The introduction of Medicare-funded antenatal and postnatal mental health screening raises questions around referral to appropriately qualified mental health clinicians. The assessment, diagnosis and treatment of perinatal patients requires specific knowledge and expertise beyond the general training received by psychologists, psychiatrists and other mental health practitioners.¹ Pregnancy and the postnatal period pose increased risk for manifesting mental health problems,² influenced by biological, psychological and social factors.³ Mental health disorders are associated with adverse pregnancy outcomes such as intrauterine growth restriction, low birth weight and prematurity,⁴, ⁵ as well as harmful longer term effects on emotional, behavioural and cognitive development in children.⁶, ⁷

Postnatal mental health disorders range from mild to severe, with suicide being one of the leading causes of maternal death.⁸ Not only is the mother’s safety at risk, the infant’s physical and emotional wellbeing is of primary concern. Infanticide is rare, but can be a devastating complication of untreated or poorly managed maternal mental illness.⁹ This article outlines the essential components of mental health care for perinatal women.

What mental health clinicians should know

Perinatal mental health clinicians need to be aware of a number of factors:

• A heightened risk for pre-existing psychiatric conditions to re-emerge
• The impact of changes to the hormonal environment and the physical and emotional difficulties that can be associated with breastfeeding
• The difference between the ‘baby blues’ and postnatal depression
• The difference between typical ‘new mother anxiety’ and clinical anxiety
• The effect of sleep deprivation and fatigue on mood stability
• The social pressures that impact new mothers
• The difficulties of becoming a mother when one’s own parenting was problematic or traumatic
• The common changes to the partner relationship after periods of infertility and after the birth of a baby
• The importance of an attuned parent-infant relationship for the baby’s ongoing wellbeing
• The psychiatric emergency that is postpartum psychosis.

Pre-conception, pregnancy and birth

Pre-conception and obstetric factors are of significance, requiring investigation by a mental health clinician.

History

Pre-conception planning is recommended when there is previous or current psychiatric disturbance. Medication may need to be assessed and revised in preparation for pregnancy and the postnatal period.¹⁰, ¹¹

History-taking is relevant for the pregnancy and the postnatal period:

• Was the pregnancy planned?
• Was there a history of infertility, assisted reproduction or donor conception and what are the ongoing implications?
• Was/is there an extreme fear of childbirth (tocophobia)?
• If there has been a previous pregnancy, is there a history of antenatal or postnatal mood, anxiety or psychotic disorder?

Reproductive loss

Reproductive loss can cause significant grief, which can have psychological implications for subsequent pregnancies¹² and the postnatal period.¹³ Therapists need to explore the implications of previous losses. How have reproductive losses such as miscarriage, stillbirth or termination affected the woman and her relationship? Is there internal conflict regarding attachment to a baby following the loss of a previous baby?

Pregnancy

Antenatal depression and anxiety are common complications of pregnancy, increasing the risk for postnatal mental health problems.¹⁴ During pregnancy, a woman’s aberrant psychological state can be dismissed as heightened emotions due to hormonal fluctuations. Conversely, the non-trained clinician may pathologise pregnancy by over-representing confounding symptoms, such as increased heart rate, sleep disturbance and appetite disturbance, that may be sequelae of pregnancy rather than symptoms of depression or anxiety. Obsessive thoughts about harm to the baby are also common and can cause significant distress.¹⁵

When assessing the woman’s emotional state during pregnancy or after delivery (depending on when she first presents), the following factors may be relevant:

• Is there a current, previous or family history of psychiatric disturbance?
• Have fetal anomalies or medical complications been diagnosed during the pregnancy?
• Does she have concerns about her changing body image or weight? Is there a history of eating disorders?
• How did the woman’s mood during pregnancy affect her birth and postnatal experience?

Pregnancy, labour and birth are formidable events. Extreme pain and a sense of loss of control can increase the traumatic potential of birth.¹⁶ Women with a history of post-traumatic stress disorder (PTSD) or sexual assault may be predisposed to developing PTSD following childbirth.¹⁷, ¹⁸ When women present prior to giving birth, the perinatal mental health clinician can play a role in collaborating with obstetric practitioners to plan for a sensitive birth,¹⁹ as well as advising obstetric staff on strategies for reducing postnatal stress in highly vulnerable women.

Birth

Issues to be aware of following birth:

• How did the woman experience her birth? Did she feel out of control or traumatised?
• Was a history of sexual abuse triggered during birth?
• Did she experience severe sleep disturbance following the birth?
• Was a difficult birth acknowledged and debriefed by health professionals?
• Were her expectations of birth met?
• Did she deliver prematurely? Was the baby in special care?
• In what way did the woman’s birth experience contribute to postnatal adjustment difficulties?

