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Treating perinatal depression & anxiety - Medical Observer

Medical & health articles | Medical Observer 13 Nov 2018
Woman holding baby looking out window

Perinatal depression and anxiety are temporary and treatable.


Mental health problems are common among women during the perinatal period; defined as the time from conception until the baby is 12 months old.

Medical Observer logo 250 67
By Prof. Jane Fisher
BSC (HONS) PHD MAPS
Clinical Psychologist; Finkel Professor of Global Health, Monash University*

In Australia, antenatal depression affects up to one in 10 women1 and postnatal depression affects one in six2. Perinatal anxiety is as common as depression, and many parents experience both at the same time. The theme of this year's Perinatal Anxiety and Depression Awareness Week (11-17 November) is 'I wish I knew'. This is "because many expecting and new mums and dads are surprised and shocked by how challenging becoming a parent can be", according to the organisers.

The birth of a baby is one of a woman's biggest life transitions. It is normal for them to feel some uncertainty and anxiety when pregnant, and to experience adjustment challenges after giving birth.

However, some find that emotions such as sadness, shame, intense worry, irritability and pessimism about the future are experienced most of the time, on most days. If anxiety or lower moods affect a woman's daily life and functioning and last more than two weeks, it is important to encourage them to seek help, as women who experience a perinatal mental health problem will fare better the earlier they seek treatment.

GPs can help women to recognise the signs and symptoms of anxiety and depression, and can play a key role in assisting women to recover. Early detection, followed by appropriate assistance and support, can significantly reduce the severity, duration and recurrence of symptoms and enable women to grow in confidence and optimism.

Signs and symptoms

Common signs and symptoms of perinatal mental health problems can include:

  • Generalised worry, often focused on fears for the health or wellbeing of the baby
  • Persistent low mood, lack of enjoyment, irritability
  • Panic attacks, such as a racing heart, palpitations, shortness of breath, shaking or feeling physically 'detached' from one's surroundings.

Consultation

Sensitive enquiry about relevant aspects of these experiences can help women to name their emotions and discuss what they need and, with their GP, identify priority areas and problem-solving strategies. The next step is working out what can be changed, what new support or information might be needed, and what resources are available.

Health of the baby

A mother often worries about their baby's health and development and her ability to correctly read their needs. Infant feeding and sleeping can be very challenging. There can be intense worry about keeping the baby safe.

Emotional state

Having a baby is a permanent life change and cannot be fully imagined in advance. Most women anticipate happiness and pleasure, but are less prepared for the inevitable loneliness, times of boredom and feeling unskilled.

Unexpected emotions like frustration, regret, and a yearning for how life used to be, can be experienced and can be hard to name or admit to.

Relationship

Women feel better if their partner provides encouragement and reassurance, and recognises the work it takes to manage an infant. Men feel better if they are encouraged to learn to care for the baby without being criticised.

External factors

Sometimes in addition to caring for the baby, parents must also manage other life demands, such as work and wider family commitments.

Difficult past experiences

Caring for a baby is hard if a mother's own experiences in early life were difficult. It can be even harder if she has experienced mental illness in the past.

Screening

While clinical assessment will inform these processes, a screening questionnaire can help to identify those who are experiencing clinically significant symptoms, and the severity of these.

Depression

The Edinburgh Postnatal Depression Scale (EPDS) is a brief 10-item questionnaire that can be used to identify whether symptoms are clinically significant. If the score is more than 12, then specific sources of distress should be identified, and a treatment plan considering these devised. This could include referral to a mental health specialist. For a woman with an EPDS score between 10–12, monitor and repeat the EPDS 2–4 weeks later as her score may increase (or decrease) subsequently.

Anxiety

Be aware that anxiety disorders, especially generalised anxiety disorder, are even more common than depression in the perinatal period and should be considered in the broader clinical assessment. As part of the clinical assessment, use anxiety items from screening tools. These include EPDS items 3, 4 and 5, the Depression, Anxiety and Stress Scale (DASS) anxiety subscale and the Kessler Psychological Distress Scale (K-10) items 2, 3, 5 and 6. A structured psychosocial assessment tool like the Antenatal Risk Questionnaire (ANRQ) can also help identify contributors to the distress.

Treatment

If clinically significant symptoms are being experienced, an active plan is needed. This might include referral to a mental health specialist, the use of drugs, cognitive-behavioural or problem-solving therapy, couple counselling or online therapy programs, such as Mum Mood Booster, or referral to a residential early parenting program.

If sub-clinical symptoms are being experienced, then a scheduled repeat visit, and encouragement to use specific evidence-based e-resources – such as What Were We Thinking!, MindMum or MUMentum – should be considered.

Patient resources

MumSpace is a self-help website providing a comprehensive range of stepped-care tools and treatment programs suitable for all expectant and new mums. The site has been developed by the Perinatal Depression e-Consortium, made up of Australia's leading perinatal mental health researchers and organisations and experts in maternal and perinatal health.

  • MumSpace offers essential skills in the transition to parenthood and includes access to leading Australian online resources such as the What Were We Thinking! and BabySteps apps
  • MindMum is an app designed to assist with emotional wellbeing in the perinatal period
  • MumMoodBooster is an effective online treatment program for perinatal depression and anxiety.

Practice Points

  • Perinatal anxiety and depression are usually temporary and treatable. Early detection can reduce severity, duration and recurrence
  • If anxiety or lower moods occur most of the time and persist for more than two weeks, women should be encouraged to seek professional help
  • Sensitive enquiry about emotions and circumstances can help women to discuss their needs and their situation, making it easier for GPs to detect early warning signs, and share relevant resources
  • Screening questionnaires are effective in assessing perinatal mental health.

About the author

*Professor Fisher is co-developer of the What Were We Thinking! app, president of the International Marcé Society for Perinatal Mental Health and a consultant to Masada Private Hospital's Early Parenting Centre.

[1] Buist A & Bilsztra J (2006) The beyondblue National Postnatal Screening Program, Prevention and Early Intervention 2001–2005, Final Report. Vol 1: National Screening Program. Melbourne: beyondblue.

[2] Woolhouse H, Gartland D, Hegarty K et al (2012) Depressive symptoms and intimate partner violence in the 12 months after childbirth: a prospective pregnancy cohort study. BJOG 119(3): 315-23.

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