Word counts
It is an important academic and practical skill to be able to communicate succinctly. It is expected that students will adhere to the word limits and not exceed the prescribed limit by more than 2,500 words (Two 1,250-word case studies) including in-text citations and the reference list. Except in previously approved circumstances, appendices should not be included to accommodate extra words. All text included in the assessment will be included in the word count (as determined by Turnitin).
Assessment: Case Study (ANALYSIS)
Word limit; 2,500 words (Two 1,250-word case studies)
Overview
Theory is useful as an underpinning to care for consumers, but it’s important to be able to move the theory into action. In these two case studies, you will have the opportunity to show you can take what you have learned and apply it to real-world scenarios.
Learning outcomes
This assessment task is aligned to the following learning outcomes:
2. Critically analyse the impacts of pharmacological treatments in mental health on the physical health status of consumers
3. Design and justify nutrition and exercise-based interventions for inclusion within mental health treatment and wellness and prevention plans
4. Design assessment and care planning practices to achieve helpful responses to the sexual health needs of consumers
5. Create strategies to effectively support the mental health needs of those who are experiencing eating disorders
Assessment details
Analyse two case studies provided in the appendix and create a holistic physical wellbeing assessment and intervention package in response to the provided clinical scenarios which is anticipated to address the presenting problems. Each package must be supported by the best available evidence. The package/plan must also be designed with specific reference to overcoming obstacles which might inhibit the person from achieving the best possible outcomes.
Each case scenario should be approximately 1000 words (allowing further room for references),
For each scenario:
1. Outline the critical biological, psychological, sexual and social health issues that need to be addressed.
2. Outline a plan to holistically address/resolve the health problems, providing reference to the research evidence and authoritative guidelines as appropriate.
3. Recommend referrals to allied health or other health service providers, if appropriate, and outline (based on research evidence or guidelines) how those professionals might respond
4. Recommend one or more community resources or agencies which the person might access to assist them in improving their health.
5. Write a brief narrative completing the scenario, describing how you anticipate the problems will be resolved (including time frames).
The scenarios are located in Appendix A of this document.
Submission format
Please submit your case studies as One Word document labeling each case study with a reference list at the conclusion.
Assessment rubric
Criterion;
Identification of Health Issues (30%):
Comprehensive and nuanced outline of the critical health issues that need to be addressed in the scenario. Uses a coherent and clear methodology.
Wellbeing assessment and intervention plan design (40%):
A comprehensive, innovative and workable plan of care that holistically appraises and addresses the patient’s health problems. Integrates supporting reference to relevant evidence and guidelines.
Plan Referrals (10%):
Plan incorporates referrals to allied health or other health service providers, and explicitly describes the contribution they will make
Community Resource Group Recommendations (10%):
Community group recommendations reflects a holistic understanding of community agencies in the promotion of health and wellbeing. How each resource can assist in well-articulated and integrated into the plan design.
Narrative Description of outcome: (10%)
The Narrative comprehensively addresses how assistance and the recommendations are likely to address the health problems, with realistic timeframes and also addresses anticipated obstacles and barriers and how these might be addressed.
Appendix A:
Scenarios for assessment Select only two scenarios
Scenario A – Metabolic Syndrome
Anton is a 20-year-old man who lives in a regional area. He was not very successful at school and smoked cigarettes and cannabis since age 14. He left school in grade 11 after obtaining a job as a commercial cleaner, working early shifts in a nearby town. He moved into a share house and his cannabis habit increased, as did his experimentation with party drugs. He lost his job after about 6 months due to concerns about his performance and having lost his driver’s license. He was admitted to a mental health unit sometime after with psychotic symptoms – He was paranoid, believing ‘people’ were watching his house and wanted to hurt him. He reported hearing stories about himself on the radio and television. He was diagnosed with a psychotic illness and discharged for GP follow-up on Risperdal Consta 37.5 IMI every two weeks (which is administered at a local GP surgery). He has trouble sleeping from time to time and takes up to 100mg of Quetiapine each night. Anton’s psychotic symptoms seem to have remitted. However, over the last 12 months he has become quite reclusive, spending most of his time playing on-line games or watching television. He used to enjoy cycling and surfing but says that since “getting sick” he has lost his motivation.
He is on disability pension and spends most of his spare money on tobacco and cannabis. He buys a $100 bag of cannabis each week and mixes it with tobacco before smoking it in a bong. He has put on around 15 kg over the year (height 180cm, weight 97kg). He is not happy about his weight gain but says he is not a very good cook eating mostly fried food washed down with his favourite drink high caffeine full sugar soft drink (of which he drinks up to 4 litres per day). Anton would like to have a girlfriend. His most recent relationship was with a woman whom he met on an on-line gaming chat room. They dated for a while, but he was concerned and embarrassed that he was impotent and is unsure whether he can ever be in a relationship. Anton would like to get a job, but he is unsure whether he could handle the stress and often sleeps in until late in the morning.
Scenario B – Perinatal Care
Breeze is a 34-year-old woman with a diagnosis of bipolar affective disorder. She is reported to have had a manic episode when she was a college student but has only ever been hospitalised for depressive episodes. She has type II diabetes. Her diabetes control was poor when she was a young adult but since entering her 30s she has been more careful with her blood sugar monitoring and insulin regime. She has been prescribed carbamazepine 600mg BD for some years, having previously been prescribed lithium and fluoxetine. She works in retail. She smokes cigarettes (~ 10 per day), drinks most nights of the week (4-6 standard drinks). Her weight is 73kg and her height is 168cm. She has been in a stable and supportive relationship with a man for several years with whom she would like to have a baby. She is contemplating having her Implanon removed.
Scenario C – Possible Eating Disorder
Cat is a 21 year old woman who is superficially known to mental health and emergency services for self-harm and suicide attempts. She has attracted a diagnosis of borderline personality disorder. She has had the experience of childhood sexual abuse and in her midteens started self-injuring in response to interpersonal stress. She is estranged from her family. She has been living in a share house with other young people and over the last 6 months has been smoking methamphetamine most weekends. During these occasions she will stay up all night and frequently engages in casual, unprotected sex. She states that she is not worried about pregnancy because she has not had her period for over a year. She states that she used to be fat (around 60kg ~ last year). Her current weight is 43kg (height 159cm). She states that she doesn’t think about food when she is high and about midweek she sometimes becomes ravenous and binges on McDonalds. She then feels guilty and induces vomiting. She often feels quite dizzy when she stands up and she feels her heart bounding in her chest. Her flatmates are worried about her as she has fainted on a couple of occasions.
Scenario D – Depression
Dion is a 55 year old man. His life has not gone to plan. He has spent most of his life working laying concrete. He had a reasonably successful concreting business. He employed a couple of labourers and his wife Joan of twenty years managed the office and kept the books. He was quite physically active for most of his life – Playing footy as a young adult and going fishing on weekends. His last few years of work were tough as he acquired a lower back injury which confined him to the office. Always a drinker at the end of the day, he began starting the day with a beer and would consume a cartoon of beer before “knock off” time. He visited his GP who prescribed him Zoloft 150mg mane. He does not feel any better and no longer goes fishing. A construction downturn and poor management meant he has recently had to close his business and he has sold it for less than he believes it is worth. Dion has reduced his alcohol intake somewhat at Joan’s request as she thinks it is affecting his sexual performance. Dion can’t seem to get an erection at all. Joan says that she has had enough of him moping about the house. She has decided to take “time out” from the relationship and stay with her sister in another town until Dion sorts himself out. Dion is quite depressed and spends most of his day at the pub playing pokies. Since Joan has left two weeks ago he has not had a home cooked meal. His GP says that his liver function tests are a problem (with elevated AST & ALT), his triglycerides are up, he has hypertension and has advised that he needs to stop smoking (20 per day) immediately. Dion doesn’t know where to start or what to do.
title sub title
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PROFESSOR DAVID JONATHAN CASTLE
MBChB MSc CGUT MD DLSHTM FRCPsych FRANZCPI
David is Professor of Psychiatry at St Vincent’s Health and The University of Melbourne. He has wide clinical
and research interests, encompassing schizophrenia and related disorders, bipolar disorder, cannabis abuse,
OCD spectrum disorders and disorders of body image. He has published over 600 papers and chapters; and
23 books. His broader interests include music, literature, theatre and art.
This article discusses the sexual side-effects of the various antidepressants
and what can be done about this issue.
Sexual Side-effects Associated with Antidepressants:
A Clinical Guide
www.healthed.com.au Page 1
Introduction
I
t is not uncommon to have patients with depression whose mood
symptoms improve with treatment, but who complain that their
libido and ability to experience orgasm is impacted negatively
by their antidepressant. Of course, sexual activity is complex
and encompasses numerous domains. These include the quality of
the relationship between sexual participants, their physical health,
any alcohol or illicit substance use and general mental health issues.
All of these factors need to be considered in the assessment and
treatment of sexual problems, and sexual dysfunction should not
automatically be attributed to an antidepressant. However, there is
no doubt that certain antidepressants can cause sexual problems,
notably decreased libido and delayed orgasm. There is also little
doubt that the various classes of antidepressants have different
propensities to induce such problems.
This article provides a clinically-focussed overview of the problem
of antidepressant-associated sexual dysfunction and there is a
particular emphasis on management. This is important, as sexual
problems impact the individual and their partner and are also a
common reason for patients to cease their antidepressant, thus
increasing the risk of relapse of depression.
EXPERT MONOGRAPH ISSUE 17
Take Home Messages
` Sexual function should be seen within the context
of the individual, the relationship and the culture.
Physical health, drug and alcohol consumption and
relationship issues should be excluded before deciding
that antidepressants are the cause of sexual dysfunction.
` Sexual dysfunction is more likely with drugs that increase
brain serotonin, notably SSRIs, SNRIs and certain TCAs.
` Generally, drugs that block 5HT2c receptors have lower
reported rates of sexual dysfunction (e.g. mirtazapine,
agomelatine). Moclobemide and vortioxetine are also
associated with relatively low rates of sexual dysfunction.
` Sexual dysfunction associated with antidepressant use
can be managed by switching to another with less
propensity, or using an augmentation strategy. Only
sildenafil and tadalafil (both for men only), and bupropion,
have placebo-controlled trial support in this regard.
title sub title
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Hormonal Contraception Trouble-shooting Part One: The Overweight Woman
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Sexual Side-effects Associated with Antidepressants: A Clinical Guide
Prevalence and mechanisms
Human sexual function is complex and impacted by individual
attitudes and mores, as well as societal, religious and cultural
factors. Relationship issues are paramount and the quality of the
intimate partnership plays a vital role in determining sexual habits
and enjoyment. All these factors need to be borne in mind when
assessing sexual functioning and determining any change that
could be associated with depression and antidepressants.
A number of factors at the biological level underpin the various
stages of sexual function.1,2 The parasympathetic and sympathetic
nervous systems interact to establish and maintain penile erection
in men, clitoral engorgement and vaginal lubrication in women,
and ultimately orgasm. Dopamine seems to be the most important
neurotransmitter in driving libido and physical arousal, whilst
serotonin impairs orgasm and ejaculation, mostly through the
5HT2c receptors in the spinal cord.3 Beta-adrenergic receptors play
a role in maintenance of erections, countered by alpha-1 receptors.3
Nitric oxide is also involved in erectile function.3
There are numerous causes of sexual dysfunction. An association
between sexual dysfunction and depression is well described.
However, reported rates depend upon whether the individual is
specifically asked, as often there is reticence in volunteering such
information spontaneously. Rates of approximately 50% have
been reported for sexual impairment in patients with depression,
but in some studies these are even higher.1 It is also important
to understand which aspects of sexual functioning are impacted.
A lack of libido and a generally decreased interest in sex is not
uncommon in patients who have depression, but the common
antidepressant–associated delayed ejaculation is not usually a
prominent issue in untreated depression.
The overall pattern is that
males suffer a higher adverse
impact on desire and orgasm,
whilst arousal is more affected
in females.
The rates and types of sexual dysfunction vary extensively with
different antidepressants, as confirmed in the meta-analysis of
Serretti and Chiesa.4 These findings are summarised in Table 1.
The rates of sexual dysfunction were highest in people taking
medications that increase serotonin levels in the brain, notably
selective serotonin reuptake inhibitors (SSRIs), serotonin-
noradrenaline re-uptake inhibitors (SNRIs) and certain tricyclic
antidepressants. Medications that block serotonin 5HT2c receptors
post-synaptically had a generally lower reported rated of sexual
dysfunction (e.g. mirtazapine, and the melatonergic M1/M2 agonist,
agomelatine). This pattern reflects what is known about sexual
physiology. Bupropion, which acts through dopaminergic and
noradrenergic mechanisms, had a relatively low rate of sexual
dysfunction, as did the reversible selective monoamine oxidase A
inhibitor, moclobemide.
Table 1: ‘Ranking’ of antidepressants in terms of overall
rate of sexual dysfunction
Highest Middle Lowest
Citalopram Fluvoxamine Agomelatine
Fluoxetine Escitalopram Bupropion
Paroxetine Duloxetine Moclobemide
Sertraline Imipramine Mirtazapine
Venlafaxine
(data from Serretti and Chiesa)4
An interesting aspect of the Serretti and Chiesa meta-analysis4 lies
in its ability to examine rates of dysfunction across the different
phases of sexual desire, arousal and orgasm. In the main, those
drugs associated with low rates of overall sexual dysfunction did
not show specific effects on particular aspects of sexual function
(albeit, mirtazapine has a small signal for desire dysfunction, and
bupropion for arousal dysfunction). In terms of gender, the overall
pattern was that males suffered a higher adverse impact on desire
and orgasm, whilst arousal was more affected in females.
In terms of the newer antidepressants, the multimodal antidepressant
vortioxetine has been shown in clinical trials to have a placebo-level
or slightly higher rate of sexual dysfunction, with substantially
lower rates than comparison agents, including duloxetine and
venlafaxine.5
It is important also to appreciate that a range of other psychiatric
medications can also impact sexual functioning. Notable amongst
these are a number of antipsychotic agents, especially those
that have a propensity to raise prolactin levels (e.g. risperidone,
paliperidone, amisulpride, haloperidol).6
Understanding sexual function and dysfunction
at the individual level
Sexual function should be seen within the context of the individual,
the relationship and the culture. Often there are sensitivities about
discussing sexual issues, but clinicians dealing with people with
mental illness need to establish an approach to such a discussion
as a matter
of routine.
