder in the short-term while awaiting the onset of action of an SSRI or TCA. Recent studies show no apparent increase in orofacial cleft defects. Benzodiazepines may be associated with sedation, preterm birth, low birth weight and low Apgar score. Long-acting benzodiazepines should be avoided. Bipolar disorder Mood stabilisers are used to treat manic episodes, treat psychotic symptoms and help reduce relapse. Sodium valproate is associated with increased risk of major birth defects and cognitive deficits and should NOT be used in pregnancy without consultation with a psychiatrist. Lithium is associated with a very small increased risk of birth defects and consultation with a psychiatrist is advised. First-generation antipsychotics are associated with low birth weight, low gestational age and preterm birth. The risks associated with second-generation antipsychotics are less clear, but clozapine should NOT be initiated during pregnancy or in women contemplating pregnancy, without consulting a psychiatrist. Wherever possible an alternative antipsychotic should be used for women contemplating pregnancy or already taking clozapine on presentation, given its risk of agranulocytosis. 14

19 7.3 PHARMACOLOGICAL TREATMENTS IN THE POSTNATAL PERIOD Depression Very low levels of SSRIs and TCAs pass into breast milk. There are no contraindications to SSRIs and TCAs in breastfeeding, however fluoxetine can accumulate in the infant and jitteriness has been described. The serotoninnorepinephrine reuptake inhibitor (SNRI) venlafaxine may accumulate in breast milk in levels at the higher end of the accepted safe range. Anxiety Short-acting benzodiazepines may be used for a limited period during breastfeeding. Long-acting benzodiazepines should be avoided. Bipolar disorder and puerperal psychosis There is limited evidence for the safety of anticonvulsants during breastfeeding. The passage of lithium into breast milk is more variable than other psychotropic medications. If a woman chooses to breastfeed, lithium should be used with particular caution and as with sodium valproate and clozapine should NOT be used without consulting a psychiatrist. Timing of medications around breastfeeding Specific regimens around the timing of breastfeeding are not considered necessary as on balance, there is a very small exposure to the infant from breast milk. The exception to this is in women taking lithium. 7.4 PRACTICE GUIDE PHARMACOLOGICAL TREATMENTS DO when considering the use of medications for women with severe symptoms, take into account her individual characteristics (e.g. age, weight, ethnicity), mental health history and tendency to relapse, the risk to the fetus or infant and the risk of not treating the disorder. be guided by careful consultation with the woman and her significant other(s) and follow existing guidelines for the general population where specific guidance is not given in this Guide. when selecting treatments, choose medications with lower risk profiles. Start at a low dose and slowly increase it to the lowest effective dose, and use monotherapy in preference to combination treatment. when discussing treatment options with a woman, provide information on the risk of relapse, the possibility of birth defects and options that would enable her to breastfeed. The woman needs to know that in most cases exposure in pregnancy will be much greater than in breastfeeding. when prescribing medications, discuss the time to onset of response (usually 2 3 weeks with most medication), side effects (occurring in first 2 3 weeks) and the risks of stopping treatment abruptly. if prescribing SSRIs, explain that anxiety and agitation may worsen and suicidal thoughts increase in the first 3 weeks, and extra support may be needed. advise women who have inadvertently taken psychotropic medications in pregnancy to seek advice from the prescribing doctor and/or seek advice through drug information services. assess women for side effects and/or lack of initial response shortly after treatment is initiated. monitor women who choose to discontinue medication during the perinatal period for relapse, being aware that effects of discontinuation manifest quickly (in days) while relapse of depression manifests slowly (in weeks). encourage women taking medications that are folate antagonists (e.g. carbamazepine, lamotrigine) to take high-dose folate supplements preconception and during the first trimester. consider a woman s physical activity levels and diet if she is taking antipsychotics in the postnatal period (due to their association with weight gain). consult a psychiatrist if using lithium. If breastfeeding where possible arrange ongoing specialist monitoring for potential adverse effects on the infant. DON T prescribe sodium valproate or clozapine to women planning pregnancy, during pregnancy or in breastfeeding mothers without consulting a psychiatrist. 15

