Postnatal mental health — structured SAQ (15 marks)

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

A score of 17 with a 2 on item 10 makes this an urgent assessment, not a referral letter. ^[1]

• The EPDS is a 10-item self-report screen, scored 0 to 3, maximum 30; a score at or above 13 indicates probable major depression and warrants a structured clinical assessment, not a diagnosis on the form.^[1]
• Item 10 asks about thoughts of self-harm and is scored and reported separately from the total. A score of 2 is a positive endorsement and must be followed up in this consultation.^[2]
• Ask directly, using plain words: whether she has had thoughts of ending her life, whether she has a plan, whether she has access to means, and whether she has thoughts of harming the baby. The risk assessment is not complete without all four.^[6]
• Establish protective factors (the baby, support, engagement), past psychiatric history (her anxiety disorder raises recurrence risk), and current function. Do not let her leave without a named plan for review today or tomorrow.^[1][6]

(b) Management plan (6 marks)

One mark each for: risk-based disposition; psychological therapy; the first-line drug with dose; the lactation rationale; the bipolar screen before prescribing; and follow-up structure. ^[1][4]

• Disposition is driven by risk. With a positive item 10 and an active thought, arrange same-day perinatal mental health review and do not rely on a routine appointment. Where risk is controlled, manage in primary care with a perinatal mental health treatment plan.^[6]
• Non-pharmacological: guided self-help, structured exercise, sleep hygiene, and evidence-based psychological therapy — cognitive behavioural therapy or interpersonal therapy, supported by the network meta-analysis of non-pharmacological interventions.^[7]
• First-line drug: sertraline 50 mg once daily, titrated to effect, usually up to 200 mg daily.^[4]
• Rationale in breastfeeding: the mother-infant serum study found sertraline and its metabolite at very low or undetectable levels in the breastfeeding infant, with no reported adverse effects, and sertraline has a low relative infant dose. Continue breastfeeding — the risk of untreated maternal depression to the dyad exceeds the drug risk.^[4][5]
• Screen for bipolar disorder before prescribing an SSRI — ask about past hypomanic episodes, because an SSRI in unrecognised bipolar disorder can precipitate mania. A family history of bipolar disorder or puerperal psychosis is a red flag.^[6]
• Follow-up within one week to assess response and tolerability, with a clear plan to escalate to combination therapy or specialist care if there is no improvement.^[1]

(c) Recurrence prediction and future pregnancy planning (3 marks)

Award a mark for each correct element. ^[3]

• Her risk factors for recurrence in a future pregnancy include the personal history of anxiety, this postnatal depressive episode, and any incomplete recovery before conception. Untreated or chronic depression recurs more often.^[3]
• Counsel that postnatal depression has a real recurrence risk and that early pregnancy is the time to plan, not the postnatal ward. Arrange a pre-conception consultation with perinatal mental health.^[6]
• Plan proactive monitoring: EPDS screening in pregnancy and postnatally, early reintroduction of psychological support, and a documented threshold for restarting medication. If she has been on an effective SSRI, continuing it through pregnancy and the postpartum is often safer than stopping and waiting to relapse.^[1]

(d) Referral pathway and safety-net advice (2 marks)

One mark for the pathway, one for the verbal safety-net. ^[6]

• Referral pathway by urgency: same-day perinatal mental health or crisis team contact given the positive item 10; her general practitioner for shared care and a mental health treatment plan; psychological therapy; and peer support. Know your local mother-and-baby unit pathway in case admission is needed.^[6]
• Safety-net, in her words and her partner's: "If you ever feel you might hurt yourself, or you cannot cope, you ring this number or go to the emergency department — any hour, day or night." Give the same advice to the partner and document it.^[6]