Perinatal mental health — structured oral station (12 minutes)

Opening prompt — "Tell me what you do from the doorway."

Model response — say it in this order: ^[1][4]

• "Her EPDS is 15, which is in the further-assessment band of 13 or more. More urgently, item 10 is marked 2 — any positive response on item 10 requires a structured risk assessment in this consultation, today, regardless of the total score."
• "I would stay with her, move to a quiet room, and take a structured suicide risk assessment: frequency of the thoughts, plan, intent, access to means, protective factors. I would also ask about infanticidal ideation and the safety of her other children if any."
• "Before any medication, I would screen for bipolar disorder — past hypomania, mania, family history, antidepressant-induced dysphoria — because an SSRI in unrecognised bipolar precipitates mania."^[5]

Probe 1 — "She describes intrusive thoughts of harm to herself but no plan. How do you act?"

• "I would assess frequency, plan, intent, means and protective factors. No plan lowers the immediate acuity, but the thoughts are frequent, so I would activate the pathway today — not the next visit. With her consent I would involve her partner, arrange a perinatal mental health review, and ensure she has crisis numbers before she leaves."^[4]
• "I would document the risk assessment and the plan in full."

Probe 2 — "She has moderate depression and asks about medication. Defend your SSRI choice."

• "Sertraline is my first-line SSRI in pregnancy and lactation — it has the lowest transfer into breast milk and the strongest overall safety data."^[1]
• "I would counsel her with numbers, not fear. The Grigoriadis BMJ 2014 meta-analysis found late-pregnancy SSRI exposure raised PPHN with an odds ratio of about 2.5, but the absolute added risk is only 2.9 to 3.5 per 1000 — a number-needed-to-harm of roughly 286 to 351. Cardiac malformation signals fade to baseline once confounders are accounted for."^[2]
• "Critically, untreated depression has its own fetal and infant harms — the decision balances a small SSRI risk against the real risk of no treatment."

Probe 3 — "She mentions a cousin with bipolar disorder. Does that change your plan?"

• "A family history of bipolar raises the stakes on the screen. I would use the Mood Disorder Questionnaire and ask directly about past hypomania — reduced need for sleep, elevated mood, impulsive behaviour. If bipolar is suspected, I would not start an SSRI alone; I would involve psychiatry and consider a mood stabiliser."^[5]
• "Lamotrigine is a relatively safer maintenance option; lithium can be continued in well women with severe disease after informed counselling, as the Patorno 2017 study showed the absolute cardiac risk is far lower than once thought."^[5]

Probe 4 — "She is frightened and her partner is in the room. Talk to her."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[1]

• Move to her eye level, use her name, normalise the screen: "I ask every woman to fill this in — it helps me look after you. Your score tells me you have been having a very hard time, and you have been brave to tell us about the thoughts of harm. You are not in trouble, and this is treatable."
• "I would like to spend time with you today to make a plan that keeps you safe. With your permission, I will involve your partner and our perinatal mental health team."
• Acknowledge fear, allocate a staff member to support the partner, avoid jargon, and commit to a follow-up plan before she leaves.^[1]

Probe 5 — "What will you do after today?"

• Place her in stepped care — Step 3 to 4: high-intensity CBT (Sockol evidence) plus an SSRI if she consents, with psychiatric involvement.^[3]
• Plan the postpartum window: the first fortnight is the highest-risk for puerperal psychosis, the first three months for postnatal depression; arrange early postpartum psychiatric review.
• Build the safety net before she needs it: GP mental health plan, crisis numbers, partner and family involvement with consent, and a planned review date within days.