20 8 Mental health questionnaires Many women experience mixed emotions during pregnancy and early parenthood. But some women are more likely to experience emotional difficulties at this time, especially if they ve experienced mental health problems in the past. For this reason, Australian women are being routinely asked questions about their feelings during pregnancy and soon after the birth (much as tests are done for blood sugar levels and baby health during this time). Below is an example of a tool that may be used to conduct a psychosocial assessment. PSYCHOSOCIAL ASSESSMENT The questions below and on the following page will not show whether you have depression or another mental health problem they are designed to help your midwife or doctor understand whether you may benefit from some extra help during this time of change. If you would like some help with any of the issues in the questions, please discuss this with your midwife or doctor. Instructions Please circle the number that most closely describes your situation or tick Yes/No as applicable. Please complete all items. 1. I have had times when I feel particularly low or down for 2 weeks or more not at all somewhat very much 2. I sometimes worry so much that it affects my day-to-day life not at all somewhat very much 3. I have needed treatment for a mental health condition (e.g. depression, anxiety, bipolar disorder, psychosis) No Yes If yes, please tick the type(s) of treatment Talking therapy Medication 4. A member of my immediate family (grandparent, parent, brother/sister) has experienced mental health problems No Yes 5. When I was growing up I always felt cared for and protected not at all somewhat very much 6. I feel safe with my current partner not at all somewhat very much 7. I think that I (or my partner) may have a problem with drugs or alcohol not at all somewhat very much 8. In the last 12 months I have experienced stress, change or loss (e.g. relationship problems, loss of someone close, illness, pregnancy loss or complications, financial worries, moving house) No Yes 9. When I was growing up, my mother was emotionally supportive of me not at all somewhat very much 10. If I need practical support, I have someone who could help me not at all somewhat very much 11. If I need emotional support, I have someone who could help me not at all somewhat very much 16

21 EDINBURGH POSTNATAL DEPRESSION SCALE (COX ET AL 1987) Instructions We would like to know how you have been feeling in the past week. Please indicate which of the following comes closest to how you have felt in the past week, not just how you feel today. Please TICK ONE BOX for each question, which is the closest to how you have felt in the PAST SEVEN DAYS. Here is a completed example. I have felt happy Yes, all the time Yes, most of the time No, not very often No, not at all This would mean: I have felt happy most of the time during the past week. Please complete the other questions in the same way. 1. I have been able to laugh and see the funny side of things 2. I have looked forward with enjoyment to things 3. I have blamed myself unnecessarily when things went wrong 4. I have been anxious or worried for no good reason 5. I have felt scared or panicky for no very good reason 6. Things have been getting on top of me 7. I have been so unhappy that I have had difficulty sleeping 8. I have felt sad or miserable 9. I have been so unhappy that I have been crying 10. The thought of harming myself has occurred to me As much as I always could Not quite so much now Definitely not so much now Not at all As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all Yes, most of the time Yes, some of the time Not very often No, never No, not at all Hardly ever Yes, sometimes Yes, very often Yes, quite a lot Yes, sometimes No, not much No, not at all Yes, most of the time I haven t been able to cope at all Yes, sometimes I haven t been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever Yes, most of the time Yes, sometimes Not very often No, not at all Yes, most of the time Yes, quite often Not very often No, not at all Yes, most of the time Yes, quite often Only occasionally No, never Yes, quite often Sometimes Hardly ever Never Source: Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression: development of the 10-item Edinburgh postnatal depression scale. Brit J Psychiatry 150: Developed as the Edinburgh Postnatal Depression Scale and validated for use in both pregnancy and the postnatal period to assess for possible depression and anxiety. 17

22 CALCULATING A SCORE ON THE EDINBURGH POSTNATAL DEPRESSION SCALE The EPDS is a 10-item questionnaire. Women are asked to answer each question in terms of the past seven days. A clean copy without scores is given on the preceding page. 1. I have been able to laugh and see the funny side of things 2. I have looked forward with enjoyment to things 3. I have blamed myself unnecessarily when things went wrong 4. I have been anxious or worried for no good reason 5. I have felt scared or panicky for no very good reason 6. Things have been getting on top of me 7. I have been so unhappy that I have had difficulty sleeping 8. I have felt sad or miserable 9. I have been so unhappy that I have been crying 10. The thought of harming myself has occurred to me As much as I always could Not quite so much now Definitely not so much now Not