REVIEW

Detection and management of mood disorders in thematernity setting: The Australian Clinical PracticeGuidelines

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, AustraliabBlack Dog Institute and University of New South Wales, Sydney, NSW 2052, AustraliacAustralian Research Centre for the Health of Women and Babies (ARCH), Robinson Institute, School of Paediatrics and ReproductiveHealth, The University of Adelaide, Ground Floor, Norwich Centre, 55 King William Road, North Adelaide, SA 5006, AustraliadBeyondblue: The National Depression Initiative, PO Box 6100, Hawthorn West, VIC 3122, Australia

Received 10 October 2011; received in revised form 1 December 2011; accepted 1 December 2011

Women and Birth (2013) 26, 2—9

KEYWORDSPostpartum depression;Systematic review;Depression screening;Psychosocial assessment;Perinatal mood disorders

Abstract

Background: Mood disorders arising in the perinatal period (conception to the first postnatalyear), occur in up to 13% of women. The adverse impact of mood disorders on mother, infant andfamily 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 Guidelinesfor Depression and Related Disorders in the Perinatal Period and to highlight the key recom-mendations and their implications for the maternity sector.Method: Using NHMRC criteria, a rigorous systematic literature review was undertaken synthe-sising the evidence used to formulate graded guideline recommendations. Where there wasinsufficient evidence for recommendations, Good Practice Points were formulated. These arebased on lower quality evidence and/or expert consensus.Findings: The quality of the evidence was good in regards to the use of the Edinburgh PostnatalDepression Scale and psychological interventions, but limited as regards medication use andsafety perinatally. Recommendations were made for staff training in psychosocial assessment;universal screening for depression across the perinatal period; and the use of evidence basedpsychological interventions for mild to moderate depression postnatally. Good Practice Pointsaddressed the use of comprehensive psychosocial assessment — including risk to mother andinfant, and consideration of the mother—infant interaction — and gave advice around the useand 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: m.austin@unsw.edu.au (M.V. Austin).

Available online at www.sciencedirect.com

jo ur n al ho mep ag e: www .e lsev ier . c om / loc ate /w om b i

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

Contents

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Aim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Guidelines development process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Formulating the clinical questions to be covered by the Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Literature search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Grading the evidence and formulating and grading of recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Key groupings of Good Practice Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

international counterparts, the Australian guidelines emphasize a more holistic, woman and familycentred 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 intopractice and providing Australian midwives and other maternity care providers with clear guidanceon the psychosocial management of women and families.Crown Copyright # 2011 Published by Elsevier Australia (a division of Reed International BooksAustralia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved.

Clinical practice guidelines for perinatal depression 3

Background

‘Perinatal’, as it applies to the mental health context,encompasses the period from conception to the end of thefirst postnatal year. The use of this term allows clinicians toconsider maternal and infant mental wellbeing when mater-nal risk of onset/relapse of mood disorder is highest and at acritical time in the development of mother—infant attach-ment. Conversely, clinicians need to be aware that a tran-siently depressed or anxious mood may be a normal responseto adjusting to the demands of parenthood.

In spite of increased awareness among maternity careproviders and the community, a significant proportion ofmental health episodes presenting in the perinatal periodwill go undiagnosed and untreated.1,2 While estimates vary,symptoms of depression and anxiety alone or in combinationare experienced by up to 19% of women during pregnancy3—6

and 16% women in the months following birth3,5,7,8 and apoint prevalence of up to 12.9% for the spectrum of postnataldepression from mild to severe episodes.5 High rates (38%) ofco-morbid anxiety disorder among women diagnosed withmajor depression at 6—8 months postpartum have also beenreported.9 In addition approximately 1—2 per 1000 womenwill experience an episode of puerperal psychosis usuallyarising within the first month postpartum. Women with pre-existing depressive or bipolar disorder will have high rates ofrelapse in pregnancy and postpartum if they discontinue orremain un-medicated.10—12 Those with a bipolar disorder willhave a 30% rate of psychotic relapse in the early postpartumand up to 60% of women with a past episode of puerperalpsychosis will also relapse.13 In those who go on to have a non-puerperal recurrence, most will be with an episode of mooddisorder.14 The adverse impact of mood disorders on mother,infant and family with potential long-term consequences are

well documented. Postpartum depression — especially whenit is prolonged,15,16 associated with comorbid diagnosis (anxi-ety or substance abuse17) or with social adversity18 — affectsthe early mother—infant relationship. This is in turn asso-ciated with suboptimal social, emotional and behaviouralinfant development.18

