Clinical Practice Guidelines Antenatal care - Module I

7.6 Depression and anxiety

Page last updated: 02 April 2013

Detecting symptoms of depression and anxiety during pregnancy relies on clinical judgement and experience. Use of the Edinburgh Postnatal Depression Scale (EPDS) complements this process. The aim is not to form a diagnosis, but to identify women who may benefit from further follow-up.

7.6.1 Background

Depression and anxiety during pregnancy and the postnatal period affect the wellbeing of the woman, her infant and her partner and have an impact on relationships within the family, during a time that is critical to the future health and wellbeing of children (Beck 1998; Halligan et al 2007).

Parental mental health is a key determinant of healthy development in infants (Murray & Cooper 2003). Infant social, psychological, behavioural and cognitive development occurs in the context of a caregiving relationship (Winnicott 1960). When the mother is experiencing depression, the mother-infant relationship is more likely to experience difficulties and infants are at increased risk of developing insecure attachment and mental health problems (Murray & Cooper 1996; Misri & Kendrick 2008; Murray 2009; Tronick & Reck 2009). Maternal distress during pregnancy influences obstetric and birth outcomes (Priest & Barnett 2008) and can adversely affect the developing fetal brain and thus influence infant behaviour (Glover & O’Connor 2002). Maternal anxiety is associated with difficult infant temperament (Austin et al 2005), increased infant cortisol (Grant et al 2009) and behavioural difficulties in childhood (O’Connor et al 2002). Antenatal distress increases risk of attentional deficit/hyperactivity, anxiety, and language delay (Talge et al 2007), and of later mental health problems (O’Connor et al 2002).

Depression and anxiety in pregnancy

Recent studies suggest that:
  • depressive symptoms are as common during pregnancy as they are in the postnatal period (Austin 2004; Milgrom et al 2008);
  • depression identified postnatally begins during pregnancy in up to 40% of women (Austin 2004); and
  • anxiety disorders may be as common as depression during pregnancy and early parenthood (Wenzel et al 2003; Austin & Priest 2005).
Depressive episodes can be a reaction to the pregnancy itself, to associated health issues or to other major life stressors. They can also be a continuation or relapse of a pre-pregnancy condition, especially among women who stop taking medication on confirmation of pregnancy (Henshaw 2004; Oates 2006).

Anxiety may occur in response to fears about aspects of the pregnancy (eg parenting role, miscarriage, congenital disorders), or as a continuation of a pre-pregnancy condition and/or with depression. Higher levels of anxiety in pregnancy increase the risk of depression postnatally (Austin et al 2007).

7.6.2 Screening for depression and anxiety

Summary of the evidence

Depression

There is a large body of evidence to support the use of the EPDS to detect possible depression (but not other mental health disorders) during pregnancy (Murray & Cox 1990; Areias et al 1996; Adouard et al 2005; Adewuya et al 2006; Felice et al 2006; Su et al 2007; Rowel et al 2008).
Recommendation - Grade B
7. Use the Edinburgh Postnatal Depression Scale as a component of the assessment of all women for symptoms of depression in the antenatal period.

Anxiety

Although the EPDS was specifically developed to detect of symptoms of depression, there is evidence to support its use in the detection of symptoms of anxiety, taking into consideration the woman’s scores on questions 3, 4 and 5 and applying clinical judgement (Matthey 2008; Phillips et al 2009).
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Consensus-based recommendation
v. Be aware that women who score 13 or more on the Edinburgh Postnatal Depression Scale (EPDS) may be experiencing anxiety, either alone or with depression. Base decisions about further assessment on the woman’s answers to questions 3, 4 and 5 of the EPDS and her response to enquiry about ‘worrying’.

