Perinatal mental health — structured SAQ (15 marks)

(a) EPDS interpretation and immediate assessment (4 marks)

One mark per point, maximum four. ^[1]

• A score of 13 or more requires further assessment by a qualified health professional for a possible depressive disorder. (Item 10 is scored separately.)^[1]
• Any positive response on item 10 (a score of 1, 2 or 3) requires an immediate structured risk assessment in the same consultation, regardless of the total score. The Qiu 2023 IPD meta-analysis confirms item 10 is a standalone risk screen whose removal from the total does not reduce EPDS accuracy.^[6]
• Perform the structured risk assessment now: frequency, plan, intent, access to means, protective factors, infanticidal ideation, child safety. Stay with her; remove access to means; activate the crisis pathway today.
• Screen for bipolar disorder before any antidepressant: past hypomania, mania, family history, antidepressant-induced dysphoria (the Mood Disorder Questionnaire). An SSRI in unrecognised bipolar precipitates mania or a mixed state.

(b) Stepped care and placement (4 marks)

One mark per step described and one for correct placement. ^[1][4]

• Step 1 — watchful waiting for subthreshold symptoms; self-help, sleep hygiene.
• Step 2 — low-intensity: guided self-help, e-CBT, peer support.
• Step 3 — high-intensity psychological therapy: CBT (Sockol meta-analysis, strong evidence) or interpersonal therapy; plus medication if moderate-severe.
• Step 4 — medication (SSRI, sertraline first-line), combined treatment, or specialist / inpatient (mother-and-baby unit) for severe illness. This woman sits at Step 3 to 4: moderate-severe depression with risk, so high-intensity therapy plus an SSRI and psychiatric involvement.^[1]

(c) SSRI safety in pregnancy (4 marks)

One mark per evidence point, quoted by name. ^[2][3]

• Sertraline is first-line — best lactation data, low fetal transfer, strongest overall safety profile.
• Cardiac malformations: Huybrechts (NEJM 2014) — once confounders are accounted for, the apparent cardiac-malformation signal for SSRIs other than paroxetine fades towards baseline.
• PPHN: Grigoriadis (BMJ 2014) — late-pregnancy SSRI exposure OR about 2.50, but the absolute added risk is only 2.9 to 3.5 per 1000 (a number-needed-to-harm of roughly 286 to 351). Counsel with the number, not the impressionistic fear.
• Autism signal attenuates substantially with adjustment for confounding by indication — the prevailing view is the maternal condition, not the SSRI, drives the association. Untreated depression has its own fetal and infant harms, so the decision balances small SSRI risk against the real risk of no treatment.^[2]

(d) Recurrence counselling (3 marks)

One mark per point. ^[1]

• Recurrence risk in future pregnancies is significant after a previous perinatal episode — counsel honestly.
• Prophylactic strategies: consider an SSRI from the third trimester; early postpartum psychiatric review; close monitoring from 32 weeks; plan continuity of care before birth.
• Plan the postpartum window now: the first fortnight is the highest-risk window for puerperal psychosis (especially if bipolar is present); the first three months for postnatal depression. Build the safety net before she needs it — GP mental health plan, perinatal mental health service, crisis numbers, partner and family involvement with consent.^[1]