The postnatal period

Postnatal literature focuses heavily on depression. This has contributed to a universal diagnosis of ‘postnatal depression’ to capture emotional distress in the postnatal period.²⁰ However, the presence of anxiety and stress (as distinct from depression) requires particular attention to identify treatment plans for specific symptom presentations. Co-morbid depression and anxiety can pose further risk for the mother.²¹ PTSD, adjustment disorder, panic disorder, generalised anxiety disorder and obsessive-compulsive disorder may manifest and require treatment at this vulnerable time.²²

Relationship and social support

The quality of a woman’s relationship with her partner and her available social supports have been well established risk and protective factors for postnatal adjustment.²³ What is the quality of her relationship? What functional and emotional support does the woman have and is she comfortable asking for help?

Bipolarity and postpartum psychosis

Particular attention should be paid to bipolar disorder with perinatal onset. The postnatal period represents significant risk for the relapse of bipolar disorder, especially when mood stabilising treatment was discontinued for pregnancy.²⁴ Patients typically first present with depressive symptoms, contributing to bipolar disorder being commonly misdiagnosed as unipolar depression, in many cases taking years for the correct diagnosis to be reached.²⁵, ²⁶ Inappropriate prescription of antidepressants can induce a rebound mania at a time in a woman’s life when her baby is dependent on her functioning as a mother.²⁷ It is vital that prudent history-taking (including family history), planning and appropriate psychiatric review be conducted.

Perinatal mental health practitioners need to be aware of the relatively rare, but acute, nature of postpartum psychosis (PPP). Prior to birth, possible risk factors should be identified in a woman’s history that may increase the likelihood of PPP developing in the postnatal period. A history of PPP is a strong risk factor for future postpartum episodes.²⁸ In addition, practitioners should discern and be comfortable with a woman’s reports of intrusive thoughts (typically associated with an obsessive-compulsive disorder profile), which, although not psychotic, can be frightening for the patient and therapist. Perinatal mental health practitioners need to be well acquainted with perinatal psychiatrists and emergency services to ensure women are treated promptly if PPP arises.

Mother-infant attachment

The postnatal period is a highly sensitive period for an infant’s development. The quality of care provided by the parent has consequences for the child’s later outcomes. The mental health practitioner needs to understand attachment theory and the impact of ruptures of attachment on the ongoing relationship between mother and child. Links should be drawn to the attachment history of the woman in her own parenting past.

Working through past attachment experiences in relation to current bonding difficulties, in part, distinguishes the perinatal mental health practitioner from the generalist. Training in parent-infant attachment is central to working effectively with new mothers. In extreme cases of attachment rupture, clinicians need to determine whether the baby is safe,²⁹ especially for women with psychosis, bipolar disorder or borderline personality disorder.

Medication

The prescription of medication in pregnancy and postpartum is an emotionally fraught issue that can cause stress and indecision for pregnant and breastfeeding women. Specialist perinatal psychiatrists are well-versed in helping women weigh up the costs and benefits of medication with regard to the mother, the fetus and the breastfed infant. Awareness of current research on medication in pregnancy and the postnatal period is partly what distinguishes perinatal psychiatrists from general adult psychiatrists.

Services and information

The perinatal mental health clinician needs to be well acquainted with maternal and child health services, supported playgroups and other community services that support vulnerable families. Given the reliance among childbearing women on seeking information and social connection through the internet and social media sites, it is fitting for the clinician to provide patients with good quality, evidence-based information.

Summary

We have highlighted some important considerations for obstetric providers regarding mental health support services for perinatal patients. Along with the general life upheaval of pregnancy and the postnatal period, patients are vulnerable to the emergence and re-emergence of mental health problems, with far-reaching implications for infants and families. It is recommended that obstetricians consider the qualifications and training of mental health practitioners to ensure the effective assessment, diagnosis and treatment of perinatal patients.

