Article summary:
- Around 1 in 5 mothers and 1 in 10 fathers experience perinatal mental health issues, impacting family wellbeing and attachment.
- Social and biological factors like isolation, trauma and hormonal changes increase risk.
- Diagnosis requires nuanced assessment to distinguish perinatal symptoms from other mental health conditions.
- Effective treatments include CBT, ACT and structured psychoeducation.
- Emerging supports like telehealth and peer models improve access but may not suit severe cases.
- Integrated, multidisciplinary care strengthens support and builds patient trust.
- The APS continues to advocate for enhanced perinatal mental health care in Australia to ensure greater continuity of care, improve access to psychological services in our regional communities, and more.
It is difficult to determine exactly how many parents experience mental health issues during the perinatal period, which is defined as the first 12 months after birth.
However, research suggests that around one in five expecting and new mothers experience anxiety, depression or both. Among fathers, it’s one in ten.
“On top of that, many experience adjustment disorders, and maternal suicide remains one of the leading causes of death among expecting and new parents,” says Karen Edwards MAPS, Clinical Director at the Gidget Foundation, a not-for-profit organisation that supports the mental health of expectant, new and potential parents to ensure they receive accessible, timely and specialist care.
Further, poor perinatal mental health affects much more than parents’ short-term wellbeing.
“It can impact obstetric and neonatal outcomes, parent-infant attachment, family relationships and long-term feelings of self-worth as a parent and partner,” says Edwards.
For psychologists, screening for, diagnosing and treating perinatal mental health issues can present unique challenges.
These include addressing social risk factors, such as cultural identity; distinguishing between usual changes and challenges experienced by new parents and those which indicate a perinatal issue; and the stigmatisation of perinatal mental health, which can cause parents to under-report symptoms.
The good news is that treatment can be highly effective.
“We see first-hand the importance of prevention, screening and early intervention,” says Edwards. “It not only improves immediate health outcomes for mothers and babies, but also fosters long-term development, as well as emotional and physical health, for the entire family.”
How do social determinants impact perinatal mental health?
For psychologists, an understanding of potential social risk factors is essential.
Among the most significant is a lack of support and/or connection. Women isolated due to distance and/or culture are more likely to experience perinatal mental health challenges.
This is exacerbated in rural and remote areas where care is inconsistent and/or inaccessible, and for women in adolescence who are cut off from social networks.
In addition, some groups experience issues at higher rates. Prevalence among Aboriginal and/or Torres Strait Islander women is more than double that for non-Indigenous women. This is due mainly to collective experiences of colonisation, trauma and racism, according to the Centre of Perinatal Excellence (COPE).
Migrant women are also at higher risk, often due to language and cultural barriers, with refugee women more likely to experience psychological morbidity.
Another significant factor is intimate partner violence.
In one study, it was experienced by two in five women who reported symptoms of perinatal depression. In another, women who reported intimate partner violence at their first antenatal visit were 7.63% more likely to score more than 13 on the Edinburgh Postnatal Depression Scale (EPDS) – a tool commonly used to screen women during pregnancy and the perinatal period.
In addition, such women were 2.4% more likely to report thoughts of self-harm and 34.2% more likely to report anxiety and depression.
These social risk factors create complexities for psychologists in screening for, diagnosing and treating perinatal mental health issues – and these complexities require sensitive solutions.
Psychological and biological risk factors
In addition to social risk factors, psychological and biological risk factors influence perinatal mental health significantly.
Among psychological factors, the most influential is a history of mental health issues.
“Others include changes in perception of self, including identity around work status, changes in financial independence and changes in values associated with adjusting to parenthood,” says Edwards.
“Personality traits, like perfectionism and challenges with emotional regulation can also play a role.”
Also relevant is the impact of a client’s personal experiences, including past events such as a childhood involving inconsistent or absent parenting, trauma, neglect and/or abuse, and contemporaneous events, such as a lack of practical and emotional support, grief, loss, separation and gender disappointment.
“Psychologists should also consider the impact of hormonal fluctuations, variations in medication, substance use, and the quality and quantity of sleep,” says Edwards.
In a critical review of research concerning the relationship between sleep and perinatal mood disorders, researchers found that reduction of perinatal sleep deprivation may provide a low-cost method of preventing and, potentially, treating perinatal depression and psychosis.
