Guideline No. 454: Identification and Treatment of Perinatal Mood and Anxiety Disorders

Objective

To help perinatal health care providers identify and assist pregnant and postpartum patients with perinatal mental illness, specifically perinatal mood and anxiety disorders. Areas of focus include risk factors and identification, screening, treatment, and referral.

Target Population

All individuals who are pregnant or in the first year postpartum.

Outcomes

Open dialogue and evidence-informed care for perinatal mood and anxiety disorders, including competency for identification, screening, treatment, and referral, which will lead to improvements in patient care.

Benefits, Harms, and Costs

Pregnant and postpartum individuals with untreated perinatal mental illness, including mood and anxiety disorders, may suffer devastating effects and their family may experience short- and long-term adverse outcomes.

Evidence

A literature search was conducted using Medline (Ovid), PubMed, Embase and the Cochrane library from inception to June 2024. Additional articles were identified from article bibliographies and grey literature published by reputable societies and organizations (see online Appendix A).

Validation Methods

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix B (Tables B1 for definitions and B2 for interpretations of strong and weak recommendations).

Intended Audience

All heath care providers who provide preconception counselling and/or care during pregnancy and the postpartum period. The term “perinatal” will be used throughout this guideline to refer to these health care providers.

Social Media Abstract

New SOGC Guideline! Identify, support, and treat perinatal mood and anxiety disorders. Focused on risk factors, screening, treatment and referrals during pregnancy and the postpartum period. Let's open dialogue and provide evidence-informed care for improved patient outcomes.

SUMMARY STATEMENTS

• 1.
  Perinatal mood and anxiety disorders are common (high); postpartum depression and anxiety are the most common maternal complications of pregnancy (high).
• 2.
  The psychological aspects of the transition to parenthood are important factors that affect perinatal mental health (moderate).
• 3.
  Suicide in the perinatal period is emerging as one of the most common causes of maternal mortality in Canada (moderate).
• 4.
  Symptoms of anxiety or depression during pregnancy are highly predictive of postpartum mental illness (high).
• 5.
  Untreated depression or anxiety during pregnancy is associated with adverse perinatal outcomes, including persistent depression in pregnant patients and their partners, maternal self-harm, low birth weight, preterm birth, and poor infant development (high).
• 6.
  Experiencing a perinatal loss, having a history of previous mental illness, and intimate partner violence are important risk factors for perinatal mood and anxiety disorders (high).
• 7.
  Race, culture, language, ability, age, and sexual identity may contribute to an individual’s risk for perinatal mental illness (high).
• 8.
  Perinatal care providers may be the patients’s first point of contact with the health care system as well as the first health care provider to establish a positive and trusting relationship with them. They play an important role in identification, screening, and referral for perinatal mood and anxiety disorders (moderate).
• 9.
  Different treatment approaches/intensities may be required, depending on the severity of illness and individual preferences (high).
• 10.
  Most of the common pharmacologic agents to treat perinatal mood and anxiety disorders are not teratogenic (high).
• 11.
  Tapering or stopping antidepressant medication during pregnancy can lead to relapse in patients with history of severe disease (moderate).
• 12.
  Pregnant and postpartum individuals will benefit from counselling focused on shared decision-making (moderate).

RECOMMENDATIONS

IDENTIFICATION AND RISK

• 1.
  Perinatal death or losing custody of the infant both increase a patient’s vulnerability for mental illness, and additional monitoring and support may be needed in these circumstances (strong, high).
• 2.
  For patients who have experienced trauma, education to help reduce fears related to childbirth should be provided (strong, moderate).
• 3.
  A review of health history should be included in mental health assessments, and risk factors should be discussed during preconception counselling and/or during pregnancy (strong, high).
• 4.
  Perinatal care providers should inquire about mental health status at each visit throughout pregnancy and in the year following the pregnancy, especially in circumstances of perinatal loss (strong, high).

SCREENING

• 5.
  Screening should be complemented with a clearly defined and locally tailored referral process (strong, high).
• 6.
  Patients with risk factors for mood and anxiety disorders should be screened at least once during pregnancy and once during the postpartum period using a validated screening tool (e.g., Edinburgh Postnatal Depression Scale, Personalized Health Questionnaire-9, Generalized Anxiety Disorder-7) (strong, moderate).
• 7.
  When a concern about mental health is identified by the patient or provider, the patient should be screened at that visit using a validated screening tool (e.g., Edinburgh Postnatal Depression Scale, Personalized Health Questionnaire-9, Generalized Anxiety Disorder-7) (strong, moderate).
• 8.
  Perinatal care providers should provide information about psychosocial and community-based supports (in person, virtual, or hybrid models) with patients presenting with perinatal mental health concerns (strong, moderate).

TREATMENT

• 9.
  For pregnant and postpartum patients with moderate perinatal depression or anxiety, health care providers should recommend psychoeducation, psychotherapy, pharmacological therapy, or a combination of these approaches as first-line treatment (strong, high).
• 10.
  Perinatal care providers should recommend that patients with perinatal mood or anxiety disorders receive routine counselling about the psychological aspects of the transition to parenthood and other important factors that can affect perinatal mental health (strong, moderate).
• 11.
  The health care provider should have a comprehensive discussion about possible maternal, fetal, and neonatal risks and side effects to initiating, continuing, or changing medication as well as its benefits (strong, high).
• 12.
  Patients with pre-existing mental health diagnoses who are well maintained on pharmacological agents should not abruptly discontinue medication during pregnancy. Patients should speak to their mental health clinician and obstetrical care provider prior to considering discontinuation or tapering medications during pregnancy (strong, moderate).
• 13.
  Patients taking certain pharmacologic agents (see online Appendix C) should be referred for preconception counselling by their health care provider; if the patient is already pregnant, consultation with a psychiatrist is warranted, particularly for individuals with mental disorders such as bipolar disorder and schizophrenia (strong, high).
• 14.
  Pregnant individuals with a severe perinatal mood or anxiety disorder should be urgently referred by their care provider to specialized psychiatric services with immediate action (strong, high).
• 15.
  Shared decision-making regarding treatment options should consider the patient’s values, beliefs, and preferences (strong, moderate).