One study reported that patients volunteered sexual dysfunction
associated with antidepressant treatment in only 14% of cases,
although 58% acknowledged problems in this regard when they
were questioned directly.7 There are established rating scales that
can assist both in assessing cross-sectional sexual functioning
and enjoyment, as well as longitudinal tracking. The two most
commonly used are the Arizona Sexual Experiences Scale (ASEX)8
and the Changes in Sexual Experience Scale (CSFQ)9.
Often there are sensitivities
about discussing sexual issues,
but clinicians dealing with
people with mental illness need
to establish an approach to
such a discussion as a matter
of routine.
It is also important to understand the usual sexual activities and
habits of the patient early during treatment. This will establish a
baseline, as well as ensure that physical health or other factors are
not contributing to any sexual dysfunction.
Balon10 following Gitlin11 suggests, inter alia, the following as
important elements of a baseline assessment of sexual function
in patients with depression. It should be noted that many of
these questions are sensitive and the level of detail may be more
appropriate to specialist psychiatric practice than to a general
practice setting. Clinical judgement is required and should be made
based on the entirety of the clinical scenario and the relationship
between the patient and the doctor, notably regarding item 1.
Items 2 and 3 should be considered part of the formal psychiatric
assessment, but are important to consider in the context of sexual
problems in particular.
1. Details of usual sexual functioning, pre-treatment and also
pre-morbidly: A longitudinal history is useful, including first
sexual experiences, enjoyment of sex, pattern of sexual
partners, usual frequency of sex and masturbation.
2. Psychiatric issues that might contribute to sexual problems:
These include not only depression, but also anxiety disorders,
post-traumatic stress disorder and body image disorders;
particular problematic sexual problems are not uncommon in
people who have experienced sexual abuse.
3. Alcohol and illicit drugs can have a profound effect on sexual
function and are also important contributors to mental health
problems; cigarette smoking can also affect sexual functioning.
4. Physical health requires careful assessment. Diabetes mellitus
and other endocrine disorders, as well as cardiovascular risk
factors (such as obesity and hypertension) can impair sexual
function. A number of medications used for physical health
problems can contribute to this issue as well (e.g. some
antihypertensive agents and antiarrhythmics, antiandrogens
and other hormonal preparations).
5. Details of sexual functioning during the current (and past, if
relevant) depressive episode; note that some people, when
depressed, actually increase their sexual activity, but this does
not provide the normal satisfaction. This could be referred to a
akin to ‘comfort eating’.
6. The personal importance of sexual activity, and the impact that
any changes in sexual function associated with the depression
has had upon the current relationship.
Management
The management of sexual dysfunction associated with
antidepressants requires a good understanding of the issues
outlined above, followed by a full and frank discussion with the
patient about therapeutic options. The offer should be made to
include the patient’s partner in at least some of these discussions.
It is particularly useful for partners to understand the impact of
antidepressants on libido, as they might otherwise believe that that
the patient has lost interest in sex because of issues to do with
sexual attraction, specifically towards their partner.
Some patients report benefit from simple explanation and
psychological strategies, but many do not. Approaches such as ‘drug
holidays’ (that is, stopping the antidepressant for the day or two
before sex), are not usually very effective and have the disadvantage
of removing the spontaneity of sex, as well as sending potentially
conflicting messages about regular medication adherence.2
In those individuals in whom such simple approaches do not
work, some will ‘accept’ a degree of sexual dysfunction as a ‘price
worth paying’ for their mood being better, and are reluctant to
countenance a change in antidepressant medication and risk
relapse. Others will be willing to take this risk, and so will need
to be offered a range of options. Table 1 details the relative
propensity of sexual side-effects associated with commonly used
antidepressants. Switching needs to be done in a controlled manner,
mindful of the relative receptor pharmacology of the agent being
switched ‘from’ and ‘to’. For example, switching from a sedating
agent to a non-sedating agent can result in insomnia, so slow
transition and/or the short-term use of a hypnotic agent should be
considered. Also, if the initial agent is used at a high dose, a slower
cross-titration is usually preferred. Attention also needs to be given
to potential pharmacokinetic interactions between the two agents.
Certain combinations are potentially dangerous and require wash-
out periods, notably monoamine oxidase inhibitors. It is important
to refer to the product information regarding the changing over of
particular medications.
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Sexual Side-effects Associated with Antidepressants: A Clinical Guide
In terms of which agent to ‘switch to’, agomelatine has the
virtue of a generally low side-effect burden and has no major
interactions with other antidepressants (except fluvoxamine). It
does carry a risk of hepatic dysfunction (0.8% 25mg and 1.9%
50mg, >3x ULN, placebo-adjusted in the clinical trials) and liver
enzymes should be measured at baseline, followed by three, six,
twelve and twenty four weeks after initiation, and after any dose
increase. This antidepressant is not available on the Pharmaceutical
Benefit Scheme (PBS) in Australia, but many private insurers offer
part-reimbursement. Bupropion is also not available on the PBS in
Australia for depression and it is rather costly. It also can cause
nausea and is associated with a risk of seizures, so should not be
used in patients with a history of fitting. Mirtazapine has sedative
effects that can be useful, but some patients may find these
excessive; it also commonly increases appetite and can result in
weight gain. Moclobemide is generally well tolerated and may be
worth considering in patients sensitive to side-effects generally,
as well as specifically those experiencing sexual side-effects.
Vortioxetine is also useful in some patients who have experienced
sexual dysfunction with an SSRI or SNRI and in whom a serotonergic
medication is required, but it is also not available on the PBS.
A different approach to treating sexual dysfunction associated with
antidepressants is to use an adjunctive agent to try to ameliorate
the sexual side-effects of the initial medication. Again, care must be
taken with potential drug-drug interactions and cumulative other
side-effects. A summary of agents which might be used as adjuncts
to SSRIs and SNRIs is shown in Table 2. It should be noted that most
Sexual Side-effects Associated with Antidepressants: A Clinical Guide
www.healthed.com.au Page 4
Table 2: Selected augmentation agents with potential use for sexual dysfunction associated with SSRIs and SNRIs*
AGENT ACTION EVIDENCE COMMENTS
Bupropion15-18 DA, NA re-uptake inhibition Efficacy at 150mg bd, but not
150mg daily
Potential for seizures
Mirtazapine19,20 Post-synaptic 5HT2 blockade
and pre-synaptic alpha 2
agonism
No RCT evidence for efficacy
as an augmenter, despite low
sexual side-effects as solo agent
Sedation and weight gain can
be problematic
Agomelatine21 Melatonin M1/M2 agonism and
post-synaptic 5HT2c blockade
No RCT evidence for efficacy
as an augmenter, despite low
sexual side-effects as solo agent
Well tolerated side-effect
profile; requires hepatic
monitoring
Cyproheptadine22 Antihistamine with anti-
serotonergic properties
Case reports only of efficacy at
mean 8.6mg daily
Sedation can be problematic
and may impede efficacy of
SSRI/SNRI
Buspirone23 5HT1a partial agonist Case reports of efficacy at
15mg to 60mg daily
Antianxiety effect can be
helpful
Amantadine22 DA agonist Case series report efficacy for
anorgasmia at 100mg to 400mg
daily
Potential DA agonist side-
effects include psychosis
Aripiprazole24 Partial DA agonist Post-hoc analysis of three RCTs
support efficacy for sexual
dysfunction in females only at
2mg to 20mg daily
Akathisia can be problematic;
additional antidepressant effect
can be helpful
Methylphenidate25
amphetamine26
pemoline27
Stimulants Case reports of efficacy for
SSRI-induced sexual dysfunction
Potential DA agonist effects,
including psychosis; potential
for dependence
Yohimbine28 Presynaptic alpha 2 blocker Case series suggest efficacy for
doses from 2.7mg to 16.2mg
daily, but single RCT failed
Can cause anxiety, nausea,
urinary retention
Ginko biloba29 Unknown Case reports of efficacy at
60mg to 120mg twice daily
Can cause gastrointestinal
upset, lightheadness and
bleeding problems
*NOTE: None of these agents are indicated or reimbursed in Australia for this indication. DA = dopamine; NA = noradrenaline; 5HT = serotonin; mg =
milligrams; bd = twice daily; SSRI = selective serotonin reuptake inhibitor; SNRI = serotonin noradrenaline reuptake inhibitor; RCT = randomised control trial
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Sexual Side-effects Associated with Antidepressants: A Clinical Guide
of these treatments have a very limited evidence base and none are
approved for use as augmentation agents in patients with sexual
dysfunction associated with SSRIs and SNRIs. Indeed, a recent
Cochrane review of treatments for sexual dysfunction associated
with antidepressants found only twenty-two studies involving
augmentation strategies.12 Two studies13,14 (n=255) found efficacy
for the phosphodiesterase, sildenafil, for erectile function in males;
the phosphodiesterase, tadalafil, was similarly effective in a single
study of fifty-four patients. In a further three studies,15-17 a benefit
was shown for bupropion (150mg twice daily) in overall sexual
function in both males and females, but this was not confirmed in a
further two studies of bupropion (150mg once daily).17, 18
Another adjunctive approach is the use of a dopamine partial
agonist antipsychotic. There is now widespread use of aripiprazole
as an adjunct to antidepressants in major depressive disorder30
(again, it is neither indicated for this nor reimbursed in Australia)
and there is support for a pharmacological mechanism regarding
an additional benefit for sexual dysfunction (largely dopaminergic
effects). Fava et al24 pooled three placebo-controlled trials of
aripiprazole used as an adjunct to a range of SSRIs and SNRIs (n=
737 female, 355 male) and reported benefits not only in mood but
also (for women only) in sexual interest and sexual satisfaction. This
effect was independent of improvement in mood and also was not
correlated with prolactin levels.
Montejo et al6 have summarised other ‘add on’ strategies, including
transdermal testosterone (some efficacy in women)31 acupuncture
(efficacy more likely in men)32, saffron (women)33 and macca root
(women)34. Clearly these approaches are not ‘mainstream’ and
side-effects and interactions need to be borne in mind if any of
these therapies are considered. Of course, many patients use over-
the-counter and herbal and other ‘remedies’, and these should be
asked about in all patients.
Conclusions
Sexual functioning is often impaired as part of a depressive
process. Some antidepressants, notably SSRIs and SNRIs, whilst
being effective in treating depression, induce sexual dysfunction.
A full assessment of the individual to exclude other causes of
sexual dysfunction, along with the offer to discuss the condition
with the partner, when appropriate, is vital. Options for addressing
the sexual dysfunction, if it is confirmed to be associated with the
antidepressant, include switching to another antidepressant with
less propensity to sexual dysfunction (e.g. agomelatine, bupropion,
Video Resources
Management of Depression and Anxiety
by Dr Tom Paterson
Management of Depression
by Prof Philip Boyce
Tailoring Antidepressant Therapy
by Dr Tom Paterson
Is it Depression or is it bipolar?
by Dr Jon-Paul Khoo
Watch full lectures on the Healthed website. Visit www.healthed.com.au/video
http://www.healthed.com.au/video/management-depression-anxiety/
http://www.healthed.com.au/video/management-of-depression/
http://www.healthed.com.au/video/tailoring-antidepressant-therapy/
http://www.healthed.com.au/video/is-it-depression-or-is-it-bipolar/
mirtaza pine, moclobemide, vortioxetine), or using an augmentation
strategy. In terms of augmenters, only the phosphodiesterases
sildenafil and tadalafil, and the dopamine/noradrenaline
antidepressant, bupropion, have placebo-controlled trial support
(and for the phosphodiesterases, this is in males only). Some data
support the benefits of the dopamine partial agonist aripiprazole for
SSRI and SNRI-induced sexual dysfunction in women. The topic of
sexual side-effects associated with antidepressants clearly requires
clinical common sense, careful questioning and a good therapeutic
relationship with the patient.
Further reading
Malhi GS, Bassett D, Boyce P, Bryant R, Fitzgerald PB, Fritz K,
Hopwood M, Lyndon B, Mulder R, Murray G, Porter R. Royal
Australian and New Zealand College of Psychiatrists clinical
practice guidelines for mood disorders. Australian & New Zealand
Journal of Psychiatry. 2015; 49:1087-206.
Castle DJ, Abel K Comprehensive Women’s Mental Health Cambridge
University Press, Cambridge 2016; ISBN 978-1107-62269-2
Declaration
Prof David Castle was commissioned by Healthed for this article.
The ideas, opinions and information presented are solely those of
the author. The advertiser does not necessarily endorse or support
the views expressed in this article.
The author’s competing interests statement can be viewed at
www.healthed.com.au/monographs.
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11. Gitlin MJ. Psychotropic medications and their effects on sexual
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Psychiatry 1994 Sep; 55(9): 406-413.
12. Taylor MJ, Rudkin L, Bullemor-Day P, Lubin J, Chukwujekwu C,
Hawton K. Strategies for managing sexual dysfunction induced
by antidepressant medication. Cochrane Database Syst Rev.
2013 May; (5):CD003382 doi:10.1002/14651858.CD003382.
pub3.
13. Nurnberg HG, Hensley PL, Gelenberg AJ, Fava M, Lauriello
J, Paine S. Treatment of antidepressant-associated sexual
dysfunction with sildenafil. JAMA. 2003 Jan; 289(1): 56-64.
14. Segraves RT, Lee J, Stevenson R, Walker DJ, Wang WC, Dickson
RA. Tadalafil for treatment of erectile dysfunction in men on
antidepressants. J Clin Psychopharm. 2007 Feb; 27(1): 62-66.
15. Labbatte LA, Pollock MH. Treatment of fluoxetine-induced
sexual dysfunction with bupropion: A case report. Ann Clin
Psychiatry. 1994 Mar; 6(1):13-15.
16. Ashton AK, Rosen RC. Bupropion as an antidote for serotonin
reuptake inhibitor-induced sexual dysfunction: A retrospective
study. J Clin Psychiatry. 1998 Mar; 59(3): 112-115.
17. Clayton AH, Warnock JK, Kornstein SG, Pinkerton R, Sheldon-
Keller A, McGarvey EL. A placebo-controlled trial of bupropion
SR as an antidote for selective serotonin reuptake inhibitor-
induced sexual dysfunction. J Clin Psychiatry. 2004 Jan; 65(1):
185-190.
18. Zisook S, Rush AJ, Haight BR, Clines DC, Rockett CB. Use of
bupropion in combination with serotonin reuptake inhibitors.
Biol Psychiatry. 2006 Feb; 59(3): 203-210.
19. Ozmenler NK, Karlidere T, Bozkurt A, Yetkin S, Doruk A, Sutcigil
L. Mirtazapine augmentation in depressed patients with
sexual dysfunction due to selective serotonin reuptake. Hum
Psychpharmacol. 2008 Jun; 23(4): 321-326.
