IntroductionResearch indicates that each year around one in ten Australian women experience depression during pregnancy and almost one in five experience depression in the weeks and months after giving birth. If left untreated, this can have a negative impact on new mothers, their babies, families and friends, including relationship problems and difficulties bonding with children. Many women who experience perinatal depression are not identified and so do not receive adequate support, placing them at risk of more serious problems.
Structure of the frameworkThis framework is divided into two parts. The first part describes the scope of the National Perinatal Depression Initiative, the roles and responsibilities of the Australian Government, State and Territory Governments and beyondblue, the key areas for action, the underlying principles and the monitoring arrangements.
The second part contains Investment Plans that have been prepared by each government. These set out the investment that each government will make to achieve the outcomes that have been agreed at the national level and set out in the first part of this document.
Scope of the initiativeAt the Australian Health Ministers' Advisory Council (AHMAC) meeting on 6 March 2008, State and Territory Governments together with the Australian Government agreed to collaborate on the development of a National Perinatal Depression Initiative to improve the prevention and early detection of antenatal and postnatal depression, and to provide better care, support and treatment for expectant and new mothers experiencing perinatal depression.
The following key elements are integral to the National Perinatal Depression Initiative:
- routine and universal screening for perinatal depression;
- follow up support and care for women assessed as being at risk of or experiencing perinatal depression;
- workforce training and development for health professionals;
- research and data collection;
- national guidelines for screening for perinatal depression; and
- community awareness.
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Roles and responsibilities
Australian GovernmentThe Australian Government will provide ongoing policy leadership for coordination, implementation and evaluation of the National Perinatal Depression Initiative.
It will work in partnership with State and Territory Governments, through the Mental Health Standing Committee of AHMAC, to develop a National Perinatal Depression Initiative framework.
The Australian Government has committed to a contribution of $55 million over five years towards the Initiative, which includes:
- $30 million to State and Territory Governments to contribute to the roll out of routine and universal screening, support services, and training for health professionals;
- $5 million to beyondblue to support implementation; and
- an additional $20 million to the Access to Allied Psychological Services (ATAPS) program to build the capacity of Divisions of General Practice to support better treatment for women with perinatal depression.
State and Territory GovernmentsState and Territory Governments will collaborate in the development of a national approach to perinatal depression and implementation of the National Perinatal Depression Initiative in individual jurisdictions in accordance with local needs and priorities.
In addition to the funding to be provided to jurisdictions by the Australian Government, State and Territory Governments will also contribute up to $30 million in funding to supplement the roll out of routine and universal screening, support services, and training for health professionals.
beyondblue: the national depression initiativebeyondblue has already undertaken significant work in the area of perinatal mental health. Its role in supporting the implementation of the Initiative will include:
- providing a centre of excellence and best practice evidence on perinatal depression, including through research activities to enhance knowledge of perinatal depression;
- providing advice and informing all governments on best practice activities in perinatal depression, including advice in relation to particular population groups, such as culturally and linguistically diverse communities and Aboriginal and Torres Strait Islander communities;
- developing materials that support professional practice, such as national perinatal depression screening guidelines and training materials; and
- undertaking community awareness activities and promotion of help-seeking behaviour in relation to perinatal depression.
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Routine screeningNational clinical practice guidelines for perinatal mental health, which will include screening guidelines for perinatal depression, are currently being developed by beyondblue through the National Health and Medical Research Council. These guidelines are expected to be available in early 2010.
In the interim, universal and routine screening for perinatal depression will be undertaken using the Edinburgh Postnatal Depression Scale (EPDS), which has been shown to be well accepted by women, including those from culturally and linguistically diverse and Aboriginal and Torres Strait Islander populations, and will be based on the following principles:
- Screening will be universally and routinely available to all women during the perinatal period, but will not be mandatory.
- Screening will be offered at least once antenatally (in the second or preferably the third trimester).
- Screening will be offered at least once postnatally (preferably about four to six weeks after the birth).
- Screening will be conducted using the EPDS at a minimum; and, ideally, in conjunction with a psychosocial assessment tool.
- Women identified as being at risk of or experiencing perinatal depression will be referred, as appropriate, for a diagnosis and, if required, treatment and/or support services.
It is anticipated that the screening will take place predominantly in primary care and child and maternal health care settings and will be undertaken by various health care professionals including general practitioners, midwives, child and maternal health nurses, Aboriginal Health Workers, practice nurses and obstetricians. Others likely to be involved in screening are community support workers, especially in rural and remote areas, and non-government organisations, which are particularly important for culturally and linguistically diverse groups.
The EPDS cut-off scores set out below should be used as a guide only and the application of clinical judgement in determining current distress and depressive symptoms is most important.
- Score of 0-9 - The likelihood of depression is considered low (may indicate the presence of some symptoms of distress that may be short-lived and are not likely to interfere with day-to-day ability to function at home or at work).