Resources

Centre of Perinatal Excellence (COPE)
Perinatal Anxiety & Depression Australia (PANDA)
Miscarriage, Stillbirth and Neonatal Death Support (SANDS)
Beyond Blue

1. Brockington I, Butterworth R, Glangeaud-Freudenthal N. An international position paper on mother-infant (perinatal) mental health, with guidelines for clinical practice. Archives of Women’s Mental Health 2017; 20(1):113-20.
2. Stein A, Pearson R, Goodman S, et al. Effects of perinatal mental disorders on the fetus and child. Lancet 2014; 384(9956):1800-19.
3. Pope S, Watts J. Postnatal depression: A systematic review of published scientific literature to 1999: An information paper 2000. Australia: National Health and Medical Research Council; 2000. 260p.
4. Stein A, Pearson R, Goodman S, et al. Effects of perinatal mental disorders on the fetus and child. Lancet 2014; 384(9956):1800-19.
5. Grote N, Bridge J, Gavin AR, et al. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight and intrauterine growth restriction. Arch Gen Psychiatry 2010; 67(10):1012-24.
6. Talge N, Neal C, Glover V. Early Stress, Translational Research and Prevention Science Network: Fetal and Neonatal Experience on Child and Adolescent Mental Health. Antenatal maternal stress and long-term effects on child neurodevelopment: How and why? Journal of Child Psychology and Psychiatry 2007; 48(3-4):245-61.
7. Grace S, Evindar A, Stewart DE. The effect of postpartum depression on child cognitive development and behavior: A review and critical analysis of the literature. Archives of Women’s Mental Health 2003; 6(4):263-74.
8. Oates M. Suicide: The leading cause of maternal death. Br J Psychiatry 2003;183(4):279-81.
9. Friedman S, Resnick P. Child murder by mothers: Patterns and prevention. World Psychiatry 2007; 6(3):137-41.
10. Brockington I, Butterworth R, Glangeaud-Freudenthal N. An international position paper on mother-infant (perinatal) mental health, with guidelines for clinical practice. Archives of Women’s Mental Health 2017; 20(1):113-20.
11. Boyce P, Buist A. Management of bipolar disorder over the perinatal period. Aust Fam Physician 2016; 45(12):890-93.
12. Boyce P, Buist A. Management of bipolar disorder over the perinatal period. Aust Fam Physician 2016; 45(12):890-93.
13. Pope S, Watts J. Postnatal depression: A systematic review of published scientific literature to 1999: An information paper 2000. Australia: National Health and Medical Research Council; 2000. 260p.
14. Milgrom J, Gemmill A, Bilszta J, et al. Antenatal risk factors for postnatal depression: A large prospective study. J Affect Disord 2008; 108(1-2):147-57.
15. Wenzel A. Anxiety in childbearing women: Diagnosis and treatment. Washington DC:APA Books; 2011. 275p.
16. Reynolds J. Post-traumatic stress disorder after childbirth: The phenomenon of traumatic birth. CMAJ 1997; 156(6):831-35.
17. Reynolds J. Post-traumatic stress disorder after childbirth: The phenomenon of traumatic birth. CMAJ 1997; 156(6):831-35.
18. Beck C, Driscoll J, Watson S. Traumatic childbirth. New York:Routledge; 2013. 272p.
19. Reynolds J. Post-traumatic stress disorder after childbirth: The phenomenon of traumatic birth. CMAJ 1997; 156(6):831-35.
20. Matthey S, Barnett B, Howie P, Kavanagh D. Diagnosing postpartum depression in mothers and fathers: Whatever happened to anxiety? J Affect Disord 2003; 74(2):139-47.
21. Miller R, Pallant J, Negri L. Anxiety and stress in the postpartum: Is there more to postnatal distress than depression? BMC Psychiatry 2006; 6(12):1-11.
22. Wenzel A. Anxiety in childbearing women: Diagnosis and treatment. Washington DC:APA Books; 2011. 275p.
23. Pope S, Watts J. Postnatal depression: A systematic review of published scientific literature to 1999: An information paper 2000. Australia: National Health and Medical Research Council; 2000. 260p.
24. Pope CJ, Sharma V, Mazmanian D. Bipolar disorder in the postpartum period: Management strategies and future directions. Women’s Health 2014; 10(4):359-71.
25. Viguera A, Tondo L, Koukopoulos A, et al. Episodes of mood disorders in 2252 pregnancies and postpartum periods. Am J Psychiatry 2011; 168(11):1179-85.
26. Singh T, Rajput M. Misdiagnosis of bipolar disorder. Psychiatry 2006; 3(10):57-63.
27. Viguera A, Tondo L, Koukopoulos A, et al. Episodes of mood disorders in 2252 pregnancies and postpartum periods. Am J Psychiatry 2011; 168(11):1179-85.
28. Wesseloo R, Kamperman A, Munk-Olsen T, et al. Risk of postpartum relapse in bipolar disorder and postpartum psychosis: A systematic review and meta-analysis. Am J Psychiatry 2016; 173(2):117-127.
29. Brockington I, Butterworth R, Glangeaud-Freudenthal N. An international position paper on mother-infant (perinatal) mental health, with guidelines for clinical practice. Archives of Women’s Mental Health 2017; 20(1):113-20.