Notre Dame medical student Juan Stephen and Dr Ramya Raman explore how GPs can play a role in identifying postnatal depression.
Perinatal depression often begins in the antenatal period, but it may not be identified until the postnatal check. One in six women experience postnatal depression (PND) in the first year, following childbirth.
PND can significantly impact on their health and their partners and is invariably associated with impaired mother-infant bonding. Moreover, PND is associated with poor cognitive and emotional development in the infant.
The perinatal period offers opportunities to diagnose and manage mild, moderate and severe mental illnesses mainly because of the greater frequency of contact women usually have with health professionals during their routine antenatal consultations, which often does not occur in postpartum period.
GPs are the usual first port of call for patients, but all health-care professionals in contact with pregnant women, especially in the postpartum period, should be alert to new symptoms for PND or those of a more chronic nature.
Previous studies show that more than 50% of women with postnatal depression are not identified in a primary-care setting. Often, this is associated with women avoiding help because of the stigma attached with PND.
Existing guidelines
Clinical practice guidelines for perinatal mental health were developed by BeyondBlue in 2011. The Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) guidelines were subsequently improved upon as ‘The National Perinatal Depression Initiative’ (2013).
It is now mandatory to screen for mental-health disorders in pregnancy and post-partum (RANZCOG, 2018). These guidelines recommend that local-health services such as GP practices devise ways of implementing screening mothers for postnatal depression using standardised and validated tools such as the Edinburgh Postnatal Depression Scale (EPDS) and the Depression Anxiety and Stress Scale (DASS-21).
Detecting postnatal depression early enables women to seek appropriate treatment and also ensures better outcomes for the mother, baby, their family and the community. From an economic viewpoint, early identification enables appropriate allocation of resources for healthcare needs.
Against such a background, a clinical audit conducted at a small outer metropolitan general practice clinic in Perth in 2020 determined that 96% of women who presented for their 6 to 8-week postnatal check was screened for PND as per the RANZCOG guidelines.
Of a sample of 55 female patients, 53 were screened for postnatal depression. For the 96% of the sample screened for postnatal depression, EPDS toolkit was used. None of the patients was found to be screened for postnatal depression using the DASS-21.
PND screening
As per the RANZCOG guidelines, 100% of women presenting at a GP practice for their 6 to 8-weeks postpartum check should be screened for postnatal depression. While this audit determined high rates of screening for PND, opportunities for improvement remain to ensure PND identification occurs in the post-natal period.
The sample of 55 women represented 38% of total number of women who presented for their postpartum check at the GP practice between January and December 2019. A larger sample size should allow better extrapolation of results.
It is hoped that this audit will help improve the rates of postnatal depression screening at a GP practice, similar audits across other practices would be necessary before rates of screening at a local, state-wide, or national level can be determined and compared to the national standard.
As a result of the audit, these recommendations were made to the GP clinic:
- Every woman is screened for postnatal depression during their 6 to 8-week check using the EPDS and a standardised proforma on the practice software
- All visiting staff are educated in the use and necessity of postnatal depression screening for women presenting at the 6 to 8-week postnatal check
- Standardised documentation of the EPDS scoring along with the risk category to ensure uniformity is maintained across staff in the practice
- Ensuring that the 6 to 8-week postnatal check is recorded under a fixed term such as ‘6 to 8-week postnatal check’ or ‘6 to 8-week postpartum check’ in the practice software to allow for easier identification of patients presenting specifically for this reason
- the reauditing done by staff or medical students to assess for improvement of screening rates within the practice.
Importance of audit
These recommendations can easily be applied to other practices that might consider a similar auditing process.
GPs are one of the first point of contact for women presenting for their first postpartum check and they are well placed to raise awareness of PND, review and monitor mental health states in women during their pregnancy, detect early symptoms and initiate further management steps and support the woman and her family through this period.
ED: The authors acknowledge the co-operation of the Skye Medical Team in the conduct of this clinical audit. In particular, they wish to thank Mrs Stephanie MacKinnon (Practice Manager) and Ms Eleanor Spencer (Office Manager) for their time and support.
Juan Stephen is a final year medical student at the University of Notre Dame. He is sponsored by the Australian Defence Force and will be commencing his internship at St John of God, Midland Public Hospital in 2021.
Ramya Raman is a GP at Skye Medical Armadale and Clinical Academic with School of Medicine, University of Notre Dame, Fremantle. Ramya is also medical educator with WAGPET and Deputy Chair of RACGP WA Council.
– References on request