Perinatal depression and anxiety are common problems, often co-occurring, with combined rates of 16 per cent of women in the first year postpartum and 10 per cent in pregnancy.¹ Increasingly well-documented obstetric effects of these conditions include preterm birth and low birth weight, increased admissions to special care nurseries and disruption to the normal transition to parenthood for the mother and her partner.² Given the frequency of health system contact, there is ample opportunity to detect these significant personal and public health problems antenatally. Postnatal depression (PND) and anxiety derail the development of healthy parenting and attachment relationships, due to the mother’s impairment in reading her infant’s cues and ability to provide responsive and sensitive care to her infant, with subsequent increased risk of emotional and behavioural disorders in children of severely depressed mothers.³ Intervention provides an opportunity to prevent intergenerational transmission of mental health burden and cost. In 2017, changes to the Medicare Benefits Schedule (MBS), allowing private obstetricians to take the time to complete a mental health assessment, recognised the key role that obstetricians can take in detecting perinatal mental illness.

Underlying risks factors include: previous episodes of depression or anxiety (any anxiety disorder); a stressful pregnancy or traumatic birth; poverty; social isolation and lack of support; conflict with a partner, particularly domestic violence; previous physical, sexual or emotional abuse, especially in childhood; pregnancy loss; and perfectionistic or borderline personality traits or disorders.⁴,⁵

Fathers matter, too. A father’s health affects obstetric outcomes,⁶,⁷ and there is increasing attention on the mental health of fathers perinatally. Ten per cent of fathers can also develop perinatal anxiety and depression,⁸ sometimes in response to the mother’s distress, especially when he is solely reliant on his partner for emotional support, or he has a history of depression or anxiety and work/life stress.

Screening for perinatal depression and anxiety

Most Australian public maternity settings, and some in New Zealand, screen women antenatally for depression and anxiety with the Edinburgh Postnatal Depression Scale (EPDS),⁹ and for psychosocial stress, with the AnteNatal Risk Questionnaire (ANRQ)¹⁰ at their first booking visit. Screening, although not diagnostic, identifies women in need of extra support and further referral for mental health assessment and treatment. The EPDS is sensitive to fluctuations in environmental stressors and concerns about the pregnancy or fetus, so the score should be seen in this context, as well as pre-existing vulnerabilities and symptoms. If temporary environmental stress or difficulties with the pregnancy are suspected and the score is 13 or above, it is worth repeating the EPDS again in four weeks. Guidelines are available on how to use the EPDS.¹¹

Pregnant women, in general, welcome enquiry about their emotional wellbeing. This, in itself, can bring relief and reduce feelings of stress and isolation, as there may be social pressure to be happy and excited at this time. Introducing discussion early as part of routine obstetric care reduces stigma and increases the chance that problems will be identified early and as they arise.

Postnatal screening with the EPDS is recommended six to 12 weeks after the birth, with further assessment to be arranged for those with scores of 13 or more.¹¹ In most jurisdictions, this is carried out by maternal and child health nurses and GPs, however, obstetricians offering mental health assessments at the six-week check will also find it a useful tool.

Treatment in pregnancy

The obstetrician’s role is firstly to identify a woman with depression and/or anxiety and to understand this in the context of her pregnancy and close family relationships. Some women may initially find a mental health diagnosis unacceptable and refuse referral elsewhere, but will feel more encouraged after discussion and accept help.¹²

The National Perinatal Mental Health Guideline,¹³ approved by the National Health and Medical Research Council (NHMRC), articulates best practice for all aspects of assessment and treatment. It advises that treatment selection needs to be founded upon a thorough assessment of the woman’s current illness, as well as any prior psychiatric history, including the severity of past episodes, intensity of any past suicidal ideation or behaviour, and whether any particular medication has been proven to be effective.

The available options need to be clearly explained to the woman and her partner/family, with the open acknowledgment that information about risks is not complete, but that her recovery is crucial to her and her baby’s health, and efforts will be made to accommodate her preferences in the treatment approach. Mild depression may improve with non-medication interventions, so these are the first option. Severe depression, by nature of its risks to both mother and baby, has a very strong mandate for rapid effective treatment. The time lag to improvement of up to six weeks for all antidepressants must be considered in light of the relative brevity of pregnancy. Patients cannot afford the time that multiple drug trials may require. A drug proven to be effective in the past may therefore be selected, even where it has less evidence in pregnancy than others.

The guideline¹⁴ further recommends that women undertaking antidepressant therapy in pregnancy warrant regular mental health monitoring by an appropriate professional, whether a GP or a general psychiatrist. If the history or presentation is complex, then an opinion from a perinatal psychiatrist is indicated. The 18–20 week morphology scan will be important if any agents are used with possible risks for malformations. Adjunctive agents such as quetiapine or olanzapine are often used to treat anxiety or augment the antidepressant, in which case an increased schedule of screening for metabolic effects such as hyperglycaemia and hypercholesterolaemia has been suggested.¹⁵

The degree of mental health support in public maternity hospitals varies greatly, ranging from no specialised workers, often the case in rural areas, to trained perinatal mental health clinicians and psychiatrists. Finding and knowing local referral pathways to assist women with perinatal mental health problems is an important part of obstetric care and can lead to a more timely response after screening and clinical assessment. GPs are often central to this process and, in Australia, they may refer to a Medicare-registered mental health professional with a mental health care plan.

