sMater | Majella Henry | Perinatal anxiety & depression

One in every five Queensland mothers experience perinatal mental health challenges in the first year after their baby's arrival. 

In this episode of sMater, Dr Majella Henry delves into the factors that increase the risk of perinatal anxiety and depression and discusses new tools for diagnosing patients.

References: Trends of perinatal mental health referrals and psychiatric admissions in Queensland - Macarena A San Martin Porter, Joemer Maravilla, Steve Kisely, Kim S Betts, Caroline Salom, Rosa Alati, 2023

GP Education activity log:
  Podcast title - sMater: Perinatal anxiety & depression
  Provider - Mater Misericordiae Ltd
  Date published - November 18, 2024
  Certificate of completion - click here

To learn more about Mater, visit https://www.mater.org.au/

Transcript

Hello and welcome to this episode of sMater. A podcast by clinicians for clinicians brought to you by Mater, an Australian leader in healthcare for more than a century. My name is Jillian Whiting and we're coming to you from Meanjin the land on which this podcast is being recorded. Hello I'm Maggie Robin, Community GP rural GP obstetrician at Beaudesert Hospital and coordinator of Mater's GP shared care education program.

In this episode we're talking about perinatal anxiety and depression with Dr Majella Henry from Mater Mothers Parenting Support Centre. Majella is a GP with a special interest in mental health and women's health. She's worked for many years with women and families with perinatal mood disorders. Majella is joining us to talk about identifying and responding to perinatal mental health conditions.

We are Mater. We are Mater. We are Mater. This is sMater.

Majella, how common are anxiety and depression in the perinatal period?

So the Queensland Health guidelines for perinatal depression and anxiety have just come out in 2023 and they have some really useful stats in them but they quote 1 in 5 women will experience anxiety or depression or a mixture of both in the perinatal which we classify as from conception up until the first year postpartum. 1 in 10 partners will experience anxiety or depression in that same time and I think the thing to remember is for about 25% of women this can be their first incidence of anxiety and depression so in a time when they anticipate joy or a really exciting period of their life they can be met with symptoms that are really scary and for them quite new.

A 2022 publication that we will link to in the podcast notes from the Australian and New Zealand Journal of Psychiatry show that between 2009 to 2015 there was an increase in referrals for mental health care during the perinatal period while postpartum admissions for mood disorders actually decreased. What how do you think we can interpret from that?

Yeah that's really disheartening isn't it because I think that what we've always known about the perinatal period is early intervention is key so that if these families seek support early that that we really can make a difference and work with families in getting them the support they need.

Are there features of perinatal anxiety and depression that set them apart from anxiety and depression at other stages of life?

Well interestingly no Maggie so the DSM-5 actually to define perinatal anxiety and depression is all about timing so we use the same criteria that we would with any other patient to diagnose their anxiety and depression but if it occurs from conception until 12 months postpartum it is coined perinatal. I think that's really interesting because I feel like it is actually a different phenomena because for me when I ever I'm seeing a new patient in this period I'm actually conscious that I've got two patients in the postpartum and always thinking of the patient as a dyad because the mother and baby are so intimately linked and we can't remove one from the other so we need to treat them as such.

How can you tell it's not what is generally termed baby blues and it potentially could be something more serious?

Yeah that's a good question. It's actually quite difficult to tease out Baby Blues versus postnatal depression or anxiety because they actually look the same so when we're thinking about those early days in the postpartum period so classically we call Baby Blues from about day 3 to day 10 so it is time limited. 

We're not really sure what causes baby blues but the theory is that there's very pregnancy is a high estrogen state and within a few days postpartum those estrogen levels have dropped and so there's a big hormonal shift and that we think contributes to feeling teary, anxious, poor sleep, insomnia is a really common feature but what we see is that they should alleviate within that week so from day 3 to day 10 we should start to see a resolution of those symptoms if we don't so in fact and as many GPs will know to diagnose anxiety we need persistent which is at least two weeks of persistent low mood and so if those baby blue symptoms are prolonged if the distress continues and that's really when women need a full mental health assessment to see whether actually the baby blues has persisted and when more thinking about a diagnosis of depression or anxiety. 

I think it's important to note there are a couple of symptoms that are really prominent in the perinatal period actually in depression and one of those is poor sleep so the inability to sleep when actually you're feeling very tired can be a sign that your anxiety's up or your depression or your mood is depressed. The second thing is this poor appetite so in a time when actually you have an increased calorie need sometimes anxiety suppresses our appetite so you should be tired and you should be hungry is what I always say to mums and when it's difficult to sleep and difficult to eat they're really good signs that anxiety and depression are increasing. The other thing that's prominent in the postnatal period is anhedonia now we describe that as a loss of interest or pleasure and often times again as I was saying when parents are anticipating to feel this to be a really exciting time they can't they can't find much joy and pleasure and that's anhedonia  a really strong feature of perinatal depression.