There is also emerging evidence for a relationshipbetween maternal anxiety, stress and depression in preg-nancy and poorer obstetric (low birth weight, and prema-turity) and neonatal outcomes (irritability and admission tonewborn care).19 Maternal pregnancy anxiety has also beenreported as being associated with less optimal cognitive,emotional and behavioural outcomes in offspring in a numberof prospective studies.20,21

Given the potentially high morbidity associated with peri-natal maternal mood disorder (see definition below), it isimperative that those women at risk, or currently sympto-matic, be identified as early as possible in the perinatalperiod and referred on for appropriate management Thisprocess of assessing psychosocial risk factors (e.g. past his-tory depression) and current symptoms (e.g. depressive) isreferred to as ‘psychosocial assessment’ and fully describedin Chapter 3 of the Guidelines.

The Clinical Practice Guidelines for Depression andRelated Disorders in the Perinatal Period,22 commissionedby beyondblue: the national depression initiative andendorsed by Australia’s National Health and Medical ResearchCouncil, are an integral part of the National Perinatal Depres-sion Initiative (2008—2013).23 The Guidelines are aimed atthe range of clinicians — midwives, early childhood nurses,general practitioners, obstetricians, mental health profes-sionals — caring for women and their families across theperinatal period and cover the detection and management ofperinatal mood disorders, anxiety and psychosis.

4 M.-P. Austin et al.

The Guidelines also specifically consider the challenges ofregional and rural service provision and the needs of Indi-genous and culturally and linguistically diverse families.Finally, the Guidelines have been developed with an empha-sis on a holistic, woman-centred approach to the provision ofpsychosocial care in the perinatal setting.

Aim

To describe the process undertaken to develop the AustralianClinical Practice Guidelines for Depression and Related Dis-orders in the Perinatal Period and to highlight the keyrecommendations and their implications for the maternitysector. For the purposes of these guidelines perinatal mooddisorders is defined as: depression, bipolar disorder andanxiety disorder arising perinatally and puerperal psychosisarising postnatally.

Methods

Guidelines development process

A Guideline Expert Advisory Committee was formed, com-prising clinical and policy-making representatives of therelevant professional bodies from midwifery, obstetrics, gen-eral practice, mental health and early childhood nursing, aswell as representation from indigenous and regional and ruralstakeholders, and consumer and carer representatives. Con-sultants were employed to undertake the systematic litera-ture review and additional searches and to write theguidelines. A rigorous Guidelines development methodology(as required by the Australian National Health and MedicalResearch Council) was followed.24—27

The draft Guidelines were extensively and independentlyreviewed by clinicians, researchers, consumers and carersduring a two month public consultation process in March—May2010. Feedback from the consultation responses was incor-porated as appropriate (after due consideration by theGuideline Expert Advisory Committee) into the final draft,which was then reviewed by an international reviewer.Potential conflict of interest was addressed in keeping withNHMRC guidelines.

Formulating the clinical questions to be coveredby the Guideline

The Guideline Expert Advisory Committee developed a set ofclinical questions broadly covering: (1) the use and validity ofpsychosocial assessment tools; (2) the use and validity of theEdinburgh Postnatal Depression Scale (EPDS)28 and other self-report measures for routine use in screening for depression andrelated disorders; (3) the use of pharmacological and psycho-logical therapies in the prevention of depression and relateddisorders; (4) the efficacy and safety of pharmacological andpsychological therapies in the treatment of these conditions;(5) the value of primary prevention methods (community andclinician awareness raising) and models of care. In addition theGuidelines examined the available literature pertaining tointerventions which address mother—infant interaction, andassessing the safety of women and their children in caseswhere serious risk has been identified.