Social work has a powerful role to play in assuring, where possible, basic access to income, housing, legal or other supports in the case of domestic violence.

Psychotherapy can be an effective treatment for depression, though research specifically in pregnancy is still limited.⁵,¹⁶ There is some evidence for efficacy for interpersonal psychotherapy, peer support, massage and aerobic exercise.

Mindfulness-based cognitive therapy is an effective treatment for depression. Many perinatal therapists are using mindfulness-based approaches, individually¹⁷ or in groups¹⁸, as there is evidence it is effective in relapse prevention of depression and reduction of stress. Some group interventions have demonstrated positive effects, but results overall are somewhat disappointing, as treatment¹⁹ and as prevention.²⁰ Internet-based treatments may be the way of the future and will perhaps provide accessibility at lower cost.²¹

Overall, the biopsychosocial model is recommended, which presupposes that treatment does not begin or end with medication. Rather, it may be one element among many that are aimed at the underlying causes and may determine direction of referral. Only one-third of depressed pregnant women will consider taking an antidepressant.²²

PND and anxiety

While many factors identified antenatally are still present, new considerations develop postnatally. Particularly relevant are deficient social support, sleep deprivation and the urgent need to mitigate the impact of PND on the newborn’s developing attachment. It is also important to understand the risks of exposing infants to psychotropic medication through breastmilk and the possibility of neonatal adaption syndrome, a short-lived response in the newborn exposed to antidepressants in utero. These risks should be discussed with women prior to commencing medication in pregnancy. Online resources (see the end of the article) and the pharmacy departments of major maternity hospitals can offer information on breastmilk drug exposure.

Biological considerations include screening for underlying organic disease that may be causal or contributory, such as thyroid disorder, iron deficiency anaemia and vitamin deficiencies, such as D, B12 and folate. This is especially true for the new onset of depression or anxiety in the postnatal period.

Education about the nature of depression is essential. We often find patients may not understand that, rather than sadness, postnatal depression can be experienced as a state of restless, numb agitation with prominent guilt and worthlessness and/or co-morbid anxiety.²³ Suicidal and infanticidal ideation, while important to identify, are not universal features, nor is disconnection from or dislike of the infant. Often, women mistakenly think they cannot be depressed because they lack these features. A careful and tactful assessment of suicidal and infanticidal ideation assists in distinguishing whether there is any urge to act upon these thoughts. This dictates the appropriate level of supervision, whether at home with family support, with a home-visiting mental health team, or in a mental health ward, preferably a mother and baby inpatient psychiatric unit where available. Intrusive thoughts of accidental or deliberate harm to the baby, accompanied by guilt or shame in harbouring these thoughts, is common. Reassurance will be valued when this is identified and discussed as a symptom of PND.²⁴

The woman and her family should be encouraged to rally all possible supports to assist in the task of reducing stress and maximising sleep for the mother, while still facilitating positive experiences between mother and baby. It is ideal for the infant if there are other loving family members who can provide emotional care while the mother recovers, as sustained exposure to maternal depression has been demonstrated to have impact on the infant’s developing attachment and future emotional and cognitive development.⁵,¹⁶ There is some evidence for efficacy of a wide range of psychological and psychosocial interventions for reducing maternal depression,²⁵ helping postpartum stress²⁶ and for positive impact on the mother-infant relationship and child development.¹⁶ There is also some evidence that professional home-visiting support and psychotherapy may prevent PND in women at high risk,²⁷ highlighting the value of identifying such women as early in pregnancy as possible.

In summary, perinatal depression and anxiety are common, with potentially serious short and long-term consequences for mothers, their infants and fathers/partners. Effective treatments are available; however, social and systemic barriers to accessing treatment exist. Obstetricians are well-positioned to facilitate increased awareness, detection and treatment.

Further reading

Centre for Perinatal Excellence (COPE)
Information for women, who can sign up to receive a regular newsletter throughout pregnancy and the postpartum. For professionals, the NHMRC-approved Perinatal Mental Health Guideline and online training in best practice for perinatal mental health disorders.

iCope, a web-based screening platform, can be downloaded onto any device to allow rapid screening and autoscoring of depression and psychosocial risk factors by patients and professionals.

Perinatal Anxiety and Depression Australia (PANDA)
Information, resources and how to access PANDA phone counselling. Professionals can refer patients online to the phone counselling service, find information and request training sessions.

Lactmed
Online database of chemical and drug exposure in breastfeeding, maintained by the US National Library of Medicine.

Sms4dads.com
Expectant fathers can sign up to receive information about their baby’s development via SMS, as well as online support, if they wish, from Prof Richard Fletcher’s team in Newcastle.