Administering the EPDS

The EPDS is generally administered in the presence of a health professional or immediately before a consultation. While the EPDS is a self-report tool, it can also be administered verbally if a woman has difficulty completing the questionnaire (eg due to language or literacy, cultural issues, disability). The use of the EPDS may be inappropriate in some circumstances (eg some cultural situations) or may not be acceptable to the woman being assessed; women also have the right to decline assessment.
Before the EPDS is administered, the aims and nature of the assessment should be explained. This includes highlighting that a score that suggests a woman may benefit from follow-up care does not mean she will develop depression. If consent is given, explanation should also be provided on how to complete the questionnaire (select appropriate response for each question) and that the woman should select the responses that are closest to her feelings over the previous 7 days, not just on that day.

Cultural considerations

Scores used to identify possible depression in Aboriginal and Torres Strait Islander and culturally and linguistically diverse populations are generally lower than those used in the general population. For Aboriginal and Torres Strait Islander women, the score may be influenced by the woman’s understanding of the language used, mistrust of mainstream services or fear of consequences of depression being identified. Translations of the EPDS developed in consultation with women from Aboriginal communities have been found to identify a slightly higher number of women experiencing symptoms of depression (Hayes et al 2006; Campbell et al 2008).

Cultural practices (such as attending the consultation with a family member) and differences in emotional reserve and the perceived degree of stigma associated with depression may also influence the performance of the EPDS in women from culturally and linguistically diverse backgrounds.

See Section 7.6.4 for a source of validated translated versions of the EPDS.

Acting on EPDS scores

The first step following the EPDS is determining whether comprehensive mental health assessment is required and, if necessary, identifying a health professional with appropriate mental health expertise to carry out this assessment. While clinical judgement is central to decision-making about further support and/or referral, it is complemented by scores from the EPDS.
  • For women with a score of 10, 11 or 12, the EPDS should be repeated within 2–4 weeks and support services reviewed and increased if needed.
  • A score of 13 or 14 is suggested as a ‘flag’ for further follow-up and women with this score should be offered the EPDS at least twice more during the pregnancy.
  • Women with a score of 15 or more require timely mental health assessment and management.
  • Women with a positive score on questions 3, 4 and/or 5 may be experiencing symptoms of anxiety and consideration should be given to repeating the EPDS in 2–4 weeks.
Chapter 5 of the beyondblue Guidelines (2011) gives more detailed information on referral.

Risk of self harm

Regardless of the total EPDS score, women who have a positive score on question 10 may be at risk of harming themselves and/or children in their care and further assessment is necessary. Health professionals should develop a system to assess the risk of suicide and ensure immediate management as needed. If a woman has a positive score on question 10 of the EPDS on one occasion, it is recommended that the EPDS be repeated as often as clinically required, with a view to reassessing risk over time.
Practice point
h. If a woman scores 1, 2 or 3 on EPDS question 10, assess her current safety and the safety of other children in her care and, acting according to clinical judgement, seek advice and/or refer immediately for mental health assessment.

The National Suicide Prevention strategy website (see Section 7.6.4) provides comprehensive resources on suicide prevention strategies, risk and protective factors, the relationship between mental health and suicide and issues specific to certain groups such as residents of Aboriginal and Torres Strait Islander communities and rural and remote communities.

Considerations beyond the first trimester

  • It is preferable for women to be offered the EPDS twice during pregnancy and as often as is clinically required.
  • Women should be offered the EPDS at least once, preferably twice in the year after the birth, ideally 6–12 weeks after the birth.
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7.6.3 Practice summary — screening for depression and anxiety

When — As early as practical in pregnancy
Who — Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander health worker; multicultural health worker
  • Seek informed consent — Before asking a woman for her consent, explain that screening for depression and anxiety is a routine part of care during pregnancy and that a score that suggests that she may benefit from follow-up care does not mean she will develop depression.
  • Identify level of support needed — Base decisions on follow-up on clinical judgement and the woman’s preferences, taking into account that not all women with a score of 13 or more will benefit from follow-up, and that low or high scores may reflect other factors.
  • Consider safety — If concerned about the woman’s mental health and safety, contact mental health services (see also Chapter 4 of the beyondblue guidelines [2011]).
  • Assist women who decline further care — If a woman chooses not to seek further care, provide her with information about consumer-led and community-led supports.

