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The purpose of this journal is to examine the assessment and management of depression in women during the antenatal and postnatal periods. It is the second of three follow-up publications which supplement the Best Practice Journal, Special Edition: “Adult Depression”, published in June 2009.

The Evidence Based Practice Guideline for the Identification of Common Mental Disorders and Management of Depression in Primary Care,1 published in July 2008 by the New Zealand Guidelines group, has formed the basis of this publication. It is intended as a resource for all primary care practitioners - including general practitioners, midwives and practice nurses.

This publication focuses on the management of depression, however any mental health disorder can occur during the antenatal and postnatal periods, including anxiety, bipolar disorder, substance use disorder and affective psychoses. The characteristics and presentation of mental health disorders in the antenatal and postnatal periods are similar to that in other adult women. However, there are some differences to consider and the treatment of mental health disorders during this period often poses challenges, especially regarding the use of antidepressants, antipsychotics and mood stabilisers during pregnancy or breastfeeding.

This publication is also a supporting information resource for the bestpractice Decision Support Module which is freely available to all New Zealand general practices.

Recommendations and key practice points

(Adapted from NZGG, 20081)

  • History

    As part of routine antenatal care, the practitioner should enquire whether a woman has any history of mental health disorder or any family history of mental illness including in the antenatal or postnatal periods.

  • Contact and screening questions

    On first contact with primary care, and subsequent postnatal checks, the practitioner should consider the use of the verbal two to three question screening tool for depression as part of routine assessment. Screening questions for anxiety and substance abuse should also be considered.

  • Further assessment

    If a woman’s response to a verbal two to three question screening tool arouses concern about a possible mental disorder (or if other issues do so) she should normally be referred promptly for further clinical assessment by her GP. This should include a check for suicidal ideation or intent. It is important to differentiate postnatal depression from milder “baby blues” or more severe bipolar disorder or psychosis (see here).

  • Information - Risks and benefits of treatment

    A woman with depression in the antenatal or postnatal period should be informed of the risks and benefits of treatment options including the risks of untreated depression.

  • Collaboration

    There should be close collaboration and sharing of information between the midwife, general practitioner and other practitioners involved in the care of a woman with antenatal or postnatal depression. All relevant information should be available to the Lead Maternity Carer.

  • Empowerment, communication and the wider family/whanau environment

    Involve women in decisions about their care. If possible, family/whanau should also be involved. Good communication is important; patients, relatives and carers should be given information that is easy to understand. Consider the needs of other children and the impact of the illness on relationships.

  • Active support and management

    This includes education, activities and the involvement of family/whanau and appropriate support people and groups. This should be combined with, and maintained during, all other treatment strategies. A woman with depression in the postnatal period should be encouraged to attend a mother and infant support group.

  • Consider non-pharmacological interventions

    Non-pharmacological interventions such as enhanced social support and/or a psychological therapy should be considered before prescribing medication for depression during pregnancy or postnatal depression, especially for a woman with mild symptoms, or in early pregnancy (first trimester).

  • Mild to moderate depression

    A brief psychological intervention, e.g. six to eight weeks of non-directive counseling, interpersonal therapy (IPT) or cognitive behavioural therapy (CBT), should be considered as a first line intervention in the management of a woman with mild to moderate depression in the antenatal or postnatal period. If there is no response to initial treatment, a more structured psychological therapy, e.g. longer courses of CBT or IPT, could be considered, in consultation with maternal mental health services.

  • Moderate to severe depression

    An antidepressant may be considered as first-line treatment for a woman with moderate to severe depression in the antenatal or postnatal period, after discussion of the likely benefits, risks of untreated depression and possible risks of treatment. A woman with severe depression should be managed in consultation with maternal mental health services or other appropriate psychiatric services.

  • Antidepressants in pregnancy and breastfeeding

    If any woman who is pregnant or planning pregnancy is being treated with an antidepressant, her treatment preference, previous history and risk should be reviewed. If appropriate, attempts should be made to withdraw the antidepressant and substitute an alternative treatment and/or ensure that the antidepressant with the lowest risk profile is used. Most commonly used antidepressants are considered to be compatible with breastfeeding.

Complications and consequences of depression in the antenatal or postnatal period2,3

Severe depression in these periods is associated with:

  • Poorer long-term outcomes for the child, including cognitive, emotional and behavioural difficulties
  • Adverse effects in other children, the woman’s partner and the family’s socioeconomic situation
  • Relationship difficulties - the woman’s partner may also become depressed
  • Suicidal behaviour - in the developed world, suicide is the major cause of maternal death in the first year postpartum, mainly due to relapse of severe mental illness. However, the suicide rate in age-matched, non-postpartum women is higher..2