Grades of recommendation (A-D and good practice point [GPP]) are defined at the end of the "Major Recommendations" field.
For the purposes of these guidelines, 'perinatal' is defined as the period covering pregnancy and the first year following pregnancy or birth.
Effective Care of Mental Health in the Perinatal Period
GPP - Primary and maternity care services should develop locally relevant strategies to ensure that they can provide appropriate, culturally responsive psychosocial care to all women in their communities.
GPP - Involving members of a woman's support network in her care as early as practical provides opportunities for all involved to gain an understanding of the impact of pregnancy and early parenthood on emotional health and well-being. It also enables assessment of psychosocial factors affecting family members and family relationships.
GPP - Psychoeducation for women and, where appropriate, their significant other(s) should be a routine component of care in the perinatal period. This should include discussion of mental health and provision of educational materials (e.g., the beyondblue Emotional Health During Pregnancy and Early Parenthood booklet).
GPP - Health professionals should ensure that communication with women in the perinatal period is empathic and non-directive, and that discussions are woman-centred.
C - As a minimum, all health professionals providing care in the perinatal period should receive training in woman-centred communication skills and psychosocial assessment.
GPP - Health professionals involved in managing women's mental health during the perinatal period should seek ongoing support or mentoring.
GPP - Clinical judgement is central to decision-making about further support and/or referral, as it informs the interpretation of answers to the psychosocial factor assessment and scores derived from the Edinburgh Postnatal Depression Scale (EPDS).
GPP - As early as practical in pregnancy and 6–12 weeks after a birth, all women should be asked questions around psychosocial domains as part of normal care. If a woman affirms the presence of psychosocial factors, she should be asked whether she would like help with any of these issues.
B - The EPDS should be used by health professionals as a component of the assessment of all women for symptoms of depression in the antenatal period.
GPP - Consider a score on the EPDS of 13 or more for detecting symptoms of major depression in the antenatal period.
B - The EPDS should be used by health professionals as a component of the assessment of all women in the postnatal period for symptoms of depression or co-occurring depression and anxiety.
C - A score of 13 or more can be used for detecting symptoms of major depression in the postnatal period.
GPP - Health professionals should be aware that women who score 13 or more on the EPDS may be experiencing anxiety, either alone or co-occurring with depression. Decision-making about further assessment for anxiety should take into account the woman's answers to questions 3, 4, and 5 of the EPDS and her response to the psychosocial assessment question about 'worrying'.
GPP - The non-diagnostic nature of the EPDS, its purpose (identification of women who may benefit from follow-up care) and the fact that it relates to the previous 7 days (not just that day) should be clearly explained to all women by the administering health professional.
GPP - All women should complete the EPDS at least once, preferably twice, in both the antenatal period and the postnatal period (ideally 6–12 weeks after the birth). Administration of the EPDS can be readily integrated with existing routine antenatal and postnatal care.
GPP - While the EPDS is a self-report tool, in some cases (e.g., difficulties relating to language or literacy, cultural issues, disability), it may be appropriate for it to be administered verbally.
GPP - For women who score 10, 11, or 12 on the EPDS: administration of the EPDS should be repeated within 2–4 weeks, and existing support services reviewed and increased if needed.
GPP - For women who score 13 or 14 on the EPDS (once postnatally or twice antenatally): referral to an appropriate health professional (ideally their usual general practitioner [GP]) should be made.
GPP - For women with high scores on the EPDS (e.g., 15 or more): the administering health professional should ensure access to timely mental health assessment and management.
GPP - For women who score 1, 2, or 3 on EPDS Question 10: the administering health professional should assess the woman's current safety and the safety of children in her care, and act according to clinical judgement, seek advice, and/or refer immediately for mental health assessment.
Other Assessments in the Perinatal Period
GPP - Assessing the mother–infant interaction should be an integral part of the care of women in the postnatal period.
GPP - Where significant difficulties are observed with the mother–infant interaction and/or there is concern about the mother's mental health, the risk of harm to the infant should be assessed.
GPP - Comprehensive mental health assessment is required for women with reported or observed marked changes in mood, thoughts, perceptions, and behaviours in the early postnatal period.
GPP - Women identified as being at risk of suicide (through clinical assessment and/or the EPDS) should be specifically assessed. Any immediate risk should be managed and support and treatment options considered. Enquiry about the safety of the infant should also be made.
Acting on Psychosocial Assessments
GPP - In cases where comprehensive mental health assessment is required, health professionals should identify referral options and actively encourage and support women to use them.
GPP - Primary care health professionals have an ongoing role in the psychosocial care of women in the perinatal period, whether they provide treatment or refer the woman to a health professional with mental health expertise.
Supporting Emotional Health and Wellbeing in the Perinatal Period
GPP - Women in the perinatal period may benefit from being provided with reliable advice on lifestyle issues and sleep, as well as assistance in planning how this advice can be incorporated into their daily activities during this time.