Sexual Side-effects Associated with Antidepressants: A Clinical Guide
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20. Ravindran LN, Eisfeld BS, Kennedy SH. Combining mirtazapine
and duloxetine in treatment-resistant depression improves
outcomes and sexual dysfunction. J Clin Psychopharmacol.
2008 Feb; 28(1): 107-108.
21. Demyttenaere K. Agomelatine: a narrative review. Eur
Neuropsychopharmacol. 2011 Sep; 21: S703-S709.
22. Ashton AK, Hammer R, Rosen R. Serotonin reuptake inhibitor-
induced sexual dysfunction and its treatment: A large scale
retrospective study of 596 psychiatric outpatients. J Sex
Martial Ther. 1997; 23(3): 165-175.
23. Norden MJ. Buspirone treatment of sexual dysfunction
associated with selective serotonin reuptake inhibitors.
Depression. 1994; 2: 109-112.
24. Fava M, Dording CM, Baker RA, Mankoski R, Tran QV, Forbes RA,
et al. Effects of adjunctive aripiprazole on sexual functioning
in patients with major affective disorder and an inadequate
response to standardised antidepressant monotherapy: a post
hoc analysis of 3 randomised, double-blind, placebo-controlled
studies. Prim Care Companion CNS Disord. 2011; 13(1).
25. Bartlik BD, Kaplan PM, Kocsis JH et al. Stimulants for SSRIs-
induced sexual dysfunction: A retrospective study. J Clin
Psychiatry 1998; 59: 112-115.
26. Gitlin MJ. Treatment of sexual side-effects with dopaminergic
agents. J Clin Psychiatry. 1995 Mar; 56(3):24.
27. Bartlik BD, Kaplan PM, Kaplan HS. Psychostimulants apparently
reverse sexual dysfunction secondary to selective serotonin
reuptake inhibitors. J Sex Marital Ther. 1995; 21(4): 264-271.
28. Hollander E, McCarley A. Yohimbine treatment of sexual
side effects induced by serotonin reuptake blockers. J Clin
Psychiatry. 1992 Jun; 53(6): 207-209.
29. Cohen AJ. Ginkgo biloba for drug-induced sexual dysfunction.
Abstracts of the Annual Meeting of the American Psychiatric
Association, San Diego, Calif 1997; 15.
30. Berman RM, Fava M, Thase ME, Trivedi MH, Swanink R,
McQuade RD, et al. Aripiprazole augmentation in major
depressive disorder: a double-blind, placebo-controlled study
in patients with inadequate response to antidepressants. CNS
Spectr. 2009 Apr; 14(4): 197-206.
31. Fooladi E, Bell RJ, Jane F, Robinson PJ, Kulkarni J, Davis SR.
Testosterone improves antidepressant-emergent loss of libido
in women: findings from a randomised double-blind, placebo-
controlled trial. J Sex Med. 2014 Mar; 11(3): 831-839.
32. Khamba B, Aucoin M, Lytle M, Vermani M, Maldonado A, Iorio
C, et al. Efficacy of acupuncture treatment of sexual dysfunction
secondary to antidepressants. J Altern Complement Med. 2013
Nov; 19(11): 862-869.
33. Kashani L, Raisi F, Saroukhani S, Sohrabi H, Modabbernia
A, Nasehi AA, et al. Saffron for treatment of fluoxetine-
induced sexual dysfunction in women: randomised double-
blind placebo-controlled study. Hum Psychopharmacol. 2013
Jan; 28(1): 54-60.
34. Dording CM, Schettler PJ, Dalton ED, Parkin SR, Walker RS,
Fehling KB, et al. A double-blind placebo-controlled trial of
maca root as treatment for antidepressant-induced sexual
dysfunction in women. Evid Based Complement Alternat Med.
2015; 2015:949036.
Sexual Side-effects Associated with Antidepressants: A Clinical Guide
www.healthed.com.au Page 7
Guidelines for preventive
activities in general practice
9th edition
racgp.org.au Healthy Profession.
Healthy Australia.
Over
25
years
of preventive health
advice
Guidelines for preventive activities in general practice, 9th edition
Disclaimer
The information set out in this publication is current at the date of first publication and is intended for use as
a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Nor
is this publication exhaustive of the subject matter. Persons implementing any recommendations contained
in this publication must exercise their own independent skill or judgement or seek appropriate professional
advice relevant to their own particular circumstances when so doing. Compliance with any recommendations
cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with
the health professional and the premises from which the health professional operates.
Whilst the text is directed to health professionals possessing appropriate qualifications and skills in
ascertaining and discharging their professional (including legal) duties, it is not to be regarded as clinical
advice and, in particular, is no substitute for a full examination and consideration of medical history in reaching
a diagnosis and treatment based on accepted clinical practices.
Accordingly, The Royal Australian College of General Practitioners (RACGP) and its employees and agents
shall have no liability (including without limitation liability by reason of negligence) to any users of the
information contained in this publication for any loss or damage (consequential or otherwise), cost or expense
incurred or arising by reason of any person using or relying on the information contained in this publication
and whether caused by reason of any error, negligent act, omission or misrepresentation in the information.
Recommended citation
The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice.
9th edn. East Melbourne, Vic: RACGP, 2016.
The Royal Australian College of General Practitioners
100 Wellington Parade
East Melbourne, Victoria 3002 Australia
Tel 03 8699 0414
Fax 03 8699 0400
www.racgp.org.au
ISBN: 978-0-86906-451-1 (Print)
ISBN: 978-0-86906-452-8 (Web)
First edition published 1989
Second edition published 1993
Third edition published 1994
Fourth edition published 1996
Fifth edition published 2001
Fifth edition (updated) published 2002
Sixth edition published 2005
Seventh edition published 2009
Eighth edition published 2012
Ninth edition published 2016
Cover image © istockphoto/skodonnell
© The Royal Australian College of General Practitioners, 2016.
We recognise the traditional custodians of the land and sea on which we work and live.
Guidelines for preventive
activities in general practice
9th edition
i
Guidelines for preventive activities in general practice
9th edition i
Acknowledgements
The Royal Australian College of General Practitioners (RACGP) gratefully acknowledges the generous contribution
of the following authors, contributors and reviewers of the Guidelines for preventive activities in general practice
(Red Book), 9th edn.
Red Book Editorial Committee
Professor Nicholas Zwar
Chair, Red Book Editorial Committee
School of Public Health and Community Medicine,
University of New South Wales, New South Wales
Dr Evan Ackermann
Chair, RACGP Expert Committee – Quality Care
Professor Mark Harris
Centre for Primary Health Care and Equity,
University of New South Wales
RACGP Expert Committee – Quality Care
Dr Meredith Arcus
Deputy Executive Director, Medical Services,
Sir Charles Gairdner and Osborne Park Health Care
Group, Western Australia
Associate Professor Pauline Chiarelli
School of Health Sciences, University of Newcastle,
New South Wales
Professor Chris Del Mar
Faculty of Health Sciences and Medicine,
Bond University, Queensland
Professor Jon Emery
Department of General Practice,
University of Melbourne, Victoria
Associate Professor Michael Fasher
Adjunct Associate Professor, University of Sydney,
New South Wales; and Conjoint Associate Professor,
University of Western Sydney, New South Wales
Associate Professor John Furler
Department of General Practice,
University of Melbourne, Victoria
Dr Caroline Johnson
Department of General Practice,
University of Melbourne, Victoria
RACGP Expert Committee – Quality Care
Professor Claire Jackson
Director, Centres for Primary Care Reform
Research Excellence
Professor in Primary Care Research, Chair,
Metro North Primary Health Network
Past President, The Royal Australian College of
General Practitioners (2010–12)
Associate Professor John Litt
Department of General Practice,
Flinders University, South Australia
Deputy Chair, RACGP Expert Committee –
Quality Care
Professor Danielle Mazza
Department of General Practice,
School of Primary Care,
Monash University, Victoria
RACGP Expert Committee – Quality Care
Professor Dimity Pond
Professor of General Practice,
School of Medicine and Public Health,
University of Newcastle, New South Wales
Associate Professor Jane Smith
Head of General Practice Discipline,
Faculty of Health Science and Medicine,
Bond University, Queensland
Professor Nigel Stocks
Head of Discipline – General Practice,
University of Adelaide, Adelaide
Dr Christine Walker
Executive Officer, Chronic Illness Alliance
Professor Tania Winzenberg
Chair, RACGP Expert Committee – Research
Professor of Chronic Disease Management,
Menzies Institute for Medical Research and Faculty
of Health, University of Tasmania, Tasmania
ii
Guidelines for preventive activities in general practice
9th edition
Conflicts of interest
This publication has been produced in accordance with the rules and processes outlined in the RACGP Conflict of
Interest (COI) Policy. The RACGP COI Policy is available at www.racgp.org.au/support/policies/organisational
Contributors
Associate Professor Lena Sanci
Department of General Practice,
University of Melbourne, Victoria
Professor Lindy Clemson
Professor in Ageing and Occupational Therapy,
University of Sydney, New South Wales
Dr Magdalena Simonis
RACGP Expert Committee – Quality Care
Reviewers
We gratefully acknowledge the expert reviewers
and representatives from the organisations who
contributed scholarly feedback.
Members of RACGP Aboriginal and Torres Strait
Islander Health
Associate Professor Anne Abbott
School of Public Health and Preventive Medicine,
Monash University, Victoria
Dr Stuart Aitken
Gold Coast Sexual Health Clinic, Queensland
Professor Craig Anderson
George Institute for Global Health, New South Wales
Associate Professor Nick Antic
Clinical Director of the Adelaide Institute
for Sleep Health
President Australasian Sleep Association,
South Australia
Professor Kaarin Anstey
ANU College of Medicine, Biology & Environment,
Australian Capital Territory
Associate Professor Kristine Barlow-Stewart
Genetic Medicine, Northern Clinical School,
Sydney Medical School, New South Wales
Professor Adrian Bauman
School of Public Health, University of Sydney,
New South Wales
Dr Glenise Berry
Australian & New Zealand Society for Geriatric
Medicine, New South Wales
Associate Professor Mark Bolland
School of Medicine, University of Auckland,
New Zealand
Dr Chris Bourne
Sydney Sexual Health Centre,
Sydney Hospital, New South Wales
Professor Hanny Calache
Centre for Population Health Research,
Deakin University, Victoria
Professor Henry Brodaty
Dementia Collaborative Research Centre,
University of New South Wales and Prince of Wales
Hospital, New South Wales
Professor Ian Caterson
Boden Institute, Charles Perkins Centre,
University of Sydney, New South Wales
Professor Derek Chew
Professor of Cardiology, Flinders University,
Flinders Medical Centre, South Australia
Professor Rufus Clarke
Faculty of Public Health Medicine,
Royal Australasian College of Physicians,
New South Wales
Professor Jacqueline Close
Consultant Geriatrician, Prince of Wales Hospital,
Director, Falls and Injury Prevention Group, NeuRA,
University of New South Wales, New South Wales
Professor Stephen Colagiuri
Director, Boden Institute, University of Sydney,
New South Wales
Dr Gary Deed
Chair, RACGP Specific Interests – Diabetes Network
Dr Joanne Dixon
National Clinical Director, Clinical Leader Genetic
Services, Genetic Health Service New Zealand
iii
Guidelines for preventive activities in general practice
9th edition
Professor Jenny Doust
Faculty of Health Sciences and Medicine,
Bond University, Queensland
Professor Peter Ebeling
Head of the Department of Medicine,
Monash Medical Centre, Victoria
Associate Professor Matt Edwards
Department of Paediatrics,
University of Western Sydney, New South Wales
Professor John Eisman
Director of Clinical Translation and Advanced
Education, Garvan Institute of Medical Research,
Darlinghurst, New South Wales
Dr Ben Ewald
Senior Lecturer in Epidemiology and General
Practitioner, Centre for Clinical Epidemiology
and Biostatistics, University of Newcastle,
New South Wales
Professor Kwun Fong
Prince Charles Hospital, Department of
Thoracic Medicine, Queensland
Professor Peter Frith
Respiratory Medicine, Flinders University,
South Australia
Clinical Professor Jack Goldblatt
School of Paediatrics and Child Health,
University of Western Australia, Western Australia
Professor Jonathon Golledge
Head of the Vascular Biology Unit, School of Medicine
and Dentistry, James Cook University, Queensland
Professor Paul Glasziou
Professor of Evidence-Based Medicine, Faculty of
Health Sciences and Medicine, Bond University,
Queensland
Associate Professor Jane Halliday
Public Health Genetics, Murdoch Childrens Research
Institute, Victoria
Dr James Harvey
Council member of Royal Australian and New Zealand
College of Obstetricians and Gynaecologists,
South Australia
Associate Professor Kelsey Hegarty
Department of General Practice,
University of Melbourne, Victoria
Ms Cristy Henderson
Assistant Director, Bowel Screening Section, Cancer
and Palliative Care Branch, Population Health & Sport
Division, Department of Health
Dr Elizabeth Hindmarsh
General Practitioner, New South Wales
Associate Professor Warrick Inder
Department of Diabetes and Endocrinology,
Princess Alexandra Hospital, Queensland
Professor Stephen Lord
Senior Principal Research Fellow, Neuroscience
Research Australia, New South Wales
Professor Finlay Macrae
Head, Colorectal Medicine and Genetics,
Royal Melbourne Hospital, Victoria
Professor, Department of Medicine, University of
Melbourne, Royal Melbourne Hospital, Victoria
Dr Catherine Mandel
MRI Radiologist, Swinburne University of Technology
Honorary Senior Fellow, Department of Radiology,
University of Melbourne, Victoria
Professor Rebecca Mason
Professor of Endocrine Physiology,
School of Medical Sciences, Sydney Medical School,
University of Sydney, New South Wales
Clinical Professor Richard Mendelson
Royal Perth Hospital, University of Western Australia,
Western Australia
Professor Sylvia Metcalfe
Genetics Education & Health Research,
