Perinatal mental health

She is 28 weeks pregnant, has been waking at 4 am every night for a fortnight, has not enjoyed anything for weeks, and her partner tells you she has stopped talking to friends. The midwife has handed her an EPDS; she has scored 15, and item 10 is marked 2. The registrar reaches for the prescription pad; the consultant reaches for the chair, the same-day assessment, the safety net. Perinatal mental illness is the most common complication of pregnancy, kills more women in the postpartum year than haemorrhage, and is among the most treatable conditions you will see — if you screen for it, act on the score, and have a pathway behind it.[1][11]

Overview and definition

The perinatal period runs from conception to 12 months postpartum. Mental illness in this window spans a spectrum — and the answer to it is stepped: screen everyone, severity-stratify, escalate, follow up. [1]

• Antenatal depression — major or minor depressive episode occurring during pregnancy, on the same DSM-5 criteria as at any other time, but under-recognised because the symptoms (fatigue, sleep disruption, low libido) overlap with pregnancy itself.
• Antenatal anxiety — generalised anxiety, panic disorder, OCD, or PTSD occurring during pregnancy. Often comorbid with depression; often missed.
• Adjustment disorder — significant distress in response to the pregnancy or transition, within three months of the stressor, beyond expected and impairing function, but not meeting criteria for another disorder.
• Pre-existing bipolar disorder, schizophrenia, other psychoses — continue through pregnancy; the postpartum is the highest-risk window for relapse.
• Puerperal (postpartum) psychosis — psychiatric emergency, onset in the first two weeks, hallucinations, delusions, confusion. (Cross-link: full discussion in our postnatal mental health topic.)[1]

The conceptual move that saves lives is the same as in substance use: treat the screen as the start of a pathway, not the end of a checklist. The COPE (Centre of Perinatal Excellence) Australian national guideline is explicit: screen, score, act, follow up. The same logic underpins NICE NG206 and ACOG Committee Opinion 757.[1][11]

References15Show ledgerHide ledger

1. [1]Cox JL, Holden JM, Sagovsky R Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry, 1987.PMID 3651732
2. [2]Spitzer RL, Kroenke K, Williams JB, Löwe B A brief measure for assessing generalized anxiety disorder: the GAD-7 Arch Intern Med, 2006.PMID 16717171
3. [3]Huybrechts KF, Hernández-Díaz S, Avorn J, et al. Antidepressant use in pregnancy and the risk of cardiac defects N Engl J Med, 2014.PMID 25229932
4. [4]Grigoriadis S, Vonderporten EH, Mamisashvili L, et al. Prenatal exposure to antidepressants and persistent pulmonary hypertension of the newborn: systematic review and meta-analysis BMJ, 2014.PMID 24429387
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9. [9]Brown HK, Hussain-Shamsy N, Lunsky Y, et al. The Association Between Antenatal Exposure to Selective Serotonin Reuptake Inhibitors and Autism: A Systematic Review and Meta-Analysis J Clin Psychiatry, 2017.PMID 28129495
10. [10]Masarwa R, Bar-Oz B, Gorelik E, et al. Prenatal exposure to selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors and risk for persistent pulmonary hypertension of the newborn: a systematic review, meta-analysis, and network meta-analysis Am J Obstet Gynecol, 2019.PMID 30170040
11. [11]Qiu X, Wu Y, Sun Y, Levis B, et al. Individual participant data meta-analysis to compare EPDS accuracy to detect major depression with and without the self-harm item Sci Rep, 2023.PMID 36899016
12. [12]Grigoriadis S, Alibrahim A, Mansfield JK, et al. Hypnotic benzodiazepine receptor agonist exposure during pregnancy and the risk of congenital malformations and other adverse pregnancy outcomes: A systematic review and meta-analysis Acta Psychiatr Scand, 2022.PMID 35488412
13. [13]Berle JØ, Steen VM, Aamo TO, et al. Breastfeeding during maternal antidepressant treatment with serotonin reuptake inhibitors: infant exposure, clinical symptoms, and cytochrome p450 genotypes J Clin Psychiatry, 2004.PMID 15367050
14. [14]Barker LC, Dennis CL, Hussain-Shamsy N, et al. Decision-making about antidepressant medication use in pregnancy: a comparison between women making the decision in the preconception period versus in pregnancy BMC Psychiatry, 2020.PMID 32033547
15. [15]Einarson TR, Einarson A Newer antidepressants in pregnancy and rates of major malformations: a meta-analysis of prospective comparative studies Pharmacoepidemiol Drug Saf, 2005.PMID 15742359