at all As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all Yes, most of the time Yes, some of the time Not very often No, never No, not at all Hardly ever Yes, sometimes Yes, very often Yes, quite a lot Yes, sometimes No, not much No, not at all Yes, most of the time I haven t been able to cope at all Yes, sometimes I haven t been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever Yes, most of the time Yes, sometimes Not very often No, not at all Yes, most of the time Yes, quite often Not very often No, not at all Yes, most of the time Yes, quite often Only occasionally No, never Yes, quite often Sometimes Hardly ever Never Score Source: Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression: development of the 10-item Edinburgh postnatal depression scale. Brit J Psychiatry 150: Developed as the Edinburgh Postnatal Depression Scale and validated for use in both pregnancy and the postnatal period to assess for possible depression and anxiety. 18

23 Clinical guidance, other resources and support for consumers CLINICAL GUIDANCE Depression Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression: development of the 10-item Edinburgh postnatal depression scale. Brit J Psychiatry 150: Lam RW, Kennedy SH, Grigoriadis S et al (2009) Clinical guidelines for the management of major depressive disorder in adults: III. Pharmacotherapy. Canadian Network for Mood and Anxiety Treatments (CANMAT). J Affective Disorders 117: S26 S43. NICE (2009) Depression: the Treatment and Management of Depression in Adults: National Clinical Practice Guideline 90 (Full Guidance). National Institute for Health and Clinical Excellence. Parikh SV, Segal ZV, Grigoriadis S et al (2009) Clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. Canadian Network for Mood and Anxiety Treatments (CANMAT) J Affective Disorders 117: S15 S25. Patten SB, Kennedy SH, Lam RW et al (2009) Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical Guidelines for the Management of Major Depressive Disorder in Adults. I. Classification, Burden and Principles of Management. J Affective Disorders 117: S5 S14. RANZCP (2004) Australian and New Zealand clinical practice guidelines for the treatment of depression. Aust NZ J Psychiatry 38: RANZCP (2009) Position Statement 57 Mothers, Babies and Psychiatric Inpatient Treatment. Royal Australian and New Zealand College of Psychiatrists. SIGN (2010) Non-pharmaceutical Management of Depression in Adults: A National Clinical Guideline. Edinburgh: Scottish Intercollegiate Guidelines Network. Anxiety disorders NICE (2004; amended 2007) Anxiety: Management of Anxiety (Panic Disorder, with or without Agoraphobia, and Generalised Anxiety Disorder) in Adults in Primary, Secondary and Community Care. National Institute for Health and Clinical Excellence. Bipolar disorder NICE (2006) The Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and Secondary Care. National Institute for Health and Clinical Excellence. RANZCP (2004) Australian and New Zealand clinical practice guidelines for the treatment of bipolar disorder. Aust NZ J Psychiatry 38: Yatham LN, Kennedy SH, Schaffer A et al (2009) Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update Bipolar Disord 11(3): OTHER RESOURCES beyondblue, the national depression and anxiety initiative beyondblue is a national, independent, not-for-profit organisation working to address issues associated with depression, anxiety and related disorders in Australia. It provides information and resources on depression, anxiety and related disorders for health professionals and consumers and carers. Beyond babyblues: Detecting and Managing perinatal mental health disorders in primary care online training program for primary health care professionals Beyond Babyblues is an accredited online training program developed for primary care health professionals working in maternity care by beyondblue, with the Parent-Infant Research Institute (PIRI) and in collaboration with Genesis Ed. The program discusses screening and further assessment of women in the perinatal period for possible depression and/or anxiety. A range of both pharmacological and non-pharmacological management modalities are discussed and the development of team-based care arrangements are explored. The program has been successfully accredited for RACGP, ACRRM and RCNA points and has also been accredited by the General Practice Mental Health Standards Collaboration (GPMHSC) as a Mental Health Skills Training (MHST) activity (with Genesis Ed as the accreditation providers). headspace What works? The headspace What works? web page provides up-to-date information about treatment interventions and models of care for young people with mental health and substance use issues. It is designed for professionals who work with young people, as well as researchers and academics and members of the community who are interested in youth mental health. Resources include evidence summaries and Mythbusters. 19

