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Routine Perinatal Mental Health Assessment

Evidence indicates that many women fail to identify themselves as depressed or to seek help (Murray, Woolgar, Murray,& Cooper, 2003). Sadly, not all health-care providers will identify their condition.As most women will access obstetric, midwifery, nursing or paediatric care during pregnancy or post natally, an ideal opportunity exists to ensure that mental as well as physical health is optimised.

There has been considerable debate regarding the best method for routine assessment to ensure reliable identification of illness or subclinical problems and a number of self-report measures have been reviewed by Muzik et al. (2000). The Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden,& Sagovsky, 1987) is the most widely used brief self-report measure of maternal distress and depressive symptomatology. It has also been validated for use antenatally (Murray & Cox, 1990) and in men (Matthey, Barnett, Howie,& Kavanagh, 2003).

It has been translated into a number of different languages and validated across a range of cultures (Cox &Holden, 2003). As the scale includes several anxiety-related items, it has recently been argued that it also identifies anxiety. Formal clinical or structured diagnostic interviews for anxiety and depressive disorders exist,such as the Composite International Diagnostic Interview (CIDI; Robins et al., 1988),but these are not appropriate for routine, universal screening or assessment in everyday clinical settings. They are indicated at the next level (usually postreferral) when accurate psychiatric diagnosis is required. Self-report measures such as the EPDS are not diagnostic tools. Studies of concurrent validity comparing EPDS scores with results on structured diagnostic interviews do show that there is an increased probability of clinical levels of depression if scores are significantly elevated (e.g.,above12 inEnglishspeaking populations).

Nevertheless, scores can also be raised on the EPDS due to transient stress, or grief reactions, as well as anxiety disorders and depression. For community screening purposes it is usually recommended that a lower threshold (over 9) be used to ensure problems are not missed. Further exploration and, if necessary, repeat administration, are recommended to establish the nature of the difficulties and whether further action or referral to a mental health professional is required (Austin & Priest, 2005). Scores over 20 indicate complex histories often involving multiple stressors, including prior traumatic experiences, and any score on item 10 (thoughts of self-harm) requires further assessment.

Downloadable versions and many translations are available. Some models for perinatal assessment also include questions about presence of psychosocial risk factors known to be associated with perinatal mood disorders and difficulties in coping with the adjustment to parenthood (ACOG, 1999). Examples include the Integrated Perinatal Care Program, the Antenatal Psychosocial Health Assessment Form, the National Postnatal Depression Program in Australia (Buist et al., 2007), and the Psychosocial Risk Assessment Model (Priest, Austin, Barnett,& Buist, 2008).

These can be used alongside symptom-based measures and have potential to identify women at psychological or social risk. Such approaches are not without their critics and further validation studies are needed before it can be established whether early identification reduces incidence or prevalence of perinatal disorders or parenting difficulties and increases uptake of relevant services.

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