Diagnosing and managing perinatal depression in primary care

The risks of undertreated perinatal depression

The severity of perinatal depression is variable, but it can be associated with serious consequences for both the mother and fetus or infant. It can reduce quality of life and increase the risk of negative maternal behaviours such as smoking, excessive use of alcohol and substance misuse.^{6, 7} Antenatal depression has been associated with an increased risk of premature delivery, low birth weight, gestational hypertension and perinatal death.¹ Postnatal depression may adversely affect mother-infant bonding, potentially contributing to neglect or abuse, poor infant development and negative outcomes later in life.^{8, 9}

In severe cases, perinatal depression can lead to self-harm or suicide. The rate of maternal suicide in New Zealand is 4.06 per 100,000 maternities^*; seven times higher than in the United Kingdom.² Māori are disproportionately represented in these statistics, accounting for 57% of suicides in New Zealand during pregnancy or within six weeks of birth (2006–2016).²

Depression in a mother also places stress on her partner and their relationship, contributing to the risk of the partner developing depression (see: “Depression in partners is more likely in the postnatal period”).¹⁰

^* Maternities are all live births and all fetal deaths at 20 weeks gestation or beyond or weighing at least 400g if gestation is unknown.²

Co-operative care and communication reduces the risk of undertreatment

During pregnancy, birth and the postpartum period, women will usually interact with multiple healthcare professionals, including their lead maternity carer (LMC – generally a midwife) and Well Child Tamariki Ora providers, e.g. Plunket or Kaupapa Māori providers. It is important that general practices continue to be involved with women during the perinatal period and communicate with other healthcare providers, as appropriate, to ensure that any mental health issues are identified and managed effectively to minimise the risk of harm.

Further information is available from: “The role of the primary healthcare team in pregnancy care”

Risk factors for perinatal depression

Assess pregnant women for risk factors for depression (see below) to help identify those at higher risk; share any pertinent information with the LMC, with the woman’s permission, e.g. in a “Dear LMC letter”. The LMC should be asked to contact the primary care team if they develop concerns about the woman’s mental health.

Risk factors for perinatal depression include:

• A personal history of:
  • Previous mental health issues
  A personal history of depression is the strongest risk factor for perinatal depression.^{5, 11} Approximately half of women who have had multiple episodes of depression will relapse during pregnancy.⁵
  • Severe premenstrual syndrome (PMS)
  Severe PMS is a risk factor for postnatal depression as both conditions are linked to changes in the serotonin transport system¹²
• A family history of:
  • Mental health issues
  A first degree relative with a history of mental health issues is a risk factor for perinatal depression³
  • Severe perinatal mental illness
  A first degree relative with a history of severe perinatal mental illness is a risk factor for postpartum psychosis (see: “Postpartum psychosis is a medical emergency”)³
• Non-European ethnicity:
  • Māori
  In a survey of 1,144 women, 22% of Māori had symptoms of depression during late pregnancy, compared to 15% of non-Māori women.¹¹ This might be explained by Māori mothers having on average more risk factors for perinatal depression, e.g. being younger, a prior history of depression, fewer qualifications, lower income and greater psychosocial adversity due to racial marginalisation, compared to New Zealand European mothers.^{11, 13}
  • Pacific
  The Growing Up in New Zealand study found that almost one-quarter of pregnant Pacific women had symptoms of antenatal depression, rising to one-third in those aged under 25 years.¹⁴ This might be explained by Pacific mothers having similar risk factors for depression as those outlined above for Māori women.¹⁴
• Socioeconomic adversity:
  • Low income or unemployment
  • Reduced education
  • Experiences of discrimination or racism
  Māori, Pacific and Asian woman in the Growing up in New Zealand study who reported unfair treatment in the housing sector were more than twice as likely to experience postnatal depression; those that reported unfair treatment by a health professional were 1.66 times more likely to experience postnatal depression.¹³
• Unplanned pregnancies
The risk of maternal depression is increased in the first trimester of unplanned pregnancies, while the woman adjusts to the idea of being a mother⁵
• Teenage pregnancies
A New Zealand study of 1,144 women in late pregnancy found those aged 16–19 years were most likely to experience symptoms of depression or significant life stress during pregnancy; this association decreased with age.¹¹
• Loss of pregnancy
Pregnancy loss generally causes intense emotional distress which usually diminishes over time, but approximately 20% of women develop persistent symptoms of depression or anxiety.¹⁵ A mental health assessment six weeks following the loss of pregnancy is recommended, at which point persistent symptoms are more likely to be due to depression, rather than grief alone.¹⁵

