Perinatal Practice Guideline

Clinical Guideline
Perinatal Anxiety and Depressive Disorders (including
Postnatal Depression)

Policy developed by: SA Maternal, Neonatal & Gynaecology Community of

Practice
Approved SA Health Safety & Quality Strategic Governance Committee on:
01 March 2017
Next review due: 31 March 2020

Summary The Perinatal Anxiety and Depressive Disorders (including

Postnatal Depression) Perinatal Practice Guideline provides
clinicians with information on prevention, diagnosis and
interventions for women at risk of or experiencing depression
and/or anxiety in the perinatal period.

Keywords perinatal anxiety and depressive disorders, PPG, perinatal

practice guideline, anxiety, depression, perinatal depression,
mood swings, EPDS, Edinburgh Postnatal Depression Scale,
psychosocial questionnaire, antenatal risk questionnaire, ANRQ,
screening for perinatal anxiety and depression, clinical guideline,
postnatal depression, PND

Policy history Is this a new policy? N

Does this policy amend or update an existing policy? Y v2.0
Does this policy replace an existing policy? N
If so, which policies?

Applies to All Health Networks

CALHN, SALHN, NALHN, CHSALHN, WCHN, SAAS

Staff impact All Staff, Management, Admin, Students, All Clinical, Medical,
Midwifery, Nursing, Allied Health, Emergency, Mental Health

PDS reference CG248

Version control and change history

Version Date from Date to Amendment

1.0 21 Sep 2010 04 Sep 2012 Original version
2.0 04 Sep 2012 28 Feb 2017 Reviewed
3.0 01 March 2017 Current
© Department for Health and Ageing, Government of South Australia. All rights reserved.
 South Australian Perinatal Practice Guidelines

Perinatal Anxiety and

Depressive Disorders
(including Postnatal
Depression)
© Department of Health, Government of South Australia. All rights reserved.

Note

This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and facilitate
standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based on a review of
published evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not
sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and
professionally assess the applicability of the relevant guideline to that clinical situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the
patient’s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful
confidential discussion. This includes:
• The use of interpreter services where necessary,
• Advising consumers of their choice and ensuring informed consent is obtained,
• Providing care within scope of practice, meeting all legislative requirements and maintaining standards of
professional conduct, and
• Documenting all care in accordance with mandatory and local requirements
Explanation of the Aboriginal artwork:
The Aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the Aboriginal culture. The horse shoe shape
design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant women. The smaller horse shoe shape in this
instance represents the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in
unison.

Australian Aboriginal Culture is the oldest living culture in the world yet
Aboriginal people continue to experience the poorest health outcomes when
compared to non-Aboriginal Australians. In South Australia, Aboriginal women are
2-5 times more likely to die in childbirth and their babies are 2-3 times more likely to
be of low birth weight. The accumulative effects of stress, low socio economic
status, exposure to violence, historical trauma, culturally unsafe and discriminatory
health services and health systems are all major contributors to the disparities in
Aboriginal maternal and birthing outcomes. Despite these unacceptable statistics
the birth of an Aboriginal baby is a celebration of life and an important cultural
event bringing family together in celebration, obligation and responsibility. The
diversity between Aboriginal cultures, language and practices differ greatly and so
it is imperative that perinatal services prepare to respectively manage Aboriginal
protocol and provide a culturally positive health care experience for Aboriginal
people to ensure the best maternal, neonatal and child health outcomes.

Purpose and Scope of PPG

The purpose of this guideline is to give clinicians information on prevention, diagnosis and
interventions for women at risk of or experiencing depression and/or anxiety in the perinatal
period.

