Common Mental Disorders Depression - New Zealand Doctor

Chapter 7 Special issues: women with mental disorders in the antenatal and postnatal period
planning should involve a discussion of how to recognise signs of deterioration
and how to access help if necessary. 101,455
The GDT notes that careful history taking, close monitoring and good psychosocial
care will be sufficient for some women. Monitoring is particularly important because
a pregnant woman with depression is at increased risk of poor antenatal and postnatal
care. 455 Her appetite may be reduced, with consequent poor weight gain during
pregnancy, and she may be at increased risk of smoking and substance abuse. 455
Her risk of suicide or self-harm should be assessed regularly. 453 Contraception needs
must be addressed, to avoid a woman proceeding from an inadequately-treated
episode of mental illness directly into a subsequent pregnancy. 103
First-line interventions
Nonpharmacological interventions, such as enhanced social support and/or a
psychological intervention, should be considered before prescribing medication
for depression in the antenatal or postnatal period, especially if the woman has
mild symptoms or is in very early pregnancy. 455
Brief psychological therapy is an appropriate first-line intervention for a woman with
mild to moderate symptoms (eg, 6–8 sessions of non-directive counselling [CBT or
IPT]). Ideally, this will be provided within primary care. 101 For a woman who has severe
depression in the antenatal or postnatal period, or does not respond to initial treatment,
a structured psychological therapy that targets depression such as CBT or IPT could be
considered, in consultation with maternal mental health services as appropriate.
An antidepressant may be considered as a first-line treatment for a woman with
moderate to severe depression in the antenatal or postnatal period, provided she
expresses a preference for this treatment after full discussion of the potential risks,
the potential benefits and the uncertain state of the evidence. 456 Antidepressants
need to be used with great care in this population and the GDT recommends that
practitioners consider consulting maternal mental health services before initiating
antidepressant treatment in women who are pregnant (see 7.5: Management of
Antenatal and Postnatal Depression, Special Issues: Antidepressant Use).
Mobilisation of support/resources for the mother, infant and wider family/whänau
are a valuable component of management, 454 as lack of social support is strongly
associated with postnatal depression. 457-459 The practitioner could check that referral
has been made to the Plunket Nurse, who can assist the family in accessing support,
and could offer referral to other health professionals (eg, social worker) or for services
that will provide ‘time out’ (eg, short-term childcare or home-help). 101 Transport
problems, domestic responsibilities and childcare needs are potential barriers to
treatment, and interventions that can be provided at the woman’s home or via the
phone or internet may be more effective. 101,458
Identification of Common Mental Disorders and Management of Depression in Primary Care 99