24 The Black Dog Institute The Black Dog Institute is a not-for-profit, educational, research, clinical and community-oriented facility offering specialist expertise in depression and bipolar disorder. It offers education and training programs, resources and online learning for health professionals. The Parent-Infant Research Institute (PIRI) The Parent-Infant Research Institute is a not-for-profit organisation with specialist expertise in perinatal depression, anxiety and the mother infant relationship. It offers evidence-based parent infant interventions, training programs and online information for health professionals. square Suicide, QUestions, Answers and REsources square is an integrated suicide prevention resource developed by General Practice SA and Relationships Australia (SA) in conjunction with the Australian and State/Territory Governments. It is part of the National Suicide Prevention Strategy and was jointly funded by the Australian Government and the Government of South Australia. Living Is For Everyone The Living Is For Everyone (LIFE) website is a suicide and self-harm prevention resource, dedicated to providing the best available evidence and resources to guide activities aimed at reducing the rate at which people take their lives in Australia. The LIFE website is designed for people across the community who are involved in suicide and self-harm prevention activities. GP Psych Support The GP Psych Support service provides GPs with patient management advice from psychiatrists within 24 hours. GP PsychSupport provides advice in general adult psychiatry, child and adolescent psychiatry, old age psychiatry and drug and alcohol psychiatry. Free Phone: You will be asked some brief questions concerning your enquiry and a psychiatrist will call you back within 24 hours. Free Fax: Using the faxback form, provide details regarding the issue for discussion. A psychiatrist will then fax or phone you to discuss case details. Mental Health First Aid Mental Health First Aid is an example of a training course to help people identify others with mental health issues. SUPPORT FOR CONSUMERS beyondblue Info line beyondblue s info line is staffed by mental health professionals trained to provide information on depression, anxiety and related disorders, available treatments and referral only (local call). Free resources for consumers, carers and health professionals can also be ordered via the beyondblue website or info line. Post and Antenatal Depression Association Inc (PANDA) (Mon Fri 9.30am 4.30pm EST) Information, support and counselling for women and their families affected by antenatal and postnatal mood disorders. Suicide Call Back Service Telephone support for those at risk of suicide, their carers and those bereaved by suicide. Black Dog Institute Information on depression (including during and after pregnancy) and bipolar disorder. Carers Australia Family carer support and counselling in each State and Territory. Centre for Clinical Intervention Resources, including workbooks, for people experiencing anxiety or depression. is a secure and password protected website. Log in and submit your questions online. For your username and password, call

25 CRUfAD Clinical Research Unit for Anxiety and Depression Information and internet-based education and treatment programs for people with depression or anxiety. Good Beginnings Information on parenting and details of support services for new parents. headspace Information on mental health problems and stories from others, plus local services for young people. Karitane Information on parenting, including a section on managing postnatal depression, and details of support services for new parents. Lifeline hour counselling, information and referral (local call). MensLine Australia hour support for men with family and relationship problems especially around family breakdown or separation. This service provides anonymous telephone support, information and referral (local call). Miracle Babies Foundation National organisation that supports families whose babies are in neonatal intensive units or a special care unit. MoodGYM Online psychological therapy. Mental Health in Multicultural Australia (MHiMA) (07) Mental health information for people from culturally diverse backgrounds. Parent-Infant Research Institute (PIRI) Australian research institute that aims to develop and apply treatments to improve the emotional wellbeing of parents and infants, and conduct basic research to maximise infant development. ParentLink Contact details for parent services in all States and Territories. Pregnancy, Birth and Baby (helpline) General health information on topics including pregnancy, birthing and parenting in the first 12 months. Relationships Australia Support and counselling for relationships. SANE Australia Helpline Information about mental illness, treatments, where to go for support and help for carers. SIDS and Kids Health promotion, bereavement support, advocacy and research. Tresillian Information on parenting and details of support services for new parents. What were we thinking? Information about common experiences in the early months of parenthood and some effective ways of thinking about and managing them. 21