The importance of assessing the safety of treatments,particularly pharmacological treatments, was also specifi-cally addressed in the literature search. Due to the limitedavailability of high-quality evidence in this field, an ExpertPharmacological Harms Panel (consisting of leading perinatalpsychiatrists and a teratologist) was convened to advise on:the benefits of pharmacological interventions for women atrisk of developing a mental health disorder in the perinatalperiod (e.g., continuation versus discontinuation of medica-tion); the potential harms to pregnant women or women inthe first year postpartum, as a result of receiving a pharma-cological intervention (e.g., obstetric complications); andthe potential harms to the foetus or breastfeeding infant as aresult 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 Reviewsup to July 2009 was conducted. Where the systematic lit-erature review had already been undertaken for the NationalInstitute for Health and Clinical Excellence (NICE) Guidelinesfor Antenatal and Postnatal Mental Health29 (interventions upto September 2006) these results were summarised and thensupplemented by a further search for the 2006—2009 period.Where appropriate (e.g., as advised by the Expert Pharma-cological Harms Panel) other key papers not fulfilling thesystematic literature review criteria were reviewed andincluded in the narrative and as a means of supporting theGuideline Expert Advisory Committee to develop relevantGood Practice Points.

Grading the evidence and formulating andgrading of recommendations

Rating of the body of evidence involved the following five keycomponents:

Evidence base: including the number of studies, level ofevidence (I—IV) and quality of studies (risk of bias); Consis-tency across studies; Clinical impact: examining effect size,relevance of evidence base to the research question andwhether the risks and benefits were considered in terms ofclinical impact; Generalisability and applicability: A judgmentby Guideline Expert Advisory Committee — based on the bodyof evidence — as to its generalisability to the Guidelines targetpopulation and its applicability to the Australian healthcarecontext, taking into account feasibility issues (workforce,geographical distance, cost) and existing health care systems.

The body of evidence components were then summarisedinto one overall grading. National Health and MedicalResearch Council Grades of Recommendation (ranging fromA to D; see Box 1) indicate the strength of the evidenceunderpinning the recommendation, thus assisting Guidelineusers to make informed clinical judgments.

Findings

There were eight Recommendations (see Box 2). Where therewas insufficient evidence for recommendations — as wasfound in the majority of cases — Good Practice Points were

Box 1. Definition of National Healthand Medical Research Council grade ofrecommendation.

Grade Description

A Body of evidence can be trusted to guide practice;based on level I evidence

B Body of evidence can be trusted to guide practicein most situations; based on level II evidenceCBody of evidence provides some support forrecommendation(s) but care should be taken in itsapplication; based on level III evidenceDBody of evidence is weak and recommendationmust be applied with caution; based on levelIV evidence

Clinical practice guidelines for perinatal depression 5

formulated (see Box 3 for summary). These are based onlower quality evidence and/or the consensus of the Guide-lines Expert Advisory Committee. Between them the Recom-mendations and Good Practice Points cover the designatedscope of the guideline.

Key groupings of Good Practice Points

The Good Practice Points have been summarised and groupedinto the clinical domains most relevant to clinicians workingin the maternity sector as per Box 3. Note that this summarydoes not include all 44 Good Practice Points.

Given that these Guidelines have been written for clin-icians on the assumption that they do not have specificmental health training, the Good Practice Points also serveto provide the reader with a certain amount of structured

Box 2. Clinical Practice Guidelines for DePerinatal Period: recommendations and gra

Recommendations

1 As a minimum, all health professionals providingreceive training in woman-centred communicati

2 The EPDS should be used by health professionalof all women for symptoms of depression in the

3 The EPDS should be used by health professionalof all women in the postnatal period for symptdepression and anxiety.

4 A score of 13 or more on the EPDS can be used

depression in the postnatal period.5 Non-directive counselling in the context of hom

of the management of mild to moderate deprespostnatal period.

6 Cognitive behavioural therapy (CBT) should be cdiagnosed mild to moderate depression in the p

7 Interpersonal therapy (IPT) can be considered foto moderate depression in the postnatal period

8 Psychodynamic therapy can be considered for trmoderate depression in the postnatal period.

guidance, and example questions (for psychosocial assess-ment) are given wherever possible. For midwives for exam-ple, this could entail administering the Edinburgh PostnatalDepression28 (see Guidelines Appendix 5) also validated forantenatal use, and a structured psychosocial risk question-naire (e.g. Antenatal Risk Questionnaire30 or a set of clinicalquestions (as outlined in the Guidelines Appendix 4). Addi-tionally, given clinicians’ concerns around the wellbeing ofthe infant (as raised in the consultation feedback of the draftGuidelines), the Good Practice Points also focus on theassessment of the mother—infant interaction and wherefeasible/appropriate the inclusion of an assessment of riskto infant (see Chapter 4 Guidelines).

