Assessing psychosocial factors that affect mental health

Psychosocial assessment allows identification of circumstances (past and present) that affect a woman’s mental health. The number and type of factors identified influences the care pathway.

The information in this chapter is based on Austin M-P, Highet N and the Expert Working Group (2017) Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline. Melbourne: Centre of Perinatal Excellence. NHMRC approval of recommendations was for that Guideline.

28.1 Background

The experience of pregnancy and parenthood differs for each woman and is influenced by the stability of her relationships and social network. While the biggest risk factor for developing perinatal mental health conditions is a past mental health history, the presence of psychosocial risk factors may be associated with greater risk of onset, relapse or exacerbation of mental health conditions. Women who feel isolated either by distance, culture, or both, are more likely to develop distress or mental health conditions in the perinatal period (Austin et al 2015). The likelihood is also greater for women who have experienced life stressors (eg family problems, loss, family violence or disability) or multiple trauma (Austin et al 2015).

28.2 Psychosocial assessment

Psychosocial assessment can be undertaken as part of the clinical interview and/or using a structured psychosocial assessment tool. Different approaches can be taken to suit the setting, health professional confidence and skills, as well as time constraints. Structured questionnaires are useful in providing a comprehensive, time-efficient overview of the woman’s circumstances, especially when the health professional is not experienced in undertaking a detailed psychosocial assessment as part of the broader clinical evaluation.

28.2.1 Psychosocial assessment tools

Tools developed with the aim of identifying psychosocial factors in the antenatal period for which there is moderate to high quality evidence include the Antenatal Risk Questionnaire (ANRQ), the Antenatal Psychosocial Health Assessment (ALPHA) and the Pregnancy Risk Questionnaire (PRQ). Evaluation of these tools for their technical performance and acceptability found the following.

• The ANRQ has acceptable technical performance in identifying women at increased risk of depression or anxiety disorder (OR 6.3 [95% CI 3.5 to 11.5]) and has a positive effect on the rates of referral for mental health assessment (moderate quality) Austin et al 2013, Reilly et al 2015. Ease of administration and acceptability among women are high.
• In contrast, the ALPHA has limited psychometric properties, is moderately acceptable to users and is effective in identifying family violence (OR 2.7; 95%CI 1.1 to 6.9) and ‘high level of psychosocial concern’ on the health professional’s part (OR 2.8; 95%CI 0.7 to 11.7) but does not have adequate capacity to identify women at increased risk of postnatal depression (moderate quality) (Carroll et al 2005).
• The PRQ has acceptable psychometric properties and is effective in predicting cases of postnatal depression and anxiety (OR 9.18; p <0.001) (moderate quality) but is considered too lengthy for routine use in the public health setting (Austin et al 2005).

28.2.2 Using the ANRQ 

The ANRQ is a 13-item structured questionnaire that generates a total psychosocial risk score (cumulative risk) and identifies specific factors that independently put the woman at greater psychosocial risk (past history of trauma or significant mental health condition) Austin et al 2013, Reilly et al 2015. It covers the relationship with her partner, social support, recent stressful life events, anxiety or perfectionism, history (and treatment) of depression or other mental health conditions, experience of abuse as a child or as an adult, and quality of relationship with her mother in childhood. A cut-off score of 23 or more is recommended but women with a significant mental health history or history of abuse are at increased risk of poor psychosocial outcome irrespective of the total ANRQ score.

28.3 Other considerations in psychosocial screening 

As a clinically useful psychosocial assessment tool needs to be brief and to cover the key risk domains, it cannot be fully comprehensive and should be used to ‘start the conversation’. 

28.3.1 Further exploration and interpretation of psychosocial assessment 

Psychosocial risk items endorsed by the woman need to be further explored and documented. The results of the evaluation need to be conveyed to the woman and then (in consultation with the woman) be translated into an approach to referral or monitoring. This will be reliant on the availability of referral pathways. 

28.3.2 Education about psychosocial risk factors

Given the potential impact that psychosocial risk factors may have on a woman’s mental health, it is important that all women are provided with information about the nature of the different risk factors that may increase her likelihood of experiencing a mental health condition. In turn this provides an opportunity to identify supports (protective factors) to assist in the prevention of mental health conditions, and/or raise awareness of the importance of early symptom recognition to facilitate early detection and intervention.

28.3.3 Culturally appropriate assessment of psychosocial risk

The psychosocial assessment tools described above are only available in English and no published evidence has been identified describing their use in Aboriginal and Torres Strait Islander or migrant and refugee women. A more conversational approach to psychosocial assessment may be needed in these groups, with a focus on developing rapport and trust.

A South Australian study (of Aboriginal women) found that women were happy to be asked about social health issues, including family and community violence, when questions were asked by Aboriginal women from the community in an interview or when women were given the option to self-complete a questionnaire (Weetra et al 2016). Similarly, involvement of multicultural health workers may be a consideration in the assessment of migrant and refugee women.

Consideration should also be given to psychosocial risk factors that are not covered in the tools but may be relevant to specific groups (eg lack of secure housing, experience of trauma).

28.4 Practice summary: psychosocial assessment

When

As early as practical in pregnancy.

Who

• Midwife
• GP
• obstetrician
• Aboriginal and Torres Strait Islander health worker
• multicultural health worker.

What

• Provide information
  Explain that pregnancy can be challenging and that some life factors make it more likely that a woman will experience symptoms of depression or anxiety.
• Seek informed consent
  Explain that asking about psychosocial factors is a part of usual care during pregnancy and ask the woman for her consent.
• Offer support
  If a woman has psychosocial risk factors ask if she would like help with any issues.

28.5 Resources

• Austin M-P, Highet N and the Expert Working Group (2017) Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline. Melbourne: Centre of Perinatal Excellence.
• COPE online training program
• COPE fact sheets for health professionals