26 Perinatal clinical Practice guidelines executive summary A guide for primary care health professionals Diagnosis and management of perinatal mental health disorders requires comprehensive assessment by a health professional with relevant training and expertise. This fact sheet aims to assist primary care health professionals involved in diagnosing and/or managing mental health disorders in the perinatal period. DIAGNOSIS Steps toward making a diagnosis Appropriate guidelines for the general population and accepted diagnostic criteria (DSM-IV-TR or ICD-10) should be used when diagnosing depression and anxiety or other mental health disorders. Considerations before making a diagnosis Other causes for symptoms, such as sleep deprivation, pain, anaemia, thyroid dysfunction or bereavement. An alternative diagnosis such as adjustment disorder or minor depression, if depressive symptoms are less severe or present for less than 2 weeks. Further evaluation of very high Edinburgh Postnatal Depression Scale (EPDS) 1 scores, as these may suggest a crisis, other mental health issues or unresolved trauma. Following a diagnosis, primary care health professionals play a critical role in providing information, monitoring, potential referral, support and/or care for women and their families. A guide for primary care health professionals TREATMENT AND MANAGEMENT Decision-making about treatment and management Managing mental health disorders is collaborative and may involve a combination of psychosocial support, psychological therapy and pharmacological treatment, depending on the severity of the woman s symptoms. The choice of treatments will depend on the woman s disorder, her preferences and the health professional s training, skills and experience. Primary care health professionals should support women and their significant other(s) to choose treatments that are appropriate to their circumstances, taking into account contextual factors including ongoing psychosocial factors, ethnicity and cultural background, age and demographic situation. To inform decision-making, the woman should be given relevant and culturally appropriate information about treatment options, with full discussion of their suitability and acceptability to her and her significant other(s). 1 Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression: development of the 10-item Edinburgh postnatal depression scale. Brit J Psychiatry 150: Developed as the Edinburgh Postnatal Depression Scale and validated for use in both pregnancy and the postnatal period to assess for possible depression and anxiety. Visit Call infoline@beyondblue.org.au Visit Call infoline@beyondblue.org.au 1 of 4 A guide for primary care health professionals Puerperal psychosis (also referred to as postpartum or postnatal psychosis) is a very serious but rare mental health disorder that affects 1 or 2 in every 1,000 mothers in the first few weeks after the birth of their babies. Recognising symptoms is essential as the mother is at serious risk of self-harm and there is risk of potential harm for the baby and/or other children. Seeking urgent professional assistance is essential. The earlier a woman is diagnosed, the sooner she will able to get the right treatment and improve her mental health and wellbeing. Although we do not know what causes puerperal psychosis, we do know that women with a history of bipolar disorder or who have experienced puerperal psychosis after previous births are at much greater risk of the illness hence it is important that the health professional is aware of any previous history. In some cases, puerperal psychosis is the first episode of bipolar disorder, or less commonly, another psychotic illness. symptoms of puerperal psychosis Puerperal psychosis causes significant changes in a woman s usual behaviour. These changes usually start within the first few days or weeks after giving birth but may develop up to 12 weeks after the birth and can last for many months. Symptoms can be extremely distressing for the woman experiencing them and for her family, and they impact on the mother s ability to care for her infant. The earlier symptoms are recognised, the sooner the woman can receive the best treatment for herself and her family. Psychotic symptoms can occur alone but most commonly occur with manic or depressive symptoms (see table). GettinG help A woman who experiences these symptoms can become very confused and may be at risk of harming herself and her baby because of strange beliefs she has as a result of the illness. Many women experience manic symptoms and may be inattentive towards the baby due to agitation and an inability to focus. For some women, this manic phase is followed by a severe depression where the woman is unable to function and may be at risk of harming herself and/or her baby. This high risk of suicide or infanticide requires urgent, careful assessment and management on an ongoing basis often for many weeks or months. If you notice any changes like those described here in a woman who has recently had a baby, seek urgent assistance from a general practitioner (GP), mental health service or a hospital emergency department as specialist treatment is