7.6.4 Resources

beyondblue (2011) Clinical Practice Guidelines Depression and Related Disorders — Anxiety, Bipolar Disorder and Puerperal Psychosis — in the Perinatal Period. A Guideline for Primary Care Health Professionals. Melbourne: beyondblue: the national depression initiative.For more information please visit beyond blue website.

Online training — beyondblue provides online training in assessing and managing mental health disorders in the perinatal period. For more information please visit Think GP website .

National Suicide Prevention Strategy website — For more information please visit Living is for everyone website.

WA Dept Health (2006) Edinburgh Postnatal Depression Scale (EPDS): Translated Versions – Validated. Perth: State Perinatal Mental Health Reference Group.www.dhi.gov.au/Multicultural-Mental-Health-Australia/Information-for-Health-Professionals/Information-for-CALD-Population/default.aspx (This website link was valid at the time of submission)

7.6.5. References

Adewuya AO, Ola BA, Dada AO et al (2006) Validation of the Edinburgh postnatal depression scale as a screening tool for depression in late pregnancy among Nigerian women. J Psychosomatic Obstetrics & Gynecol 27: 267–72.

Adouard F, Glangeaud-Freudenthal NMC, Golse B (2005) Validation of the Edinburgh postnatal depression scale (EPDS) in a sample of women with high-risk pregnancies in France. Arch Womens Mental Health 8: 89–95.

Areias ME, Kumar R, Barros H et al (1996) Comparative incidence of depression in women and men, during pregnancy and after childbirth. Validation of the Edinburgh postnatal depression scale in Portuguese mothers. Brit J Psychiatry 169: 30–35.

Austin M-P (2004) Antenatal screening and early intervention for perinatal distress depression and anxiety: where to from here? Arch Women’s Ment Health 7: 1–6.

Austin M-P & Priest SR (2005) Clinical issues in perinatal mental health: new developments in the detection and treatment of perinatal mood and anxiety disorders. Acta Psychiatr Scand 112: 97–104.

Austin M-P, Hadzi-Pavlovic D, Leader L et al (2005) Maternal trait anxiety, depression and life event stress in pregnancy: relationships with infant temperament. Early Hum Dev 81(2): 183–90.

Austin M-P, Tully L, Parker G (2007) Examining the relationship between antenatal anxiety and postnatal depression. J Affective Disord 101: 169–74.

Beck CT (1998) The effects of postpartum depression on child development: a meta-analysis. Arch Psychiatr Nurs 12(1): 12–20.

beyondblue (2011) Clinical Practice Guidelines Depression and Related Disorders — Anxiety, Bipolar Disorder and Puerperal Psychosis — in the Perinatal Period. A Guideline for Primary Care Health Professionals. Melbourne: beyondblue: the national depression initiative. For more information please visit beyondblue website.

Campbell A, Hayes B, Buckby B (2008) Aboriginal and Torres Strait Islander women’s experience when interacting with the Edinburgh Postnatal Depression Scale: a brief note. Aust J Rural Health 16: 124–31.

Felice E, Saliba J, Grech V et al (2006) Validation of the Maltese version of the Edinburgh Postnatal Depression Scale. Arch Women’s Mental Health 9: 75–80.
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Glover V & O’Connor T (2002) Effects of antenatal stress and anxiety: implications for development and psychiatry. Brit J Psychiatry 180: 389–91.

Grant K-A, McMahon C, Austin M-P et al (2009) Maternal prenatal anxiety, postnatal caregiving and infants’ cortisol responses to the still-face procedure. Dev Psychobiol 51(8): 625–37.

