Perinatal depression and anxiety

 

Early recognition and management of perinatal depression is essential

  • Talk and ask about depression, anxiety, other mental health issues at all routine antenatal and postnatal checks for woman and baby
  • If history of severe mental illness (eg depression, bipolar disorder, psychosis) will need mental health team involved in care, especially if taking medicines — even if no current symptoms
  • Consider screening and further mental health assessment if
    • Sad, more down than usual, feeling hopeless and helpless
    • Unmotivated, does not want to see people
    • Not enjoying things they normally enjoy, low energy
    • Not interacting with baby, not caring for herself or baby as well as expected
    • More irritable and angry than normal, behaviour changed
    • Disturbed sleep not related to pregnancy or baby waking
    • Decreased appetite or more hungry. Weight loss or gain

Ask

May be hard to talk to a stranger. Make woman comfortable and give her lots of time to talk freely.  Reassure and validate her feelings — may take several visits to build up trust before she talks

Explain that you ask all new mothers these questions to see if they need extra help

  • Does she feel down, depressed or hopeless
  • Any loss of interest or pleasure in doing things
    • If yes to both — do they want help
  • Tell new mother it is not uncommon to have unwanted thoughts of harming self or baby — ask if they have had any thoughts like that
    • If yes — ask how often and if they have done any type of harm
  • Ask about risk factors — Table 2.6

Table 2.6  Medical consult if risk factors identified

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • Hb
  • U/A, pregnancy test if postnatal
  • Head-to-toe exam 
  • Current medicines

Edinburgh Postnatal Depression Scale Table 2.7 (EPDS)

  • Do at least twice during pregnancy and once in early postnatal period but can do as often as needed.
    • As a minimum first antenatal visit THEN third trimester of pregnancy AND 6-12 week postnatal THEN once in first postnatal year
  • If EPDS score between 10 and 12 — monitor and repeat in 2-4 weeks as score may increase
  • Repeat EPDS at any time in pregnancy and in the first postnatal year if clinically indicated
  • If woman has low English literacy
    • May need help to answer questions
    • Consider using interpreter — not family or someone who knows woman or she may not answer openly

If postnatal

  • Check interactions with baby, appropriate response to baby's needs
  • Safety and wellbeing of baby
    • Does mother have any thoughts of harming baby
    • Poor level of care or growth faltering can indicate postnatal depression

Do

Most important thing to decide — is there immediate or short-term risk to safety of mother or baby. Know the mandatory reporting requirements for your jurisdiction 

  • EPDS is not diagnostic. If mental health issues indicated — further mental health assessment needed
  • If immediate risk to mother or baby — medical/mental health consult to develop short-term safety plan
  • Talk to woman about perinatal depression/anxiety or other disorders if needed — ask if she wants further help or treatment
  • Explore any fears she may have about disclosing further or accepting help or treatment, reassure her that you can provide her with support
  • Make management plan
  • Medicines may be needed for women with severe symptoms or risk — medical/mental health consult
    • Potential for harm to foetus or breastfed baby must be balanced with harm to woman or child if she remains untreated
    • If no safe options for effective local treatment — consider transfer to regional centre or hospital

Follow-up

  • In follow-up visits always give new mothers opportunities to talk about their feelings about themselves and their babies
  • If you have any concerns — medical consult

Scoring EPDS

Add scores for the marked items for total score. See EPDS scoring guide. If positive answer to Q10- always do mental health assessment straight away

  • 0–9 — likelihood of depression low
    • No formal action needed, reassure woman — unless positive response to Question 10 or high score on single question
  • 10–12 — likelihood of depression moderate
    • Supportive treatment — see Do, repeat EPDS in 2 weeks
  • 13 or more — likelihood of depression high medical consult
    • Treat — see Do

If positive answer to Q10 — always do mental health assessment straight away. In postpartum women also assess risk to baby

Table 2.7   Edinburgh Postnatal Depression Scale (EPDS)

Table 2.8   EPDS scoring guide

Supporting resources