Perinatal mental health: EPDS screening, sertraline, and postpartum psychosis

Why perinatal mental health deserves specific attention

Perinatal mental health conditions — those arising during pregnancy (“antenatal”) or within the first twelve months postpartum (“postnatal”) — are among the most common complications of pregnancy in Australia. Perinatal depression affects approximately 10% of women antenatally and 16% postnatally. Perinatal anxiety disorders (generalised anxiety, panic disorder, OCD, social anxiety, PTSD) affect roughly 13% antenatally and 17% postnatally, and they frequently co-occur with depression.

Maternal suicide is a leading cause of maternal mortality in Australia and across high-income countries. Underdetection and undertreatment remain significant public health problems: many women are reluctant to disclose because of stigma, fear their baby will be removed, or assume their feelings are a normal part of new parenthood. Universal screening, rather than relying on women to self-present, exists specifically to address this gap.

The spectrum of perinatal mental illness runs from adjustment difficulties and baby blues (normal and self-resolving) through mild-to-moderate depression and anxiety (highly treatable with psychological therapy) to severe depression, bipolar relapse, and postpartum psychosis (psychiatric emergencies requiring inpatient care). The approach differs substantially at each level.

A. Core clinical — the AU general-practice framework

The conditions in scope

Perinatal depression — meets DSM-5 criteria for a major depressive episode with peripartum onset specifier (during pregnancy or within four weeks of delivery in the DSM; broadly applied to the first twelve months postpartum in clinical practice). Features: persistent low mood, anhedonia, guilt, sleep disturbance beyond infant care demands, appetite change, poor concentration, worthlessness, suicidal ideation.

Perinatal anxiety disorders — generalised anxiety, panic disorder, OCD with perinatal onset or exacerbation, social anxiety, PTSD. Frequently co-occur with depression; the EPDS does not comprehensively screen for anxiety — supplement with the GAD-7 if anxiety is the primary concern.

Postpartum psychosis — rapid onset, almost always within the first two weeks postpartum; psychotic symptoms (delusions, hallucinations), severe mood lability (rapid cycling between elation and despair), disorganised thinking, confusion, and severe insomnia. This is a psychiatric emergency: mortality risk to mother (suicide) and infant. Approximately one to two per thousand births.

Bipolar postpartum relapse — the most high-risk situation: 50–70% relapse rate in women with established bipolar disorder who discontinue mood stabilisers during pregnancy without prophylaxis restarted immediately postpartum. Requires specialist co-management throughout pregnancy.

Birth-related PTSD — traumatic birth experience producing intrusion, avoidance, and hyperarousal symptoms; under-recognised and under-treated; responds to trauma-focused psychological therapy.

Perinatal OCD — intrusive thoughts about harming the baby are common (present in 20–40% of new mothers), intensely distressing, ego-dystonic (unwanted), and rarely acted upon. They are not psychotic ideation. Distinguishing them from psychotic ideation — which does carry risk — requires careful clinical assessment. OCD responds to CBT (exposure and response prevention) and SSRI.

Validated screening tools

Edinburgh Postnatal Depression Scale (EPDS) — 10-item self-report; ≥10 indicates possible depression; ≥13 probable depression; Question 10 (thoughts of self-harm) requires immediate clinical response regardless of total score.

Antenatal Risk Questionnaire (ANRQ) — screens psychosocial risk factors (prior mental illness, trauma history, domestic violence, poor social support, substance use) at the booking visit; complements the EPDS.

K10 — general psychological distress; useful if EPDS score is in the intermediate range or when anxiety is the primary concern.

The COPE 2023 Australian Clinical Practice Guideline recommends universal EPDS screening at three time points: antenatal booking, 28 weeks of pregnancy, and 6 weeks postpartum. Higher-risk women (prior perinatal mental illness, established bipolar disorder, significant psychiatric history) should be screened more frequently and referred to perinatal psychiatry early.

History to take

• Current mood and anxiety symptoms, onset, trajectory
• Structured suicide risk assessment — ideation, intent, plan, access to means
• Infant safety concerns — thoughts of harming the baby (distinguish ego-dystonic OCD from psychotic ideation)
• Birth experience — traumatic delivery, unexpected complications, loss of control
• Past psychiatric history — prior perinatal episodes, bipolar diagnosis, hospitalisation
• Domestic and family violence — peaks during pregnancy and postpartum; use a routine, sensitive inquiry framework
• Substance use — alcohol, cannabis, other substances (implications for infant care and neonatal outcomes)
• Social support — partner involvement, family support, housing stability, financial stress
• Sleep — quantity and quality, distinguishing infant-driven disruption from psychiatric insomnia
• Breastfeeding intentions and status — influences medication choice discussion

Investigations

• EPDS (universal) and ANRQ (at booking) as described
• TSH — postpartum thyroiditis is common (6–12 weeks postpartum); can mimic depression and anxiety; often self-resolving but thyroid hormone replacement needed in hypothyroid phase
• FBC, iron studies, B12, vitamin D — deficiency anaemia, iron deficiency, and vitamin D deficiency all contribute to low mood, fatigue, and cognitive symptoms in the postpartum period

B. Management — guideline-aligned

Primary guidelines: COPE 2023 · RANZCP Mood and Anxiety Disorders CPGs · eTG — Psychotropic · AMH — pregnancy and breastfeeding sections · MotherSafe NSW (1800 647 848).

Psychological therapy — first-line for mild-to-moderate illness

Psychological therapy is first-line for mild-to-moderate perinatal depression and anxiety. COPE 2023 supports:

• CBT — including pregnancy-adapted protocols addressing perinatal-specific cognitions (perfectionism, identity change, infant-related anxiety)
• IPT (interpersonal therapy) — particularly well-evidenced in the perinatal context; addresses role transitions, relationship conflict, grief, and social isolation
• Mindfulness-based cognitive therapy (MBCT) — for relapse prevention in recurrent depression
• Digital self-help — MumMoodBooster (AU-developed, CBT-based, clinical trial evidence); This Way Up perinatal modules
• Peer support — PANDA peer support groups, new parents’ groups; social connectedness is strongly protective

Access via Mental Health Care Plan — MBS items 2715/2717 (preparation), 2712 (review); 10 individual psychology sessions per year under the Better Access programme. Specify a psychologist with perinatal mental health experience on the referral.

Antidepressants — for moderate-to-severe illness

Shared decision-making is essential. The discussion should explicitly address: risk of untreated illness (to mother, infant, and pregnancy), known medication risks, the limited absolute magnitude of those risks, and the option of monitoring versus immediate pharmacotherapy.

Per COPE 2023, AMH, and MotherSafe:

Sertraline — the preferred SSRI in pregnancy and breastfeeding. Most safety data; minimal placental transfer; no established teratogenic signal; low and clinically non-significant breast milk transfer in most infants. Neonatal adaptation syndrome (mild irritability, feeding difficulty in first two to three days) occurs in a small proportion of neonates; usually mild and self-resolving.

Escitalopram and citalopram — acceptable alternatives; lower breast milk transfer than fluoxetine.

Fluoxetine — long half-life (active metabolite norfluoxetine half-life 7–15 days); significant breast milk transfer; reasonable if the patient is already stable on fluoxetine but consider alternatives if initiating.

Paroxetine — a modest cardiac defect signal in first trimester; significant neonatal withdrawal; avoid initiating in pregnancy; taper if established.

Valproate — absolutely avoid in women of childbearing potential without highly effective contraception. High rates of neural tube defects, neurodevelopmental impairment, and facial dysmorphism; risk is not eliminated by folate supplementation at standard doses. If a woman of childbearing potential is on valproate, this requires urgent specialist psychiatric review.

Lithium — small increased risk of Ebstein’s anomaly in the first trimester (1/1000 vs background ~1/20,000); acceptable in many situations with specialist co-management, high-resolution fetal echocardiography at 18–20 weeks, and frequent level monitoring (renal clearance increases substantially in pregnancy). Postpartum restart immediately — lithium is the most effective bipolar prophylaxis postpartum (~10% relapse rate with prophylaxis vs 50–70% without).

Lamotrigine — generally preferred over valproate for bipolar in women of childbearing potential; modest cleft lip/palate signal (1–2%, vs background ~0.1%); levels fall substantially in pregnancy — requires monitoring and dose adjustment.

All antidepressants are available on the PBS general schedule (sertraline, escitalopram, citalopram, fluoxetine). Lithium is general schedule; lamotrigine requires Authority. Atypical antipsychotics (quetiapine, olanzapine) are Authority Required.

Postpartum psychosis — emergency management

Postpartum psychosis requires immediate emergency action:

• Emergency department presentation — same day; do not manage in general practice
• Inpatient admission — mother-baby unit (MBU) preferred where available (preserves maternal-infant bond and supports breastfeeding); general psychiatric unit if MBU unavailable
• Antipsychotic + mood stabiliser combination is typical first-line; lithium postpartum is highly effective for bipolar-related postpartum psychosis
• ECT — first-line in severe, rapidly deteriorating, or medication-refractory cases; highly effective and rapidly acting; safe postpartum
• Specialist perinatal psychiatry — essential; most states have a perinatal psychiatry consultation-liaison service

Mother-baby units exist across Australia — availability varies by state; elective referral to a perinatal psychiatrist before delivery is the best risk-mitigation strategy for high-risk women (established bipolar disorder, prior postpartum psychosis).

C. Evidence summary for key perinatal decisions

Decision	COPE 2023 / evidence position
Universal EPDS screening	Strongly recommended at three time points
Psychological therapy first-line (mild-moderate)	Strongly recommended; IPT and CBT preferred
Sertraline in pregnancy	Recommended where medication indicated; most evidence
Valproate in women of childbearing potential	Avoid — high teratogenic and neurodevelopmental risk
Lithium postpartum prophylaxis in bipolar	Strongly recommended; restart immediately postpartum
ECT for severe postpartum psychosis	Effective, rapidly acting; first-line in severe cases
Mother-baby unit for severe postpartum illness	Preferred over general psychiatric admission

D. Australian operations

MBS pathways relevant to perinatal mental health:

• GP standard attendances — items 23/36/44; telehealth equivalents 91790/92029/92060
• Mental Health Care Plan — items 2715/2717 (preparation); 2712 (review); 10 psychology sessions/year; eligible across pregnancy and postpartum
• Pregnancy Support Counselling — MBS items 4001/4003/4005; three sessions per pregnancy from a GP, eligible nurse/midwife, psychologist, or social worker; specifically for psychosocial support during pregnancy
• Antenatal shared care — standard shared-care items; mental health integrated into antenatal schedule; see antenatal shared care article for MBS specifics
• GPCCMP (items 965/967) — for women with a diagnosed mental health condition (e.g., established depression, bipolar disorder) persisting through pregnancy; can bundle allied health
• ATSI Health Assessment item 715 — includes perinatal mental health screening for eligible patients

State mother-baby units:

Each state has at least one inpatient MBU. Access varies significantly by region; rural and remote access remains limited. Your GP or obstetrician can provide a referral; perinatal psychiatry consultation-liaison services at major maternity hospitals in each state capital can also facilitate MBU access.

Medication safety advice lines:

MotherSafe NSW — 1800 647 848 provides specialist medication safety advice for pregnancy and breastfeeding. Equivalent services include the Women’s and Children’s Hospital medication in pregnancy services in each state.

Consumer and crisis support:

• PANDA — 1300 726 306 — national perinatal anxiety and depression helpline
• Lifeline — 13 11 14 — 24/7 crisis support
• Beyond Blue Healthy Families — perinatal mental health information and peer forums
• 1800RESPECT — 1800 737 732 — domestic and family violence support (DV peaks during pregnancy and postpartum)

E. Special populations

Women with established bipolar disorder: This group warrants joint management between GP, obstetrician, and perinatal psychiatrist from preconception or as soon as pregnancy is confirmed. Medication decisions (lithium vs lamotrigine vs atypical antipsychotic) are complex and individualised. Postpartum relapse risk without prophylaxis is 50–70%; with lithium restarted immediately postpartum, approximately 10%. A written postpartum mental health management plan — including escalation thresholds and who to call — should be prepared in the third trimester.

Aboriginal and Torres Strait Islander women: Higher rates of psychosocial adversity, domestic violence, and prior trauma; culturally safe, community-based approaches are essential. Involve Aboriginal health workers and liaison services. ATSI Health Assessment (item 715) includes perinatal mental health screening and can be coupled with a care plan.

Adolescent parents: Higher risk of perinatal mental illness; also higher risk of not engaging with standard services. Specialised young-parent programmes and outreach services improve engagement. Involve child and family health nurses early.

Women with prior perinatal mental illness: The single strongest predictor of a new perinatal episode is a prior episode. Offer enhanced screening (more frequent EPDS), proactive psychological therapy, and early specialist consultation if pharmacotherapy is anticipated.

When to escalate

Escalate urgently when:

• Suicidal ideation with plan or intent — same-day mental health or emergency assessment
• Postpartum psychosis features — emergency department; do not wait
• Thoughts of harming the infant that are ego-syntonic or appear command-driven — distinguish from ego-dystonic OCD; if any doubt, escalate
• Severe bipolar relapse — specialist perinatal psychiatry urgently
• Infant safety concern — mandatory child protection notification where threshold is met; also engage child and family health nurse and social work support

Refer routinely when:

• Moderate-to-severe perinatal depression or anxiety not responding to initial psychological therapy
• Established mental health condition (bipolar disorder, schizophrenia, previous postpartum psychosis) entering pregnancy
• Pharmacotherapy decision is complex (polypharmacy, prior adverse reactions, breastfeeding preference)
• Birth-related PTSD requiring trauma-focused therapy (EMDR, TF-CBT)

What this article is and is not

This is general health information drawn from current Australian guidelines — COPE 2023, eTG Psychotropic, AMH, RANZCP CPGs, and RACGP. It is not personal medical advice and does not create a doctor–patient relationship. Medication decisions in pregnancy and breastfeeding are made collaboratively with your own GP and specialist team.

For a perinatal mental health crisis: PANDA 1300 726 306, Lifeline 13 11 14, or attend your nearest emergency department.

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Sources cited

1. COPE — Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline (2023)
2. RANZCP — Clinical Practice Guidelines for Mood Disorders (2020)
3. Therapeutic Guidelines (eTG) — Psychotropic
4. Australian Medicines Handbook (AMH)
5. RACGP
6. PANDA — 1300 726 306
7. MotherSafe NSW — 1800 647 848
8. Beyond Blue Healthy Families
9. HealthDirect — Postnatal depression
10. MumMoodBooster
11. PBS
12. MBS Online