required. steps to treatment and recovery Urgent mental health assessment Women experiencing symptoms of puerperal psychosis should seek urgent assistance through a GP, mental health service or the emergency department. As puerperal psychosis is a serious and complex mental health disorder, a specialist psychiatrist needs to be consulted and provide continuing care. symptoms of depression and mania Symptoms Mania Depression Sleep, energy, appetite, libido Thoughts and experiences e.g. thoughts of self harm and/or harming baby Lack of need for sleep, increase in energy and libido Feeling strong, powerful, unbeatable Hearing voices or seeing things that aren t there (hallucinations) Having false beliefs e.g. that they or baby have special powers or someone is trying to harm the baby (delusions) Behaviour Being disorganised Talking quickly, often not finishing sentences Making lots of unrealistic plans Seeming confused and forgetful Overspending, getting into arguments, sexual indiscretions Mood Changing moods in a short space of time e.g. from elevated to irritable Excessively happy Lack of energy, unable to sleep or eat, loss of libido Wanting to die Thoughts of harming herself (and/or her baby) Hearing critical voices (hallucinations) Having false beliefs e.g. that they are guilty or should be punished for being a bad person/ mother (delusions) Difficulty concentrating Difficulty coping with usual activities e.g. caring for baby, home duties Withdrawing from everyone Unable to enjoy anything Feeling hopeless, helpless and worthless, especially as a mother Persistently depressed mood, not reactive in any A guide for primary care health professionals Bipolar disorder is a serious mental health disorder that affects between 1 and 3% of women. Women who have already experienced bipolar disorder have a significant risk of relapse in the early postnatal period. Relapse may also occur during pregnancy, especially if a woman ceases medication when planning to become pregnant or on confirmation of pregnancy. Some women will experience a bipolar episode for the first time postnatally, with those who have a family history being most at risk. Recognising symptoms early and talking to a doctor is important. The earlier a woman is diagnosed, the sooner she will able to get the right treatment and improve her mental health and wellbeing. symptoms of bipolar disorder Bipolar disorder, involves episodes of depression (low mood) and mania (high, elevated mood). The depressive symptoms of bipolar disorder during pregnancy and early parenthood are the same as those of depression at other times. A woman may focus her fears and be excessively worried about the pregnancy or whether she will be a good mother. After the birth, her concerns may focus on the baby s health or the feeling that she is inadequate as a parent. During manic episodes, she will feel unusually confident, overactive, have lots of energy, need less sleep and behave in ways that are out of character. Whether the woman is in a depressed or manic phase, her ability to care for her baby will be significantly affected and she may be at risk of suicide or harming herself or her baby. Symptoms of depression and mania Signs of Depression Moodiness that is out of character Increased irritability and frustration Finding it hard to take minor personal criticisms Spending less time with friends and family Loss of interest in food, sex, exercise or other pleasurable activities Being awake throughout the night Increased alcohol and drug use Staying home from work or school Increased physical health symptoms (e.g. fatigue or pain) Slowing down of thoughts and actions Hallucinations and/or delusions (psychosis)* Suicidal thoughts or thoughts of harming baby Signs of Mania Increased energy Irritability Overactivity Increased spending Being reckless or taking unnecessary risks (e.g. driving fast or dangerously) Increased sex drive Racing thoughts Rapid speech Decreased sleep Grandiose ideas Hallucinations and/or delusions (psychosis)* * Some women with bipolar disorder also have symptoms of psychosis in the depressive or manic phase. These include seeing things or hearing sounds/voices that are not there (hallucinations), feeling everyone is against them or trying to harm them (paranoia) and having beliefs that are not based on reality (delusions). If these symptoms are not acted upon immediately, there can be significant risk to both the mother and the fetus/baby. Visit Call the beyondblue info line on infoline@beyondblue.org.au Summary Managing perinatal depression and anxiety is important for maternal, as well as infant, wellbeing 1. Persistent maternal stress, depression and anxiety can result in detrimental effects on infant development, both during pregnancy and postnatally. However, on average, many individual children are unaffected and can differ in vulnerability and resilience to these problems. Severe and prolonged maternal antenatal stress is associated with higher rates of emotional and cognitive problems in children. A likely mechanism, whereby maternal stress during pregnancy influences foetal, brain and general