Clinical Practice Guidelines for Depression and Related Disorders – Anxiety, Bipolar Disorder and Puerperal Psychosis – in the Perinatal Period
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CLINICAL PRACTICE GUIDELINES Depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period A guideline for primary care health professionals February 2011 beyondblue: the national depression initiative is an independent, not-for-profit organisation. Since beyondblue’s establishment in October 2000, it has been the policy of the beyondblue Board not to accept funding from or partner with pharmaceutical companies. None of beyondblue’s activities is funded by pharmaceutical companies. This allows beyondblue to retain independence and impartiality and promote evidence-based approaches to depression, anxiety and related disorders across all program areas. Disclosure of interests All those invited to become members of the Guidelines Expert Advisory Committee (GEAC) were asked to complete a ‘Certification of Disclosure of Interest’ form, which advised that there were no conflicts of interest, prior to their being accepted onto the GEAC. Throughout the development of the Guidelines, members were requested to advise beyondblue and the GEAC Chair if any potential competing interest arose during the development of the Guidelines, for example, being offered an honorarium (financial or in-kind), or payment for travel expenses, to present at a pharmaceutical company event or conference. An enquiry by the GEAC Chair into any potential or perceived conflict of interest was a standing item at the beginning of every committee meeting, with a thorough explanation provided of what may constitute a potential or perceived conflict of interest. In the case of a member being an author of a paper under discussion, where it could be seen to present a competing interest, particularly in the development of either a recommendation or a good practice point, members were requested to leave meetings for the duration of the item. This was to avoid the potential for the member influencing any decision made and was duly recorded in the minutes of the meeting. Any issue raised that had the potential to present a conflict of interest, such as an invitation to present at a pharmaceutical company-sponsored conference, was addressed by the Chair and member, and managed so as to ensure that no conflict of interest occurred. The disclosure of interest management process was robust, transparent and drawn to members’ attention frequently. Systematic literature review The systematic literature review that provides the evidence base for these Guidelines was conducted by Health Technology Analysts Pty Ltd. Technical writing Ampersand Health Science Writing was responsible for drafting and editing the Guidelines in consultation with the GEAC. Suggested citations beyondblue (2011) Clinical practice guidelines for depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period. A guideline for primary care health professionals. Melbourne: beyondblue: the national depression initiative. or Austin M-P, Highet N and the Guidelines Expert Advisory Committee (2011) Clinical practice guidelines for depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period. A guideline for primary care health professionals. Melbourne: beyondblue: the national depression initiative. Publication approval These guidelines were approved by the Chief Executive Officer of the National Health and Medical Research Council (NHMRC) on 11 February 2011, under Section 14A of the National Health and Medical Research Council Act 1992. In approving these guidelines the NHMRC considers that they meet the NHMRC standard for clinical practice guidelines. This approval is valid for a period of 5 years. NHMRC is satisfied that they are based on the systematic identification and synthesis of the best available scientific evidence and make clear recommendations for health professionals practising in an Australian health care setting. The NHMRC expects that all guidelines will be reviewed no less than once every five years. This publication reflects the views of the authors and not necessarily the views of the Australian Government. © Beyond Blue Ltd ISBN: 978-1-921821-06-6 Foreword beyondblue is pleased to issue these Clinical Practice Guidelines for Depression and Related Disorders – Anxiety, Bipolar and Puerperal Psychosis – in the Perinatal Period. The Guidelines summarise published evidence and make recommendations on key areas of perinatal mental health care. In areas for which there is insufficient evidence for recommendations, the Guidelines include good practice points (GPPs), which are based on lower quality evidence and/or best-practice clinical judgement. The recommendations and GPPs were revised after the public consultation