Murdoch Childrens Research Institute, Victoria
Dr Mark Morgan
General Practitioner, South Australia
Senior Lecturer, Discipline of General Practice,
University of Adelaide, South Australia
Professor Paul Norman
Winthrop Professor of Vascular Surgery,
University of Western Australia, Western Australia
Professor Mark Nelson
Chair, Discipline of General Practice,
University of Tasmania, Tasmania
Professional Research Fellow, Menzies Research
Institute, University of Tasmania, Tasmania
Mark Nevin
Senior Executive Officer, Faculty of Clinical Radiology,
Royal Australian and New Zealand College of
Radiologists, New South Wales
Professor Doug McEvoy
Senior Director, Adelaide Institute for Sleep Health;
Staff Consultant in Sleep and Respiratory Medicine
at Repatriation General Hospital and Flinders Medical
Centre, South Australia
Dr Nicki Murdoch
President, Paediatrics & Child Division, Royal
Australasian College of Physicians, New South Wales
Professor Frank Oberklaid
Director, Centre for Community Child Health,
Royal Children’s Hospital, Victoria
iv
Guidelines for preventive activities in general practice
9th edition
Dr Jan Orman
GP Services Consultant, Black Dog Institute,
Prince of Wales Hospital, New South Wales
Professor Kelly Phillips
Peter MacCallum Cancer Centre, Victoria
Professor Matthew Peters
Head of Respiratory Medicine,
Concord Hospital, New South Wales
Professor Ian Reid
Deputy Dean, Faculty of Medical and Health
Sciences, University of Auckland, New Zealand
Professor Ann Roche
National Centre for Education and Training on
Addiction, Flinders University, South Australia
Professor John Saunders
Consultant Physician in Internal Medicine and
Addiction Medicine, New South Wales
Professor Virginia Schmied
School of Nursing and Midwifery,
University of Western Sydney, New South Wales
Associate Professor Jonathan Shaw
Baker IDI Heart & Diabetes Institute, Victoria
Professor Maria Fiatarone Singh
Chair of Exercise and Sport Science, Exercise, Health
and Performance Group, Faculty of Health Sciences,
Sydney Medical School, New South Wales
Associate Professor John Slavotinek
Gastroenterologist
Honorary Senior Associate,
Cancer Council Victoria, Victoria
Professor Denis Spelman
Deputy Director, Clinical Infectious Diseases Unit
and Head, Microbiology Department,
Monash University, Victoria
Professor James St John
Gastroenterologist
Honorary Senior Associate,
Cancer Council Victoria, Victoria
Dr Michael Tam
Staff Specialist, General Practice,
University of New South Wales, New South Wales
Dr Wendy Tsui
RACGP Fellow, Family & Sports Medicine Centre,
New South Wales
Dr Angela Taft
Professor and Director, Judith Lumley Centre,
La Trobe University, Victoria
Dr Brendan White
Australian Dental Association (NSW Branch),
New South Wales
Clinical Associate Professor Liz Wylie
Medicine and Pharmacology Royal Perth Hospital
Unit, University of Western Australia, Western Australia
Professor Graeme Young
Flinders Centre for Innovation in Cancer,
Flinders University, South Australia
Professor Helen Zorbas
Chief Executive Officer, Cancer Australia,
New South Wales
Australian & New Zealand Society for Geriatric
Medicine Council
Australasian Sleep Association
Australian Diabetes Society
Australian Dental Association
Cancer and Palliative Care Branch, Population
Health & Sport Division, Department of Health
Cancer Australia
Cancer Council Victoria
Centre for Population Health, NSW Ministry of
Health, Harm Reduction and Viral Hepatitis Branch
Continence Foundation of Australia
Haemochromatosis Society Australia
Human Genetics Society of Australasia
Dental Health Services Victoria
Exercise & Sports Science Australia
Kidney Health Australia
National Stroke Foundation
National Heart Foundation of Australia
NSW STI Programs Unit, Sydney Sexual Health
Centre, Sydney Hospital, New South Wales
Optometry Australia
Royal Australian and New Zealand College of
Obstetricians and Gynaecologists
Representatives from Cancer Council Victoria
Royal Australian and New Zealand College of
Radiologists
Royal Australian College of Ophthalmologists
SANE Australia
Urological Society of Australia and New Zealand
v
Guidelines for preventive activities in general practice
9th edition v
Acronyms
13vPCV 13-valent pneumococcal conjugate vaccine
23vPPV 23-valent pneumococcal polysaccharide
vaccine
AAA abdominal aortic aneurysm
ABCD asymmetry, border, colour, diameter
ABI ankle:brachial index
ABS Australian Bureau of Statistics
ACE angiotensin converting enzyme
ACIR Australian Childhood Immunisation Register
ACR albumin-to-creatinine ratio
ACS asymptomatic carotid artery stenosis
ADHD attention deficit hyperactivity disorder
AEDC Australian Early Development Census
AF atrial fibrillation
ALA alpha-linolenic acid
AMD aged-related macular degeneration
APC adenomatous polyposis coli
ApoE apolipoprotein E
ARB angiotensin receptor blocker
ASCIA Australasian Society of Clinical Immunology
and Allergy
AUDIT-C Alcohol Use Disorders Identification Test –
Consumption
AUSDRISK Australian type 2 diabetes risk assessment
tool
BCG Bacillus Calmette-Guérin
BMD bone mineral density
BMI body mass index
BNP B-type natriuretic peptide
BP blood pressure
BRCA1 breast cancer susceptibility gene 1
BRCA2 breast cancer susceptibility gene 2
BUA broadband ultrasound attenuation
CA cancer antigen
CA125 cancer antigen 125
CAD coronary artery disease
CALD culturally and linguistically diverse
CCTA coronary computed tomography angiography
CEA carotid endarterectomy
CEITC Centre for Excellence in Indigenous
Tobacco Control
CF cystic fibrosis
CHD coronary heart disease
CKD chronic kidney disease
CDK-EPI Chronic Kidney Disease Epidemiology
Collaboration
COPD chronic obstructive pulmonary disease
CRC colorectal cancer
CRP C-reactive protein
CT computed tomography
CVD cardiovascular disease
DALY
DASH
disability-adjusted life year
dietary approaches to stop hypertension
DBP diastolic blood pressure
DNA deoxyribonucleic acid
DLCN Dutch Lipid Clinic Network (criteria)
DPA docosapentaenoic acid
DRE digital rectal examination
DT diphtheria, tetanus
DTPa diphtheria, tetanus, acellular pertussis
(child version)
dTpa diphtheria, tetanus, acellular pertussis
(adolescent/adult version)
DXA dual-energy X-ray absorptiometry
ECG electrocardiogram
EFG elevated, firm, growing for more than
one month
eGFR estimated glomerular filtration rate
EPDS Edinburgh Postnatal Depression Scale
ESRD end-stage renal disease
FAP familial adenomatous polyposis
FH familial hypercholesterolaemia
FHSQ family history screening questionnaire
FOBT faecal occult blood test
GP general practitioner
GPCOG general practitioner assessment
of cognition
HbA1c glycated haemoglobin
HCG human chorionic gonadotrophin
HDL high-density lipoprotein
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Guidelines for preventive activities in general practice
9th editionvi
HDL-C high-density lipoprotein-cholesterol
HHC hereditary haemochromatosis
Hib haemophilus influenzae type b
HIV human immunodeficiency virus
HNPCC hereditary non-polyposis colon cancer
HPV human papillomavirus
hsCRP high sensitivity C-reactive protein
HSIL high-grade squamous intraepithelial lesion
IADL instrumental activities of daily living
IBIS International Breast Cancer Intervention Study
IFG impaired fasting glucose
IGT impaired glucose tolerance
IPV inactivated polio vaccine
IS intussusception
KICA Kimberley Indigenous Cognitive Assessment
tool
LDL low-density lipoprotein
LDL-C low-density lipoprotein-cholesterol
LSIL low-grade squamous intraepithelial lesion
LUTS lower urinary tract symptoms
LVH left ventricular hypertrophy
MBS Medicare Benefits Schedule
MCH mean corpuscular haemoglobin
MCV mean corpuscular volume
MI myocardial infarction
MMR measles, mumps and rubella
MMRV measles, mumps, rubella and varicella
MMSE mini-mental state examination
MRI magnetic resonance imaging
MS multiple sclerosis
MSM men who have sex with men
MSU mid-stream urine
MTHFR methylenetetrahydrofolate reductase
MUKSB Modified UK Simon Broome (criteria)
NAAT nucleic acid amplification test
NHMRC National Health and Medical Research
Council
NIP National Immunisation Program
NIPS National Immunisation Program Schedule
NIPT non-invasive prenatal test
NMSC non-melanocytic skin cancer
NTD neural tube defect
Pap test Papanicolaou test
OSA obstructive sleep apnoea
PBS Pharmaceutical Benefits Scheme
PCR polymerase chain reaction
PEDS parents’ evaluation of developmental status
PET-CT positron emission tomography – computed
tomography
PLCO Prostate, Lung, Colorectal and Ovarian trial
PND postnatal depression
PVD peripheral vascular disease
RACGP The Royal Australian College of General
Practitioners
RCT randomised controlled trial
SBP systolic blood pressure
SCC squamous cell carcinoma
SES socioeconomic status
SIDS sudden infant death syndrome
SMMSE standardised mini-mental state examination
SNAP smoking, nutrition, alcohol, physical activity
SNP single nucleotide polymorphism
SOS speed of sound
SPF sun protection factor
SSRI selective serotonin reuptake inhibitor
STI sexually transmissible infection
SUDI sudden unexpected death in infancy
T2D type 2 diabetes
TB tuberculosis
TG triglyceride
TGA Therapeutic Goods Administration
TIA transient ischaemic attack
TUGT timed up and go test
UACR urine albumin-to-creatinine ratio
UKCTOCS UK Collaborative Trial of Ovarian Cancer
Screening
USPSTF US Preventive Services Task Force
UV ultraviolet
VIVAS Vaccination Information and Vaccination
Administration System
VV varicella vaccination
VZV varicella zoster virus
WHO World Health Organization
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Guidelines for preventive activities in general practice
9th edition
1. Contents
Acknowledgements i
Red Book Editorial Committee i
Conflicts of interest ii
Contributors ii
Reviewers ii
Acronyms v
I. Introduction 1
The Red Book 3
The Australian experience 3
Benefits and harms of preventive health activities 4
Prevention in the practice population 5
Screening versus case finding 6
Opportunistic versus systematic prevention 6
Screening principles 7
II. Patient education and health literacy 8
Impact of patient education 8
Approaches to patient education 8
Health inequity 9
Supporting patient education and health literacy in disadvantaged groups 10
III. Development of the Red Book 11
Recommendations 11
IV. How to use the Red Book 12
Organisational detail 12
References – Chapters I–IV 14
V. What’s new in the 9th edition? 16
1. Preventive activities prior to pregnancy 18
References 22
2. Genetic counselling and testing 24
References 28
Appendix 2A. Family history screening questionnaire 29
Appendix 2B. Dutch Lipid Clinic Network Criteria for making a diagnosis of familial
hypercholestrolaemia in adults 30
3. Preventive activities in children and young people 32
References 38
Appendix 3A ‘Red flag’ early intervention referral guide 41
4. Preventive activities in middle age 42
References 44
viii
Guidelines for preventive activities in general practice
9th edition
5. Preventive activities in older age 45
5.1 Immunisation 46
5.2 Physical activity 46
5.3 Falls 47
5.4 Visual and hearing impairment 50
5.5 Dementia 51
References 53
6. Communicable diseases 57
6.1 Immunisation 57
6.2 Sexually transmissible infections 61
References 64
7. Prevention of chronic disease 66
7.1 Smoking 67
7.2 Overweight 69
7.3 Nutrition 73
7.4 Early detection of at-risk drinking 75
7.5 Physical activity 77
References 80
8. Prevention of vascular and metabolic disease 85
8.1 Assessment of absolute cardiovascular disease risk 86
8.2 Blood pressure 87
8.3 Cholesterol and other lipids 89
8.4 Type 2 diabetes 92
8.5 Stroke 94
8.6 Kidney disease 95
8.7 Atrial fibrillation 97
References 98
Appendix 8A. Australian cardiovascular disease risk charts 102
9. Early detection of cancers 104
9.1 Prostate cancer 104
9.2 Colorectal cancer 105
9.3 Breast cancer 109
9.4 Skin cancer 113
9.5 Cervical cancer 117
9.6 Ovarian cancer 121
9.7 Testicular cancer 121
References 122
10. Psychosocial 126
10.1 Depression 127
10.2 Suicide 129
10.3 Intimate partner violence 130
References 132
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Guidelines for preventive activities in general practice
9th edition
11. Oral health 134
References 136
12. Glaucoma 137
References 137
13. Urinary incontinence 138
References 139
Appendix 13A. The 3 Incontinence Questions (3IQ) 140
14. Osteoporosis 141
References 145
15. Screening tests of unproven benefit 147
References 153
Lifecycle chart 158
1
Guidelines for preventive activities in general practice
9th edition
I. Introduction
General practice is at the forefront of healthcare in Australia and in a pivotal position to deliver preventive
healthcare. More than 137 million general practice consultations take place annually in Australia and 85% of the
Australian population consult a general practitioner (GP) at least once a year.1 Preventive healthcare is an important
activity in general practice. It includes the prevention of illness, the early detection of specific disease, and the
promotion and maintenance of health. The partnership between GP and patient can help people reach their goals
of maintaining or improving health. Preventive care is also critical in addressing the health disparities faced by
disadvantaged and vulnerable population groups.
Prevention of illness is the key to Australia’s future health – both individually and collectively. About 32% of
Australia’s total burden of disease can be attributed to modifiable risk factors (Figure I.1 and Table I.1).2
Figure I.1. Leading risk factors contributing to the burden of disease3
*Total burden of disease and injury measured by disability-adjusted life year (DALY)
A healthy lifestyle is vital for preventing disease, including prevention of cancer. Cancer Australia4 summarises the
recommendations for adults to reduce their risk of cancer and stay healthy as the following:
• Do not smoke
• Maintain a healthy weight
• Be active
• Eat a balanced and nutritious diet
• Limit alcohol consumption
• Be sun smart
• Protect against infection
The evidence of associations between behavioural and biomedical risk factors and chronic diseases is summarised
in Table I.1.