In the anxious parent as well as having the normal criteria of anxiety that that is listed in the DSM-5 we actually see a really increased rate of intrusive thoughts. Now intrusive thoughts are thoughts that pop into our head that are distressing some really common ones that that women will describe in the postpartum are things like the thought that you'll drop your baby or being on a deck and a thought pops into your head that your baby could fall over. These thoughts are not thoughts that mothers want to harm their babies but instead intrusive thoughts that harm will come to your baby. They're really common they're common in actually most women have describe that they have experienced them but for anxious women they're happening many times a day and they're causing a lot of distress and they find it really difficult to come down from that high anxiety.

What's the best method for screening for perinatal depression and anxiety and when's the best time to do it?

So we use the Edinburgh postnatal depression scale which is has been around for many years. It's a really acceptable screen to women. It's only 10 questions so it can be done really within 5 minutes. It's validated and it has quite good sensitivity and specificity so it's quite good at picking up who it's worth doing a further assessment on. We usually use the cut off of an EPDS greater than 12 is worth pursuing a mental health assessment. It is important to note that in the EDPS screen we the question number 10 is a question of thoughts of self harm and of course doesn't really matter what the score is if your patient has answered positively to that question of course we need to do some safety planning and some further support around that.

In terms of the timing of screening so in pregnancy we recommend as soon as practically possible so in the in the first trimester would be good and that often falls to GPs to do that screening but it also through the public health system through antenatal care that will be done in the first to second trimester then we recommend somewhere in the third trimester often done around 28 weeks and as I said that's done really well. What is still unfortunately a little bit inconsistent is postpartum screening so we recommend that parents are screened within 6 to 12 weeks postpartum and then again within the first year of life but really that screen can be used at any time when somebody walks into your office and you're a little bit worried about their mood or they're not presenting quite like themselves so we urge you know a lot of that work will fall to GPs to be doing those postpartum screening.

A 2018 Australian study involving 1,507 women collected data from pregnancy through to 4 years postpartum. Findings revealed that self harm ideation was most frequently reported within the first 12 months postpartum with a prevalence of 4.6%. Throughout the study period 15% of women reported self harm ideation at least once and 7% experienced persistent thoughts of self harm indicating chronic distress with potential implications for the parent infant relationship. While the majority of women with suicidal ideation do not act on these thoughts it signifies underlying psychiatric conditions particularly postpartum psychosis bipolar effective disorder and depression. 

Is there a typical patient who is likely to be at risk and someone that GP should keep a closer eye on?

Certainly. There are some psychosocial risk factors that would make postnatal or perinatal anxiety and depression more likely. These are actually covered in what's called the antenatal risk questionnaire which is the Center of Perinatal Excellence (the COPE guidelines) actually recommend that in pregnancy we do antenatal screening to try to identify risk factors that may make anxiety and depression more likely so some of the things covered in there is a previous history of anxiety depression or any mental health disorder, a history of childhood adverse events yourself so certainly any form of trauma in your childhood can put you at greater risk an absent or difficult relationship with your own mother or parents put you at increased risk. 

Certain personality traits maybe people who identify as being anxious worriers or have perfectionistic traits and also current levels of stress what's happened in the last 12 months and included in this can be maybe a difficult fertility journey leading up to this pregnancy or recent bereavement, financial stress of course domestic and family violence is something that that is also worth asking about. Most of those things are covered in the antenatal risk questionnaire so that it's a lovely again a short questionnaire that that helps you as the GP actually open up some conversation about what's potentially putting your patients at risk.

What about postpartum?

Well actually there is a newly developed postnatal risk questionnaire and it does it covers a lot of the same things as the antenatal risk questionnaire, but it adds a couple of things which are really important one is birth experience so we know that having a traumatic birth certainly puts women at increased risk it we can also ask it in the postnatal risk questionnaire there about feeding issues, levels of support, so when mums are feeling isolated and have limited support that really does increase their risk.

It's also important to include First Nations people. What unique challenges are there with treating first nation's population?

Yeah unfortunately as with most mental health diagnosis the First Nations population we do see an increase in perinatal anxiety and depression. The EDPS has been um modified a little bit and it's a to it's a scale called the Kimberly Mums Mood Scale which is more culturally appropriate for First Nations women so I think probably the first tip is that screening may we may not be able to use the typical screens and and looking at the the screening tools that are more appropriate. We need to really be conscious of asking the question and then following up with what will be culturally safe and appropriate care maybe through an Aboriginal and/or Torres Straight Islander Medical Centre. 

What are the key principles of treatment for perinatal anxiety and depression?

I think we start with the basics. Sometimes as GPs we want to reassure and normalize and we need to be careful in fact a lot of there's a lot of consumer feedback to say that women felt quite dismissed in this period and I think it's I don't think it's intentional I think it's good natured but it's kind of those off the hand comments like oh the first six weeks is tough for everyone or yeah you'll get no sleep you know and it's to be expected I think that sometimes patients do feel it's minimizing their symptoms and and I think it shuts down the conversation when you know if we normalize things like women feeling like this is the worst they've felt in their life and we try to tell them that that's normal that actually means that they won't seek further treatment and in fact we want the opposite of that to be true we know that early intervention is really important and so we want women to know that treatment is available and treatment is safe and treatment works.