Depression may be more difficult to detect during the perinatal period

Some symptoms, e.g. low mood, loss of pleasure or enjoyment, low self-esteem and feelings of self-worthlessness and guilt, may be more obvious than others, e.g. tiredness, sleep disturbance, changes in weight and loss of libido, when distinguishing depression from pregnancy-related changes and the demands of caring for an infant.⁵ There are also other causes of similar symptoms, e.g. iron deficiency anaemia and thyroid dysfunction may cause tiredness.⁵ Women with perinatal depression can also present with non-classical symptoms such as headaches, pain, anger, irritability or the use of alcohol or other substances.

Perinatal depression may be under-reported by women because they think the symptoms are normal or expected, they do not recognise that they are depressed or because they perceive that reporting symptoms would mean they were failing as a parent.⁵ Cultural differences may also influence how the symptoms of depression are reported or if they are reported at all.

The patient’s appearance, behaviour, body language and in some situations the rate, volume and content of their speech may be useful in diagnosing depression, anxiety disorders and other mental illnesses.⁵ Perinatal obsessive-compulsive disorder occurs in 2–3% of women.¹⁶ This is characterised by intrusive thoughts about causing accidental or intentional harm to the fetus or infant and ritualised behaviours performed to control the resultant anxiety.¹⁶ Post-partum psychosis occurs in < 0.1% of pregnancies; it can be characterised by a manic presentation, excessive sense of wellbeing, grandiosity or paranoia and a reduced need to sleep (see: “Postpartum psychosis is a medical emergency”).

Distinguishing depression from the “baby blues”

It is important to distinguish the persistent symptoms of depression from the transitory feelings of anxiety, unhappiness and fatigue associated with the rapid postpartum depletion of oestrogen. These transitory feelings of distress, sometimes referred to as the “baby blues”, are experienced by up to 80% of new mothers, typically beginning three days after birth and resolving in 10–14 days.¹⁷ Women with perinatal transitory distress can generally be managed with support and reassurance from an empathetic health professional, her partner, family and other support networks (see: “Resources for patients”). If symptoms persist for more than two weeks, postnatal depression is more likely.⁵

Screening questions and assessment tools

Screening questions are used to identify women who may benefit from a more structured assessment of their mental health, e.g. How often have you been bothered by:³

• ...feeling down, depressed or hopeless in the past month?
• ...having little interest or pleasure doing things in the past month?
• ...feeling nervous, anxious or on edge in the past two weeks?
• ...not being able to stop or control worrying in the past two weeks?

If the patient reports that they have been bothered by any of these symptoms a full assessment is recommended using the Patient Health Questionnaire (PHQ-9) or the Edinburgh Postnatal Depression Scale (EPDS), and the Generalised Anxiety Disorder 7-item (GAD-7) scale if anxiety is thought to be a significant component (see: “Tools to assess mental health”).

Perform a risk assessment

Following a diagnosis of depression, a risk assessment for the mother and any children should be performed. This is best done transparently to avoid increasing maternal anxiety.⁵ An appropriate question may be:

After having a baby lots of women feel down, some may even think about harming themselves or their baby. Have you ever had thoughts like this?

Assess the woman’s access to social supports and her ability to cope with any children and provide contact details for resources and services (see: “Resources for patients”). The presence of additional risk factors, e.g. relationship problems or domestic violence, should be identified.