0 1 2 3 4 5 6 7 8
Low fruit and
vegetable consumption
Alcohol
High blood cholesterol
Physical inactivity
Overweight/obesity
High blood pressure
Tobacco
% DALYS*
2
Guidelines for preventive activities in general practice
9th edition
Table I.1. Strong evidence of direct associations between selected chronic diseases and
behavioural and biomedical risk factors5
Chronic
disease
Behavioural
Tobacco
smoking
Behavioural
Insufficient
physical
activity
Behavioural
Excessive
alcohol
consumption
Behavioural
Dietary risks
Biomedical
Obesity
Biomedical
High blood
pressure
Biomedical
Abnormal
blood lipids
CVD • • — •* • • •
Stroke • • • — • • •
Type 2 diabetes • • — •* • — —
Osteoporosis • • • •† — — —
Colorectal
cancer
• — • •‡ • — —
Oral health •§ — •|| •# — — —
CKD • — — — • • —
Breast cancer
(female)
— — • — •** — —
Depression — — — — • — —
Osteoarthritis — — — — • — —
Rheumatoid
arthritis
• — — — — — —
Lung cancer • — — — — — —
Cervical cancer†† • — — — — — —
COPD • — — — — — —
Asthma • — — — — — —
• Strong evidence in support of a direct association between the chronic disease and risk factor
— There is either not a direct association or the evidence for a direct association is not strong
*For coronary heart disease and type 2 diabetes, dietary risks relate to high intake of saturated fat
†For osteoporosis, dietary risks relate to insufficient calcium and vitamin D. The recommendation is to enhance vitamin D levels through
adequate sun exposure and/or supplements if required
‡For colorectal cancer (CRC), dietary risks relate to high intakes of processed (preserved) meat. In addition, a high intake of red meat
is associated with an increased risk of CRC. The Australian dietary guidelines (ADG) therefore recommend that processed meat intake
should be limited (also because of its high saturated fat content). In addition, to enhance dietary variety and reduce some of the health
risks associated with consuming red meat, the ADG recommend Australian adults should consume up to a maximum of 455 g per week
(one serve [65 g] per day) of lean red meats
§The evidence for tobacco smoking and oral health relate to oral cancer and adult periodontal diseases
||The evidence for excessive alcohol consumption and oral health relate to oral cancer
#For oral health, dietary risks relate to amount and frequency of free sugars for dental caries, soft drinks and fruit juices for dental erosion,
excess fluoride for enamel developmental defects, and deficiency of vitamin C for periodontal disease
**The evidence for obesity and breast cancer is for postmenopausal women
††Persistent infection with the human papillomavirus (HPV) is a central cause of cervical cancer. HPV infection is not identified in Table I.1
as it only includes those risk factors that are implicated in more than one chronic disease and have the greatest prevalence within the
population. It is important to recognise that the behavioural risk factors of multiple sexual partners and early age at initiation of sexual
activity reflect the probability of being infected with HPV
The chronic diseases included in Table I.1 are those that currently contribute the most to burden of disease and/or are the focus of
ongoing national surveillance efforts
The behavioural and biomedical risk factors included in Table I.1 are those that are implicated in more than one chronic disease and
have the greatest prevalence within the population
ADG, Australian dietary guidelines; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CRC, colorectal cancer;
CVD, cardiovascular disease; HPV, human papillomavirus
Reproduced with permission from Australian Institute of Health and Welfare. Chronic disease risk factors. Canberra: AIHW, 2016
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The Red Book
The Royal Australian College of General Practitioners (RACGP) has published the Guidelines for preventive activities
in general practice (Red Book) since 1989 to support evidence-based preventive activities in primary care. The Red
Book is now widely accepted as the main guide to the provision of preventive care in Australian general practice.
Purpose
The Red Book is designed to provide the general practice team with guidance on opportunistic and proactive
preventive care. It provides a comprehensive and concise set of recommendations for patients in general practice
with additional information about tailoring advice depending on risk and need. The Red Book provides the evidence
and reasons for the efficient and effective use of healthcare resources in general practice.
The Red Book’s companion publication, National guide to a preventive health assessment for Aboriginal and Torres
Strait Islander people, 2nd edn, is intended for all health professionals delivering primary healthcare to Aboriginal
and Torres Strait Islander peoples.
Scope
The Red Book covers primary (preventing the initial occurrence of a disorder) and secondary (preventive early
detection and intervention) activities. These guidelines focus on preventive activities applicable to substantial portions
of the general practice population rather than specific subgroups. This means, in general, recommendations apply
to asymptomatic (low-risk) people. However, there is an emphasis on equity, with recommendations aimed at major
disadvantaged groups at higher risk of disease and those who are less likely to receive preventive care.
These guidelines do not include:
• detailed information on the management of risk factors or disease (eg what medications to use when treating
hypertension)
• information about the prevention of infectious diseases. This information has been limited largely to immunisation
and some sexually transmissible infections (STIs).
There is limited advice about travel medicine. This information can be obtained from the Centers for Disease
Control and Prevention at wwwnc.cdc.gov/travel or World Health Organization (WHO) International Travel and
Health at www.who.int/ith/en
The Australian experience
The role of general practice in prevention has been recognised by the Council of Australian Governments (COAG)6
and in the Australian Government’s National Preventative Health Strategy and National Primary Health Care
Strategic Framework.2,7
Deaths and hospitalisations from preventable illness have continued to decline in Australia. However, the leading
causes of death and disability in Australia are preventable or able to be delayed by early treatment and intervention
(Figure I.2).8
http://wwwnc.cdc.gov/travel
http://www.who.int/ith/en/
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Guidelines for preventive activities in general practice
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Figure I.2. Age-standardised death rates for potentially avoidable deaths,
1997–2010*9
1997
150
100
50
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
D
e
a
th
s
p
e
r
1
0
0
,0
0
0
p
o
p
u
la
ti
o
n
Treatable
Preventable
Age-standardised death rates for potentially avoidable deaths, 1997–2010
*Deaths among people <75 years of age that are potentially avoidable within the present healthcare system
Potentially avoidable deaths are divided into potentially preventable deaths (cases amenable to screening and primary prevention) and
treatable deaths (cases from potentially treatable conditions amenable to therapeutic interventions). There were 32,919 potentially avoidable
deaths in Australia in 2010; 62% were classified as potentially preventable and 38% as potentially treatable.8 Preventable death rates fell from
142 to 91 deaths per 100,000 between 1997 and 2010 (36%), and treatable death rates fell by 41% (from 97 to 57 deaths per 100,000)
Reproduced with permission from Australian Institute of Health and Welfare. Australia’s health 2014. Canberra: AIHW, 2014.
An Australian review10 concluded that lifestyle interventions could have a large impact on population health. The
absolute cardiovascular disease (CVD) risk approach and screening for diabetes and chronic kidney disease (CKD)
were also given high priority for action.
Despite this evidence and wide acceptance of its importance, preventive interventions in general practice remain
underused, being the primary reason for the consultation in only seven of every 100 clinical encounters.11 This
is small when it is considered that preventable chronic diseases, along with biomedical risk factors, account for
approximately one-fifth of all problems currently managed in Australian general practice.12
Each preventive activity uses up some of the available time that GPs have to spend with their patients. It may also
involve direct or indirect costs to the patient. Much more needs to be done to support and improve proper evidence-
based preventive strategies, and to minimise practices that are not beneficial or have been proven to be harmful.
The RACGP has been championing this cause since its foundation, and encourages all general practices, GPs and
their teams to prioritise evidence-based preventive health activities.
Benefits and harms of preventive health activities
‘Prevention is better than cure’ makes intuitive sense. Yet there is evidence that some preventive activities are not
effective, some are actually harmful. It has been said ‘all screening programs do some harm; some do good as
well’.13 Screening of asymptomatic patients may lead to overdiagnosis, causing needless anxiety, appointments,
tests, drugs and even operations, and may leave the patient less healthy as a consequence. Therefore, it is crucial
that evidence clearly demonstrates that benefits outweigh those harms for each preventive activity.
Determining whether a preventive activity is beneficial, harmful or of indeterminate effect (ie there is not enough
evidence on which to base a decision) requires a consistent, unbiased, evidence-based approach.
Cancer screening, in particular, can polarise different sectors of the health profession and broader community.
The objective interpretation of evidence, balancing harms and benefits, and considering overdiagnosis and
overtreatment is a goal of the Red Book.
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Guidelines for preventive activities in general practice
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In the Red Book, the RACGP provides information to assist GPs in caring for their patients, including in areas
where the evidence is uncertain or contentious. Screening activities are only recommended where evidence
demonstrates that benefits outweigh harms. Chapter 15 provides some guidance on common tests where this is
not the case or where the evidence is either unclear or not available.
Prevention in the practice population
The risk of illness and disease is associated with a range of factors that operate on the individual across the
lifecycle. For example, poor nutrition and lack of antenatal care during pregnancy are associated with later risk
of chronic diseases in the child. Risk behaviours in childhood may become entrenched, leading to progressive
physiological changes that can cause chronic diseases in later life. All these factors are in turn influenced by the
social determinants of health, which operate at the local community and broader societal levels; these are poverty,
housing, education and economic development (Figure I.3). Thus, it is highly desirable for general practice to
think beyond the preventive healthcare needs of the individual patient, towards a practice population approach to
primary prevention.
Figure I.3. The determinants of health and illness9
Broad features of
society
Culture
Affluence
Social cohesion
Social inclusion
Political
structures
Media
Language
Environmental
factors
Natural
Built
Geographical
location
Remoteness
Latitude
Socioeconomic
characteristics
Education
Employment
Income and
wealth
Family,
neighbourhood
Housing
Access to
services
Migration/
refugee status
Food security
Knowledge,
attitudes and
beliefs
Health literacy
Health
behaviours
Tobacco use
Alcohol
consumption
Physical activity
Dietary behaviour
Use of illicit drugs
Sexual practices
Vaccination
Psychological
factors
Stress
Trauma, torture
Safety factors
Risk taking,
violence
Occupational
health and safety
Biomedical
factors
Birth weight
Body weight
Blood pressure
Blood cholesterol
Glucose tolerance
Immune status
Health and wellbeing
over time
Life expectancy, mortality
Subjective health
Functioning, disability
Illness, disease
Injury
Individual physical and psychological make-up
Genetics, antenatal environment, gender, ageing, life course and intergenerational influences
Note: Bold highlights selected social determinants of health
Reproduced with permission from Australian Institute of Health and Welfare. Australia’s health 2014. Canberra: AIHW, 2014.
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Guidelines for preventive activities in general practice
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General practice has a practical role to play in addressing these determinants and helping to break the cycle that
may exist linking social and economic factors to illness and injury. This requires a systematic approach across
the whole practice population, not just for those who seek out or are most receptive to preventive care. This may
include auditing medical records to identify those who are missing out, using special strategies to support patients
with low literacy, and being proactive in following up patients who are most at risk. It will usually require teamwork
within the practice as well as links with other services.
General practice also has a broader role in facilitating health improvement for vulnerable and disadvantaged groups
in the local community, in association with other services and providers. In some cases, this may involve advocacy
for their needs. Information on local vulnerable and disadvantaged groups and their access to healthcare can be
obtained from local Primary Health Networks (PHNs) or state and territory health networks. Measures to improve
access to preventive healthcare by Aboriginal and Torres Strait Islander peoples are especially important given their
higher burden of disease and the barriers that exist to preventive healthcare. More information is available in the
National guide to preventive health assessment for Aboriginal and Torres Strait Islander people, 2nd edn.
Screening versus case finding
Many clinicians confuse screening and case-finding tests. Screening is defined as ‘the examination of
asymptomatic people in order to classify them as likely or unlikely to have a disease’.14 The primary purpose of
screening tests is to detect early disease in apparently healthy individuals.
Case finding is the examination of an individual or group suspected of having, or at risk of, the condition. Case
finding is a targeted approach to identifying conditions in select patients who may already have symptoms.15
A diagnostic test is any kind of medical test performed to establish the presence (or absence) of disease as a basis
for treatment decisions in symptomatic or screen-positive individuals (confirmatory test). Examples include taking
a mid-stream urine (MSU) sample for evaluation of a urinary tract infection and performing a mammogram for a
suspicious breast lump.
Screening and case finding carry different ethical obligations. If a clinician initiates screening in asymptomatic
individuals, there needs to be conclusive evidence that the procedure can positively affect the natural history of
the disorder. Moreover, the risks of screening must be carefully considered as the patient has not asked the health
professional for assistance.
This situation is somewhat different from case finding, where the patient has presented with a particular problem
or has asked for some level of assistance. In this situation, there is no guarantee of benefit of the tests undertaken.
It could be argued that there is at least some implied exposure to risk (eg performing colonoscopy to investigate
abdominal pain).
Opportunistic versus systematic prevention
Most preventive activities are undertaken in Australia opportunistically – that is when patients present for other
reasons, and the preventive activity is an add-on.16 This approach is supported by evidence, which shows that
visits just for ‘a general check-up’ are not effective or necessary.17
However, systematic approaches to register and recall patients for some specific targeted conditions are
worthwhile – including childhood immunisations; and screening for cervical, breast and colorectal cancers (CRC),
and diabetes. Proactive recall of patients for screening is warranted for high-risk groups, those who may have
difficulty accessing services and for conditions where population coverage has been identified by the government
as a public health priority.15
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Screening principles
The World Health Organization (WHO) has produced guidelines18,19 for the effectiveness of screening programs.
These and the National Health Service’s (NHS) guidelines20 in the UK have been kept in mind in the development of
recommendations about screening in the Red Book.
Condition
• It should be an important health problem.
• It should have a recognisable latent or early symptomatic stage.
• The natural history of the condition, including development from latent to declared disease, should be
adequately understood.
Test
• It should be simple, safe, precise and validated.
• It should be acceptable to the target population.
• The distribution of test values in the target population should be known and a suitable cut-off level defined
and agreed.
Treatment
• There should be an effective treatment for patients identified, with evidence that early treatment leads to
better outcomes.
• There should be an agreed policy on who should be treated and how they should be treated.
Outcome
• There should be evidence of improved mortality, morbidity or quality of life as a result of screening, and the
benefits of screening should outweigh the harm.
• The cost of case finding (including diagnosis and treatment of patients who are diagnosed) should be
economically balanced in relation to possible expenditure on medical care as a whole.
Consumers
• Consumers should be informed of the evidence so they can make an informed choice about participation.
In Australia, there is an increasing number of Medicare Benefits Schedule (MBS) items for health assessments in
particular population groups: Aboriginal and Torres Strait Islander children and adults, refugees, people with an
intellectual disability, those aged 45–49 years (with a risk factor), and those aged ≥75 years. There is evidence that
these assessments improve the likelihood of preventive care being received.21 However, it is important that such
‘health checks’ involve preventive interventions where there is clear evidence of their effectiveness.
