Published: 17 December 2019
It is strongly recommended that the linked article is read before considering the questions.
Depression and anxiety are the most common mental health
issues women experience in the perinatal period. It is important
that these conditions are effectively managed as the potential
consequences can be severe. Suicide is the leading cause of
maternal mortality in New Zealand with rates* seven times higher
than in the United Kingdom; over half of these deaths (57%) occur in Māori.
* The rate of maternal suicide in New Zealand is 4.06 per 100,000 maternities, i.e.
all live births and all fetal deaths at 20 weeks or beyond or weighing at least 400g if gestation is unknown
To identify potential mental health issues early, primary
healthcare professionals should consider the presence of risk
factors for women who are trying to conceive or once their
pregnancy has been confirmed. When a woman is identified
as needing additional mental health and wellbeing support,
there needs to be a clear understanding between the patient,
the LMC and the general practice about who is taking overall
clinical responsibility for this. It is important that general
practices continue to be involved during the perinatal period
and to communicate with other healthcare providers, where appropriate.
Some of the symptoms associated with perinatal depression,
e.g. tiredness, sleep disturbance, changes in weight and loss of
libido, can be difficult to distinguish from pregnancy-related
changes and the demands of caring for an infant. It is therefore
important to distinguish the persistent symptoms of depression
from the transitory feelings of distress, sometimes referred to
as the “baby blues”, that are experienced by up to 80% of new
mothers, typically beginning three days after birth and resolving
in 10–14 days. If symptoms persist for more than two weeks,
postnatal depression is more likely
Screening questions are used to identify women who may
benefit from a more structured assessment of their mental
health. Active follow-up is recommended.
The management of perinatal depression follows a similar
approach to depression at other stages in life, but with the
additional considerations of the pregnancy, fetus or infant and
the mother-infant relationship:
- Mild depression is treated with behavioural and psychological interventions, reassurance and support
- Moderate to severe depression or persistent depression usually requires the addition of an antidepressant; generally a selective serotonin reuptake inhibitor (SSRI)
Management is also guided by the relative success of any
treatments for previous episodes of depression and the
patient’s preference for treatment. Referral to secondary care
is appropriate for women with severe mental illness, including
post-partum psychosis which is a medical emergency most
likely to occur three to ten days after birth.
Non-pharmacological interventions are the first-line treatment
for depression or anxiety, e.g. behavioural activation (connecting
with family/whānau and friends), exercise, relaxation techniques,
cognitive behavioural therapy (CBT) and avoiding alcohol and
drugs . These interventions focus on developing coping strategies,
building resilience against relapses and establishing social
supports. Social media may exacerbate unrealistic expectations
of motherhood and it may be appropriate to recommend that
some patients minimise their contact with these platforms.
When considering pharmacological treatments for perinatal
depression, explain to patients that the benefits of
antidepressants prescribed appropriately generally outweigh
the risks. Sertraline, citalopram and escitalopram are often the
preferred SSRIs due to their relative safety and efficacy. The
differences in the safety of antidepressants does not, however,
outweigh the potential risks of switching antidepressants in
women who are already receiving effective treatment. Breast
feeding is encouraged regardless of the antidepressant that is being taken.
Questions for discussion
- What factors do you think might contribute to the high rate of maternal suicide in New Zealand in comparison with other countries such as the United Kingdom? What can
health professionals in primary care due to help to reduce this burden, especially among Māori?
- What strategies, if any, does your practice have to increase opportunities to assess the mental health of new and expectant mothers and their families/whānau?
- What do you think are the risk factors to identify women who are more likely to experience perinatal depression? Or do you not think that it is possible to predict this?
- It can be challenging to distinguish women with transient stress and anxiety in the perinatal period from those with
persistent depression. Are there certain clinical features that help you to make this distinction?
- What non-pharmacological treatments do you think are most useful for women with perinatal depression? Do you
recommend online CBT? If so, are there particular courses that you choose and why?
- If pharmacological treatment is indicated, what are the main factors that you consider when selecting an antidepressant
for a woman who is pregnant or who is breastfeeding? How long do you usually continue treatment for?