Download Detection and management of mood disorders in the maternity

Women and Birth (2013) 26, 2—9
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/wombi
REVIEW
Detection and management of mood disorders in the
maternity setting: The Australian Clinical Practice
Guidelines
Marie-Paule V. Austin a,b,*, Philippa Middleton c, Nicole M. Reilly a,b,
Nicole J. Highet d
a
Perinatal and Women’s Mental Health Unit, St John of God Health Care, 23 Grantham St, Burwood, NSW 2134, Australia
Black Dog Institute and University of New South Wales, Sydney, NSW 2052, Australia
c
Australian Research Centre for the Health of Women and Babies (ARCH), Robinson Institute, School of Paediatrics and Reproductive
Health, The University of Adelaide, Ground Floor, Norwich Centre, 55 King William Road, North Adelaide, SA 5006, Australia
d
Beyondblue: The National Depression Initiative, PO Box 6100, Hawthorn West, VIC 3122, Australia
b
Received 10 October 2011; received in revised form 1 December 2011; accepted 1 December 2011
KEYWORDS
Postpartum depression;
Systematic review;
Depression screening;
Psychosocial assessment;
Perinatal mood disorders
Abstract
Background: Mood disorders arising in the perinatal period (conception to the first postnatal
year), occur in up to 13% of women. The adverse impact of mood disorders on mother, infant and
family with potential long-term consequences are well documented. There is a need for clear,
evidence-based, guidelines for midwives and other maternity care providers.
Aim: To describe the process undertaken to develop the Australian Clinical Practice Guidelines
for Depression and Related Disorders in the Perinatal Period and to highlight the key recommendations and their implications for the maternity sector.
Method: Using NHMRC criteria, a rigorous systematic literature review was undertaken synthesising the evidence used to formulate graded guideline recommendations. Where there was
insufficient evidence for recommendations, Good Practice Points were formulated. These are
based on lower quality evidence and/or expert consensus.
Findings: The quality of the evidence was good in regards to the use of the Edinburgh Postnatal
Depression Scale and psychological interventions, but limited as regards medication use and
safety perinatally. Recommendations were made for staff training in psychosocial assessment;
universal screening for depression across the perinatal period; and the use of evidence based
psychological interventions for mild to moderate depression postnatally. Good Practice Points
addressed the use of comprehensive psychosocial assessment — including risk to mother and
infant, and consideration of the mother—infant interaction — and gave advice around the use
and safety of psychotropic medications in pregnancy and breastfeeding. In contrast to their
* Corresponding author at: Perinatal and Women’s Mental Health Unit, St John of God Hospital, PO Box 261, Burwood, NSW 1805, Australia.
Tel.: +61 2 9715 9224; fax: +61 2 9747 6845.
E-mail address: [email protected] (M.V. Austin).
1871-5192/$ — see front matter. Crown Copyright # 2011 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved.
doi:10.1016/j.wombi.2011.12.001
Clinical practice guidelines for perinatal depression
3
international counterparts, the Australian guidelines emphasize a more holistic, woman and family
centred approach to the management of mental health and mood disorders in the perinatal setting.
Conclusion: The development of these Guidelines is a first step in translating evidence into
practice and providing Australian midwives and other maternity care providers with clear guidance
on the psychosocial management of women and families.
Crown Copyright # 2011 Published by Elsevier Australia (a division of Reed International Books
Australia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved.
Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Aim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Guidelines development process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Formulating the clinical questions to be covered by the Guideline. . . . .
Literature search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Grading the evidence and formulating and grading of recommendations
Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Key groupings of Good Practice Points . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Background
‘Perinatal’, as it applies to the mental health context,
encompasses the period from conception to the end of the
first postnatal year. The use of this term allows clinicians to
consider maternal and infant mental wellbeing when maternal risk of onset/relapse of mood disorder is highest and at a
critical time in the development of mother—infant attachment. Conversely, clinicians need to be aware that a transiently depressed or anxious mood may be a normal response
to adjusting to the demands of parenthood.