ISBN number: 978-1-74243-355-4

Endorsed by: South Australian Maternal, Neonatal & Gynaecology Community of Practice
Last Revised: 06/03/2017
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
 South Australian Perinatal Practice Guidelines

Perinatal Anxiety and Depressive Disorders

(including Postnatal Depression)

Table of Contents
Summary of Practice Recommendations
Abbreviations
Introduction
Risk Factors
Psychological
Biological / Medical
Diagnosis
Major depressive disorder criteria
Other relevant factors in severe depression postpartum
Borderline Personality Disorder (complex trauma)
Dysthymic Disorder
Substance Use
Anxiety Disorders
Management
Prevention, early identification and intervention
Resources
References
Acknowledgements

Summary of Practice Recommendations

> Approximately 1 in 5 women will experience anxiety and/or depression in the perinatal
period
> Maternal suicide is a common cause of maternal death in Australia
> Early diagnosis through screening and follow up managed by a health professional
improves the mental health outcomes of women
> Urgent specialised mental health referral is imperative when women express suicidal or
infanticidal ideation
> Perinatal depression and/or anxiety can impact child development and functioning with
ongoing effects into adolescence

Abbreviations
CFH Child and Family Health
EPDS Edinburgh (postnatal) depression scale
e.g. For example
et al. And others
GP General Practitioner
KEMH King Edward Memorial Hospital
PND Postnatal depression
SA South Australia

ISBN number: 978-1-74243-355-4

Endorsed by: South Australian Maternal, Neonatal & Gynaecology Community of Practice
Last Revised: 06/03/2017
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Page 2 of 12
 South Australian Perinatal Practice Guidelines

Perinatal Anxiety and Depressive Disorders

(including Postnatal Depression)

Introduction
> Anxiety and depressive disorders are common in the perinatal period (conception to 12
months post-natal), occurring in 1 in 5 women
> Women are more likely to develop a mental health disorder during this time of life than any
1
other
2
> Depression and anxiety may occur together , are often present antenatally and persist if not
3
treated. These disorders can have a wide range of effects for the fetus , the infant, partner
4
and family
> Antenatal anxiety is associated with preterm birth, low birth weight and other obstetric
5
complications
6
> Perinatal depression and anxiety may be associated with poorer cognitive and behavioural
7 8 9
functioning in children , emotional problems , reduced attention span, childhood anxiety ,
10
and mother-infant attachment disorders . Risks of depression for children can continue into
11
adolescence
> Maternal death through suicide can be a result of severe mood disorder and ranks equal to
12
obstetric haemorrhage as cause of maternal death in Australia .
13
> Suicide is a major cause of maternal death in high income countries
> It is important to exclude underlying physical problems which present as depression or
anxiety or which may make symptoms worse i.e. anaemia, thyroid malfunction
> Recent bereavement or unresolved loss may be a factor requiring separate consideration
> Other contextual factors such as age, history of abuse and cultural factors may impact on
the expression of distress and form of help seeking
> Sometimes extreme exhaustion and sleep deprivation may mirror depression and anxiety or
may be a risk factor for the development of these disorders
> Anxiety and depression, and the potential consequences for mother, infant and family, will
benefit greatly by early identification, support and good clinical management. This treatment
4
of the mother alone may not be adequate to assuage the effect on the children (see
“assessing parent infant relationship” PPG in the A-Z index
www.sahealth.sa.gov.au/perinatal)

ISBN number: 978-1-74243-355-4

Endorsed by: South Australian Maternal, Neonatal & Gynaecology Community of Practice
Last Revised: 06/03/2017
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Page 3 of 12
 South Australian Perinatal Practice Guidelines

Perinatal Anxiety and Depressive Disorders

(including Postnatal Depression)

Risk factors
Where risks are identified, document details about the nature and degree of risk

Psychological
14,15
> Antenatal anxiety, depression or mood swings
14,15
> Previous history of anxiety, depression, or mood swings , especially if occurred
perinatally
15,16
> Family history of anxiety, especially in first degree relatives
17
> Alcohol abuse
> Personal characteristics of being guilt-prone, perfectionistic, feeling unable to achieve, low
18
self-esteem
> Edinburgh postnatal depression score ≥ 13
> Borderline Personality Disorder

Social
14,15
> Lack of emotional and practical support from partner and / or others
16
> Domestic violence, history of trauma or abuse (including childhood sexual abuse)
14,15
> Many stressful life events recently
14,15
> Low socioeconomic status, unemployment
14,15
> Unplanned or unwanted pregnancy
> Increased parity