Mummoodbooster.com
An online research project led by the Parent-Infant Research Institute (Australia) and the Oregon Research Institute (USA). Women who sign up receive an eight-week online treatment program.

Sockol L. A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression. J Affect Disord 2015 May 15;177:7-21.

Stephens S, Ford E, Paudval P, et al. Effectiveness of psychological interventions for postnatal depression in primary care: a meta-analysis. Ann Fam Med. 2016 Sep;14(5):463-72.

1. Gelave B, Rondon M, Araya R, et al. Epidemiology of maternal depression, risk factors and child outcomes in low-income and middle-income countries. Lancet Psychiatry 2016;3(10):973-962.
2. Jarde A, Morais M, Kingston D, et al. Neonatal outcomes in women with untreated antenatal depression compared with women without depression: a systematic review and meta-analysis. JAMA Psychiatry 2016 Aug 1;73(8):826-37.
3. Murray L, Fearon P, Cooper P. Postnatal depression, mother–infant interactions and child development: prospects for screening and treatment. In: Milgrom J, Gemmill AW, editors. Identifying Perinatal Depression and Anxiety. Wiley, 2015.
   pp139-164.
4. Biaggi A, Conroy S, Pawlby S, Pariante C. Identifying the women at risk of antenatal anxiety and depression: A systematic review.
   J Affect Disord. 2016;191:62-77.
5. Howard L, Molyneux E, Dennis C-L, et al. Non-psychotic disorders in the perinatal period. Lancet 2014;384:1775-1788.
6. Olderied, N, Wennerholm U, Pinborg A, et al. The effect of paternal factors on perinatal and paediatric outcomes: a systematic review and meta-analysis. Hum Reprod Update 2018; 1;24(3):320-389.
7. Meng Y, Groth S. Fathers Count: the impact of paternal risk factors on birth outcomes. Matern Child Health J. 2018; 22(3):401-408.
8. Paulson J, Bazemore S. Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. JAMA 2010;303(19):1961-9.
9. Cox J, Holden J, Sagovsky R. Detection of postnatal depression. Development of the ten-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-6.
10. Austin M, Hadzi-Pavlovic D, Saint K, et al. Antenatal screening for the prediction of postnatal depression: validation of a psychosocial pregnancy risk questionnaire. Acta Psychiatr Scand 2005;112(4):310-17.
11. www.cope.org.au/health-professionals-3/perinatal-mental-health-disorders/calculating-score-epds/
12. Byatt N, Levin L, Ziedonis D, et al. Enhancing participation in depression care in outpatient perinatal care settings: a systematic review. Obstet Gynecol 2015 Nov; 126(5):1048-58.
13. Austin M-P, Highet N, Expert Working Group. Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline . Melbourne (2017): Centre of Perinatal Excellence.
14. http://cope.org.au/health-professionals-3/perinatal-mental-health-disorders/decision-making-making-management/
15. Galbally M, Snellen M, Walker S, et al. Management of antipsychotic and mood stabilizer medication in pregnancy: recommendations for antenatal care. ANZ J Psychiatry 2010;44(2):99-108.
16. Letourneau N, Dennis CL, Cosic N, et al. The effect of perinatal depression treatment for mothers on parenting and child development. Depress Anxiety 2017 Oct;34(10):928-966.
17. Dhillon A, Sparkes E, Duarte R.V Mindfulness-based interventions during pregnancy: a systematic review and meta-analysis. Mindfulness 2017;8(6):1421-1437.
18. Pan W, Gau M, Lee T, et al. Mindfulness-based programme on the psychological health of pregnant women. Women Birth 2018 May 8; pii S1871-5192(17)30717-5.
19. Bittner A, Peukert J, Zimmerman C, et al. Early intervention in pregnant women with elevated anxiety and depressive symptoms: efficacy of a cognitive-behavioral group program. J Perinat Neonatal Nurs. 2014;28(3):185-95.
20. Austin M-P. Targeted group antenatal prevention of postnatal depression: a review. Acta Psychiatr Scand. 2003 Apr; 107(4):244-50.
21. Forsell E, Bendix M, Hollandare F, et al. Internet delivered cognitive behavioural therapy for antenatal depression: a randomised controlled trial. J Affect Disord. 2017 Oct 15;221:56-64.
22. Goodman J. Women’s attitudes, preferences and perceived barriers to treatment for perinatal depression. Birth 2009; 36(1):60-69.
23. Ali E. Women’s experiences with postpartum anxiety disorders: a narrative literature review. Int J Womens Health 2018; 29(10):237-249.
24. Fairbrother N, Woody S. New mothers’ thoughts of harm related to the newborn. Arch Womens Ment Health 2008 Jul; 11(3):221-9.
25. Dennis C, Hodnett E. Psychosocial and psychological interventions for treating postpartum depression. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD006116.
26. Song J, Kim T, Ahn J. A systematic review of psychosocial interventions for women with postpartum stress. J Obstet Gynecol Neonatal Nurs. 2015 Mar-Apr;44(2):183-92.
27. Dennis C, Dowswell T. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database Syst Rev 2013;(2):CD001134.