development, is through changes in the mother s physiological state. Postnatal depression and anxiety have also been found to be associated with compromised cognitive, emotional, social and behavioural development of children. Postnatal depression and anxiety are thought to impact on child development by interfering with the mother s capacity to provide consistent, nurturing care to her infant. Low mood, loss of interest and motivation, fatigue, and feelings of guilt and worthlessness can all contribute to this problem. The early mother infant relationship provides the building blocks for future social and emotional development of children. Infancy is marked by periods of rapid brain development. Infants develop optimally when they feel secure, nurtured and have their needs met quickly and predictably. Re-establishing a healthy mother infant interaction postnatally can have beneficial effects in reducing the impact of perinatal stress on infants. way GettinG help Bipolar disorder does not go away without medical treatment and medication is required to treat and manage this biological condition. Recognising symptoms and talking to a doctor is important. The earlier a woman is diagnosed, the sooner she can get the right treatment. If you observe these symptoms in a woman who is pregnant or recently had a baby, seek urgent assistance from a general practitioner (GP), mental health service or a hospital emergency department. steps to treatment and recovery Urgent mental health assessment Women experiencing symptoms of bipolar disorder should seek urgent assistance through a GP, mental health service or the hospital emergency department. Hospital admission A woman with severe symptoms will in most instances need to go into a psychiatric hospital setting, especially if she, or her partner or family, feels she may be at risk of harming herself or her baby. Time in hospital helps symptoms to become stable and allows a woman to start treatment while she is in a safe place with ongoing monitoring by health professionals. Some psychiatric hospital settings have a mother and baby unit where a woman can stay with her baby while getting additional specialist support. Following discharge from hospital, ongoing support and monitoring of mother and baby by a specialist mental health professional is required. Medication Bipolar disorder is treated and managed using medications that stabilise symptoms and help to reduce the likelihood of relapse. Different types of medication are used to treat the range of possible symptoms that a woman may experience including depression, mania or both depression and mania (mixed episode). Perinatal depression and anxiety Evidence relating to infant cognitive and emotional development Visit Call infoline@beyondblue.org.au Provide care as usual. Offer information about consumer-led and community-led supports. Further Assessment Antenatal: Use clinical judgement. Repeat EPDS in 2 4 weeks; if second score is 1 refer for further assessment. Postnatal: Use clinical judgement, Arrange referral to a health professional with appropriate skills and knowledge (ideally the woman s usual GP) for ongoing care/mental health assessment. If referral is needed, actively encourage attendance. Interpreting Edinburgh Postnatal Depression Scale (EPDS) in the antenatal and postnatal period Anxiety: Check scores on Q3 5 for possible anxiety, as well as the woman s answer to the psychosocial question about worrying (please see over). Possibility of depression relatively high Safety: For scores of 1, 2 or 3 on Q10, judgement, seek advice and/or refer the woman immediately for mental health assessment. Assess assess the safety of the woman and children in her care. Using clinical the need for emergency supports. Information for health professionals a comprehensive perinatal management plan Targeting barriers to maternal care-giving includes managing maternal depression and anxiety, and other psychosocial stressors, as well as considering both the partner and mother infant relationships. Maternal mood symptoms Consider depression and anxiety in all mothers perinatally and ask about it. Screen using the EPDS 2 and conduct further assessment as needed. Encourage stress management in pregnancy. Actively treat depression and anxiety. Consider other risk factors during pregnancy and after birth that may also require management. Support the mother s efforts by adding practical and emotional supports from the immediate and extended family, friends and others. Consider the partner relationship and the partner s own need for support. Discuss issues and barriers to accessing treatment. The mother infant relationship Postnatally, maternal depression may be effectively treated, but the mother infant relationship may need additional support. Observe interactions between mother and infant, and also consider the availability of other family members to supplement and support the mother s care-giving. Provide psychoeducation about needs of newborns and development (motor, cognitive, emotional). Skill acquisition, modelling, sleep and settling programs may be a first step; for others, this