Perinatal depression
While depression during pregnancy or early parenthood (i.e. the perinatal period) is the same as at any other time of life, the risk of it developing at this time is greater.
Australian research indicates that depression is experienced by up to one in ten women (10%) during pregnancy and one in seven women (16%) in the year following birth. The rates of anxiety disorders are likely to be even higher and many women are likely to experience both depression and anxiety disorders concurrently.
Depression may develop gradually or within a short period of time. The causes of depression at this time can be complex and are often the result of a combination of factors. While up to 80% of women experience the ‘baby blues’ in the days immediately following the birth, depression is longer-lasting and may persist for many months, or even years, if not treated.
Depression can have significant effects on the health and wellbeing of not only of the mother but also her partner and the development of the foetus/baby and other children. In many instances, perinatal depression is not recognised, as symptoms are often viewed in the context of pregnancy or adjusting to the baby. In addition, high levels of stigma may prevent women seeking help.
It is important to also consider whether symptoms of depression may be occurring in the context of other serious mental health disorders, such as bipolar disorder or puerperal psychosis.
Symptoms of perinatal depression
The symptoms of perinatal depression are reflected in the Edinburgh Postnatal Depression Scale (EPDS), which is used as a component of assessment for depressive symptoms. Women who have symptoms of depression may experience:
- Low mood and/or feeling numb
- Loss of interest in things that would normally be enjoyable
- Feeling inadequate, like a failure, guilty, ashamed, worthless, hopeless, helpless, empty or sad
- Feeling unmotivated and unable to cope with the daily routine
- Insomnia or excessive sleep
- Often feeling close to tears
- Thoughts of self-harm or suicide
There are also a range of different depressive symptoms that can be associated with other mental health conditions.
Assessing perinatal depression
Assessing women for perinatal depression involves considering psychosocial factors that are known to be associated with a high likelihood of mental health disorders in the perinatal period and identifying possible symptoms using the Edinburgh Postnatal Depression Scale (EPDS).
About the EPDS
The EPDS is a questionnaire developed to assist in identifying symptoms of depression in the postnatal period. It also has adequate sensitivity and specificity to identify depressive symptoms in the antenatal period and is useful in identifying symptoms of anxiety.
The EPDS is not a diagnostic tool – rather it aims to identify women who may benefit from follow-up care, such as mental health assessment, which may lead to a diagnosis based on accepted diagnostic criteria (DSM-V or ICD-10). Translated versions of the EPDS have been validated in some languages.
How often the EPDS should be completed
All women should complete the EPDS at least once, preferably twice, in both the antenatal period and the postnatal period (ideally six–12 weeks after the birth).
The non-diagnostic nature of the EPDS, its purpose and the fact that it relates to the previous seven days (not just that day) should be clearly explained.
Interpreting EPDS scores
Clinical judgement is integral to interpreting EPDS scores as, in some cases, the score may not accurately represent a woman’s mental health. For example, a woman may have a low score, even though there is good reason to believe that she is experiencing depressive symptoms. A very high EPDS score could suggest a crisis, other mental health issues or unresolved trauma.
Scores may be influenced by several factors, including the patient’s understanding of the language used, their fear of the consequences if depression is identified, and differences in emotional reserve and perceived degree of stigma that is associated with depression.
When follow-up care is required
In the management of perinatal depression, a total score of 13 or more is considered a flag for the need for follow up of possible depressive symptoms.
In the antenatal period, repeat the EPDS in 2-4 weeks if a woman’s score is 13 or more 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 general practitioner.
In the postnatal period, arrange referral or ongoing care if a woman’s score is 13 or more in line with clinical judgement.
Follow-up may also be needed if scores on Questions 3, 4 and 5 suggest possible symptoms of anxiety.