With respect to the use of medication, the Guidelinesadvise close monitoring to enhance relapse minimisation inthose with existing mood disorder, especially when they havedecided to cease medication. The Guidelines give simpleadvice on the areas that require discussion when consideringmedication in pregnancy and breastfeeding, and specificGood Practice Points address safety issues in pregnancyand breastfeeding (see Chapter 8 Guidelines).

Discussion

Given the lack of an extensive evidence base in the field ofdepression and related disorders arising in the perinatalperiod, only a small number of recommendations could bemade. Our multidisciplinary Guidelines Expert Advisory Com-mittee made a considered judgment that the potential ben-efits to women and their families were sufficient to make arecommendation to use EPDS as a component of both antena-tal and postnatal assessments for symptoms of depression.

These recommendations to use EPDS may be regardedas controversial as other groups have not gone quite as faras formally recommending the use of EPDS. However the

pression and Related Disorders in theding.

Grade

care in the perinatal period shouldon skills and psychosocial assessment.

C

s as a component of the assessment antenatal period.

B

s as a component of the assessmentoms of depression or co-occurring

B

for detecting symptoms of major C

e visits can be considered as partsion for women in the

C

onsidered for treating women withostnatal period.

B

r treating women with diagnosed mild.

C

eating women with diagnosed mild to D

Box 3. Clinical Practice Guidelines for Depression and Related Disorders in thePerinatal 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 possible2. 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 questions4 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 identifysignificant 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 forspecific dosages, efficacy, etc.� Antenatal use: undertake general discussion of potential risks and benefits to woman and foetus of treating versus nottreating� Antenatal use and birth defects: provide woman and partner detailed explanation of baseline, absolute and relative risks ofusing 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 relapseidentification or withdrawal symptoms

(b) SSRIs� Use of SSRI can be considered in pregnancy as this is the best researched antidepressant category and current evidenceshows 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 withincreased 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 decisionwith 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 orTCA in treating anxiety disorders.� Avoid long-acting benzodiazepines as much as possible

6 M.-P. Austin et al.

American College of Obstetrics and Gynecology doesacknowledge the benefits of assessing women for symptomsof depression31 and base their Tools document on use of theEPDS.32 While the British NICE Guidelines did not recommendroutine universal assessment using EPDS, they stated thatEPDS could be considered as part of subsequent assessment orroutine monitoring of outcomes.29 A recent randomised con-trolled trial has provided important new evidence about theeffect of postnatal screening using EPDS on maternal out-comes. This study demonstrated improved maternal mentalhealth outcomes at six months for women in the screeningprogram compared with those under usual care, in the con-text of adequate pathways to care.33

Although the Good Practice Points supporting the use ofthe EPDS make suggestions around EPDS cut-off scores, theGuidelines clearly highlight that the use of cut-offs are onlyan indicator and that clinical judgment is a fundamentalcomponent of the assessment process. The Guidelines goon to advocate that the EPDS be combined with a systematicenquiry around a woman’s psychosocial context, i.e., thepsychosocial and mental health risks that are present for herin the perinatal period.

In developing these Guidelines, we examined those cur-rently in use both nationally and internationally. The mostcomprehensive and methodologically rigorous are the BritishNational Institute for Health and Clinical Excellence (NICE)

Clinical practice guidelines for perinatal depression 7

Guidelines for Antenatal and Postnatal Mental Health.29 Withrespect to psychosocial assessment, the NICE guidelines focustheir recommendations and statements primarily on theprediction of maternal mental illness and the detection ofdepression or severe mental illness, rather than taking abroader, more systemic approach to assessment of mother,infant and family. They do not recommend routine ‘psycho-social assessment’ (i.e., assessing all domains of risk formental health morbidity plus current symptoms) for allwomen.

The Scottish Intercollegiate Postnatal Depression guide-lines,34—36 similarly recommend asking about past or familyhistory, but also suggest that risk factors for mood disordersshould be systematically recorded antenatally, and recom-mend routine use of EPDS for depression screening in thepostnatal period. The British Columbia (Canadian) Reproduc-tive Mental Health guidelines,37 like the Australian guide-lines, recommend routine psychosocial assessment usingboth a symptom rating scale and a structured psychosocialquestionnaire or interview. They also focus on the need toview women in the context of their infant and family and onthe promotion of mother—infant attachment. Neither theScottish nor Canadian guidelines are underpinned by a sys-tematic literature review.