Aboriginal women may experience feelings of disconnectedness from family and

country and may need to talk to the nominated aboriginal health professional

Biological / medical
> Ceased psychotropic medications recently
> History of serious pregnancy or birth complications (current or previous), neonatal loss, poor
17 19
physical health, chronic pain or disability , or premenstrual syndrome
> Perinatal sleep deprivation
20
> Multiple pregnancy
17
> Chronic/ medical illness
21
> Preterm birth/low birth weight - as a complication in the current pregnancy is a risk for
postnatal depression and anxiety
22
> Neonatal medical problems or difficult temperament

ISBN number: 978-1-74243-355-4

Endorsed by: South Australian Maternal, Neonatal & Gynaecology Community of Practice
Last Revised: 06/03/2017
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Page 4 of 12
 South Australian Perinatal Practice Guidelines

Perinatal Anxiety and Depressive Disorders

(including Postnatal Depression)

Diagnosis
Major depressive disorder criteria:
23
Note: Symptoms must be present and persistent for at least two weeks
> Depressed mood
> Anhedonia – loss of the capacity to experience pleasure
> Unexpected change in weight or appetite
> Markedly increased or decreased sleep-typically mother cannot get back to sleep after baby
wakes and is settled and ruminates
> Fatigue or loss of energy
> Feelings of worthlessness and guilt
> Reduced concentration
> Recurrent thoughts of suicide or death
> Physical agitation or slowing (psychomotor retardation)

Other relevant factors in severe depression postpartum

> Mothers may also report obsessive thoughts or images about harming themselves or their
infant. Guilt and shame can prevent them talking to family or professionals and thereby
receiving help
> See ‘Psychosis in pregnancy and postpartum’ in the A to Z index at
www.sahealth.sa.gov.au/perinatal

Borderline Personality Disorder

> For further information, see ‘Personality disorders and pregnancy’ in the A to Z index at
www.sahealth.sa.gov.au/perinatal
> Women with a diagnosis of BPD may have many complex traumas in their past including
verbal, physical & sexual abuse
24,25
> Women with this personality style may also become depressed but on a background of
chronic mood instability (particularly anger), impulsivity, interpersonal difficulties and
26
deliberate self harm
> These mothers often have difficulties managing their infants particularly with soothing and
27
settling; they may become very anxious and overwhelmed easily with caretaking tasks .
They are perhaps more likely to harm their infant than other women. Infants are at risk of
28
dysregulated behaviour

Dysthymic disorder
> Some women report chronic low grade depressive symptoms that persist for years and can
substantially interfere with their quality of life, attachment to their infant and parenting but
may go unrecognised without specific enquiry
> Thus, women may enter pregnancy with chronic depression which will interfere with not only
their own functioning and at times, views of their pregnancy, but also is now known to
29
impact on the fetus, for instance in raising serum cortisol . Thus recognition and active
treatment is entirely appropriate (See ‘screening for perinatal anxiety and depression’ in the
A to Z index at www.sahealth.sa.gov.au/perinatal)

ISBN number: 978-1-74243-355-4

Endorsed by: South Australian Maternal, Neonatal & Gynaecology Community of Practice
Last Revised: 06/03/2017
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Page 5 of 12
 South Australian Perinatal Practice Guidelines

Perinatal Anxiety and Depressive Disorders

(including Postnatal Depression)

Substance use
> A significant number of women with mental health concerns including depression and
anxiety also use substances either as a way of reducing symptoms or as a secondary effect
of substance misuse
> For further information see ‘substance use in pregnancy’ in the A to Z index at
www.sahealth.sa.gov.au/perinatal

Aboriginal women should be referred to an aboriginal health professional as soon as