For scores of 1, 2 or 3 on Question 10, the safety of the woman and children in her care should be assessed and, according to clinical judgment, advice sought and/or mental health assessment arranged.
| Low risk | Possible risk | Possible high risk |
|---|---|---|
| TOTAL EPDS SCORE (Symptoms of Depression) | ||
| Score of 10, 11, 12 | Score of 13 or more | Score of 15 or more |
| - Arrange repeat EPDS in two to four weeks -Review existing supports | - Antenatal: arrange repeat EPDS in two to four weeks - Postnatal: refer to health professional with appropriate skills and knowledge (preferably usual GP) for ongoing care and/or mental health assessment | - Ensure timely access to mental health assessment |
| SELF-HARM QUESTION (Question 10) | ||
| Score of 0 | Score of 1, 2 or 3 | |
| - Care as usual | - Assess safety of woman, fetus or infant and other children in her care - Seek timely advice and/or refer for mental health assessment |
|
Management of perinatal depression
Support and early intervention for women experiencing distress or depressive symptoms may help to prevent more serious mental health problems from developing. Depending on the severity of a woman’s symptoms, management may involve a combination of psychosocial support, psychological therapy and pharmacological treatment. Appropriate responses to assessments and clinical judgement are fundamental to decision-making about management.
1. Psychosocial support
Psychosocial interventions that are used as preventive approaches or as part of the management of depression include non-directive counselling, psychoeducation (e.g. our free e-guide Ready to COPE) and peer support.
Remember, women may also benefit from being given information about options for support in their communities (e.g. parent education groups, support groups, playgroups) and suggestions for where to seek practical support with tasks like cooking, cleaning and taking care of the baby or any older children (e.g. family, friends, neighbours or community services).
2. Psychological therapy
When considering the different forms of psychological therapy for treating depression in the perinatal period, cognitive behavioural therapy (CBT), interpersonal psychotherapy (IPT) and psychodynamic therapy have been shown to improve depressive symptoms in the postnatal period. Women may also benefit from participating in group CBT.
Psychological therapies that are effective in the postnatal period, and at times other than in the perinatal period, would be expected to be effective in the antenatal period, as the disorders differ little from disorders among non-pregnant women in both their presentation and course.
3. Pharmacology
During pregnancy, the use of selective serotonin reuptake inhibitors (SSRIs) can be considered, as there is no evidence for a consistent pattern of birth defects.
Tricyclic antidepressants (TCAs) can also be considered, especially if they have been effective previously, but should be used with caution due to the risk of overdose.
Both SSRIs and TCAs can also be safely used during breastfeeding. Short-term use of short-acting benzodiazepines may be considered while awaiting onset of action of SSRIs.
For more detail on the safety and effectiveness of pharmacological treatments, see the National Perinatal Mental Health Guideline developed by COPE. Guidelines for the use of antidepressants and benzodiazepines in the general population should also be consulted.
Key points to remember
Some things to remember when assessing and managing depression in the perinatal period are:
- The EPDS is used as a component of assessing women for symptoms of depression in both antenatal and postnatal periods: While the EPDS is a self-report tool, it may be appropriate for it to be administered verbally in situations where there are difficulties relating to language or literacy, cultural issues or disability.
- Explain the purpose of assessment: Before the EPDS is administered, women need clear explanation of the purpose of the assessment, including that it is part of normal care and will remain confidential, so that they can provide informed consent. If a woman does not consent to assessment, this should be documented and assessment offered at subsequent consultations.
- Decision-making should be based on woman’s preferences and clinical judgement: Decision-making about the need for and type of follow-up mental health care is based on the woman’s preferences and health professional’s clinical judgement.
- Not everyone needs or will want further monitoring or mental health assessment: Providing information and encouraging continuing contact with an appropriate health professional can support women to seek further assistance if indicated.
- GPs can provide continuing mental health care management: Ideally, a woman’s regular general practitioner will provide continuing mental health care management in the perinatal period. However, not all women have access to this type of care or choose it when it is available. Women should be assisted to identify a health professional with the skills, knowledge and cultural competence to provide appropriate ongoing care.
- Continuity of care is an important aspect of effective care: It is important to document all assessments and share relevant information with the next health professional providing care to the woman (e.g. midwife passes information to maternal and child health nurse).
- Mental health can be subsidised under Medicare: To access Medicare counselling items, a General Practitioner needs to provide a letter of referral for pregnancy support counselling or to develop a mental health treatment plan with the woman for more formalised mental health treatment. The general practitioner then refers to a mental health care professional, through the Better Access Scheme.