- Score of 10-12 - The likelihood of depression is considered moderate (may indicate the presence of symptoms of distress that may be discomforting). A score above 10 indicates that the EPDS should be repeated within two weeks. Two scores above 12 indicate that further assessment is required to establish if a clinical disorder is present.
- Score of 13 or more - The likelihood of depression can be considered high (14 or more antenatally).
- Positive responses to Q10 (thoughts of self-harm) - This must be immediately addressed.
- lack of social or emotional support
- recent stressors (in the last year)
- low self-esteem (including self-confidence and perfectionistic traits)
- history of depression, anxiety or other mental health problem
- partner's history of mental health problems and substance misuse
- adverse childhood experience (including poor relationship with the mother)
- domestic violence
- the couple's relationship
- experience of parenting the baby (postnatal)
- Given that routine and universal screening for perinatal depression should be undertaken by one of the main health care professionals involved in the woman's care during the perinatal period, details of the screening (date, score and any actions required/taken and by whom) should be communicated to other relevant health care professionals.
- The woman should be advised that her EPDS score will be shared with other relevant health care professionals involved in her care.
- The EPDS score should be shared with other health care professionals, irrespective of the score, to ensure that there is no omission or duplication of screening.
- Specific consent will be requested from the woman regarding sharing of broader psychosocial assessment information.
- Information may need to be shared (without consent) in exceptional situations where the woman is unable to give consent or the woman and/or child may be at risk (in accordance with relevant jurisdictional legislation as it relates to privacy, child protection, mental health and domestic violence).
- Wherever possible, existing communication pathways should continue to be used in relation to perinatal depression screening.
Community awarenessCurrently there is limited awareness in the community about perinatal depression. Awareness raising activities are therefore needed as part of the implementation of the National Perinatal Depression Initiative to optimise and promote the benefits of early intervention to women at risk of or experiencing perinatal depression, their partners and families.
Community awareness activities will:
- promote the importance of routine screening as a way of ensuring early detection and identification of perinatal depression, and therefore early intervention;
- promote the benefits of management and treatment of perinatal depression for women, as well as the benefits for her family including the development of the child; and
- provide accessible information to the community in forms that meet the needs of diverse groups, including people with a diverse cultural and linguistic background.
The types of information that will be included are awareness raising about perinatal depression, including signs and symptoms; information about screening and treatment; and encouraging help-seeking behaviours. Community awareness activities will be delivered through a range of methods, including media campaigns, information shared by health care professionals at the point of service, and information in brochures, fact sheets and websites.
Workforce training and developmentTraining, development and materials to support professional practice will be available to help health professionals in three key areas:
- awareness of perinatal depression;
- screening using nationally recognised tools to identify women who are at risk of or experiencing perinatal depression, and refer or direct women to treatment, support and care services that meet the individual's needs; and
- provision of treatment and appropriate support.
The target groups for workforce training and development include health professionals who will undertake screening and provide treatment, care and support, such as general practitioners, obstetricians, child and maternal health nurses, midwives, Aboriginal Health Workers, community health nurses, allied health professionals and specialised mental health service providers. Training and information can be delivered through formal training, case studies, online modules, local seminars and networking opportunities, and through brochures, fact sheets and websites.
In addition, a variety of broader, non-health professionals in the government, non-government and private sectors will also have specific workforce training and development needs. These professionals may include child care workers and child protection services. It is anticipated that this group will require training or information about perinatal depression (including its signs and symptoms) and encouraging help-seeking behaviours. This information can be delivered through local seminars and networking opportunities and information in brochures, fact sheets and websites.
beyondblue will support this element of the Initiative by developing materials that support professional practice, such as national perinatal depression screening guidelines and training materials.
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Follow-up support and careThe availability of appropriate pathways to care and support will result in improved outcomes for those women identified as being at risk of or experiencing perinatal depression.
Principles regarding follow-up support and care include:
- both clinical and non-clinical follow-up support and care services are important for women experiencing perinatal depression and their families;
- investment by State and Territory Governments should be used to expand follow-up support and care service pathways for women with perinatal depression, noting that pathways provided by general practitioners are only one of the pathways available;
- a variety of community-based and in-patient services should be available through the government, non-government and private sectors for women experiencing perinatal depression and their families; and
- special attention should be given to ensure that follow-up support and care are available for specific population groups such as rural and remote communities, Aboriginal and Torres Strait Islander peoples and culturally and linguistically diverse populations.
Measuring the progress of the initiativeAll governments are committed to working together to achieve outcomes against the key elements of the Initiative. The following measures have been identified to track progress against the outcomes.
- Improved early detection of antenatal and postnatal depression (by the routine and universal screening of women during the perinatal period). This will enable early intervention for those women identified through screening as experiencing perinatal depression. Progress outcomes are:
- The proportion of the target population (ie women in the perinatal period) who have been screened for antenatal depression.
- The proportion of the target population (ie women in the perinatal period) who have been screened for postnatal depression.
An evaluation plan for the Initiative will be developed in 2009-10, the scope of which will be collaboratively developed by the Australian Government and State and Territory Governments.
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