practicable to support their care

Anxiety Disorders
> Generalized Anxiety Disorder - persistent and excessive worry of more than 6 months
30
duration, may be more common in post-natal women than the general population
> Fear and phobias may emerge for the first time or be magnified by the normal stressors of
pregnancy and childbirth
> Tokophobia (a fear of giving birth), may cause some women to want to terminate the
pregnancy or ask for a caesarean section in attempt to control their fear
> Panic Disorder is characterised by panic attacks-acute onset of shortness of breath,
palpitations, tremor and or dizziness with feelings of dread. This may worsen in the post-
natal period with some women becoming agoraphobic and socially isolated
31
> Women are at higher risk of Obsessive Compulsive Disorder in pregnancy and postpartum
> Obsessive Compulsive Disorder may be extremely debilitating postpartum if not under
control as women become exhausted performing compulsive behaviours and rituals or
become pre-occupied with obsessive thoughts, leaving little time and energy for caring for
their infant, themselves or other children. Previously mild symptoms may become
exacerbated postpartum
> Post-traumatic stress disorder may arise from a life threatening event during pregnancy or
birth (ante or postpartum haemorrhage) or may be pre-existing from earlier life trauma -
women who have experienced prolonged childhood abuse especially sexual abuse may
present with a complex trauma syndrome which is exacerbated during the pregnancy and
post-partum (see also ‘sexual abuse in childhood: care considerations for women who are
pregnant’ in the A to Z index at www.sahealth.sa.gov.au/perinatal)
32
> Post-traumatic stress disorder in the perinatal period is highly comorbid with depression
> Antenatal depression and anxiety is clearly associated with an increase risk of Post-
33
traumatic stress disorder

ISBN number: 978-1-74243-355-4

Endorsed by: South Australian Maternal, Neonatal & Gynaecology Community of Practice
Last Revised: 06/03/2017
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Page 6 of 12
 South Australian Perinatal Practice Guidelines

Perinatal Anxiety and Depressive Disorders

(including Postnatal Depression)

Management
> Maternal mental health is improved for women whose postnatal depression was identified
34-36
through screening and then follow up managed by trained health professionals
> Early detection is crucial either by the woman herself via screening in pregnancy or
postpartum which can occur with the Edinburgh Postnatal depression scale (EPDS), history
taking and psychosocial screening (see ‘screening for perinatal anxiety and depression’ in
the A to Z index at www.sahealth.sa.gov.au/perinatal)
> Treatment can be suggested through a woman’s GP or other health counsellors
> A mental health care plan can be made with referral to a psychologist or direct referral to
mental health specialist if more severe
> In South Australia, public metropolitan hospitals have access to specialised perinatal mental
health services who offer consultation and liaison with midwifery and obstetric staff
4, 37
> Non pharmacological treatment options are important in the perinatal period .

Prevention, early identification and intervention:

> There is little evidence to suggest an intervention to prevent perinatal depression and
anxiety Simple measures for mild depressive or anxiety symptoms include ensuring women
get enough sleep, rest and social support, regular exercise, adequate diet, access to
support for parenting, practical help in the home and PND support groups
> Long term family home visits by nurses such as offered by CFH are helpful to promote the
attachment relationship with her infant which can be affected by maternal mental illness
> More severe disorders require mental health interventions, i.e. medication (link to
psychotropic meds in pregnancy and post partum), cognitive behaviour therapy and
interpersonal therapy and if severe hospitalisation in Helen Mayo House –the state-wide
mother baby unit (telephone 08 70871037). Referral information is available at:
http://www.wch.sa.gov.au/services/az/divisions/mentalhealth/helenmayo/dayptserv/index.ht
ml
> Urgent specialised mental health referral is imperative whenever suicidal or infanticidal
ideation is present in the context of depressed mood, and / or when there is a delusional
mood disorder
> These women and their babies (and partners) will often need specialised parent-infant
therapies as well (Advice on availability through Helen Mayo House on 08 83031183 OR 08
83031425)
> Efforts should be made to ensure that mothers and infants remain together whenever safety
factors permit this, particularly with younger infants
> Suicidal thoughts: Midwives and medical staff should always ask women who are
depressed about suicidal thoughts and plans in as matter of fact way if possible (see also
‘suicidal ideation and self harm’ in the A to Z index at www.sahealth.sa.gov.au/perinatal)
> In particular they should enquire as to whether it is likely plans will be carried out (are they
active?) and whether the woman has the means to do this as well level of impulsivity and
control over her thoughts / impulses
> Consultation with mental health services should be sought immediately if there is active
suicidal thinking

