Accurately identifying women experiencing symptoms of depression and anxiety enables referral for more formal mental health assessment and suitable follow-up.
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.
27.1 Background
Depressive disorders in the antenatal period are symptomatically the same as those at other times and range from mild to severe. Anxiety disorders at this time include generalised anxiety disorder, obsessive compulsive disorder, panic disorder, social phobia, specific phobia and post-traumatic stress disorder and are often reported as equally prevalent as depressive disorder at this time (Fairbrother et al 2016).
27.1.1 Prevalence of depressive and anxiety disorders
Australian and other studies have reported the 4-year period prevalence [20] of antenatal depression as up to one in ten women (Buist & Bilsztra 2006). Primary anxiety disorders are prevalent and their comorbidity with depression is very high (Wisner et al 2013). Point prevalence of anxiety disorder of one in five in the third trimester of pregnancy has been reported (Giardinelli et al 2012).
Depression may arise in pregnancy or pre-date the pregnancy. In a subset of women in a large US study of women assessed at 6 weeks postnatally, two in five episodes of depression began postnatally, one in three during pregnancy and one in four before pregnancy (Wisner et al 2013). Australian studies have reported persistence of maternal depressive symptoms beyond the first year postpartum, with more mothers reporting depressive symptoms at 4 years follow-up than in the first 12 months postpartum (Woolhouse et al 2015), symptoms persisting from pregnancy to 4 years postpartum in one in eleven women (Giallo et al 2017) and symptoms persisting from the first year to 6–7 years postpartum in one in six women (Giallo et al 2014).
27.1.2 Impact of depressive and anxiety disorders
Obstetric complications in women with depression (independent of antidepressant use) are slightly increased risk of preterm birth, low birth weight, gestational hypertension and perinatal death (Grigoriadis et al 2013).
Anxiety disorders during pregnancy may have a negative influence on obstetric, fetal and perinatal outcomes, including more pregnancy symptoms (nausea and vomiting); more medical visits; increased alcohol or tobacco consumption or unhealthy eating habits; pre-eclampsia and preterm birth; and postnatal depression and mood disorders (Marc et al 2011). High levels of maternal anxiety during pregnancy is associated with increased exposure of the fetus to maternal cortisol and risk of adverse neurodevelopmental outcomes O’Donnell et al 2012.
27.2 Screening for depression
27.2.1 Effectiveness of screening tools
Review of evidence on four screening tools for depression in the antenatal period (the Edinburgh Postnatal Depression Scale [EPDS], the depression module of the Patient Health Questionnaire [PHQ-9], the Whooley Questions and the Kessler Psychological Distress Scale [K-10]) found that:
- a score of 13 or more on the EPDS has moderate sensitivity and high specificity for detecting possible depression in pregnant women and a score of 10 or more has moderate sensitivity and specificity (high quality) NICE 2015
- it is uncertain whether the other tools (at relevant cut-offs) have adequate sensitivity or specificity to detect possible depressive disorders in pregnant women (very low to low quality) NICE 2015.
Assessment of the non-technical characteristics of the tools found that ease of administration and implementability were high for all tools, acceptability was high for the EPDS and unknown but likely to be good for the other tools. The EPDS is the only one of the tools for which effectiveness (defined as positive impact on depressive symptoms, services referred or utilised and impact on a woman’s mental health) is rated ‘good’ and that has been validated in other languages.
Recommendation
Use the Edinburgh Postnatal Depression Scale (EPDS) to screen women for a possible depressive disorder.
Approved by NHMRC in October 2017; expires October 2022
Recommendation
Arrange further assessment of woman with an EPDS score of 13 or more.
Approved by NHMRC in October 2017; expires October 2022
27.2.2 Other considerations in screening for depression
Timing of screening
The timing of screening should reflect available resources and existing contacts between the woman and the health professionals caring for her. An obvious contact point is the first antenatal visit. However, it is acknowledged that the time available at this visit and the number of other assessments undertaken may limit opportunities for assessment of mental health. Timing of repeat screening is based on results of the initial screen and clinical indications.
Recommendation
Conduct screening as early as practical in pregnancy and repeat at least once later in pregnancy.
Approved by NHMRC in October 2017; expires October 2022
Recommendation
For a woman with an EPDS score between 10 and 12, monitor and repeat the EPDS in 4–6 weeks as her score may increase subsequently.
Approved by NHMRC in October 2017; expires October 2022
Recommendation
Repeat the EPDS at any time in pregnancy if clinically indicated.
Approved by NHMRC in October 2017; expires October 2022
Mode of assessment
As a self-report tool, the EPDS is usually completed by the woman, preferably without consultation with others. At times it may be appropriate for a health professional to verbally administer the questionnaire (face-to-face or by phone). Electronic screening is an emerging practice.
Risk of harm
Regardless of the total EPDS score, perinatal women who score positive on Question 10 may be at risk of harming themselves and/or their children and further assessment is necessary.
Recommendation
For a woman with a positive score on Question 10 on the EPDS, undertake or arrange immediate further assessment and, if there is any disclosure of suicidal ideation, take urgent action in accordance with local protocol/policy.
Approved by NHMRC in October 2017; expires October 2022
27.2.3 Culturally appropriate screening for depression
Aboriginal and Torres Strait Islander women
For Aboriginal and Torres Strait Islander women, EPDS 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 (ie involvement of child protections services). 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. A recent adaptation of the EPDS assessed in the Kimberley region of Western Australia includes an additional component of psychosocial assessment, acknowledging the contribution that stressful events and social health issues play in mental health (Marley et al 2017). Many elements of the approach taken to adapting this instrument (ie the way in which questions are asked, implementation by Aboriginal health workers) are likely to have broader relevance to urban as well as remote and regional Aboriginal and Torres Strait Islander communities.
