Perinatal depression

Question 1

“Describe the screening tools at our disposal to aid in the early detection of depression arising in women in the perinatal period. What are the treatments (psychological and pharmacological) available for the treatment of depression at this time; please include a brief comment on the safety of antidepressants in pregnancy.

2020 stem: Woman 8 weeks pregnant, feeling guilty and as though not fit to be a mother. Difficult conception requiring IVF. Husband supportive though works a lot. Previously seen psychologist. Husband noticed more withdrawn than usual. Mother had perinatal depression which lasted quite some time post-partum. Notes that her mother was emotionally unavailable. Works as lawyer, planning to take maternal leave at 38 weeks. Take history from patient but examiner will give you answers in the third person. Discuss assessment and management. “

Answer 1

Screening tools:
As a part of the SAFESTART program for pregnancy, women are recommended to undertake the EPDS and the psychosocial screening survey (ANRQ) in the antenatal period. there is also the perinatal integrated psychosocial assessment (PIPA) tool, also conducted by midwives/nurses.

• RANZCOG recommends the Edinburgh Postnatal Depression Scale (EPDS) and psychosocial assessment in the setting of ?perinatal depression. This is just a screening tool. Is a 10 question tool, the tenth question is about risk. Doesn’t replace clinical assessment. Conducted by Midwives
• Antinatal risk questionnaire (ANRQ): Explores risk factors (trauma, DV, stressors, low SES, past psych history, single, etc). Conducted by Midwives. Identifies people at high risk.

The SAFESTART multidisciplinary team meets to discuss patients and plan appropriate management/referral pathways.

Question 2

Perinatal depression - Antidepressant safety

Answer 2

Antidepressant safety
ALL antidepressants are associated with a slight increase in the risk of malformations and congenital heart defects. Previous studies have highlighted as being of a greater risk for birth defects.

However, there is no increase above the baseline risk (2-3%) once controlled for the increase in the risk for malformations due to maternal psychiatric disorders themselves. No risk of ADHD/autism from recent sibling studies.

Key points:

• try keep dose low
• if possible, avoid treatment in 1st trimester

Question 3

Perinatal depression - Assessment

Answer 3

Assessment
Psychiatric history:
Sx - focus on cognitive rather than physical sx of depression more
- Mood
- lack of pleasure
- hopelessness
- social withdrawal
- marital problems
- anxiety
- self-harm, suicide, thoughts of harming baby
- attachment/bonding issues
Rest of the psych history: screen for anxiety, psychosis, mania, substance use disorder. Risk assessment (suicide, violence)

Mental state examination:

Assessment tools:

• Edinburgh perinatal depression scale
• ANRQ

Question 4

Perinatal depression - Management

Answer 4

Management
Consider safety issues (other dependents in particular).

Consider setting of treatment.

Non-pharmacological:

• psychoeducation
• group therapy/interpersonal
• CBT
• IBT
• ECT (if severe, treatment resistant, need obstetrician present, specialised anaesthetic, foetal monitoring required)

Pharmacological:
For severe perinatal depression. Balance risk of poor mental health vs potential medication risks. Avoid paroxetine (historical)
1) SSRIs - any in particular. Aim low dose, try avoid use in 1st trimester
2) TCAs (Nortiptyline preferred - safe in pregnancy)

Ongoing:

• mothersafe
• psychologist referral
• trauma informed care
• Psych antenatal care
• GP review and f/u