ISBN number: 978-1-74243-355-4

Endorsed by: South Australian Maternal, Neonatal & Gynaecology Community of Practice
Last Revised: 06/03/2017
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Page 7 of 12
 South Australian Perinatal Practice Guidelines

Perinatal Anxiety and Depressive Disorders

(including Postnatal Depression)

> Partners - can also suffer from perinatal depression and anxiety either secondary from the
38
stress of managing the mother’s symptoms or as a primary problem
> It is important to assess a partner’s mental health and their understanding of the mother’s
distress as well as any relationship difficulties arising from mother’s depression or which
maybe compounding her depression
39
> Depression in fathers is also linked to adverse effects on children .
> Encouraging partners to seek help for themselves is clearly appropriate when problems are
identified, and starting points could be through the family general practitioner, or with
information from Beyond Blue (listed below)

Resources
> Beyond Blue. Available from URL: http://www.beyondblue.org.au/index.aspx?
> WCHN Perinatal and Infant Mental Health Services at WCH and Helen Mayo House (State-
wide service)
> Lyell McEwin Perinatal Infant Mental Health Service
> Flinders Medical Centre
> WCHN – Child and Family Health Services (CaFHS)
> Rural and Remote Telemedicine/Telepsychiatry Unit
> General Practitioner (+/- referral to Mental Health Practitioner)

ISBN number: 978-1-74243-355-4

Endorsed by: South Australian Maternal, Neonatal & Gynaecology Community of Practice
Last Revised: 06/03/2017
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Page 8 of 12
 South Australian Perinatal Practice Guidelines

Perinatal Anxiety and Depressive Disorders

(including Postnatal Depression)

References
1. Austin MP, Priest SR, Sullivan EA. Antenatal psychosocial assessment for reducing
perinatal mental health morbidity. Cochrane Database of Systematic Reviews 2008,
Issue 4. Art. No.: CD005124. DOI: 10.1002/14651858.CD005124.pub2 (Level I).
Available from URL:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005124/pdf_sta
ndard_fs.html
2. Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and
diagnoses in postpartum women with screen-positive depression findings. JAMA
Psychiatry 2013; 70: 490–98.
3. Davis EP, Glynn LM, Schetter CD, Hobel C, Chicz-Demet A, Sandman CA. Prenatal
exposure to maternal depression and cortisol influences infant temperament. J Am
Acad Child Adolesc Psychiatry 2007; 46: 737-46.
4. Howard LM, Molyneaux E, Dennis C-L, Rochat T, Stein A, Milgrom J. Non-psychotic
mental disorders in the perinatal period. Lancet 2014; 384: 1775–88.
5. Wadhwa PD, Sandman CA, Porto M, Dunkel-Schetter C, Garite TJ. The association
between prenatal stress and infant birth weight and gestational age at birth: a
prospective investigation. Am J Obstet Gynecol 1993; 169: 858-65.
6. Letourneau NL, Tramonte L, Willms JD. Maternal depression, family functioning and
children’s longitudinal development. J Pediatr Nurs 2013; 28: 223–34.
7. Reck C, Muller M, Tietz A, Mohler E. Infant distress to novelty is associated with
maternal anxiety disorder and especially with maternal avoidance behavior. J Anxiety
Disord 2013; 27: 404–12.
8. Leis JA, Heron J, Stuart EA, Mendelson T. Associations between maternal mental
health and child emotional and behavioural problems: does prenatal mental health
matter? J Abnorm Child Psychol 2013; 42: 161–71.
9. Davis EP, Sandman CA. Prenatal psychobiological predictors of anxiety risk in
preadolescent children. Psychoneuroendocrinology 2012; 37: 1224–33.
10. Lyons-Ruth K, Zoll D, Connell D, Grunebaum HU(1986) The depressed mother and
her one-year-old infant: environment, interaction, attachment and infant development.
in Maternal depression and infant disturbance. New directions for child development.
eds Tronick EZ, Field T (Jossey-Bass, San Francisco), 34.
11. Pearson RM, Evans J, Kounali D, et al. Maternal depression during pregnancy and
the postnatal period: risks and possible mechanisms for off spring depression at age
18 years. JAMA Psychiatry 2013; 70: 1312–19.
12. Slaytor EK, Sullivan EA, King JF. Maternal deaths in Australia 1997-1999. AIHW Cat.
No. PER 24.Sydney: AIHW National Perinatal Statistics Unit: Australian Institute of
Health and Welfare 2004. Available from URL: http://www.aihw.gov.au/index.cfm
13. Cantwell R, Clutton-Brock T, Cooper G, et al. Saving mothers’ lives:
reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report
of the Confi dential Enquiries into Maternal Deaths in the United Kingdom. BJOG
2011; 118 (suppl 1): 1–203.
14. Fisher J, Cabral de Mello M, Patel V, et al. Prevalence and determinants of common
perinatal mental disorders in women in low- and lower-middle-income countries: a
systematic review. Bull World Health Organ 2012; 90: 139G–49G.
15. Sawyer A, Ayers S, Smith H. Pre- and postnatal psychological wellbeing in Africa: a
systematic review. J Aff ect Disord 2010; 123: 17–29.
16. Howard LM, Oram S, Galley H, Trevillion K, Feder G. Domestic violence and
perinatal mental disorders: a systematic review and meta-analysis. PLoS Med 2013;
10: e1001452.