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Guidelines for preventive activities in general practice
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II. Patient education and health literacy
Impact of patient education
Patient education and counselling contribute to behaviour change for the primary prevention of disease.21 More
broadly, they may also help to create greater ‘health literacy’ – the knowledge and skills patients require to maintain
their own health, including use of health services. The use of behavioural techniques, especially for self-monitoring,
is recommended, as is the use of personal communication and written or other audiovisual materials.22
Patients view the general practitioner (GP) as a key first contact and credible source of preventive advice. Factors
that increase the effectiveness of patient education delivered by GPs include:
• assessing the patient’s health literacy23
• the patient’s sense of trust in their GP24
• face-to-face delivery25
• patient involvement in decision making26–28
• highlighting the benefits and costs29,30
• strategies to help the patient remember what they have been told31
• tailoring the information to the patient’s interest in change32
• strategies that address the difficulty in adherence28,33
• the use of decision aids.34
Many preventive activities involve a change in health-related behaviour. In general practice, it may take at least six
to eight sessions to discuss and see changes to diet, physical activity or weight loss. This will often require referral,
which should be followed up by the general practice. As the patient plays a large role in making this happen, it is
useful to facilitate more active inclusion of patients in their care. This process is an essential component of self-
management support strategies35,36 and has the potential to increase the patient’s responsibility for their health. In
addition, it:
• enhances the quality of communication37,38
• enhances the doctor–patient consultation26
• can reduce the cost of aspects of care through better informed patients27
• increases the demand and use of appropriate referral to other health professionals and agencies38
• increases adherence to recommended preventive activities and therapeutic regimens.38,39
For those whose first language is not English, a professional interpreter should be considered.
Approaches to patient education
Patients need to develop their own understanding of the problem and what can be done about it. For simple
behavioural changes, such as having a cervical cancer screening test, patients weigh up the perceived benefits and
costs.40 These benefits and costs may include answers to the following questions:
• How big is the problem to the individual?
• What are the consequences of not doing the test?
• What are the benefits?
• What are the barriers?
Some health education may require more complex actions over a period of time, such as changing diet, stopping
smoking or increasing physical activity.
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There are a number of theoretical approaches to understanding and supporting behaviour change including the:
• Theory of planned behaviour41
• Health belief model42
• capability, opportunity and motivation (COM-B) system, which has been proposed by Michie et al as a way of
representing the necessary conditions for behaviour change to occur43
• ‘stages of change model’,44 which proposes five stages of change, which are viewed as a cyclical, ongoing
process during which the person has differing levels of motivation or readiness to change, and the ability to relapse
or repeat a stage. Although there is a lack of evidence for greater effectiveness of stage-based approaches,45
this model provides a useful framework for clinicians to identify patients’ interest in behaviour change in the
consultation and to provide tailored support in a way that is time efficient and likely to be well received.46
Support from the GP and/or practice nurse may involve motivational interviewing. This is an evidence-based
counselling technique based on a therapeutic partnership that acknowledges and explores the patient’s
ambivalence about a behaviour in a way that allows them to clarify what goals are important to them and to
organise their reasons in a way that supports actions.
Motivational interviewing is a counselling philosophy that values patient autonomy and mutual respect, and the use
of open-ended questions, affirmations, reflection and summarising.47
Further information about motivational interviewing and its application in general practice can be found in The Royal
Australian College of General Practitioners’ (RACGP) Smoking, nutrition, alcohol and physical activity (SNAP): A
population health guide to behavioural risk factors in general practice (www.racgp.org.au/your-practice/guidelines/
snap) and Putting prevention into practice: Guidelines for the implementation of prevention in the general practice
setting (Green Book; www.racgp.org.au/your-practice/guidelines/greenbook).
Health inequity
It is well recognised that socioeconomic disadvantage has a profound impact on people’s health, and GPs are
often in a good position to confront this.48
However, poverty is not evenly spread across Australia, and it is likely that GPs who see some patients with
socioeconomic disadvantage will see many. Similarly, GPs are not evenly spread with respect to poverty. The
Australian Bureau of Statistics (ABS) have shown that, in 2006, 11% of GPs worked in the most disadvantaged
areas, while 24% worked in the least disadvantaged.49
Healthcare in communities that are socioeconomically deprived is often complex. As well as having more chronic
health conditions, and more health behaviours leading to increased risk, there may be a lack of local support and
infrastructure to improve the situation. General practices are often one of the few resources patients have to call on.
There are often significant personal and social barriers to achieving change. As well as good communication skills,
GPs may need to help patients navigate health, housing, welfare and legal systems. This often makes for more-
frequent, longer, more-complex consultations. However, the long-term relationships GPs develop with patients are
significant enablers for patients who are socioeconomically deprived to be able to make changes.
Health equity issues are more complex than just socioeconomic factors. There are specific issues for Aboriginal and
Torres Strait Islander peoples, where an ongoing history of colonisation, dispossession and racism interact with a
lack of economic opportunity. The National guide to a preventive health assessment for Aboriginal and Torres Strait
Islander people, 2nd edn50 provides extensive detail on specific preventive care issues facing Aboriginal and Torres
Strait Islander peoples, and the health equity material canvassed here should be read in conjunction with those
guidelines. They provide much more in-depth and important guidance on preventive healthcare strategies that are
recommended for practitioners working with Aboriginal and Torres Strait Islander peoples and communities. In
addition, GPs should optimise their use of Medicare Benefits Schedule (MBS) Item 715 that supports health checks
in Aboriginal and Torres Strait Islander peoples and their use of Close the Gap provisions in ensuring affordable
access to medicines. GPs should also proactively address cost barriers to referral to other services faced by
Aboriginal and Torres Strait Islander peoples.
http://www.racgp.org.au/your-practice/guidelines/snap
http://www.racgp.org.au/your-practice/guidelines/snap
http://www.racgp.org.au/your-practice/guidelines/greenbook
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Supporting patient education and health literacy in
disadvantaged groups
What are the key equity issues and who is at risk?
• The complex needs and health problems of disadvantaged groups, and the interactions between social,
psychological, environmental and physical determinants of health mean that special effort is required for patient
education to be effective.
• Socioeconomic disadvantage and low health literacy are linked. Health literacy is a key factor in how patient
education leads to patient empowerment. It allows individuals to access, understand and use information to
negotiate the health system and support self-management.51 Health literacy is important as low health literacy is
associated with poorer health outcomes and lower utilisation of health services such as screening and preventive
care.
• Other groups that require particular focus in patient education include Aboriginal and Torres Strait Islander
peoples and culturally and linguistically diverse (CALD) groups.52
What can GPs do?
A range of strategies can be used by GPs to help patients with low health literacy and to promote health-related
behaviour changes.51,53 These include:
• specific communication techniques such as asking patients to ‘teach back’ what has been taught to them and
the ‘ask me 3’ health education program based on three patient-led questions54 (https://npsf.site-ym.com/
default.asp?page=askme3)
• motivational interviewing and counselling techniques
• plain-language and culturally appropriate written materials (explicitly asking about reading skills may be important)
• use of web-based or computer-based programs (explicitly asking about internet access, eg at home or through a
library may be important)
• helping patients navigate the healthcare system to improve access to care, for example, by working in
collaboration with other services such as community health centres and consumer organisations to access
community health and group education programs.
Effective patient education for CALD populations means ensuring that health services and messages are accessible
and relevant. GPs should:
• offer interpreter services during consultations. There is good evidence that interpreter services improve care
experience and clinical outcomes55
• use patient education materials in plain English or those that are culturally and linguistically sensitive (eg have a
range of patient material in relevant different languages in your practice)
• link individuals to specific community-based health programs.56,57
Cultural competence is important in providing appropriate patient education to all communities. This is particularly
important in working with Aboriginal and Torres Strait Islander communities.58 It is important for GPs to better
appreciate Aboriginal and Torres Strait Islander peoples’ perspectives on health, culture and history, and provide
services within a culturally appropriate framework.59 This could be facilitated through:
• reading about the history and impact of colonisation on Aboriginal and Torres Strait Islander peoples and their
health, nationally and locally60
• arranging Aboriginal and Torres Strait Islander cultural awareness training for themselves and practice staff
(www.racgp.org.au/yourracgp/faculties/aboriginal/education/resources-for-gps-and-practice-staff/cultural-
awareness)
• linking your practice and Aboriginal and Torres Strait Islander patients to local Aboriginal community controlled
health services61
• developing relationships with your local Aboriginal and Torres Strait Islander community, and resources, people
and services that can provide you with assistance and cultural mentorship.
https://npsf.site-ym.com/default.asp?page=askme3
https://npsf.site-ym.com/default.asp?page=askme3
http://www.racgp.org.au/yourracgp/faculties/aboriginal/education/resources-for-gps-and-practice-staff/cultural-awareness
http://www.racgp.org.au/yourracgp/faculties/aboriginal/education/resources-for-gps-and-practice-staff/cultural-awareness
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III. Development of the Red Book
The Red Book, 9th edn, has been developed by a team of general practitioners (GPs) and experts to ensure
that the content is the most valuable and useful for GPs and their teams. The content broadly conforms to the
highest evidence-based standards according to the principles underlying the Appraisal of Guidelines Research and
Evaluation (AGREE) tool.62,63
The dimensions addressed are:
• scope and purpose
• clarity of presentation
• rigour of development
• stakeholder involvement
• applicability
• editorial independence.
The Red Book maintains developmental rigour, editorial independence, and relevance and applicability to general
practice.
Recommendations
The recommendations in the Red Book are based on current, evidence-based guidelines for preventive
activities. Focus has been on those most relevant to Australian general practice. Usually, this means that the
recommendations are based on Australian guidelines such as those endorsed by the National Health and Medical
Research Council (NHMRC).
Where NHMRC guidelines are not available or recent, other sources have been used, such as guidelines from the
National Heart Foundation of Australia, Canadian or US preventive guidelines, or the results of systematic reviews.
References to support these recommendations are listed. However, particular references may relate only to part of
the recommendation (eg only relating to one of the high-risk groups listed), and other references in the section may
have been considered in formulating the overall recommendation.
These recommendations are based on the best available information at the time of writing (May 2015 to May 2016).
Any updated information will be posted on The Royal Australian College of General Practitioners’ (RACGP) website.
More information and guidelines can be found on the NHMRC website www.nhmrc.gov.au/guidelines-publications,
the Australian Government clinical guidelines portal (www.clinicalguidelines.gov.au) and the Cochrane Collaboration
website (www.cochrane.org).
http://www.nhmrc.gov.au/guidelines-publications
www.clinicalguidelines.gov.au
http://www.cochrane.org
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IV. How to use the Red Book
The Red Book is designed to be used in a number of ways, all of which can be useful in day-to-day general
practice. The Red Book can be used as a:
• guide to establish who is most at risk and for whom screening or preventive care is most appropriate
• refresher to check the latest recommendations
• reminder to check at a glance what preventive activities are to be performed in various age groups and
how often
• checklist of preventive activities used according to an individual patient’s health profile
• patient education tool, to demonstrate to patients the evidence that exists for preventive activities
• study guide – a comprehensive list of references is provided in each chapter. This allows more in-depth
information on a particular topic.
Organisational detail
The information in the Red Book is organised into three levels.
The first level is the lifecycle chart, which highlights when preventive activities should be performed and the
optimum frequency for each activity. The lifecycle chart is organised by age and clinical topic. Simply check the
column under a particular age group to see what activities should be considered for the patient. The preventive
activities that are recommended for everyone within a particular age range, and for which there is sound research
evidence, are shaded in red. Activities to be performed only in patients with risk factors or where the evidence is
not as strong are shaded in light red or pink.
A copy of this chart can be downloaded and attached to the patient record as a systematic reminder for preventive
activities. General practitioners (GPs) can also use it as a wall chart or keep it handy on the desk.
The second level is more detailed and presents a summary of recommendations in addition to tables that identify
what preventive care should be provided for particular groups in the population. This edition of the Red Book
adopts the existing National Health and Medical Research Council (NHMRC) levels of evidence and grades of
recommendations.64 Future editions will consider adopting the GRADE system (www.gradeworkinggroup.org) for
evaluating the quality of evidence for outcomes reported in systematic reviews.
Recommendations in the tables are graded according to the levels of evidence and strength of recommendation.
The levels of evidence are coded by the roman numerals I–IV while the strength of recommendation is coded by
the letters A–D. Practice Points are employed where no good evidence is available. Refer to Table IV.1 for more
information.
http://www.gradeworkinggroup.org
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Table IV.1. Coding scheme used for levels of evidence and grades of recommendation64
Levels of evidence
Level Explanation
I Evidence obtained from a systematic review of level II studies
II Evidence obtained from a randomised controlled trial (RCT)
III–1 Evidence obtained from a pseudo-randomised controlled trial (ie alternate allocation or some other method)
III–2
Evidence obtained from a comparative study with concurrent controls:
• non-randomised, experimental trial
• cohort study
• case-control study
• interrupted time series with a control group
III–3
Evidence obtained from a comparative study without concurrent controls:
• historical control study
• two or more single arm study
• interrupted time series without a parallel control group
IV Case series with either post-test or pre-test/post-test outcomes
Practice
Point
Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert
committees
Grades of recommendations
Grade Explanation
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation(s) but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Only key references used to formulate the recommendations are included in the tables. Where the evidence is available on the internet,
the web link is given to enable easy access to original materials. There is also information on how the preventive care should be
implemented, for example, a brief outline of the method of screening
Finally, there is a third level of information, which is on particular disadvantaged population groups that may be at
risk of not receiving preventive care and what should be done to increase their chance of preventive care.
14
Guidelines for preventive activities in general practice
9th edition
References – Chapters I–IV
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22. Dolan M, Simons-Morton D, Ramirez G, Frankowski R,
Green L, Mains D. A meta-analysis of trials evaluating
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23. Nutbeam D. Building health literacy in Australia. Med J
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27. Mead N, Bower P. Patient-centred consultations
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28. Rao J, Weinberger M, Kroenke K. Visit-specific
expectations and patient-centred outcomes: Literature
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29. Schauffler H, Rodriguez T, Milstein A. Health education
and patient satisfaction. J Fam Pract 1996;42(1):62–68.
30. Littell J, Girvin H. Stages of change: A critique. Behav
Modif 2002;26(2):223–73.
31. Ley P, editor. Patients’ understanding and recall in clinical
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behavioral counseling on stage of change in fat intake,
physical activity, and cigarette smoking in adults at
http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/content/AEC223A781D64FF0CA2575FD00075DD0/$File/nphs-overview
http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/content/AEC223A781D64FF0CA2575FD00075DD0/$File/nphs-overview
http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/content/AEC223A781D64FF0CA2575FD00075DD0/$File/nphs-overview
http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/content/AEC223A781D64FF0CA2575FD00075DD0/$File/nphs-overview
https://canceraustralia.gov.au/publications-and-resources/position-statements/lifestyle-risk-factors-and-primary-prevention-cancer
https://canceraustralia.gov.au/publications-and-resources/position-statements/lifestyle-risk-factors-and-primary-prevention-cancer
https://canceraustralia.gov.au/publications-and-resources/position-statements/lifestyle-risk-factors-and-primary-prevention-cancer
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http://www.health.gov.au/internet/main/publishing.nsf/Content/nphc-strategic-framework
http://www.health.gov.au/internet/main/publishing.nsf/Content/nphc-strategic-framework
http://www.aihw.gov.au/publication-detail/?id=6442467914
http://www.aihw.gov.au/publication-detail/?id=6442467914
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Guidelines for preventive activities in general practice
9th edition
increased risk of coronary heart disease. Am J Public
Health 2001;91(2):265–69.