process in March to May 2010, and the Guidelines as a whole benefited greatly from the thoughtful contributions of a wide range of health professionals, consumers and carers, both at workshops and through written submissions. While the Guidelines are intended as a resource for all health professionals working with women in the perinatal period (pregnancy and the following year), they are primarily targeted at primary care health professionals. Individual use of the guidance will depend on the knowledge and skills of the health professional involved. Women, their infants and significant others should be at the centre of care, wherever it is provided. These Guidelines will be implemented within the context of current activity at national, jurisdictional and local levels, and of the existing policy framework of the National Perinatal Depression Initiative (NPDI). This national collaboration, introduced by the Australian Government in the 2008–09 Budget, was informed by beyondblue’s National Action Plan for Perinatal Mental Health (2008). The Guidelines Expert Advisory Committee recognises that routine psychosocial assessment of women in the perinatal period is an area of continuing debate among jurisdictions, academics and the health sector and that its introduction may have resource implications (including undertaking psychosocial assessment, health professional training and devising local pathways to care). This is being considered in the implementation of the NPDI. It is anticipated that the Guidelines will contribute to broader understanding of mental health care in the perinatal period, greater consistency in approaches to this care, and improved support and outcomes for women and their families. Prof Marie-Paule Austin (Chair) on behalf of the Guidelines Expert Advisory Committee iii Contents Foreword iii 4 Other assessments in the perinatal period 28 Summary vi 4.1 Assessment of the mother–infant interaction 28 4.2 Assessing for risk to the infant 29 Summary of recommendations vii 4.3 Assessing for symptoms of puerperal psychosis 30 Introduction xiii 4.4 Assessing and managing the risk of suicide 30 4.4.1 Assessing the risk of suicide 31 1 Mental health in the perinatal period 1 4.4.2 Managing immediate risk 32 4.4.3 Developing a safety plan 32 1.1 Mental health problems in the perinatal period 1 1.1.1 Antenatal period 1 5 Acting on psychosocial assessments 33 1.1.2 Postnatal period 1 5.1 Considering whether comprehensive mental health 1.2 Impact of mental health disorders in the perinatal period 2 assessment is required 34 1.2.1 Impact on women 2 5.2 Selecting an appropriate referral and care pathway 34 1.2.2 Impact on infants 2 5.2.1 Considerations when mental health referral is not 1.2.3 Impact on significant others 3 accepted or taken up 35 1.2.4 Impact on other children in the woman’s care 3 5.2.2 Case planning for complex cases 35 1.2.5 Impact on extended family members 3 5.3 Ongoing role of primary care health professionals 35 1.3 Sociocultural groups at increased risk of depression 5.3.1 Preventive approaches 35 and related disorders in the perinatal period 3 5.3.2 Supporting management of depression and 1.3.1 Aboriginal and Torres Strait Islander women 3 related disorders 36 1.3.2 Women from culturally and linguistically 5.4 Practice summary — acting on psychosocial diverse backgrounds 4 assessments 37 1.3.3 Women who have resettled in Australia under 6 Supporting emotional health and wellbeing a refugee program 4 in the perinatal period 38 1.3.4 Women living in regional, rural or remote areas 4 1.3.5 Adolescent mothers 4 6.1 Promoting emotional health and wellbeing 38 1.4 Barriers to and facilitators of mental health care 5 6.1.1 Lifestyle advice 38 1.4.1 Barriers for women and their families 5 6.1.2 Support in the early postnatal period 39 1.4.2 Facilitators for women and their families 6 6.2 Providing psychosocial support 40 1.4.3 Barriers for health professionals 6 6.2.1 Summary of the evidence 40 2 Effective care of mental health in the 6.2.2 Non-directive counselling 41 perinatal period 7 6.2.3 Debriefing/active listening 41 6.2.4 Peer support 41 2.1 Culturally responsive perinatal mental health care 7 6.3 Practice summary — supporting emotional health 2.2 Understanding the woman’s context 8 and wellbeing 42 2.3 Taking a family-centred approach 9 7 Psychological therapies 43 2.3.1 Psychoeducation 10 7.1 Summary of the evidence 43 2.4 Maintaining the therapeutic relationship 10 7.2 Decision-making about psychological therapies 43 2.5 Overall approach to care 11 2.5.1 Training and support for health professionals 12 7.3 Evidence-based psychological therapies 44 2.5.2 Continuity of care 13 7.3.1 Cognitive behavioural therapy (CBT) 44 2.5.3 Complex cases 13 7.3.2 Interpersonal psychotherapy (IPT) 45 7.3.3 Psychodynamic