Refer to secondary care if symptoms are severe or the woman is at serious risk

Women with severe mental illness during the perinatal period should be managed in secondary care as they require more intensive treatment to reduce the risk of serious adverse outcomes including maternal suicide, stillbirth and neonatal death.⁷ Refer pregnant women to a secondary mental health service if they have a history of severe mental illness or they develop symptoms consistent with severe mental illness,³ e.g:

• A recent significant deterioration in mental state
• Thoughts of harm to self or the baby, or suicidal thoughts
• Psychotic or manic features

Non-pharmacological interventions are recommended for all patients with depression or anxiety

Non-pharmacological interventions are the first-line treatment for depression or anxiety. These focus on promoting a healthy lifestyle with adequate nutrition, exercise and sleep and providing psychoeducation, i.e. information and problem-solving techniques, developing coping strategies, building resilience against relapses and establishing social supports. The patient’s thoughts and concerns should be explored to identify contributing factors, e.g. a perceived failure to meet expectations, problems with the physical limitations of pregnancy and childbirth, financial concerns or social isolation.²² If there are financial or accommodation stressors it may be helpful to provide a letter of support to a relevant agency.

Support groups can be valuable as they help to connect people with similar experiences and facilitate socialising, e.g. antenatal group meetings or Parents Centre groups (see: “Resource for patients”).

Encourage engagement with friends and family

Behavioural activation, e.g. re-engaging with enjoyable activities and the support of family/whānau/friends, should be encouraged. In general, recommend face-to-face contact with friends and family and that social isolation be avoided. Social media may exacerbate unrealistic expectations of motherhood and it may be appropriate to recommend that some patients minimise their contact with these platforms.

Cognitive behavioural therapy is the most effective perinatal psychological intervention

Cognitive behaviour therapy (CBT) is a form of psychotherapy that helps people understand their response to challenging circumstances, thereby enabling them to improve their management of the situation. Online CBT is available (see: “Resources for patients”). Patients may also be referred to counselling (depending on local availability) or pay for private sessions with a clinical psychologist. CBT is associated with significant improvements in the symptoms of postnatal depression over the short and long-term.²³

Several other psychological therapies may also be used to manage perinatal depression and anxiety, although they are less commonly available than CBT. Interpersonal therapy (IPT) focuses on resolving relationship problems and is an effective intervention for depression during pregnancy, although in general it appears to be less effective than CBT.²⁴ Acceptance and Commitment Therapy (ACT) utilises mindfulness and focuses patients on values, forgiveness, acceptance and compassion. Several trials are currently assessing the effectiveness of ACT in treating perinatal mood disorders.

The pharmacological management of perinatal depression

The indications for the pharmacological treatment of perinatal depression are the same as for depression occurring at other stages, i.e. moderate to severe depression or persistent mild to moderate depression that has not responded to non-pharmacological interventions.^{8, 21}

Women can be reassured that the benefits of appropriately prescribed antidepressants generally outweigh the risks.^{1, 7} If a woman already taking an antidepressant becomes pregnant it is recommended that she continue taking the same medicine (see: “Withdrawing antidepressants during pregnancy is not recommended”).⁷

The potential for an antidepressant to cause adverse effects in the fetus or breastfeeding infant is influenced by a number of factors, including:⁷

• The timing of exposure during pregnancy
• The individual risks associated with the specific antidepressant
• The infant dose received while breastfeeding

The differences in the relative safety between antidepressants is, however, not considered to be sufficient to outweigh the potential risks of switching antidepressants in women who are already receiving effective treatment.⁷ Breast feeding is encouraged regardless of the antidepressant that is being taken.¹

SSRIs are often the preferred antidepressants during the perinatal period

SSRIs have been extensively studied during the perinatal period and are generally the preferred class of antidepressant during this time on the basis of safety and efficacy (see: “The risks of taking SSRIs during the perinatal period”).⁷ SSRIs are also generally the first-line antidepressant for depression occurring at other stages of life, therefore continuity of pharmacological treatment may be a consideration for some patients.