ISBN number: 978-1-74243-355-4

Endorsed by: South Australian Maternal, Neonatal & Gynaecology Community of Practice
Last Revised: 06/03/2017
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Page 9 of 12
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Perinatal Anxiety and Depressive Disorders

(including Postnatal Depression)

17. Ross LE, Dennis C-L. The prevalence of postpartum depression among women with
substance use, an abuse history, or chronic illness: a systematic review. J Womens
Health (Larchmt) 2009; 18: 475–86.
18. Ross, L.E., Sellers, E.M., Gilbert Evans, S.E., Romach, M.K. (2004). Mood changes
during pregnancy and the postpartum period: development of a biopsychosocial
model. Acta Psychiatrica Scandinavica: 2004, 109: 457-466.
19. Craig MC. Should psychiatrists be prescribing oestrogen therapy to their female
patients? Br J Psychiatry 2013; 202: 9–13.
20. Ross LE, McQueen K, Vigod S, Dennis CL. Risk for postpartum depression
associated with assisted reproductive technologies and multiple births: a systematic
review. Hum Reprod Update 2011; 17: 96–106.
21. Vigod SN, Villegas L, Dennis CL, Ross LE. Prevalence and risk factors for
postpartum depression among women with preterm and low-birth-weight infants: a
systematic review. BJOG 2010; 117: 540–50.
22. King Edward Memorial Hospital (KEMH). Perinatal depressive and anxiety disorders
2007. Women and Newborn Health Service. WA Perinatal Depressive and Anxiety
Guidelines. Available from URL:
http://www.kemh.health.wa.gov.au/brochures/health_professionals/8393.pdf
23. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders: DSM-5 (5th ed.). Arlington, VA: American Psychiatric Publishing.
24. Paris J. The treatment of borderline personality disorder: implications of research on
diagnosis, etiology, and outcome. Annual Rev Clin Psychol 2009; 5: 277-90.
25. Zanarini MC, Frankenburg FR. The essential nature of borderline psychopathology. J
Pers Disord 2007; 21: 518-35.
26. Börjesson K, Ruppert S, Bågedahl-Strindlund M. A longitudinal study of psychiatric
symptoms in primiparous women: relation to personality disorders and
sociodemographic factors. Arch Women Ment Health 2005; 8: 232–42.
27. Newman L, Stevenson C. Issues in infant--parent psychotherapy for mothers with
borderline personality disorder. Clin Child Psychol Psychiatry 2008; 13:505-14.
28. Conroy S, Pariante CM, Marks MN, et al. Maternal psychopathology and infant
development at 18 months: the impact of maternal personality disorder and
depression. J Am Acad Child Adolesc Psychiatry 2012; 51: 51–61.
29. Field T, Diego M. Cortisol: the culprit prenatal stress variable. Int J Neurosci 2008;
118: 1181.
30. Ross LE, McLean LM. Anxiety Disorders in the postpartum period a systemic review.
J Clin Psych 2006; 67:1285-98.
31. Russell EJ, Fawcett JM, Mazmanian D. Risk of obsessive-compulsive disorder in
pregnant and postpartum women: a meta-analysis. J Clin Psychiatry 2013; 74: 377–
85.
32. Seng JS, Rauch SA, Resnick H, et al. Exploring posttraumatic stress disorder
symptom profi le among pregnant women. J Psychosom Obstet Gynaecol 2010; 31:
176–87.
33. Andersen LB, Melvaer LB, Videbech P, Lamont RF, Joergensen JS. Risk factors for
developing post-traumatic stress disorder following childbirth: a systematic review.
Acta Obstet Gynecol Scand 2012; 91: 1261–72.
34. Morrell CJ, Warner R, Slade P, et al. Psychological interventions for postnatal
depression: cluster randomised trial and economic evaluation. The PoNDER trial.
Health Technol Assess 2009; 13: iii–iv, xi–xiii, 1–153.
35. Leung SSL, Leung C, Lam TH, et al. Outcome of a postnatal depression screening
programme using the Edinburgh Postnatal Depression Scale: a randomized
controlled trial. J Public Health (Oxf) 2011; 33: 292–301.

