This term refers to depression occurring either in the antenatal period or in the 12 months after delivery. It affects 9% of women during pregnancy and 16% after the birth15 and affects the well-being of the woman, the baby and significant others. Anxiety is likely to be as or more common.15 Women at risk of perinatal depression include those with previous mental health problems, those who do not have support, those who have been through difficult times (e.g. family problems, abuse or loss), or who feel isolated either by distance or culture or both.
Because it is so prevalent, routine screening is recommended by the beyondblue guidelines. This involves implementing the use of the Edinburgh Postnatal Depression Scale (EPNDS), a validated screening tool, at least once, preferably twice, both antenatally and postnatally. Asking permission and explaining the process before implementing the screening is helpful. Women at higher risk will require more intense screening and monitoring.
If perinatal depression is identified, the GP should take into account the individual woman’s context, her family and cultural setting, and use a family-centred approach. Because of the intense emotions involved in having a baby, establishing a strong therapeutic relationship, using an open collaborative approach and active listening techniques, will help to develop trust, confidence, mutual respect and empowerment. Psycho-education should be provided and appropriate follow-up and continuity of care, with (if appropriate) a co-ordinated team approach.
If a woman or a baby is at risk, urgent referral is recommended. Pharmacological therapies can be used in pregnancy, but the benefits need to be balanced against the risks to both mother and fetus. Psychosis in perinatal depression is fortunately rare but does occur, and requires urgent psychiatric assessment. Refer to CHAPTER 109.
Recurrent brief depression
There is a high prevalence in general practice of patients presenting with recurrent episodes of depression of short duration, about 3 to 7 days, as often as monthly. Premenstrual dysphoria may be a factor. As a rule antidepressants are ineffective. Lithium is an alternative medication for long-term use. Management is based on psychotherapy, especially CBT.
Seasonal affective disorder
SAD or ‘winter blues’ is a recurrent depressive disorder seen in people living in cold climates where the winters are bleak and dark. Features of depression include sleeping difficulty, sadness, lethargy, irritability and anxiety while atypical symptoms include somnolence and increased appetite (carbohydrate craving). Treatment is based on psychotherapy, phototherapy and medication such as the SSRIs. Refer to www.sada.org.uk.