Sertraline, citalopram and escitalopram are the first-choice SSRIs

Sertraline is often preferred for women with perinatal depression as it has the lowest infant exposure during breast feeding.^{1, 7} There is also evidence suggesting that sertraline is the SSRI associated with the lowest risk of persistent pulmonary hypertension (PPHT).²⁵ Citalopram and escitalopram are also reasonable choices during the perinatal period on the basis of safety and efficacy.^{1, 26}

Paroxetine has low to undetectable serum levels in breastfed infants, however, an increased risk of congenital cardiac defects and neonatal behavioural syndrome following in utero exposure means that another SSRI would generally be preferred.^{7, 26} Fluoxetine is the least preferred SSRI during breastfeeding, as its long half-life increases exposure in breastfed infants.^{1, 27}

Prescribe the same SSRI if previous treatment has been successful

For women with a history of successful treatment with a SSRI, it is recommended that clinicians offer the same medicine, unless there are compelling reasons to recommend an alternative.⁷ When discussing options with the patient, the rationale is that it is preferable to prescribe a medicine that is known to be tolerated and effective for an individual, even if there is research suggesting the risks may be lower in an alternative medicine.⁷

Prescribe the lowest effective dose

Treatment with an SSRI should begin at the lower end of the therapeutic dose range, e.g. 50 mg of sertraline daily,²⁷ and then slowly titrated upwards, if necessary, until the woman feels that her symptoms are manageable. It is important to be mindful of the risks of under-dosing which may expose the woman and fetus to adverse effects without treating the depression adequately.⁵ It may be necessary to increase the dose of the antidepressant during the third trimester to account for changes in metabolism or haemodilution if clinical monitoring indicates that depressive symptoms are returning. If the woman’s symptoms are well-controlled the previous dosing regimen can be reinstated in the weeks following childbirth.

The optimal duration of treatment is unknown

There is no specific guidance for the duration of antidepressant treatment for perinatal depression.⁵ A similar duration of treatment for depression occurring at other stages of life is therefore recommended, i.e. for at least one year following a single episode of depression and at least three years for recurrent episodes.⁸ Earlier withdrawal of an antidepressant may be considered for patients who have responded well to treatment. The PHQ-9 questionnaire can be used to assess treatment response and guide treatment decisions.

Second-line options if SSRIs are ineffective or not tolerated

Tricyclic antidepressants (TCAs) are generally considered to be safe during pregnancy and breastfeeding and are associated with a similar risk of fetal and infant adverse effects as SSRIs.⁷ TCAs are, however a second-line option as they may cause maternal adverse effects such as sedation and are more likely to be fatal in overdose.²⁶

Venlafaxine may be a treatment option for women who have not responded to an SSRI, however, due to an increased risk of neonatal withdrawal (including seizures), venlafaxine is only considered if safer treatment options have not been successful.^{26, 27}

Antidepressants should be withdrawn gradually

If an antidepressant is withdrawn, this should be done slowly with the woman monitored closely for symptoms of relapse and SSRI discontinuation reactions, and where appropriate other health professionals involved in her care informed.⁷ It may also be necessary to intensify non-pharmacological treatment.

Further information on the use of antidepressants for the treatment of depression is available from: “The role of medicines for the management of depression primary care”

Arrange a follow-up within the next two weeks

Active follow-up is recommended for all patients who present with mental health issues, e.g. negotiate a review plan involving a phone call from the practice after 24–48 hours, a follow-up appointment in one or two weeks and where appropriate passing on any relevant information to her LMC.²⁸ If the patient does not attend the follow-up appointment, they should be contacted to check on their well-being.⁵

Encourage the patient to bring her partner or other family member to the next consultation as their support is important and they may provide insights into her condition. The partner should also feel supported by the primary care team and know who to contact if they have concerns.

For further information on identifying and managing perinatal depression, see the Goodfellow Unit webinar presented by Dr Mark Huthwaite: www.goodfellowunit.org/events/perinatal-mood-and-anxiety-disorders