ISBN number: 978-1-74243-355-4

Endorsed by: South Australian Maternal, Neonatal & Gynaecology Community of Practice
Last Revised: 06/03/2017
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Page 10 of 12
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Perinatal Anxiety and Depressive Disorders

(including Postnatal Depression)

36. Yawn BP, Dietrich AJ, Wollan P, et al, and the TRIPPD practices. TRIPPD: a
practice-based network eff ectiveness study of postpartum depression screening and
management. Ann Fam Med 2012; 10: 320–29.
37. Pearlstein T. Perinatal depression: treatment options and dilemmas. J Psychiatry
Neurosci 2008; 33: 302–318.
38. Ramchandri P, Stein A, Evans J, O’Connor TG. Paternal depression in the perinatal
period and child development a prospective study. Lancet 2005; 365: 2201-5.
39. Stein A, Pearson RM, Goodman SH. Effects of perinatal mental disorders on the
fetus and child. Lancet 2014; 384: 1800–19.

Acknowledgements
King Edward Memorial Hospital (KEMH). Perinatal depressive and anxiety disorders. Women
and Newborn Health Service. WA Perinatal Depressive and Anxiety Guidelines. Available
from URL: http://www.kemh.health.wa.gov.au/brochures/health_professionals/8393.pdf

The South Australian Perinatal Practice Guidelines gratefully acknowledge the contribution of
clinicians and other stakeholders who participated throughout the guideline development
process particularly:
Write Group Lead
Dr Ros Powrie
Dr Ann Sved Williams
Pauline Hall

Write Group Members

Rebecca Hill
Tracey Semmler-Booth

Other contributors
Dr Elinor Atkinson
SAPPG Work Group
Perinatal Mental Health Work Group

SAPPG Management Group Members

Sonia Angus
Dr Kris Bascomb
Lyn Bastian
Dr Feisal Chenia
John Coomblas
A/Prof Rosalie Grivell
Dr Sue Kennedy-Andrews
Jackie Kitschke
Catherine Leggett
Dr Anumpam Parange
Dr Andrew McPhee
Rebecca Smith
Simone Stewart-Noble
A/Prof John Svigos
Dr Laura Willington

ISBN number: 978-1-74243-355-4

Endorsed by: South Australian Maternal, Neonatal & Gynaecology Community of Practice
Last Revised: 06/03/2017
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Page 11 of 12
 South Australian Perinatal Practice Guidelines

Perinatal Anxiety and Depressive Disorders

(including Postnatal Depression)

Version control and change history

PDS reference: OCE use only

Version Date from Date to Amendment

1.0 21 Sep 2010 04 Sep 2012 Original version
2.0 04 Sep 2012 19 April 2016 Reviewed
3.0 19 April 2016 06 March 2017 Reviewed
4.0 06 March 2017 Current

ISBN number: 978-1-74243-355-4

Endorsed by: South Australian Maternal, Neonatal & Gynaecology Community of Practice
Last Revised: 06/03/2017
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
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