Remote Primary Health Care Manuals

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
Red Flags — Urgent Medical Consult
  • If you think there may be a risk of harm to mother or child

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

Childhood
  • Did they feel safe and cared for
  • Who grew them up. Were they loving and supportive
    • If not biological mother or caring it may affect their ability to attach to baby
Abuse
  • Any past or current abuse – physical, sexual or psychological
Mental health
  • Any past or present mental health problems (eg 2 weeks of feeling really down or stressed, anxiety, bipolar, psychosis)
  • Any family members with mental health problems
Anxiety (in last 2 weeks)
  • Any anxious, nervous feelings or on edge
  • OR not able to stop or control worry
Substance use
  • Current drug or alcohol use — mother and/or partner
Living arrangements
  • Do they feel safe and cared for at home
  • Who can help them if they are not coping
    • Consider if woman is in her own or another community/clan, “right skin” relationship, if partners family supportive
Life stressors
  • Anything happened in last 12 months that has been particularly stressful — relationship problems, domestic/family violence, death in family, gambling or money issues, housing problems (eg overcrowding), pregnancy loss
    • If yes — how did they cope
Attitude
  • Did they ever try to believe they were not pregnant
  • Were there any problems before birth — for them or baby
  • How do they feel about the baby and being a mother

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)

Date: _________________ Weeks pregnant:__________ Weeks post birth: ____________
Surname: __________________________Given Name:________________________
As you have recently had a baby or are pregnant, we would like to know how you are feeling. Please circle the number next to the answer which comes closest to how you have felt in the last 7 days, not just how you feel today. 

I have felt happy:
(  ) Yes, all of 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.

In the past 7 days
1. I have been able to laugh and see the funny side of things:
(  ) As much as I always could
(  ) Not quite as much now
(  ) Definitely not so much now
(  ) Not at all		 6. Things have been getting on top of me:
(  ) 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
2. I have looked forward with enjoyment to things:
(  ) As much as I always did
(  ) Rather less than I used to
(  ) Definitely less than I used to
(  ) Hardly at all		 7. I have been so unhappy that I have had difficulty sleeping:
(  ) Yes, most of the time
(  ) Yes, sometimes
(  ) Not very often
(  ) No, not at all
3. I have blamed myself unnecessarily when things went wrong:
(  ) Yes, most of the time
(  ) Yes, some of the time
(  ) Not very often
(  ) No, never		 8. I have felt sad or miserable:
(  ) Yes, most of the time
(  ) Yes, quite often
(  ) Not very often
(  ) No, not at all
4. I have been anxious or worried for no good reason:
(  ) No, not at all
(  ) Hardly ever
(  ) Yes, sometimes
(  ) Yes, very often		 9. I have been so unhappy that I have been crying:
(  ) Yes, most of the time
(  ) Yes, quite often
(  ) Only occasionally
(  ) No, never
5. I have felt scared or panicky for no good reason:
(  ) Yes, quite a lot
(  ) Yes, sometimes
(  ) No, not much
(  ) No, not at all		 10. The thought of harming myself has occurred to me:
(  ) Yes, quite often
(  ) Sometimes
(  ) Hardly ever
(  ) Never
TOTAL SCORE:

Table 2.8   EPDS scoring guide

1. I have been able to laugh and see the funny side of things:
(0)As much as I always could
(1) Not quite as much now
(2) Definitely not so much now
(3) Not at all		 6. Things have been getting on top of me:
(3) Yes, most of the time I haven’t been able to cope at all
(2) Yes, sometimes I haven’t been coping as well as usual
(1) No, most of the time I have coped quite well
(0) No, I have been coping as well as ever
2. I have looked forward with enjoyment to things:
(0) As much as I always did
(1) Rather less than I used to
(2) Definitely less than I used to
(3) Hardly at all		 7. I have been so unhappy that I have had difficulty sleeping:
(3) Yes, most of the time
(2) Yes, sometimes
(1) Not very often
(0) No, not at all
3. I have blamed myself unnecessarily when things went wrong:
(3) Yes, most of the time
(2) Yes, some of the time
(1) Not very often
(0) No, never		 8. I have felt sad or miserable:
(3) Yes, most of the time
(2) Yes, quite often
(1) Not very often
(0) No, not at all
4. I have been anxious or worried for no good reason:
(0) No, not at all
(1) Hardly ever
(2) Yes, sometimes
(3) Yes, very often		 9. I have been so unhappy that I have been crying:
(3) Yes, most of the time
(2) Yes, quite often
(1) Only occasionally
(0) No, never
5. I have felt scared or panicky for no good reason:
(3) Yes, quite a lot
(2) Yes, sometimes
(1) No, not much
(0) No, not at all		 10. The thought of harming myself has occurred to me:
(3) Yes, quite often
(2) Sometimes
(1) Hardly ever
(0) Never
TOTAL SCORE:

Supporting resources