At the risk of preaching to the choir, now is a good time to make sure that we’re all singing from the same hymn sheet in regards to perinatal mental health.
Australian health practitioners working with pregnant women and new mothers now have a comprehensive, up-to-date and evidence-based set of guidelines to assist us to effectively identify and support women who are vulnerable to mental health problems. The guidelines are designed to inform a range of professions including obstetricians, midwives, GPs, maternal/child/family health care workers, psychologists, psychiatrists and mental health nurses. The most common perinatal mental health problem – depression – is highlighted, but the guidelines also cater for anxiety, bipolar disorder and puerperal psychosis.
The ‘Clinical Practice Guidelines for Depression and Related Disorders in the Perinatal Period’ can be downloaded for free at http://beyondblue.org.au/guidelines or ordered by calling the beyondblue info line: 1300 22 4636. By way of introducing the guidelines, I would like to highlight a few aspects that I think are especially important.
The Edinburgh Depression Scale (EDS) is recommended by the guidelines as a tool to use antenatally and postpartum to screen all perinatal women. As you may know, the EDS is a simple,
ten-item self-report scale that rates symptoms within the previous week. Three questions explore anxiety symptoms, six questions explore common neurovegetative symptoms of depression and question ten asks about thoughts of self-harm. The EDS is a screening tool not a diagnostic tool, but it does give a common language to communicating symptom severity among health professionals and perinatal women. There are self-scoring versions of the Edinburgh Depression Scale available online at: http://justspeakup.com.au/info_and_support/checklist and www. blackdoginstitute.org.au/public/depression/inpregnancypostnatal/self-test.cfm.
It is important to note that the EDS alone does not effectively fulfill the goals of universal screening. The EDS measures psychopathology in the last week, whereas comprehensive screening will also investigate social vulnerabilities and a history of trauma or psychiatric problems. Suggested tools for this aspect of screening include our capacity for empathy and developing rapport, our communication and clinical skills, and using an aide mémoire to assist us to make appropriate enquiries. Example questions for psychosocial screening can be found in Chapter 3 of the guidelines and a sample psychosocial screening tool is included in Appendix 4.
Prevention, early detection and prompt intervention
A few years ago, Prof Ian Hickie contrasted the traditional response to mental health problems with the standard response to breast cancer. He articulated that no GP would send a woman with a lump in her breast away and ask her to not to come back unless it became critical. In contrast, when it comes to mental health problems, Prof Hickie identified that the response is often delayed until the symptoms become serious or overwhelming.
The guidelines support a proactive approach to preventing, detecting and treating perinatal mental health problems. There’s nothing to be gained from waiting for a pregnant woman or new mother to be in crisis before intervening, but there is much to be gained in preventing symptoms becoming severe or debilitating. If we make the assumption that usually the primary care-giver
of newborns is the mother, then there are even more convincing arguments for this proactive approach: if we help mum we will be helping the baby.
Perinatal women deserve to have the best advice on which to base treatment decisions, because the treatment decisions will be theirs to make. As health professionals, our role is to share the information we have access to and to steer our clients towards evidence-based decisions; we are competing for attention and credibility with the internet, glossy magazines, hearsay and Tom Cruise.
Chapter 1 of the guidelines discusses some of the known risks of not treating perinatal mental health problems. This needs to be taken into account when we are discussing the risks of continuing or commencing treatment: do the known risks of treatment outweigh the known risks of not treating? Chapters 6, 7 and 8 discuss treatment options, namely: supporting emotional well-being, psychological therapies and pharmacological treatment. It is important to emphasise that pharmacological treatment is an option, but that it is not the only option – supportive and psychological approaches also have a sound evidence base in terms of effectiveness and safety.
With regards to pharmacological treatment in the perinatal period, the guidelines offer good practice points, based on the best available evidence up to April 2009. The guidelines emphasise supported and informed decision-making by the woman and her significant other(s) in collaboration with her health care providers.
It has been more than ten years since the Therapeutic Goods Administration (TGA) publication, Prescribing medicines in pregnancy, has been updated, so that’s not a reliable source of up-to-date information. However – along with journal articles and your local clinical networks – there are regularly updated publications, such as Medications and Mothers’ Milk, in addition, each State and Territory has an obstetric drug information service that can provide updates.
The Australian Federal Government has committed to $55 million over five years towards the National Perinatal Depression Initiative, $20 million of which supports the Access to Allied Psychological Services (ATAPS) program to build the capacity of Divisions of General Practice to support better treatment for women with perinatal depression. Given that interventions such as cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) are considered equivalent to pharmacological treatments in terms of their efficacy in many reviews, this support of ATAPS creates an obvious referral pathway for clinicians.
It would be fair to say that availability of specialist perinatal mental health service in Australia has been patchy. In some health districts, perinatal mental health services have evolved without specific funding, often emerging as a component of consultation liaison mental health. However, until recently there hasn’t been a coordinated approach to perinatal mental health at a national level. This should be addressed, in part at least, by Federal, State and Territory Governments using National Perinatal Depression Initiative funding to seed specific services and models of service delivery at various urban and regional centres. In Queensland, for example, there will a dozen or so ‘perinatal mental health clinical nurse consultants’ seeded in a number of strategic locations around the state, with the hope/intent of developing sustainable referral pathways and contributing to workforce training and development in this area.
Being proactive and respectful of maintaining good mental health in perinatal women is part of holistic obstetric care. To play your part, please consider these questions:
- Does your practice/organisation undertake universal screening yet?
- Do you know the ATAPS referral pathway in your area?
- Does your local mental health service have a perinatal specialist/coordinator?
- Have you a copy of Clinical Practice Guidelines for Depression and Related Disorders in the Perinatal Period saved on your computer and/or sitting in your bookcase?
- The Clinical Practice Guidelines for Depression and Related Disorders in the Perinatal Period can be downloaded for free from: http://www.beyondblue.org.au/guidelines or ordered by calling the beyondblue info line: 1300 22 4636.
- There are self-scoring versions of the Edinburgh Depression Scale available online at: http://justspeakup.com.au/info_and_ support/checklist and http://www.blackdoginstitute.org.au/public/depression/inpregnancypostnatal/self-test.cfm .