So how would you word that Maggie and Majella?

Yeah so I certainly know as a GP looking after women before during after pregnancy particularly if there's risk factors there. I say we know that the postpartum is the most vulnerable period in a woman's life for developing mental health issues whether or not she's had them before and so if you start to find that more days than not you are not enjoying being a mom you're not enjoying your baby you are struggling make sure you know that you can reach out and ask for help and it's so much better to do that earlier rather than later because it's much easier to help you before you've sort of fallen to the bottom of the hole. 

Yeah that's right and we know that if the symptoms are prolonged and persistent that the impact on the patient in front of you the woman but also her family is much greater so we want the symptoms to be for the shortest period possible and to lessen the severity as soon as we can and in this period it is definitely worth discussing the role of medication and we know that for mild to moderate anxiety and depression that psychological therapies is first line but once that those symptoms become moderate to severe certainly there is a role for medication and worth having really open discussions with your patients about this.

What about breastfeeding women what are the concerns with medication there?
Yeah women come with lots of concerns and we know that unfortunately there is no anti-depressant that doesn't transfer into the milk but we can try to use the medications first line that have the lowest transfer into breast milk and certainly we would start off with something like sertraline or lexapro which we know has a lot of good evidence effective in this period for reducing  symptoms as well as very safe. I think a really important conversation to have with your patient when you're concerned or they're concerned about medication is that there is a risk of not treating so if we allow as we were saying before depression and anxiety symptoms to go on for a long time those adverse consequences are far-reaching. A really useful database that I use commonly is LactMed and it has great up-to-date information on medications in pregnancy and breastfeeding and so if you need some reassurance that's often a really good source.

What are the different referral pathways for urgent and non- urgent cases?

Yeah so non-urgent cases where we sit in that mild to moderate symptoms that is often times managed by the GP so again you know might be a referral onto psychology some parents might opt to do some online therapy so mood booster is a a common one. The Center for Clinical Interventions has some excellent modules that people might like to work through themselves we know there are some excellent websites PANDA, COPE which provide some really good psycho education and can start discussions about management for your non-urgent patients. 

This is the time of course where we if we can we involve families because it is a real team approach and it's sometimes it's really helpful to do some practical things like could you get more sleep could you could your partner give a bottle so that you could get more sleep, could mum come over during the day all of those really practical things that sometimes when you're in the thick of it you can't see it's almost like you know can't see a way that things could get better. So urgent cases is when we start to think about how safe is this woman sometimes those women can just   refer them to the emergency department so they get that acute care we're very fortunate now 12 months ago the Mater opened Catherine's House which is a statewide service for mothers and babies to be admitted in the postpartum for severe mental health issues and any GP statewide can refer into that service as well as the Lavender Unit at the Gold Coast and there are some options privately. MH CALL is a super useful resource I call MH CALL on behalf of patients with their permission all the time but patients can also be given that number and it's a 24/7 Mental Health Service that they can contact so if it's 3 in the morning and they're feeling really distressed there is a number there that they can call and often times that then the next day they can organize an assessment. 

Majella thank you so much for join us today but before you go we want to introduce you to our segment we call The Checkup. We want to know more about you as Majella the medical professional and the person as well so Maggie's got five quick questions for you they're pretty easy you ready to go we'll see over to you Maggie. 

Majella do you listen to podcasts and if so what are your favorites? I do, gosh this is like a confessional, so I love the Imperfects I have to say but for my pop psychology I really love Esther Perell who does a podcast on relationships called Where Should We Begin I love that and I'm a Chat 10 Looks 3 girl as well because I just love their book and film recommendations. I love them. Me too. 

Tell me about your first pet. Oh gosh my first pet was a guinea pig. We weren't really a pet family to be honest and my mum says that that guinea pig is responsible for my brother having a parasite and never putting on any weight for many years so that's yeah that's my first pet didn't last too long poor all guinea pig. 

What's the best outfit that you've ever worn to a costume party? You might want to cut these so when my brother had his 21st I was not quite I think I was still finishing school and it was his called Paul and it was a P party and so I went as pregnant and I just put a balloon under my dress but during the course which I thought looked very obvious that I wasn't actually pregnant but during the course of the night one of his friends said I can't believe how well their mum is taking Majella's pregnancy but thankfully I held off a lot longer until actually pregnancy was real so that was the most convincing. They nailed that costume and we're keeping it in fantastic.

If you had a day off today what would you do? Ideally would be starting off with a massage or a facial something just lovely and relaxing and then a long lunch with some girlfriends who I haven't seen in a while.

If a genie could grant you one wish what would it be a bit more time I feel like yeah it's the constant busyness isn't it that is the juggle of having kids and work and family and friends I mean you wouldn't trade it for the world but sometimes yeah just a few more hours in the day. It would be very helpful. 

Majella thanks so much for joining us on sMater. It's been a pleasure. Thank you for our listeners at home or in the car or having a well-deserved break between patients thanks for tuning in. See you next time on sMater.