33. Branch L, Rabiner D. Rediscovering the patient’s role
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34. O’Connor AM, Bennett CL, Stacey D, et al. Decision aids
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management education programs in chronic disease:
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36. Ofman J, Badamgarav E, Henning J, et al. Does disease
management improve clinical and economic outcomes in
patients with chronic diseases? A systematic review. Am J
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37. Joos S, Hickam D, Gordon G, Baker L. Effects of
physician communication intervention on patient care
outcomes. J Gen Intern Med 1996;11(3):147–55.
38. Hibbard J. Engaging health care consumers to improve
quality of care. Med Care 2003;41(1 Suppl):I61–70.
39. Bodenheimer T, Wagner E, Grumbach K. Improving
primary care for patients with chronic illness. JAMA
2002;288(14):1775–79.
40. Rosenstock I. The health belief model and preventative
health behaviour. Health Educ Monogr 1974;2:27–57.
41. Armitage CJ, Conner M. Efficacy of the theory of planned
behaviour: A meta-analytic review. Br J Soc Psychol
2001;40(Pt 4):471–99.
42. Janz NK, Becker MH. The health belief model: A decade
later. Health Educ Q 1984;11(1):1–47.
43. Michie S, van Stralen MM, West R. The behaviour change
wheel: A new method for characterising and designing
behaviour change interventions. Implement Sci 2011;6:42.
44. Cassidy C. Using the transtheoretical model to facilitate
behaviour change in patients with chronic illness. J Am
Acad Nurse Pract 1999;11(7):281.
45. Cahill K, Lancaster T, Green N. Stage-based interventions
for smoking cessation. Cochrane Database Syst Rev
2010;11:CD004492.
46. Prochaska JO, Velicer WF, Redding C, et al. Stage-
based expert systems to guide a population of primary
care patients to quit smoking, eat healthier, prevent skin
cancer, and receive regular mammograms. Prev Med
2005;41(2):406–16.
47. Miller WR, Rollnick S. Motivational interviewing – Helping
people change. 3rd edn. New York: Guildford Press,
2012.
48. Watt G, Brown G, Budd J, et al. General practitioners
at the deep end: The experience and views of general
practitioners working in the most severely deprived areas
of Scotland. Occasional paper. Edinburgh: Royal College
of General Practitioners, 2012.
49. Australian Bureau of Statistics. Australian social trends,
Mar 2010. Canberra: ABS, 2010. Available at www.abs.
gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Featur
es30Mar+2010 [Accessed 29 April 2016].
50. National Aboriginal Community Controlled Health
Organisation and The Royal Australian College of General
Practitioners. National guide to a preventive health
assessment for Aboriginal and Torres Strait Islander
people. 2nd edn. South Melbourne, Vic: RACGP, 2012.
51. Harris M, Taggart J, Williams A, et al. Effective
interventions to improve health literacy in the management
of lifestyle risk factors in primary health care. Paper
presented at 6th Health Service & Policy Research
Conference. Brisbane: Health Service & Policy Research
Conference, 2009.
52. Rodriguez V, Andrade AD, Garcia-Retamero R, et al.
Health literacy, numeracy, and graphical literacy among
veterans in primary care and their effect on shared
decision making and trust in physicians. J Health
Commun 2013;18:273–89.
53. Harris M, Kidd M, Snowdon T. New models of primary
and community care to meet the challenges of chronic
disease management and prevention: A discussion
paper for NHHRC: National Health and Hospitals Reform
Commission. Canbera: Australian Government, 2008.
54. Adams RJ, Stocks NP, Wilson DH, et al. Health literacy:
A new concept for general practice? Aust Fam Physician
2009;38(3):144–47.
55. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do
professional interpreters improve clinical care for patients
with limited English proficiency? A systematic review of the
literature. Health Serv Res 2007;42(2):727–54.
56. Belintxon M, Lopez-Dicastillo O. The challenges of health
promotion in a multicultural society: A narrative review. An
Sist Sanit Navar 2014;37(3):401–09.
57. Ethnic Communities’ Council of Victoria. An investment
not an expense: Enhancing health literacy in culturally
and linguistically diverse communities. Carlton, Vic: Ethnic
Communities’ Council of Victoria, 2012.
58. Abbott P, Reath J, Gordon E, et al. General practitioner
supervisor assessment and teaching of registrars
consulting with Aboriginal patients – Is cultural
competence adequately considered? BMC Med Educ
2014;14:167.
59. Vass A, Mitchell A, Dhurrkay Y. Health literacy and
Australian indigenous peoples: An analysis of the role
of language and worldview. Health Promot J Aust
2011;22(1):33–37.
60. Eckermann A, Dowd T, Chong E, Nixon L, Gray R. Binan
Goonj: Bridging cultures in Aboriginal health. 3rd edn.
Chatswood, NSW: Elsevier Australia, 2010.
61. Ware VA. Improving the accessibility of health services
in urban and regional settings for Indigenous people.
Canberra: Australian Institute for Health and Welfare,
2013.
62. Harris MF, Bailey L, Snowdon T, et al. Developing
the guidelines for preventive care – Two decades of
experience. Aust Fam Physician 2010;39(1–2):63–65.
63. Development and validation of an international appraisal
instrument for assessing the quality of clinical practice
guidelines: The AGREE project. Qual Saf Health Care
2003;12(1):18–23.
64. National Health and Medical Research Council.
NHMRC additional levels of evidence and grades for
recommendations for developers of guidelines. Canberra:
NHMRC, 2009. Available at www.nhmrc.gov.au/guidelines-
publications/information-guideline-developers/resources-
guideline-developers [Accessed 6 January 2016].
http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features30Mar+2010
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http://www.nhmrc.gov.au/guidelines-publications/information-guideline-developers/resources-guideline-developers
http://www.nhmrc.gov.au/guidelines-publications/information-guideline-developers/resources-guideline-developers
http://www.nhmrc.gov.au/guidelines-publications/information-guideline-developers/resources-guideline-developers
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Guidelines for preventive activities in general practice
9th edition
V. What’s new in the 9th edition?
Chapter Change
1. Preventive activities prior to
pregnancy
Advice on nutrition, weight assessment and oral health has been included in
Table 1.1
Information on health inequity is presented under ‘What are the key equity issues
and who is at risk?’ and ‘What can GPs do?’, highlighting the key issues and
strategies
2. Genetic counselling and testing Information on referral to clinical genetic services has been added
Inclusion of the use of a simple family history screening questionnaire to identify
individuals in general practice who may require a more detailed assessment of their
family history of cancer, heart disease or diabetes (Appendix 2A. Family history
screening questionnaire)
Additional advice added regarding Down syndrome – for all pregnant women –
hereditary haemochromatosis, haemoglobinopathies and thalassaemias (Table 2.1)
Non-invasive prenatal test now included
3. Preventive activities in children
and young people
Content has been edited and layout simplified to enable faster appreciation of the
recommendations ‘at a glance’
Information on health inequity is presented under ‘What are the key equity issues
and who is at risk?’ and ‘What can GPs do?’, highlighting the key issues and
strategies
4. Preventive activities in middle
age
Information on health inequity is presented under ‘What are the key equity issues
and who is at risk?’ and ‘What can GPs do?’, highlighting the key issues and
strategies
5. Preventive activities in older age Falls and physical activity are now in separate sections
Physical activity recommendations relevant to the Australian environment are
included
6. Communicable disease Inclusion of new information on the consent process before vaccination
New information on the prevalence of chlamydia, gonorrhoea, syphilis and human
immunodeficiency virus (HIV) in Australia
Information on health inequity is presented under ‘What are the key equity issues
and who is at risk?’ and ‘What can GPs do?’, highlighting the key issues and
strategies
7. Prevention of chronic disease Additional information on identifying nutrition-related complications in children and
adolescents (Table 7.3.1)
Change of title of Section 7.4 from ‘Problem drinking’ to ‘Early detection of at-risk
drinking’. Additional advice and information on effective interventions
Section 7.5. Physical activity includes assessment advice and referral information for
different age groups, and those at increased risk
Consumption of red meat and processed meat recommendations modified to align
with World Health Organization (WHO) recommendations
Information on health inequity is presented under ‘What are the key equity issues
and who is at risk?’ and ‘What can GPs do?’, highlighting the key issues and
strategies
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Guidelines for preventive activities in general practice
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8. Prevention of vascular and
metabolic disease
Information added on assessing need for anticoagulation (Table 8.5.2)
New information on atrial fibrillation
New advice about screening for diabetes based on US Preventive Services Task
Force (USPSTF) guidelines
Information on health inequity is presented under ‘What are the key equity issues and
who is at risk?’ and ‘What can GPs do?’, highlighting the key issues and strategies
9. Early detection of cancer Sections rearranged in order of incidence – that is, most commonly reported in
Australia (www.aihw.gov.au/cancer/cancer-in-australia-overview-2012/ch2/#t3)
After reviewing information from recent large trials of prostate cancer screening,
population screening for prostate cancer by prostate-specific antigen (PSA) testing
continues to not be recommended. Therefore, GPs have no obligation to offer
prostate cancer screening to asymptomatic men. Reference included to a decision
aid to assist discussion of possible benefits and harms of screening with PSA in men
who have individual concerns about prostate cancer
Inclusion of information on the cervical cancer screening program to commence in
May 2017
New information about the risks and benefits of screening mammogram; in
particular, the risk of over-diagnosis
Oral cancer section moved to Chapter 11. Oral health
Information on health inequity is presented under ‘What are the key equity issues and
who is at risk?’ and ‘What can GPs do?’ highlighting the key issues and strategies
10. Psychosocial Additional information on adolescents and those at average risk included for intimate
partner violence (Table 10.3.1)
Information on health inequity is presented under ‘What are the key equity issues and
who is at risk?’ and ‘What can GPs do?’, highlighting the key issues and strategies
11. Oral health Title of chapter has changed from ‘Oral hygiene’ to ‘Oral health’ to include
information on both oral hygiene and cancer
14. Osteoporosis Inclusion of an additional section on quantitative ultrasound as an alternative imaging
technique for assessing fracture risk
15. Screening tests of unproven
benefit
Additional screening tests not recommended:
• Coronary computed tomography (CT) angiography for coronary artery disease
• Cardiac calcium scoring for coronary heart disease
• Thermography and single nucleotide polymorphisms testing for breast cancer
• Optical colonoscopy and CT colonography for colorectal cancer
• Heel ultrasound for osteoporosis
• Carotid artery ultrasound for asymptomatic carotid artery stenosis
• Enquiry about sleep for obstructive sleep apnoea
• Bimanual pelvic exam during a routine Pap smear in asymptomatic women
• Genetic testing for methylenetetrahydrofolate reductase (MTHFR)
• Genetic testing for apolipoprotein E (ApoE)
‘Genetic profiling’ has been renamed ‘genomic sequencing’
http://www.aihw.gov.au/cancer/cancer-in-australia-overview-2012/ch2/#t3
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Guidelines for preventive activities in general practice
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1. Preventive activities prior to
pregnancy
Age <2 2–3 4–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 ≥65
Every woman of reproductive age should be considered for preconception care (C). This consists of interventions
that aim to identify and modify biomedical, behavioural and social risks to a woman’s health or pregnancy
outcome through prevention and management.1 Preconception care should include reproductive planning and the
effective use of contraception to prevent unplanned pregnancy (A), smoking cessation (A)2 and advice to consider
abstinence from alcohol (especially if planning a pregnancy, or if the woman could become pregnant or is in the
early stages of pregnancy),3 folic acid and iodine supplementation (A),4,5 nutrition and weight assessment,6 review of
immunisation status (C),7 medications (B),8 oral health,9 and chronic medical conditions, especially glucose control
in patients with diabetes (B).10
There is evidence to demonstrate improved birth outcomes with preconception healthcare in women with diabetes,
phenylketonuria and nutritional deficiency,11 as well as benefit from the use of folate supplementation12 and a
reduction in maternal anxiety.13 Below is information about all the potential interventions in preconception care that
expert groups have recommended (C).
What does preconception care include?
Medical issues
Reproductive life plan
Assist your patients to develop a reproductive life plan that includes whether they want to have children. If they do,
discuss the number, spacing and timing of intended children, and provide effective contraception to enable the
implementation of this plan and reduce the risk of an unplanned pregnancy. If relevant, discuss reduction in fertility
with advancing maternal age.
Reproductive history
Ask if there have been any problems with previous pregnancies such as infant death, fetal loss, birth defects
(particularly neural tube defects [NTD]), low birth weight, preterm birth, or gestational diabetes. Also, if there are any
ongoing risks that could lead to a recurrence in a future pregnancy.
Medical history
Ask if there are any medical conditions that may affect future pregnancies. Are chronic conditions such as diabetes,
thyroid disease, hypertension, epilepsy and thrombophilia well managed? Consider if current management is
optimal for early pregnancy given that early embryogenesis will occur prior to any consultation in pregnancy.
Medication use
Review all current medications for teratogenic effects, including over-the-counter medications, vitamins and
supplements.
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Guidelines for preventive activities in general practice
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Genetic/family history (also refer to Chapter 2. Genetic counselling and testing)
Increased frequency of intellectual disability, multiple pregnancy losses, stillbirth or early death, and children with
congenital abnormalities may suggest the presence of genetically determined disease. Patients of particular
ethnic backgrounds may be at increased risk and can benefit from genetic testing for specific conditions. Possible
consanguinity (eg cousins married to each other) should be explored, for example, by asking, ‘Is there any chance
that a relative of yours might be related to someone in your partner’s family?’ General practitioners (GPs) should
consider referral to, or consultation with, a genetic service for testing because test results, which rely on sensitivity,
specificity and positive predictive value, are not straightforward. Testing often involves complex ethical, social and
legal issues. The time on waiting lists for genetic services is usually longer than one month, so direct consultation
and liaison by telephone are necessary when the genetic advice could affect a current pregnancy. Provide
opportunity for carrier screening for genetic conditions (eg cystic fibrosis, haemoglobinopathies) and referral for
genetic counselling based upon risk factors.