is not the entire answer and there may be some underlying reason for not being able to respond to the infant s needs. Consider specific programs targeting mother infant interaction including playgroups, mothers groups, and more specialised therapeutic programs to optimise the care of babies following postnatal depression. Individual approaches to the mother infant relationship antenatally may include exploring feelings of attachment and tuning in to her developing child (e.g. imagining her baby, talking to her baby). Maternal and Child Health Nurses working collaboratively with community agencies and General Practitioners to support parenting are often the first point of contact. Safety: For scores of 1, 2 or 3 on Q10, assess the safety of the woman and children in her care. Using clinical judgement, seek advice and/or refer the woman immediately for mental Possibility of depression and/or anxiety Anxiety: Check scores Q3 5 for possible anxiety, as well as the woman s answer to the psychosocial question about worrying (please see over). 1 of 2 1 of 2 1 of 4 WHEN At least once, preferably twice, in both the antenatal and postnatal period (ideally 6 12 weeks after the birth). HOW Use the EPDS before or during a consultation having explained the non-diagnostic nature of the assessment and that questions relate to the previous 7 days. NOTE Developed as the Edinburgh Postnatal Depression Scale and validated for use in both pregnancy and the postnatal period to assess for possible depression and anxiety. ACKNOWLEDGEMENTS Cox et al (1987) Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Brit J Psychiatry 150: Visit Call infoline@beyondblue.org.au The beyond babyblues guide to EMOTIONAL HEALTH AND WELLBEING DURING PREGNANCY AND EARLY PARENTHOOD MANAGING MENTAL HEALTH CONDITIONS DURING PREGNANCY AND EARLY PARENTHOOD A guide for women and their families Information resources beyondblue has a number of information resources available for health professionals, women and their families. To download PDF files or order hard copies of available information resources please visit to access beyondblue s online ordering catalogue. FOR HEALTH PROFESSIONALS FOR WOMEN AND THEIR FAMILIES Clinical practice guidelines for depression and related disorders anxiety, bipolar disorder and puerperal psychosis in the perinatal period The beyond babyblues guide to emotional health and wellbeing during pregnancy and early parenthood Perinatal clinical practice guidelines Executive summary: A guide for primary care health professionals Managing mental health conditions during pregnancy and early parenthood: A guide for women and their families Management of perinatal mental health disorders Psychosocial assessment and management of perinatal mental health disorders: A guide for primary care health professionals Hey Dad: Fatherhood First 12 Months booklet Puerperal (Postpartum) Psychosis Fact Sheet Puerperal (postpartum) psychosis: A guide for primary care health professionals Fact Sheet 22 Postnatal depression Bipolar disorder during pregnancy and early parenthood Fact Sheet Bipolar disorder during pregnancy and early parenthood: A guide for primary care health professionals Fact Sheet 24 Getting help: Finding out the costs Fact Sheet Perinatal depression and anxiety: Evidence relating to infant cognitive and emotional development beyondblue Guide for Carers: Supporting and caring for a person with depression, anxiety and/or a related disorder Usual Care Repeat EPDS Repeat EPDS in 2 4 weeks. Use clinical judgement review existing support services and increase if needed. Further Assessment For scores of 15 or more assess the safety of mother and infant and the need for crisis support. Ensure access to timely mental health assessment. Probability of significant depression Possibility of anxiety with or without depression Anxiety: Check scores on Q3 5 for possible anxiety, as well as the woman s answer to the psychosocial question about worrying (please see over). Safety: For scores of 1, 2 or 3 on Q10, assess the safety of the woman and children in her care. Using clinical judgement, seek advice aand/or refer the woman immediately for mental health assessment. Assess the need for emergency supports. health assessment. Assess the need for emergency supports. Further Assessment For scores of 15 or more assess the safety of mother and infant and the need for crisis support. Ensure access to timely mental health assessment. immediately for mental health assessment. Assess the need for emergency supports. Depression unlikely Anxiety possible Anxiety: Check scores on Q3 5 for possible anxiety, as well as the woman s answer to the psychosocial question about worrying (please see over). Safety: For scores of 1, 2 or 3 on Q10, assess the safety of the woman and children in her care. Using clinical judgement, seek advice and/or refer the woman Edinburgh Postnatal Depression Scale (EPDS) and Psychosocial Questionnaire scoring wheel for health professionals What Australians know about perinatal depression and anxiety beyondblue Perinatal Monitor

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