Halligan SL, Murray L, Martins C et al (2007) Maternal depression and psychiatric outcomes in adolescent offspring: a 13-year longitudinal study. J Affect Disord 97(1–3): 145–54.

Hayes B, Geia LK, Egan ME (2006) Development and evaluation of the Edinburgh Postnatal Depression Scale for Aboriginal and Torres Strait Islander Women in North Queensland, Plenary Address. Proceedings of the 1st Aboriginal and Torres Strait Islander Perinatal and Infant Mental Health Conference: Working with ‘Ghosts in the Nursery’; 4–6 May 2006, Sydney.

Henshaw C (2004) Perinatal psychiatry. Medicine 32(8): 42–43.

Matthey S (2008) Using the Edinburgh Postnatal Depression Scale to screen for anxiety disorders. Depression & Anxiety 25: 926–31.

Misri S & Kendrick K (2008) Perinatal depression, fetal bonding, and mother-child attachment: a review of the literature. Curr Paediatric Rev 4: 66–70.

Murray D & Cox J (1990) Screening for depression during pregnancy with the Edinburgh Postnatal Depression Scale (EPDS). J Reprod & Infant Psych 8(2): 99–107.

Murray L (2009) The development of children of postnatally depressed mothers: Evidence from the Cambridge Longitudinal study. Psychoanalytic Psychother 23(3): 185–99.

Murray L & Cooper PJ (1996) The impact of postpartum depression on child development. Int Rev Psychiatry 8: 55–63.

Murray L & Cooper PJ (2003) The impact of postpartum depression on child development. In: Goodyer I (ed) Aetiological Mechanisms in Developmental Psychopathology. Oxford: Oxford University Press.

O’Connor TG, Heron J, Glover V; Alspac Study Team (2002) Antenatal anxiety predicts child behavioral/emotional problems independently of postnatal depression. J Am Acad Child Adolesc Psychiatry 41(12): 1470–77.

Oates M (2006) Perinatal psychiatric syndromes: clinical features. Psychiatry 5(1): 5–9.

Phillips J, Charles M, Sharpe L et al (2009). Validation of the subscales of the Edinburgh Postnatal Depression Scale in a sample of women with unsettled infants. J Affect Disord 118: 101–12.

Priest S & Barnett B (2008) Perinatal anxiety and depression: issues, outcomes and interventions. In: Sved-Williams A & Cowling V (eds) Infants of Parents with Mental Illness: Developmental, Clinical, Cultural and Personal Perspectives. Bowen Hills: Australian Academic Press.

Rowel D, Jayawardena P, Fernando N (2008) Validation of the Sinhala translation of Edinburgh Postnatal Depression Scale. Ceylon Med J 53: 10–13.

Su KP, Chiu TH, Huang CL et al (2007) Different cutoff points for different trimesters? The use of Edinburgh Postnatal Depression Scale and Beck Depression Inventory to screen for depression in pregnant Taiwanese women. Gen Hosp Psychiatry 29: 436–41.

Talge NM, Neal C, Glover V et al (2007) Antenatal maternal stress and long-term effects on child neurodevelopment: how and why? J Child Psychology & Psychiatry 48(3–4): 245–61.

Tronick E & Reck C (2009) Infants of depressed mothers. Harvard Rev Psychiatr 17(2): 147–56.

Wenzel A, Haugen EN, Jackson LC et al (2003) Prevalence of generalised anxiety at eight weeks postpartum. Arch Womens Ment Health 6: 43–49.

Winnicott DW (1960) The theory of the parent-infant relationship. In: The Maturational Processes and the Facilitating Environment. New York: International Universities Press, 1965, pp. 37–55.

1.The information in this section, including the recommendations, is based on Section 3.3 in beyondblue (2011) Clinical Practice Guidelines on Depression and Related Disorders in the Perinatal Period. For more information please visit beyondblue website.
2.The EPDS questionnaire is included in Appendix 4 of beyondblue (2011) and is also available on the beyondblue website.


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