Peri-natal Mental Health

Perinatal mental illness covers the whole pregnancy-to-first-year window. The GP’s job is to screen, to keep effective treatment going rather than stopping it reflexively, and to recognise the small number of presentations that are psychiatric emergencies.

Screening and case-finding

Screen in pregnancy and again postnatally, at the same visits as the routine physical checks. The Edinburgh Postnatal Depression Scale (EPDS) is the usual tool; PHQ-9 and GAD-7 are reasonable alternatives.

• The EPDS is a 10-item questionnaire that patients complete within a few minutes, scored out of a possible 30.
• Recommendations on the threshold that should prompt a mental health referral vary, but many services use a total score above 9 or 10, or any positive answer on the self-harm item.
• Item 10, the self-harm item, is checked on every completed form whatever the total score.
• Screening is a case-finding step and not a diagnosis, so a positive score always needs a clinical interview.

Local timing and bands (HNE HealthPathways). Screen antenatally as early as practical and repeat at least once later in pregnancy; postnatally, screen first at 6–12 weeks and again at least once in the first postnatal year. Severity bands: 10–12 mild, 13–14 mild to moderate, and 15 or above severe or complex — as are puerperal psychosis and any thought of harming herself or the infant. A score of 1, 2 or 3 on question 10 triggers a risk assessment whatever the total. Watch the scoring direction: questions 1, 2 and 4 run top-box 0 to bottom-box 3, while questions 3 and 5–10 are reverse scored.

Pair the EPDS with a psychosocial tool — the Antenatal/Postnatal Risk Questionnaire (ANRQ/PNRQ) is the one local services use, though it is not validated in First Nations or culturally and linguistically diverse populations. Pregnancy is itself a risk factor for intimate partner abuse, affecting 4–9% of pregnant women; abused pregnant women are twice as likely to miscarry, and assaults often target the breasts, abdomen and genitals. Consider it in anyone who does not present for antenatal care until the third trimester, and ask when she is alone.

Source (local): Antenatal Care — Initial Visits and Maternal Postnatal Check, Community HealthPathways Hunter New England (registry: hne-healthpathways-antenatal-care-initial-visits, hne-healthpathways-maternal-postnatal-check; verified 2026-08-31).

Under-detection is the main problem, not over-detection. Up to half of perinatal depression cases remain undiagnosed, largely because women are reluctant to disclose the symptoms.

Depression and anxiety

Antenatal depression is at least as common as postnatal depression, and the two are best treated as one condition spanning the perinatal period. Untreated antenatal depression is associated with worse obstetric and neonatal outcomes, poorer appointment attendance, and worse adherence with supplements, smoking, alcohol and nutrition advice. Perinatal depression also carries an increased risk of maternal suicide.

Risk factors worth asking about:

• Previous depression or anxiety, and any previous perinatal episode.
• Family history of psychiatric illness.
• High-risk pregnancy, hospitalisation during pregnancy, or a traumatic birth.
• A preterm or low-birth-weight infant.
• Absent social support, intimate partner violence, or financial stress.

Treatment. Psychological therapy comes first for mild to moderate illness, and combined therapy plus an antidepressant for moderate to severe illness. Aim for remission rather than partial response, and re-score with the same tool to track it.

• Sertraline and escitalopram are the usual first choices in pregnancy and lactation.
• Fluoxetine and paroxetine are not first-line agents, but are reasonable choices where that drug has previously worked well for this particular woman.
• Prefer a single agent at the lowest effective dose over polypharmacy or serial switching between drugs.
• Continue treatment for at least 6–12 months once an effective dose is reached.
• Taper over 2–4 weeks if stopping, because abrupt cessation causes discontinuation symptoms.

Dose requirements often rise during pregnancy, so a woman who was stable pre-conception may relapse on an unchanged dose. Do not reduce the dose in the third trimester in an attempt to avoid neonatal effects.

Neonatal adaptation syndrome follows late-pregnancy SSRI exposure: irritability (rarely seizures), gastrointestinal upset, respiratory difficulty, low Apgars and increased NICU admission. It is self-limiting and has generally settled by about two weeks.

Other antidepressants. TCAs remain acceptable where indicated, and nortriptyline is the usual choice for its lower anticholinergic burden and measurable serum levels, but doxepin should be avoided in breastfeeding. Venlafaxine has been linked with spontaneous abortion but not fetal abnormality, and it accumulates in the breastfed infant on prolonged treatment. Mirtazapine data are sparse and it is not a first-line drug in pregnancy.

Breastfeeding. Most SSRIs are highly protein-bound and transfer poorly into milk. Encourage breastfeeding while on an SSRI rather than stopping either one.