Conclusion

The development of these Guidelines comes at a criticaltime in the implementation of the National Perinatal Depres-sion Initiative.23,38 The Guidelines acknowledge that uni-versal depression screening and psychosocial assessmenthave been strongly debated in a number of different set-tings, and have significant resource implications (training,workload and access to mental health services). In the UK, acost-effectiveness study of routine screening for postnataldepression (using hypothetical data) concluded that screen-ing for postnatal depression in primary care does not repre-sent value for money, due mostly to the impact of false-positive screening results on cost estimate.39 A key assump-tion in that analysis was that all the ‘false positives’ wouldstill have supportive counselling on the basis of a depressionscreening cut-off score alone. This approach is in contrast tothe recommendations made in the Australian Guidelines:namely, that a depression score is not an endpoint or sub-stitute for diagnosis, but the platform from which the appro-priate women will be referred for further mental healthassessment and treatment as needed.40 While there is nocost-effectiveness data relevant to the Australian context,costs related to introducing routine psychosocial assess-ment, including training costs, were estimated as part ofthe economic modeling undertaken in the 2008 beyondblueNational Action Plan for Perinatal Mental Health41 whichinformed the implementation component of the NationalPerinatal Depression Initiative. Although the Guidelineswere not pre-tested at national level, routine psychosocialassessment has been extensively undertaken in the last tenyears in key maternity hospitals across a number of Austra-lian states42—47 and can thus be considered as sites of pre-guideline piloting.

These Guidelines are a first step in translating researchevidence into practice and developing a broader evidencebase. They provide midwives with a both a comprehensive

clinical document and easy reference. Future researchshould include an examination of the cost-benefit and/orcost-effectiveness of universal depression screening andpsychosocial assessment at a population level (for mother,infant and family), as well as barriers to the uptake ofreferral and treatment options and the effectiveness oftreatment services provided across the community. It isexpected they will provide Australian midwives and otherkey maternity care providers with clear guidance on thepsychosocial assessment and management of women andfamilies in the perinatal period.

In contrast to other guidelines around the world, theAustralian guidelines are underpinned by a systematic litera-ture review, as well as encompassing the full spectrum ofpsychosocial assessment for both mother and infant andgiving guidance for management across the full range ofmaternal mood disorders.

Acknowledgements

We gratefully acknowledge beyondblue: the national depres-sion initiative for funding and logistic support for the devel-opment of the Clinical Practice Guidelines for Depression andRelated Disorders (Anxiety, Bipolar Disorder and PuerperalPsychosis) in the Perinatal Period.

We also gratefully acknowledge the other Expert AdvisoryCommittee members, writers and reviewers who led thedevelopment of these Guidelines (in alphabetical order):Guidelines Expert Advisory Committee: Prof Anne Buist,Ms Lyn Chaplin, Ms Jo Duffy, Ms Michelle Dykman, Mr NickJanjic, Dr Carol Johnson, Dr Sally Lambert, Dr Helen Lindner,Ms Rachael Lockey, Prof Jeremy Oats, Ms Jenny Parham, MsCarol Purtell, A/Prof Jonathan Rampono, Dr Jan Taylor, DrDebra Wiens; Expert Pharmacological Harms Panel: ProfPhilip Boyce, Prof John Condon, Dr Debra Kennedy; Amper-sand (writers): Elizabeth Hall and Jenny Ramson; HTAnalysts( for the systematic literature review): Dr Sarah Norris, MsSuzanne Campbell, Dr Lisa Elliott and team.

We would also like to thank Christine Benger, RachelKomen and Suzanne Pope at beyondblue; Vesna Cvjeticaninand her team from the National Health and MedicalResearch Council; and all those who gave feedback, writ-ten and via public consultations, on the draft version of theguidelines.

Sources of financial supportFunding and logistic support for the development of the

‘Clinical Practice Guidelines for Depression and Related Dis-orders (Anxiety, Bipolar Disorder and Puerperal Psychosis) inthe Perinatal Period’ was provided by beyondblue: thenational depression initiative.

MPA is a recipient of current research funding from theNational Health and Medical Research Council (Project Grant#604003; Program Grant 510135) and the Bupa Foundation.She has previously received speaker’s fees from AstraZenecaand Pfizer.

NR is a recipient of current research funding from the BupaFoundation.

PM received funding from the National Health and MedicalResearch Council to provide methodological support fordevelopment of these guidelines.

8 M.-P. Austin et al.

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