C - Non-directive counselling in the context of home visits can be considered as part of the management of mild to moderate depression for women in the postnatal period.
GPP - Psychological therapies in the perinatal period should be undertaken by registered practitioners with accredited training in the relevant therapy.
GPP - Decision-making about the type of psychological therapy should be based on the woman's preferences, the suitability of a particular therapy to the individual woman, the severity of her disorder and the availability of a suitably trained practitioner.
B - Cognitive behavioural therapy should be considered for treating women with diagnosed mild to moderate depression in the postnatal period.
C - Interpersonal psychotherapy can be considered for treating women with diagnosed mild to moderate depression in the postnatal period.
D - Psychodynamic therapy can be considered for treating women with diagnosed mild to moderate depression in the postnatal period.
GPP - When a woman is experiencing a significant mental health disorder and has difficulties interacting with her infant, both problems need to be addressed. The wellbeing of the infant needs to be considered at all times.
GPP - In decision-making about the use of pharmacological treatment in the antenatal period, consideration should be given to the potential risks and benefits to the pregnant woman and fetus of treatment versus non-treatment.
GPP - In decision-making about the use of pharmacological treatment in the postnatal period, this needs to be weighed against minimal possible exposure to the infant during breastfeeding.
GPP - When the risk of birth defects is discussed, women should be provided with a detailed explanation of the baseline, absolute and relative risks to the fetus or infant of pharmacological treatment, as well as the potential impact on the offspring of treatment versus non-treatment.
Depression during Pregnancy
GPP - If a decision is made to commence or continue antidepressant medication during pregnancy, use of selective serotonin reuptake inhibitors (SSRIs) can be considered as this is the antidepressant category about which most is known. The current evidence on SSRIs shows no consistent pattern of additional risk of birth defects. While the safety of tricyclic antidepressants (TCAs) is supported by a lesser body of evidence, they can also be considered, especially if they have been effective previously.
GPP - If a decision is made to discontinue or decrease antidepressant medication, it is important to gradually taper the dose, closely monitor, and have a plan to identify relapse early.
GPP - Withdrawal symptoms of antidepressants need to be distinguished from symptoms of relapse, therefore close monitoring post discontinuation/reduction is essential. Expert psychiatric advice should be sought if necessary.
GPP - Guidelines for the use of antidepressants in the general population should be consulted (see Appendix 6 of the original guideline document).
Anxiety Disorders during Pregnancy
GPP - Use of benzodiazepines can be considered for short-term treatment of severe anxiety in pregnant women while awaiting the onset of action of an SSRI or TCA. Long-acting benzodiazepines should be avoided as much as possible.
GPP - Guidelines for the use of benzodiazepines in the general population should be consulted (see Appendix 6 of the original guideline document).
Bipolar Disorder during Pregnancy
GPP - Sodium valproate should not be prescribed for bipolar disorder in women of childbearing age. Exposure in pregnancy is associated with an increased risk of major birth defects and adverse cognitive outcomes for the infant.
GPP - If a decision is made to discontinue or decrease a mood stabiliser during pregnancy it is important to closely monitor and have a plan to identify relapse early.
GPP - Clozapine should not be initiated during pregnancy. Wherever possible an alternative antipsychotic should be used for women contemplating pregnancy or already taking clozapine on presentation.
Depression in the Postnatal Period
GPP - Women with healthy full-term infants who plan to breastfeed can be advised that SSRIs are not contraindicated.
Anxiety Disorders in the Postnatal Period
GPP - Use of benzodiazepines can be considered for short-term treatment of severe anxiety in breastfeeding women while awaiting the onset of action of an SSRI or TCA.
Bipolar Disorder and Puerperal Psychosis in the Postnatal Period
GPP - If a decision is made to not recommence a mood stabiliser immediately after the birth, it is important to closely monitor and have a plan to identify relapse early, given the increased risk of relapse at this time.
GPP - The passage of lithium into breast milk is more variable than other psychotropic medications. If the woman chooses to breastfeed, lithium should be used with particular caution. The decision should be made in consultation with a specialist physician and where possible there should be ongoing specialist monitoring for potential adverse effects on the breastfed infant.
GPP - Where possible, clozapine is best avoided in breastfeeding mothers due both to relatively high breast milk concentrations and possible toxic effects for the infant.
GPP - If antipsychotics are prescribed, consideration needs to be given to the woman's physical activity levels and diet to minimise weight gain associated with antipsychotic use.
Definition of Grades of Recommendations
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation(s) but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Source: NHMRC Levels of Evidence and Grades for Recommendations for Developers of Guidelines (NHMRC 2009).
For areas of clinical practice where evidence is lacking or limited, the Guidelines Expert Advisory Committee developed good practice points (GPPs) based on lower quality evidence and clinical consensus.