In spite of increased awareness among maternity care
providers and the community, a significant proportion of
mental health episodes presenting in the perinatal period
will go undiagnosed and untreated.1,2 While estimates vary,
symptoms of depression and anxiety alone or in combination
are experienced by up to 19% of women during pregnancy3—6
and 16% women in the months following birth3,5,7,8 and a
point prevalence of up to 12.9% for the spectrum of postnatal
depression from mild to severe episodes.5 High rates (38%) of
co-morbid anxiety disorder among women diagnosed with
major depression at 6—8 months postpartum have also been
reported.9 In addition approximately 1—2 per 1000 women
will experience an episode of puerperal psychosis usually
arising within the first month postpartum. Women with preexisting depressive or bipolar disorder will have high rates of
relapse in pregnancy and postpartum if they discontinue or
remain un-medicated.10—12 Those with a bipolar disorder will
have a 30% rate of psychotic relapse in the early postpartum
and up to 60% of women with a past episode of puerperal
psychosis will also relapse.13 In those who go on to have a nonpuerperal recurrence, most will be with an episode of mood
disorder.14 The adverse impact of mood disorders on mother,
infant and family with potential long-term consequences are
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well documented. Postpartum depression — especially when
it is prolonged,15,16 associated with comorbid diagnosis (anxiety or substance abuse17) or with social adversity18 — affects
the early mother—infant relationship. This is in turn associated with suboptimal social, emotional and behavioural
infant development.18
There is also emerging evidence for a relationship
between maternal anxiety, stress and depression in pregnancy and poorer obstetric (low birth weight, and prematurity) and neonatal outcomes (irritability and admission to
newborn care).19 Maternal pregnancy anxiety has also been
reported as being associated with less optimal cognitive,
emotional and behavioural outcomes in offspring in a number
of prospective studies.20,21
Given the potentially high morbidity associated with perinatal maternal mood disorder (see definition below), it is
imperative that those women at risk, or currently symptomatic, be identified as early as possible in the perinatal
period and referred on for appropriate management This
process of assessing psychosocial risk factors (e.g. past history depression) and current symptoms (e.g. depressive) is
referred to as ‘psychosocial assessment’ and fully described
in Chapter 3 of the Guidelines.
The Clinical Practice Guidelines for Depression and
Related Disorders in the Perinatal Period,22 commissioned
by beyondblue: the national depression initiative and
endorsed by Australia’s National Health and Medical Research
Council, are an integral part of the National Perinatal Depression Initiative (2008—2013).23 The Guidelines are aimed at
the range of clinicians — midwives, early childhood nurses,
general practitioners, obstetricians, mental health professionals — caring for women and their families across the
perinatal period and cover the detection and management of
perinatal mood disorders, anxiety and psychosis.
4
The Guidelines also specifically consider the challenges of
regional and rural service provision and the needs of Indigenous and culturally and linguistically diverse families.
Finally, the Guidelines have been developed with an emphasis on a holistic, woman-centred approach to the provision of
psychosocial care in the perinatal setting.
Aim
To describe the process undertaken to develop the Australian
Clinical Practice Guidelines for Depression and Related Disorders in the Perinatal Period and to highlight the key
recommendations and their implications for the maternity
sector. For the purposes of these guidelines perinatal mood
disorders is defined as: depression, bipolar disorder and
anxiety disorder arising perinatally and puerperal psychosis
arising postnatally.
Methods
Guidelines development process
A Guideline Expert Advisory Committee was formed, comprising clinical and policy-making representatives of the
relevant professional bodies from midwifery, obstetrics, general practice, mental health and early childhood nursing, as
well as representation from indigenous and regional and rural
stakeholders, and consumer and carer representatives. Consultants were employed to undertake the systematic literature review and additional searches and to write the
guidelines. A rigorous Guidelines development methodology
(as required by the Australian National Health and Medical
Research Council) was followed.24—27
The draft Guidelines were extensively and independently
reviewed by clinicians, researchers, consumers and carers
during a two month public consultation process in March—May
2010. Feedback from the consultation responses was incorporated as appropriate (after due consideration by the
Guideline Expert Advisory Committee) into the final draft,
which was then reviewed by an international reviewer.
Potential conflict of interest was addressed in keeping with
NHMRC guidelines.
Formulating the clinical questions to be covered
by the Guideline
The Guideline Expert Advisory Committee developed a set of
clinical questions broadly covering: (1) the use and validity of
psychosocial assessment tools; (2) the use and validity of the
Edinburgh Postnatal Depression Scale (EPDS)28 and other selfreport measures for routine use in screening for depression and
related disorders; (3) the use of pharmacological and psychological therapies in the prevention of depression and related
disorders; (4) the efficacy and safety of pharmacological and
psychological therapies in the treatment of these conditions;
(5) the value of primary prevention methods (community and
clinician awareness raising) and models of care. In addition the
Guidelines examined the available literature pertaining to
interventions which address mother—infant interaction, and
assessing the safety of women and their children in cases
where serious risk has been identified.
M.-P. Austin et al.
The importance of assessing the safety of treatments,
particularly pharmacological treatments, was also specifically addressed in the literature search. Due to the limited
availability of high-quality evidence in this field, an Expert
Pharmacological Harms Panel (consisting of leading perinatal
psychiatrists and a teratologist) was convened to advise on:
the benefits of pharmacological interventions for women at
risk of developing a mental health disorder in the perinatal
period (e.g., continuation versus discontinuation of medication); the potential harms to pregnant women or women in
the first year postpartum, as a result of receiving a pharmacological intervention (e.g., obstetric complications); and
the potential harms to the foetus or breastfeeding infant as a
result of exposure to a pharmacological intervention (e.g.,
birth defects; neurodevelopmental outcomes).
Literature search strategy
A comprehensive search of EMBASE, Medline, PsycInfo,
CINAHL and the Cochrane Database of Systematic Reviews
up to July 2009 was conducted. Where the systematic literature review had already been undertaken for the National
Institute for Health and Clinical Excellence (NICE) Guidelines
for Antenatal and Postnatal Mental Health29 (interventions up
to September 2006) these results were summarised and then
supplemented by a further search for the 2006—2009 period.
Where appropriate (e.g., as advised by the Expert Pharmacological Harms Panel) other key papers not fulfilling the
systematic literature review criteria were reviewed and
included in the narrative and as a means of supporting the
Guideline Expert Advisory Committee to develop relevant
Good Practice Points.
Grading the evidence and formulating and
grading of recommendations
Rating of the body of evidence involved the following five key
components:
Evidence base: including the number of studies, level of
evidence (I—IV) and quality of studies (risk of bias); Consistency across studies; Clinical impact: examining effect size,
relevance of evidence base to the research question and
whether the risks and benefits were considered in terms of
clinical impact; Generalisability and applicability: A judgment
by Guideline Expert Advisory Committee — based on the body
of evidence — as to its generalisability to the Guidelines target
population and its applicability to the Australian healthcare
context, taking into account feasibility issues (workforce,
geographical distance, cost) and existing health care systems.
The body of evidence components were then summarised
into one overall grading. National Health and Medical
Research Council Grades of Recommendation (ranging from
A to D; see Box 1) indicate the strength of the evidence
underpinning the recommendation, thus assisting Guideline
users to make informed clinical judgments.
Findings
There were eight Recommendations (see Box 2). Where there
was insufficient evidence for recommendations — as was
found in the majority of cases — Good Practice Points were
Clinical practice guidelines for perinatal depression
Box 1. Definition of National Health
and Medical Research Council grade of
recommendation.
Grade Description
A
B
C
D
Body of evidence can be trusted to guide practice;
based on level I evidence
Body of evidence can be trusted to guide practice
in most situations; based on level II evidence
Body of evidence provides some support for
recommendation(s) but care should be taken in its
application; based on level III evidence
Body of evidence is weak and recommendation
must be applied with caution; based on level
IV evidence
formulated (see Box 3 for summary). These are based on
lower quality evidence and/or the consensus of the Guidelines Expert Advisory Committee. Between them the Recommendations and Good Practice Points cover the designated
scope of the guideline.
Key groupings of Good Practice Points
The Good Practice Points have been summarised and grouped
into the clinical domains most relevant to clinicians working
in the maternity sector as per Box 3. Note that this summary
does not include all 44 Good Practice Points.
Given that these Guidelines have been written for clinicians on the assumption that they do not have specific
mental health training, the Good Practice Points also serve
to provide the reader with a certain amount of structured
5
guidance, and example questions (for psychosocial assessment) are given wherever possible. For midwives for example, this could entail administering the Edinburgh Postnatal
Depression28 (see Guidelines Appendix 5) also validated for
antenatal use, and a structured psychosocial risk questionnaire (e.g. Antenatal Risk Questionnaire30 or a set of clinical
questions (as outlined in the Guidelines Appendix 4). Additionally, given clinicians’ concerns around the wellbeing of
the infant (as raised in the consultation feedback of the draft
Guidelines), the Good Practice Points also focus on the
assessment of the mother—infant interaction and where
feasible/appropriate the inclusion of an assessment of risk
to infant (see Chapter 4 Guidelines).
With respect to the use of medication, the Guidelines
advise close monitoring to enhance relapse minimisation in
those with existing mood disorder, especially when they have
decided to cease medication. The Guidelines give simple
advice on the areas that require discussion when considering
medication in pregnancy and breastfeeding, and specific
Good Practice Points address safety issues in pregnancy
and breastfeeding (see Chapter 8 Guidelines).
Discussion
Given the lack of an extensive evidence base in the field of
depression and related disorders arising in the perinatal
period, only a small number of recommendations could be
made. Our multidisciplinary Guidelines Expert Advisory Committee made a considered judgment that the potential benefits to women and their families were sufficient to make a
recommendation to use EPDS as a component of both antenatal and postnatal assessments for symptoms of depression.
These recommendations to use EPDS may be regarded
as controversial as other groups have not gone quite as far
as formally recommending the use of EPDS. However the
Box 2. Clinical Practice Guidelines for Depression and Related Disorders in the
Perinatal Period: recommendations and grading.
Recommendations
1
2
3
4
5
6
7
8
As a minimum, all health professionals providing care in the perinatal period should
receive training in woman-centred communication skills and psychosocial assessment.
The EPDS should be used by health professionals as a component of the assessment
of all women for symptoms of depression in the antenatal period.
The EPDS should be used by health professionals as a component of the assessment
of all women in the postnatal period for symptoms of depression or co-occurring
depression and anxiety.
A score of 13 or more on the EPDS can be used for detecting symptoms of major
depression in the postnatal period.
Non-directive counselling in the context of home visits can be considered as part
of the management of mild to moderate depression for women in the
postnatal period.
Cognitive behavioural therapy (CBT) should be considered for treating women with
diagnosed mild to moderate depression in the postnatal period.
Interpersonal therapy (IPT) can be considered for treating women with diagnosed mild
to moderate depression in the postnatal period.
Psychodynamic therapy can be considered for treating women with diagnosed mild to
moderate depression in the postnatal period.
Grade
C
B
B
C
C
B
C
D
6
M.-P. Austin et al.
Box 3. Clinical Practice Guidelines for Depression and Related Disorders in the
Perinatal Period: summary of Good Practice Points across key clinical themes.
1. General Depression Screening and Psychosocial Assessment issues
Consider routine, psychosocial assessment (EPDS and psychosocial questions as suggested in the Guidelines Appendix)
for all women
Clinical judgment should inform interpretation of psychosocial assessment at all times
Timing of psychosocial assessment: early in pregnancy and 6—12 weeks after birth
Marked mental state changes: consider severe mental disorder and refer to Mental Health services as soon as possible
Involve significant others (partners, family), as soon as possible
2. Acting on Edinburgh Depression Scale (EPDS) Scores
Consider a postnatal score of 13 or more for possible depression
Scores of 10—12 at any time: repeat EPDS 2—4 weeks later
High scores: (15 or more at any time): ensure access to timely mental health assessment
Scores positive on self-harm Question 10: assess safety (mother and child/ren) and refer urgently as appropriate.
Anxiety symptoms/disorder: score 13 or more may indicate significant anxiety (or disorder), especially if EPDS questions
4 and 5 are positive.
3. The Infant
Well-being of the infant needs to be considered at all times
Mother—infant interaction assessment is an integral part of postnatal care (checklist provided in Guidelines)
Where significant difficulties are observed in mother—infant interaction (see checklist in Guidelines) and/or identify
significant maternal mental health or risk issues, assess risk of harm to infant (example questions are provided in Guidelines)
4. Pharmacological considerations:
(a) General
Given paucity of evidence base in perinatal population, consult general population psychotropic medication guidelines for
specific dosages, efficacy, etc.
Antenatal use: undertake general discussion of potential risks and benefits to woman and foetus of treating versus not
treating
Antenatal use and birth defects: provide woman and partner detailed explanation of baseline, absolute and relative risks of
using specific medication
Postnatal use: weigh medication use against minimal possible exposure to infant through breastfeeding
If a collaborative decision is made to cease psychotropic medication: slowly taper, monitor closely and plan for early relapse
identification or withdrawal symptoms
(b) SSRIs
Use of SSRI can be considered in pregnancy as this is the best researched antidepressant category and current evidence
shows no consistent pattern of additional risk for birth defects (above baseline 2% seen in general population)
Breastfeeding while using SSRIs is not contraindicated in healthy, full term infants.
(c) Mood stabilisers
Valproate: should not be prescribed for bipolar women of childbearing age. Exposure in pregnancy is associated with
increased risk of major birth defects and adverse cognitive outcomes for the infant
Lithium: use with particular caution in breastfeeding due to variable passage into breast milk. Where possible make decision
with specialist, and organise for ongoing infant monitoring.
(d) Benzodiazepines
Can be considered as a short-term option for antenatal and postnatal use, while waiting for the onset of action of an SSRI or
TCA in treating anxiety disorders.
Avoid long-acting benzodiazepines as much as possible
American College of Obstetrics and Gynecology does
acknowledge the benefits of assessing women for symptoms
of depression31 and base their Tools document on use of the
EPDS.32 While the British NICE Guidelines did not recommend
routine universal assessment using EPDS, they stated that
EPDS could be considered as part of subsequent assessment or
routine monitoring of outcomes.29 A recent randomised controlled trial has provided important new evidence about the
effect of postnatal screening using EPDS on maternal outcomes. This study demonstrated improved maternal mental
health outcomes at six months for women in the screening
program compared with those under usual care, in the context of adequate pathways to care.33
Although the Good Practice Points supporting the use of
the EPDS make suggestions around EPDS cut-off scores, the
Guidelines clearly highlight that the use of cut-offs are only
an indicator and that clinical judgment is a fundamental
component of the assessment process. The Guidelines go
on to advocate that the EPDS be combined with a systematic
enquiry around a woman’s psychosocial context, i.e., the
psychosocial and mental health risks that are present for her
in the perinatal period.
In developing these Guidelines, we examined those currently in use both nationally and internationally. The most
comprehensive and methodologically rigorous are the British
National Institute for Health and Clinical Excellence (NICE)
Clinical practice guidelines for perinatal depression
Guidelines for Antenatal and Postnatal Mental Health.29 With
respect to psychosocial assessment, the NICE guidelines focus
their recommendations and statements primarily on the
prediction of maternal mental illness and the detection of
depression or severe mental illness, rather than taking a
broader, more systemic approach to assessment of mother,
infant and family. They do not recommend routine ‘psychosocial assessment’ (i.e., assessing all domains of risk for
mental health morbidity plus current symptoms) for all
women.
The Scottish Intercollegiate Postnatal Depression guidelines,34—36 similarly recommend asking about past or family
history, but also suggest that risk factors for mood disorders
should be systematically recorded antenatally, and recommend routine use of EPDS for depression screening in the
postnatal period. The British Columbia (Canadian) Reproductive Mental Health guidelines,37 like the Australian guidelines, recommend routine psychosocial assessment using
both a symptom rating scale and a structured psychosocial
questionnaire or interview. They also focus on the need to
view women in the context of their infant and family and on
the promotion of mother—infant attachment. Neither the
Scottish nor Canadian guidelines are underpinned by a systematic literature review.