The complexities of diagnosis
One of the biggest challenges of perinatal diagnosis is that perinatal mental health issues often have symptoms in common with other mental health issues.
To overcome this, conducting a nuanced assessment is crucial.
“Screening instruments like the EPDS can help flag risks or concerns, but are not diagnostic instruments,” says Edwards.
“What’s most important is looking at a nuanced bio-psycho-social history, which is key in establishing an understanding of what might be life-long symptoms exacerbated by perinatal challenges versus what’s emerging as a perinatal presentation,” says Edwards.
“This requires asking questions about when the symptoms first presented, whether they relate specifically to the perinatal period, whether they’re continuous or episodic, and their nature.
“For example, is anxiety focused on the health and wellbeing of the baby, or is it more a general feeling of worry and concern?”
Evidence-based therapeutic approaches
Evidence-based models effective in treating perinatal mental health issues include cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), interpersonal therapy (IPT) and mentalisation-based therapy (MBT).
“When choosing a modality, look at the presenting issue, then determine which is most efficacious,” says Edwards. “For example, CBT might be efficacious with anxiety or depression, but you might learn towards MBT for a personality issue.”
The National Institute for Health and Care Excellence (NICE) (UK) recommends that for women with mild or moderate to severe depression, a clinician-led, “high-intensity psychological intervention” should be considered.
“There are also many effective parent-infant approaches, including attachment-based approaches, as well as other approaches, such as structured psychoeducation, psycho-social support and directive counselling,” says Edwards.
According to one meta-analysis, structured psychoeducation reduces symptoms of psychological distress and depression. It could be particularly useful as an initial intervention, given its low cost and ease of accessibility.
The interventions studied ranged from the delivery of “passive materials”, such as leaflets, emails and websites, to “active” group interventions, featuring a therapist’s guidance and exercises.
When choosing between therapeutic modalities, psychologists should consider the client’s capacity to attend and afford treatment.
“The approach needs to work with the model of care you’re able to provide,” says Edwards.
“Briefer interventions might be appropriate for clients who can only access ten sessions under Medicare, while long-term interventions might be appropriate for those who can engage over a longer period, or with more frequent or intensive attendance.”
It's also worth noting that group therapy sessions can be accessed in addition to the 10 individual Medicare sessions clients are entitled to each year, making it a good supplement for those seeking additional support or a connection point with a group of people undergoing similar circumstances.
Emerging interventions and innovations
Emerging interventions and innovations in perinatal mental health care include telehealth, online behavioural activations, the provision of information and resources online and peer-based support.
While some psychologists find these emerging interventions useful for those struggling to access face-to-face care, others argue they are no substitute for in-person care.
“There’s no one-size-fits all approach,” says Edwards. “For example, online behavioural activations have been shown to be effective in improving symptoms of perinatal depression and anxiety, particularly for those at risk of, or in the mild range, but they don’t work for everyone – those with more severe symptoms often need more intensive interventions.”
Further, it can take time to determine whether innovations work.
“For example, it is now established that telehealth has significantly improved access to, and continuity of, mental health care. Many expecting and new parents benefit from blended models, where they come in for some face-to-face sessions and attend telehealth for others, but this hasn’t always been available.
“Peer support models can provide a complementary workforce to health professionals, bringing unique perspectives and insights,” says Edwards.
“We know parents find it helpful to listen to, and learn from, other parents – to know that they’re not alone and that other parents also struggle.”
Supporting a continuum of care
“We know from research that access to a primary care provider, who the client feels understands them, and has mutual trust with, increases the likelihood that the client will communicate openly and honestly, and feel less traumatised by care decisions,” says Edwards.
“Psychologists are well placed in this role, as they’re in the unique position of advocating for the client across the spectrum of medical, physical and social care needs.”
Perinatal mental health care should be integrated with the rest of perinatal care, such as that concerning pregnancy, childbirth and breastfeeding. This means that a collaborative, multi-disciplinary approach is most effective.
“It’s really challenging when multidisciplinary care is just lots of different health professionals providing siloed care,” says Edwards.
“It’s important that [they] come together and support parents with consistent messages across both their physical and psycho-social wellbeing.
“Care should be integrated, and involve smooth transitions, warm handovers, and shared decision-making and care planning, so expecting and new parents feel heard and validated.”
Additional resources
If you would like to upskill in the perinatal mental health space, APS offers some useful courses: