What’s so special about perinatal mental health?

There are widely recognised perinatal mental health disorders such as postnatal depression and postpartum psychosis that highlight the uniqueness of perinatal events and their potential impact on mental health. In reality, perinatal mental health research, policy and practice are a balancing act of identifying what is unique to women in the perinatal period and what is similar to mental health in the general population. For example, should we use well validated general symptom checklists or develop pregnancy specific checklists to screen for mental health disorders in pregnancy? There are a number of well validated symptom checklists for depression in the general population, such as the Patient Health Questionnaire. One of the difficulties in using such measures is that questions on tiredness and sleep disturbance can be hard to interpret as it may not be clear if these somatic symptoms are pregnancy related or mental health related. This does not mean that such questions are redundant, rather they provide a clear rationale for taking an integrated health approach to try to disentangle the unique features of psychological health in the perinatal period. An additional consideration is that there may be psychological experiences related to pregnancy that may be missed in general measures, e.g. negative perceptions of body image or changes in relationships, that are picked up in pregnancy specific measures. Until we have a better understanding of how these items reflect maternal mental health status we should include both general and pregnancy specific measures in research.

It is thought that up to 20% of women may experience a mental health problem in the perinatal period (Bauer, Parsonage, Knapp, Lemmi, & Adelaja, 2014) so low cost, accessible, effective interventions are required to support demand on services. A range of psychological therapies and medication are available for use. While medication can be effective, women are often reluctant to take medications in the perinatal period (Dennis & Chung-Lee, 2006) and some have been associated with side effects. For example, serotonin reuptake inhibitor treatment for anxiety disorders during pregnancy has been found to be associated with hypertensive disease of pregnancy and caesarean delivery (Yonkers, Gilstad-Hayden, Forray, & Lipkind, 2017). Concerns about medication place more of an emphasis on the use of psychological therapies many of which are considered to be effective in the general population. It could be said that as we know that psychological therapies, such as CBT and mindfulness, work in the general population there is no need to evaluate effectiveness in a perinatal population. However, NICE guidelines on antenatal and postnatal mental health recommend adapting psychological therapies for the perinatal period.

‘Psychological interventions should be tailored to the (sometimes highly specialist) needs of women in pregnancy and the postnatal period, and to support the baby’s development, attachment and mental health’. National Institute for Health and Care Excellence [NICE], (2014)

A major concern is that adapting interventions considered to be effective in the general population can impact on the fidelity of the programme being delivered and consequently its effectiveness. In addition, while the pathway to impact for an intervention may be similar for women in the perinatal period as it would be at other times in the life course, there are many more outcomes to consider in the perinatal period than are not addressed in trials in the general population. Such outcomes include maternal-infant attachment and child health and wellbeing. Interventions need to treat a woman’s mental health disorder and provide help with associated caregiving difficulties but there is limited research evaluating the impact of psychological therapies on these additional important outcomes (Stein et al., 2014).

Finally, the perinatal period provides a opportunity to support maternal mental health through routine, regular contact with maternity services. Much can and needs to be done to support the mental health and wellbeing of women and their families and we should make the most of this special opportunity. We should also remember that many women will have a relatively uneventful, healthy pregnancy and adjust well to parenting so an important goal should be to optimise their mental health. Focusing on perinatal mental health should help all women flourish.