Conclusion
The development of these Guidelines comes at a critical
time in the implementation of the National Perinatal Depression Initiative.23,38 The Guidelines acknowledge that universal depression screening and psychosocial assessment
have been strongly debated in a number of different settings, and have significant resource implications (training,
workload and access to mental health services). In the UK, a
cost-effectiveness study of routine screening for postnatal
depression (using hypothetical data) concluded that screening for postnatal depression in primary care does not represent value for money, due mostly to the impact of falsepositive screening results on cost estimate.39 A key assumption in that analysis was that all the ‘false positives’ would
still have supportive counselling on the basis of a depression
screening cut-off score alone. This approach is in contrast to
the recommendations made in the Australian Guidelines:
namely, that a depression score is not an endpoint or substitute for diagnosis, but the platform from which the appropriate women will be referred for further mental health
assessment and treatment as needed.40 While there is no
cost-effectiveness data relevant to the Australian context,
costs related to introducing routine psychosocial assessment, including training costs, were estimated as part of
the economic modeling undertaken in the 2008 beyondblue
National Action Plan for Perinatal Mental Health41 which
informed the implementation component of the National
Perinatal Depression Initiative. Although the Guidelines
were not pre-tested at national level, routine psychosocial
assessment has been extensively undertaken in the last ten
years in key maternity hospitals across a number of Australian states42—47 and can thus be considered as sites of preguideline piloting.
These Guidelines are a first step in translating research
evidence into practice and developing a broader evidence
base. They provide midwives with a both a comprehensive
7
clinical document and easy reference. Future research
should include an examination of the cost-benefit and/or
cost-effectiveness of universal depression screening and
psychosocial assessment at a population level (for mother,
infant and family), as well as barriers to the uptake of
referral and treatment options and the effectiveness of
treatment services provided across the community. It is
expected they will provide Australian midwives and other
key maternity care providers with clear guidance on the
psychosocial assessment and management of women and
families in the perinatal period.
In contrast to other guidelines around the world, the
Australian guidelines are underpinned by a systematic literature review, as well as encompassing the full spectrum of
psychosocial assessment for both mother and infant and
giving guidance for management across the full range of
maternal mood disorders.
Acknowledgements
We gratefully acknowledge beyondblue: the national depression initiative for funding and logistic support for the development of the Clinical Practice Guidelines for Depression and
Related Disorders (Anxiety, Bipolar Disorder and Puerperal
Psychosis) in the Perinatal Period.
We also gratefully acknowledge the other Expert Advisory
Committee members, writers and reviewers who led the
development of these Guidelines (in alphabetical order):
Guidelines Expert Advisory Committee: Prof Anne Buist,
Ms Lyn Chaplin, Ms Jo Duffy, Ms Michelle Dykman, Mr Nick
Janjic, Dr Carol Johnson, Dr Sally Lambert, Dr Helen Lindner,
Ms Rachael Lockey, Prof Jeremy Oats, Ms Jenny Parham, Ms
Carol Purtell, A/Prof Jonathan Rampono, Dr Jan Taylor, Dr
Debra Wiens; Expert Pharmacological Harms Panel: Prof
Philip Boyce, Prof John Condon, Dr Debra Kennedy; Ampersand (writers): Elizabeth Hall and Jenny Ramson; HT Analysts
( for the systematic literature review): Dr Sarah Norris, Ms
Suzanne Campbell, Dr Lisa Elliott and team.
We would also like to thank Christine Benger, Rachel
Komen and Suzanne Pope at beyondblue; Vesna Cvjeticanin
and her team from the National Health and Medical
Research Council; and all those who gave feedback, written and via public consultations, on the draft version of the
guidelines.
Sources of financial support
Funding and logistic support for the development of the
‘Clinical Practice Guidelines for Depression and Related Disorders (Anxiety, Bipolar Disorder and Puerperal Psychosis) in
the Perinatal Period’ was provided by beyondblue: the
national depression initiative.
MPA is a recipient of current research funding from the
National Health and Medical Research Council (Project Grant
#604003; Program Grant 510135) and the Bupa Foundation.
She has previously received speaker’s fees from AstraZeneca
and Pfizer.
NR is a recipient of current research funding from the Bupa
Foundation.
PM received funding from the National Health and Medical
Research Council to provide methodological support for
development of these guidelines.
8
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