A national approach to perinatal mental health in Australia: exercising caution in the roll-out of a public health initiative

• Routine screening for depression during pregnancy and a follow-up check at 2 months after birth;

• Follow-up support and care for women who are assessed to be at risk of or experiencing depression; and

• Training for health professionals to help them screen and assess expectant and new mothers for depression.1

This national focus on a major public health issue, together with designated funding, provides opportunities to develop and evaluate new approaches to assessing perinatal depression and the range of psychosocial issues that may underlie or contribute to this condition. It also provides opportunities to develop and test strategies for supporting women and their families during pregnancy and after birth.

We offer a cautionary note about the first goal of the national plan — routine screening of all women during pregnancy and postnatally — and consider the possibilities for building a stronger evidence base to inform the implementation of the perinatal depression initiative.

Screening women for psychosocial problems, including depression during pregnancy and postnatally, is advocated in a number of countries including the United Kingdom, where guidelines for clinical management of perinatal mental health include the use of routine screening.2 To date, the situation in Australia has been somewhat different. Localised antenatal and postnatal depression screening programs have been undertaken for many years as part of routine clinical practice by some hospitals3 and primary care services.4 On a larger scale, the beyondblue perinatal depression program screened over 12 000 Australian women5 using the Edinburgh Postnatal Depression Scale (EPDS)6 to determine the prevalence of probable postnatal depression and acceptability of a screening program. Before the announcement of the NPDP, there was no national approach or guidelines for the assessment and management of perinatal depression in Australia.

There is no doubt that perinatal depression is an important public health problem. A meta-analysis of 59 studies yielded a mean prevalence of 13% in the first few weeks postpartum.7 As a “hidden” form of maternal morbidity, depression has major consequences for the mother, child and family.8

The “to screen or not to screen” debate continues as we approach the roll-out of the NPDP. The evidence for effectiveness of universal antenatal and postnatal screening for depression is scarce.9 Austin and Lumley urge health professionals to be cautious when using screening tools to select women for antenatal interventions, citing the high proportion of false positives among women identified as “at risk” and the high proportion of women identified as “low risk” who go on to develop depression after childbirth.9

This calls into question what screening is aiming to achieve. Is its purpose to identify “cases” or to identify women “at risk”? The aims are not always explicit, although the focus of antenatal studies has primarily been on determining the risk of developing depression, and the focus of most postnatal studies has been on identifying cases.

While the potential for harm associated with the high proportion of false positives and false negatives identified by risk-screening tools is clear, so too is the possibility of harm if women who are labelled as “at risk” or “depressed” do not perceive themselves in this way and do not wish to discuss their mental health status with health professionals. In a follow-up to the beyondblue perinatal depression screening initiative, 18% of women who screened positive for depression did not agree with the screening assessment. One in five of these women ignored the assessment and 40% were reported to be “a little upset” by it.10 The stigma of being labelled as having a mental health condition or the belief that support and help are not available may lead women to deliberately under-report symptoms or risk factors.11

Increasingly, clinicians and researchers are suggesting that focusing on depression as a separate entity obscures the likelihood that there will be comorbidities such as anxiety and complex psychosocial factors. Several commentators have argued for screening for psychosocial risk, in recognition of the fact that anxiety and depression during pregnancy, psychiatric illness, stressful life events and perceived levels of social support are all predictors of postnatal depression.12 Others have suggested that, in designing a tool with acceptable sensitivity and specificity to identify depression, a broader range of psychosocial risk factors needs to be considered.8

The poor sensitivity and specificity of available screening tools, women’s reluctance to disclose sensitive issues to health professionals, and health professionals’ reluctance to enquire about psychosocial issues have led to calls for alternative approaches to psychosocial assessment. An evaluation of a Victorian health professional education program, the ANEW program, which is aimed at promoting practitioners’ skills in active listening, has produced some promising results.13,14 Other studies have also identified psychosocial assessment tools as a way of leading into a conversation about mood disorders or other psychosocial issues.15 The third goal of the NPDP — training for health professionals — provides an opportunity to develop and evaluate models of health professional training in how to assess women’s emotional and social health during pregnancy and after birth.