If use of the EPDS is considered inappropriate, involvement of an Aboriginal health worker may facilitate assessment of symptoms.
Recommendation
When screening Aboriginal and Torres Strait Islander women, consider language and cultural appropriateness of the tool.
Approved by NHMRC in October 2017; expires October 2022
Migrant and refugee women
Scores used to identify possible depression in migrant and refugee women are generally lower than those used in the general Australian population. Specific scores are given in translated versions of the tool.
Cultural practices (such as attending the consultation with a family member) and the perceived degree of stigma associated with depression may also influence the performance of the EPDS.
Recommendation
Use appropriately translated versions of the EPDS with culturally relevant cut-off scores.
Approved by NHMRC in October 2017; expires October 2022
27.3 Screening for anxiety
The evidence on screening for anxiety is heterogeneous in terms of study characteristics and cut-off values used and firm conclusions cannot be drawn.
In the absence of a freely available practical screening tool for anxiety disorders with adequate evidence in the antenatal period, clinical judgment must be used. This may include consideration of items 3, 4 and 5 of the EPDS Matthey et al 2013a, Matthey et al 2013b and relevant items from the Depression Anxiety Stress Scale (DASS), the K-10 and the Antenatal Risk Questionnaire (ANRQ).
Recommendation
Be aware that anxiety disorder is very common in the perinatal period and should be considered in the broader clinical assessment.
Approved by NHMRC in October 2017; expires October 2022
Recommendation
As part of the clinical assessment, use anxiety items from other screening tools (eg EPDS items 3, 4 and 5; Depression Anxiety Stress Scale anxiety items; and Kessler Psychological Distress Scale items 2, 3, 5 and 6) and relevant items in structured psychosocial assessment tools (eg the Antenatal Risk Questionnaire [ANRQ]).
Approved by NHMRC in October 2017; expires October 2022
27.4 Practice summary: depression and anxiety
When
As early as practical in pregnancy.
Who
- Midwife
- GP
- obstetrician
- Aboriginal and Torres Strait Islander health worker
- multicultural health worker.
What
- Establish referral pathways
Identify appropriate health professionals available to provide follow-up care and to assist if there are concerns for the safety of the woman or fetus. Identify other professionals from whom you can seek advice, clinical supervision or support regarding mental health care in the antenatal period. - Seek informed consent
Explain the purpose of screening for depression and anxiety and emphasise that this is part of usual care and results will generally remain confidential. - Identify level of support needed
Base decisions on follow-up on clinical judgement and the woman’s preferences, taking into consideration 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.
27.5 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
References
- 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.
- 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(3): 124–31.
- Fairbrother N, Janssen P, Antony MM et al (2016) Perinatal anxiety disorder prevalence and incidence. J Affect Disord 200: 148–55.
- Giallo R, Cooklin A, Nicholson JM (2014) Risk factors associated with trajectories of mothers' depressive symptoms across the early parenting period: an Australian population-based longitudinal study. Arch Womens Ment Health 17(2): 115-25.
- Giallo R, Pilkington P, McDonald E et al (2017) Physical, sexual and social health factors associated with the trajectories of maternal depressive symptoms from pregnancy to 4 years postpartum. Soc Psychiatry Psychiatr Epidemiol 52(7): 815-28.
- Giardinelli L, Innocenti A, Benni L et al (2012) Depression and anxiety in perinatal period: prevalence and risk factors in an Italian sample. Arch Womens Ment Health 15(1): 21–30.
- Grigoriadis S, VonderPorten EH, Mamisashvili L et al (2013) The impact of maternal depression during pregnancy on perinatal outcomes: a systematic review and meta-analysis. J Clin Psychiatry 74(4): e321–41.
- 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. Proceedings of the 1st Aboriginal and Torres Strait Islander Perinatal and Infant Mental Health Conference: Working with 'Ghosts in the Nursery', Sydney.
- Marc I, Toureche N, Ernst E et al (2011) Mind-body interventions during pregnancy for preventing or treating women's anxiety. Cochrane Database Syst Rev(7): CD007559.
- Marley JV, Kotz J, Engelke C et al (2017) Validity and Acceptability of Kimberley Mum's Mood Scale to Screen for Perinatal Anxiety and Depression in Remote Aboriginal Health Care Settings. PLoS One 12(1): e0168969.
- Matthey S, Fisher J, Rowe H (2013a) Using the Edinburgh postnatal depression scale to screen for anxiety disorders: conceptual and methodological considerations. J Affect Disord 146(2): 224–30.
- Matthey S, Valenti B, Souter K et al (2013b) Comparison of four self-report measures and a generic mood question to screen for anxiety during pregnancy in English-speaking women. J Affect Disord 148(2-3): 347–51.
- NICE (2015) Antenatal and Postnatal Mental Health. The NICE Guideline on Clinical Management and Service Guidance. London: National Institute for Health and Care Excellence.
- O'Donnell KJ, Bugge Jensen A, Freeman L et al (2012) Maternal prenatal anxiety and downregulation of placental 11beta-HSD2. Psychoneuroendocrinology 37(6): 818–26.
- Wisner KL, Sit DK, McShea MC et al (2013) Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry 70(5): 490–8.
- Woolhouse H, Gartland D, Mensah F et al (2015) Maternal depression from early pregnancy to 4 years postpartum in a prospective pregnancy cohort study: implications for primary health care. BJOG 122(3): 312-21.
- 19 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.
- 20 Period prevalence is the prevalence over a specific time period (eg from a longitudinal study) and point prevalence is that a specific point of time (eg from a cross-sectional study).