Postpartum blues

Not an illness. Between about half and three-quarters of women experience it, symptoms start within two to three days of delivery and settle within about two weeks, and it does not impair daily function or the ability to care for the baby. No treatment is needed beyond support and sleep. Severe blues does predict later perinatal depression, so re-screen rather than close the issue off.

Postpartum psychosis

A psychiatric emergency. Onset is typically within the first few days to weeks after delivery, and it usually requires inpatient management, ideally in a mother-and-baby unit.

• Rare, occurring in only 1 to 2 per 1000 pregnancies.
• Presents with agitation, confusion, disorganised thinking, sleep disturbance, hallucinations or delusions, and prominent affective symptoms.
• Carries a real risk of both maternal suicide and infanticide.
• Strongly associated with bipolar disorder and can be its first presentation, and many affected women have no prior psychiatric history at all.
• Treated with antipsychotics, lithium, mood stabilisers and, where needed, ECT.

Any new mother with acute confusion, rapidly fluctuating mood or thoughts of harming the infant needs same-day psychiatric assessment, not a review appointment.

Bipolar disorder

The hard case, because teratogenicity and relapse risk both matter. Relapse is common when medication is withdrawn, and the first postpartum year is the highest-risk period in a woman’s life for a bipolar episode.

Mood-stabiliser teratogenicity, drawn from the Australian Pregnancy Register and related antiepileptic data:

• Valproate is the clearest risk and it is dose-dependent. The Australian Pregnancy Register reported the risk to be as high as 16% for first trimester fetal exposure to valproate at doses above 1400 mg/day, compared with 6% at doses below 1400 mg/day. Avoid it in women of reproductive age wherever possible.
• Carbamazepine has long been associated with neural tube defects, but no pregnancy register has yet shown any statistically significant increase in risk relative to the total population.
• Lamotrigine carries a reported increase in oral clefts, at a rate of 8.9 per 1000 compared with 0.37 per 1000 in the reference population, and dose-related teratogenesis above 200 mg/day. Its plasma concentration falls through pregnancy and rebounds within days postpartum, so it needs monitoring and prompt postpartum dose reduction.
• Combination therapy carries a higher risk than monotherapy.
• Lithium carries a first-trimester cardiac malformation risk and is generally advised against in early pregnancy and during lactation, though recent series report lower cardiac risk than older figures suggested. Where it is used, monitor infant serum lithium concentration together with renal and thyroid function, and always take specialist advice.

Pre-conception planning: stabilise on an antipsychotic before conceiving where that is achievable, and get specialist input early.

Unplanned pregnancy (about half of all pregnancies): weigh the current medication against illness severity. In mild disease a mood stabiliser can be withdrawn slowly over 3–4 weeks with an antipsychotic started if symptoms recur; in severe disease continue the mood stabiliser; in between, hold an informed risk-benefit discussion.

Pregnancy discovered in the second trimester: the main teratogenic window has passed, so prioritise anomaly ultrasound rather than abruptly stopping lithium or an antiepileptic.

Schizophrenia and other psychotic illness

Needs specialist input. Severity fluctuates through pregnancy, with a clear increase in relapse risk in the first postpartum year. Untreated psychosis harms both mother and baby, and that harm generally outweighs the risk of continuing an antipsychotic, so under-treatment is the bigger error. Do not withdraw antipsychotics simply because a woman is pregnant.

• Studies examining the use of the older antipsychotic drugs in pregnancy have not shown a significantly increased risk of birth defects above the baseline rate of 3% in the general population.
• Babies exposed to haloperidol and chlorpromazine in utero may show extrapyramidal abnormalities, similar to those seen in adults, for weeks after birth.
• Atypicals (olanzapine, risperidone, quetiapine, clozapine) have shown no excess malformation rate in the available cohorts, and are the usual maintenance choice.
• The older antipsychotic drugs increase prolactin, resulting in significantly lower fertility rates than with the atypical antipsychotic drugs.
• Because of olanzapine-associated weight gain and a theoretical relative folate deficiency, some experts suggest that women planning pregnancy while taking olanzapine should take 5 mg folate rather than the usual 0.5 mg.
• Avoid anticholinergic drugs for extrapyramidal side effects during pregnancy.
• Women who wish to breastfeed should be managed with a single antipsychotic drug if possible, watching the baby for lethargy, sedation and developmental milestones.

Referral and safety

Refer the same day for suicidal ideation with intent or plan, thoughts of harming the infant, psychotic symptoms, or acute confusion. Refer routinely for bipolar disorder or schizophrenia in a woman planning pregnancy, for treatment-resistant depression, and for any woman needing a decision about lithium or valproate. ECT remains an option in severe refractory illness, particularly with psychotic depression or active suicidal or infanticidal intent.