Unlike the UK, which has guidelines for routine screening and management of perinatal depression,2,16 Australia has taken a more “hands-off” approach, leaving the states with designated federal funding to determine the best approaches to screening and pathways for care. This is not to underestimate concern regarding this issue. Australian clinicians, researchers and state health departments have been calling for some time for the use of routine standardised screening and psychosocial risk assessment tools to identify women who may be at risk.17,18

Little is known about how primary care services approach psychosocial assessment and support for women experiencing psychosocial problems during and after pregnancy. A Victorian study found that, even when locally based efforts are made to introduce an integrated approach to screening women for postnatal depression in a primary care setting, implementation may be fragmented and ad hoc.4 Striking findings of the study were that the well established program of universal screening was not effective in detecting probable depression and that there was no collaborative planning between maternal and child health services and general practitioners for affected women.4 Another Victorian study — the Re-organising the Care of Depression and Related Disorders in the Australian Primary Health Care Setting (RE-ORDER) study — demonstrated how difficult it was for even highly motivated primary care services to implement systemic changes to improve care of people with depression.19

The Integrated Perinatal and Infant Care initiative in New South Wales uses a model of assessment, prevention and early intervention to identify the mental health and physical health needs of parents and their infants during pregnancy and after birth. Implementation has been widespread, although evaluation of the initiative appears to be confined to individual hospitals that have implemented routine psychosocial assessment in their antenatal clinics.3,20

Understanding the way that services have responded to calls for screening is an important first step in developing new approaches. A survey by our research group of all hospitals with maternity facilities in South Australia (n = 35) and Victoria (n = 75) sheds some light on how services currently approach psychosocial assessment. We conducted the study to inform the development of a population-based survey of women giving birth in both states in 2007.21 Midwifery unit managers completed questionnaires on routine approaches to psychosocial assessment and the use of risk assessment tools. Among public hospitals, a third (9/30) in SA and a half (29/56) in Victoria reported using a psychosocial screening tool during pregnancy. The Edinburgh Depression Scale (EDS),6 a well validated instrument for identifying probable clinical depression, was commonly used (Box 1). Most of the other psychosocial assessment tools in use contained a number of questions about women’s emotional health. There was no consistency among the tools with regard to their format or the questions contained in them.

Fewer hospitals reported the routine use of a psychosocial risk assessment tool postnatally (Box 2): 3/35 hospitals in SA (all used the EPDS and 12/75 hospitals in Victoria (three used the EPDS). No private hospitals in SA and only one in Victoria routinely used a screening tool during the postnatal period.

Our survey of over 100 Australian hospitals in two states21 revealed striking diversity in how hospitals interpret and respond to initiatives encouraging assessment of psychosocial issues during pregnancy and after birth. Few hospitals reported routinely using psychosocial assessment tools, and there was no standardised approach in either state. The focus was on emotional wellbeing, primarily on depression. Very few hospitals reported routine enquiry regarding intimate partner violence or psychosocial issues other than depression.

Hospitals that have already implemented specific approaches to psychosocial assessment, such as screening with the EDS, may be resistant to change.22 Equally, hospitals that have already introduced an alternative approach to psychosocial assessment, such as the ANEW program in Victorian hospitals, may be reluctant to adopt the standardised screening approach recommended in the NPDP.

Primary care services are well placed to assess women’s psychosocial health. There is a need for greater focus on integrated primary health care at the community level. Policymakers implementing the NPDP need to consider how to foster stronger links between primary and specialist services and a more cohesive approach to supporting women and their families in the longer term. A challenge for primary care services, particularly infant health services, is to focus on the health of the mother, when so much care during the postnatal period is oriented towards the child.

A recent Victorian longitudinal cohort study found that anxiety and depressive symptoms were associated with different patterns of help-seeking behaviour. Less than half of women experiencing anxiety symptoms postnatally had spoken to a health professional, compared with two-thirds of women experiencing depressive symptoms. Women experiencing emotional difficulties were significantly more likely to talk to a GP than to a maternal and child health nurse,23 a finding that supports other studies suggesting that women may be reluctant to disclose such issues to staff of maternal and child health services.24

New approaches to assessing and managing perinatal psychosocial issues will need to be developed, paying attention to workability and integration from the perspective of practitioners and women themselves.22 Developing new service models and systems will take time and require a participatory approach involving clinicians (GPs, midwives, maternal and child health workers, practice nurses, obstetricians and psychologists), practice managers, hospital managers, funders and policymakers.

With so many questions about the effectiveness of screening, it is critical that new approaches to assessment and enquiry be evaluated before a universal population-based screening program is rolled out.