General physical assessment
Conduct a breast examination and, if it is due, perform a cervical screening test (eg Papanicolaou [Pap] test) before
pregnancy. Also assess body mass index (BMI) and blood pressure (BP), and check the oral cavity.
Substance use
Ask about tobacco, alcohol and illegal drug use. Offer counselling and referral for specialised assistance when use
is identified.
Vaccinations
The need for vaccination, particularly for hepatitis B, rubella and varicella, should be assessed as part of any pre‐
conception health check. Vaccinations can prevent some infections that may be contracted during pregnancy,
and relevant serological testing can be undertaken to ascertain immunity to hepatitis B and rubella. Routine
serological testing for varicella does not provide a reliable measure of vaccine-induced immunity; however, it can
indicate whether natural immunity has occurred due to prior infection. Women receiving live viral vaccines such
as measles, mumps and rubella (MMR) and varicella should be advised against becoming pregnant within 28
days of vaccination. It is also important that women of child‐bearing age who present for immunisation should
be questioned regarding the possibility of pregnancy as part of the routine pre-vaccination screening, to avoid
inadvertent administration of a vaccine(s) not recommended in pregnancy (refer to Section 2.1.4 Pre‐vaccination
screening in the Australian immunisation handbook, 10th edn). Recommended preconception vaccinations are:
• MMR
• varicella (in those without a clear history of chickenpox or who are non-immune on testing)
• influenza (recommended during pregnancy)
• diphtheria, tetanus, acellular pertussis (dTpa; to protect newborn from pertussis).
Lifestyle issues
Family planning
Based on the patient’s reproductive life plan (refer to above), discuss fertility awareness and how fertility reduces
with age, chance of conception, the risk of infertility, and fetal abnormality. For patients not planning to become
pregnant, discuss effective contraception and emergency contraceptive options.
Folic acid supplementation
Women should take a 0.4–0.5 mg per day supplement of folic acid for at least one month prior to pregnancy,
and for the first three months after conception. Where there is a known increased risk of NTD (ie patients
taking anticonvulsant medication, or with pre-pregnancy diabetes mellitus, previous child or family history of
NTD, 5-methyltetrahydrofolate deficiency or BMI >30 kg/m2) or a risk of malabsorption, a 5 mg daily dose is
recommended.14
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Guidelines for preventive activities in general practice
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Iodine supplementation
Women who are pregnant, breastfeeding or considering pregnancy should take an iodine supplement of 150 μg
each day.5
Healthy weight, nutrition and exercise
Discuss weight management and caution against being overweight or underweight. Recommend regular,
moderate-intensity exercise and assess risk of nutritional deficiencies (eg vegan diet, lactose intolerance, and
calcium, iron or vitamin D deficiency due to lack of sun exposure).
Psychosocial health
Discuss perinatal mental health, including anxiety and depression, pre‐existing mental health conditions,
psychological or psychiatric assessment and treatment, use of medication, and the risk of exacerbation of mood
disorders in pregnancy and postpartum. Mental health screening should include a psychosocial assessment.
Smoking, alcohol and illegal drug cessation (as indicated)
Smoking,15 illegal drug16 and excessive alcohol use17 during pregnancy can have serious consequences for an
unborn child and should be stopped prior to conception.
Healthy environments
Repeated exposure to hazardous toxins in the household and workplace environment can affect fertility and
increase the risk of miscarriage and birth defects. Discuss the avoidance of TORCH infections: Toxoplasmosis,
Other (eg syphilis, varicella, mumps, parvovirus and human immunodeficiency virus [HIV], listeriosis), Rubella,
Cytomegalovirus and Herpes simplex.
• Toxoplasmosis: Avoid cat litter, garden soil, raw/undercooked meat and unpasteurised milk products; wash all
fruit and vegetables.
• Cytomegalovirus, parvovirus B19 (fifth disease): Discuss the importance of frequent hand-washing. Those who
work with children or in the healthcare sector can further reduce risk by using gloves when changing nappies.
• Listeriosis: Avoid paté, soft cheeses (eg feta, brie, blue vein), prepackaged salads, deli meats and chilled/
smoked seafood. Wash all fruit and vegetables before eating. Refer to Food Standards Australia New Zealand
(www.foodstandards.gov.au/consumer/generalissues/pregnancy/Pages/default.aspx) regarding folate, listeria
and mercury.
• Fish: Limit fish containing high levels of mercury. Refer to www.betterhealth.vic.gov.au/health/healthyliving/
mercury-in-fish
http://www.foodstandards.gov.au/consumer/generalissues/pregnancy/Pages/default.aspx
http://www.betterhealth.vic.gov.au/health/healthyliving/mercury-in-fish
http://www.betterhealth.vic.gov.au/health/healthyliving/mercury-in-fish
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Guidelines for preventive activities in general practice
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Table 1.1. Preconception: Preventive interventions
Intervention Technique References
Folate
supplementation
Most women: 0.5 mg/day supplementation, beginning ideally at least one month
prior to conception and continuing for the first trimester
High-risk women: 5 mg/day supplementation, ideally beginning at least one month
prior to conception and continuing for the first trimester
4, 18–20
Iodine
supplementation
All women who are pregnant, breastfeeding or considering pregnancy should take
an iodine supplement of 150 μg each day
5, 14
Nutrition
and weight
assessment
All women, especially those who become pregnant in adolescence or have closely-
spaced pregnancies (interpregnancy interval less than six months), require nutritional
assessment and appropriate intervention in the preconception period with an
emphasis on optimising maternal body mass index (BMI) and micronutrient reserves
6, 21
Check oral cavity
and referral
Ask the woman if she has bleeding gums, swellings, sensitive teeth, loose teeth,
holes in teeth, broken teeth, toothache, or any other problems in the mouth
Check oral cavity to confirm. Reassure the patient that it is safe to have a range of
dental treatments during pregnancy
Smoking
cessation
Inform women who smoke that tobacco affects fetal growth and advise them to
stop smoking. Evidence exists to suggest improved cognitive ability in children of
mothers who quit smoking during gestation (III, A). Consider pharmacotherapy when
a pregnant woman is otherwise unable to quit, and when the likelihood and benefits
of cessation outweigh the risks of pharmacotherapy and potential continued smoking
22
Alcohol and illicit
drug use
For women who are pregnant or planning a pregnancy, not drinking is the safest
option. The risk of harm to the fetus is highest when there is high, frequent maternal
alcohol intake. The risk of harm to the fetus is likely to be low if a woman has
consumed only small amounts of alcohol before she knew she was pregnant. Inform
pregnant women that illicit drugs may harm the fetus and advise them to avoid use
1
Interpregnancy
interval
Perinatal outcomes are worse with interpregnancy intervals <18 months or >59
months; the outcomes affected are preterm birth, low birth weight and small size for
gestational age
23
Chronic diseases Optimise control of existing chronic diseases (eg diabetes, hypertension, epilepsy).
Avoid teratogenic medications
18
BMI, body mass index
22
Guidelines for preventive activities in general practice
9th edition
Health inequity
What are the key equity issues and who is at risk?
Preconception care is especially important to adolescents and young women in vulnerable populations.24
Adolescent parenthood is more common in low socioeconomic groups and Aboriginal and Torres Strait Islander
communities, and is associated with poor birth outcomes and adverse health effects, including mental health
issues and substance misuse.25–29
Decreased folate supplementation is associated with being a woman from a lower socioeconomic group, being
an Aboriginal and Torres Strait Islander person, or being younger or from a rural area.30 Awareness of folic acid is
related to income, educational level and younger age.31,32 Other dietary supplements may follow similar gradients.
Smoking and alcohol use in pregnancy show socioeconomic gradients. Women who are young, on a low
income and of low socioeconomic status, Aboriginal and Torres Strait Islander women, single mothers, and
women experiencing addiction, violence and mental health issues are all more likely to smoke during pregnancy.33,34
Women from culturally and linguistically diverse (CALD) backgrounds are more likely to experience poorer perinatal
outcomes.36–38
What can GPs do?
• Provide youth-friendly care to adolescent parents through non-judgemental, competent, considerate and
respectful advice and services.39
• Offer women culturally appropriate resources, including in the mother’s own language, about health issues
and the health system, and consider the use of interpreters.
• Link women into English language and perinatal education courses, and offer cultural brokerage through
maternity liaison officers or bilingual health workers wherever possible.39
• Refer to ‘Antenatal care for Aboriginal and Torres Strait Islander women’ in the Australian Health Ministers’
Advisory Council’s Clinical practice guidelines: Antenatal care – Module 1.39
• Refer to the general principles of providing patient education and supporting health literacy in disadvantaged
groups.
References
1. Johnson K, Posner SF, Biermann J, et al.
Recommendations to improve preconception health
and health care – United States. MMWR Recomm Rep
2006;55(RR-6):1–23.
2. Lumley J, Chamberlain C, Dowswell T, Oliver S, Oakley
L, Watson L. Interventions for promoting smoking
cessation during pregnancy. Cochrane Database Syst
Rev 2009;3:CD001055.
3. National Health and Medical Research Council. Australian
guidelines to reduce health risks from drinking alcohol.
Canberra: NHMRC, 2009.
4. Lumley J, Watson L, Watson M, Bower C. Periconceptual
supplementation with folate and/or multivitamins for
preventing neural tube defects. Cochrane Database Syst
Rev 2001;3:CD001056.
5. National Health and Medical Research Council. Iodine
supplementation for pregnant and breastfeeding women.
Canberra: NHMRC, 2010. Available at www.nhmrc.
gov.au/_files_nhmrc/file/publications/synopses/new45_
statement [Accessed 8 December 2015].
6. Dean SV, Lassi ZS, Imam AM, Bhutta ZA. Preconception
care: Nutritional risks and interventions. Reprod Health
2014;11 Suppl 3:S3.
7. Australian Technical Advisory Group on Immunisation
(ATAGI). The Australian immunisation handbook. 10th edn
(2015 update). Canberra: Department of Health, 2015.
8. Australian Department of Health and Aged Care.
Prescribing medicines in pregnancy. 4th edn. Canberra:
Therapeutic Goods Administration, 1999.
9. Rogers JG. Evidence-based oral health promotion
resource. Melbourne: Prevention and Population Health
Branch, Department of Health, 2011.
10. Korenbrot CC, Steinberg A, Bender C, Newberry S.
Preconception care: A systematic review. Matern Child
Health Journal 2002;6(2):75–88.
11. Gjerdingen DK, Fontaine P. Preconception health care: A
critical task for family physicians. J Am Board Fam Pract
1991;4(4):237–50.
12. Hodgetts VA, Morris RK, Francis A, Gardosi J, Ismail
KM. Effectiveness of folic acid supplementation in
http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/new45_statement
http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/new45_statement
http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/new45_statement
23
Guidelines for preventive activities in general practice
9th edition
pregnancy on reducing the risk of small-for-gestational
age neonates: A population study, systematic review and
meta-analysis. BJOG 2015;122(4):478–90.
13. de Jong-Potjer LC, Elsinga J, le Cessie S, et al. GP-
initiated preconception counselling in a randomised
controlled trial does not induce anxiety. BMC Fam Pract
2006;7:66.
14. The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists. Vitamin and mineral
supplementation and pregnancy (C-Obs 25), November
2014, amended May 2015. East Melbourne, Vic:
RANZCOG, 2015. Available at www.ranzcog.edu.au/
doc/vitamin-and-mineral-supplementation-in-pregnancy.
html [Accessed 5 September 2015].
15. The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists. Women and smoking
(C-Obs 53). East Melbourne, Vic: RANZCOG, 2011.
Available at www.ranzcog.edu.au/college-statements-
guidelines.html [Accessed 27 May 2016].
16. The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists. Substance use in
pregnancy (C-Obs 55). East Melbourne, Vic: RANZCOG,
2013. Available at www.ranzcog.edu.au/college-
statements-guidelines.html [Accessed 27 May 2016].
17. The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists. Alcohol in pregnancy
(C-Obs 54). East Melbourne, Vic: RANZCOG, 2014.
Available at www.ranzcog.edu.au/college-statements-
guidelines.html [Accessed 27 May 2016].
18. National Institute for Health and Care Excellence.
Diabetes in pregnancy: Management of diabetes and
its complications from preconception to the postnatal
period. London: NICE, 2015.
19. Wilson RD, Johnson JA, Wyatt P, et al. Pre-conceptional
vitamin/folic acid supplementation 2007: The use
of folic acid in combination with a multivitamin
supplement for the prevention of neural tube defects
and other congenital anomalies. J Obstet Gynaecol Can
2007;29(12):1003–26.
20. US Preventive Services Task Force. Guide to clinical
preventive services: Report of the US Preventive Services
Task Force. 2nd edn. Alexandria, VA: Williams & Wilkins,
2002.
21. Opray N, Grivell RM, Deussen AR, Dodd JM. Directed
preconception health programs and interventions for
improving pregnancy outcomes for women who are
overweight or obese. Cochrane Database Syst Rev
2015;7:CD010932.
22. The Royal Australian College of General Practitioners.
Supporting smoking cessation: A guide for health
professionals. Melbourne: RACGP, 2011.
23. Conde-Agudelo A, Rosas-Bermúdez A, Kafury-
Goeta AC. Birth spacing and risk of adverse perinatal
outcomes: A meta-analysis. JAMA 2006;295:1809–23.
24. Hanson MA, Gluckman PD, Ma RCW, Matzen P, Biesma
RG. Early life opportunities for prevention of diabetes in
low and middle income countries. BMC Public Health
2012;12.
25. Hodgkinson S, Beers L, Southammakosane C, Lewin
A. Addressing the mental health needs of pregnant and
parenting adolescents. Pediatrics 2014;133(1):114–22.
26. Payne NA, Anastas JW. The mental health needs of
low-income pregnant teens: A nursing-social work
partnership in care. Research on Social Work Practice
2015 Sep;25(5):595–606.
27. Penman-Aguilar A, Carter M, Snead MC, Kourtis AP.
Socioeconomic disadvantage as a social determinant of
teen childbearing in the US Public Health Reports 2013;
128:5–22.
28. Hilder L, Zhichao Z, Parker M, Jahan S, Chambers
G. Australia’s mothers and babies 2012. Canberra:
Australian Institute of Health and Welfare, 2014.
29. Middleton P. Preventing infant deaths among Aboriginal
and teenage women in South Australia. Adelaide: The
Strategic Health Research Program Team, The University
of Adelaide, 2009.
30. Australian Institute of Health and Welfare. Mandatory folic
acid and iodine fortification in Australia and New Zealand:
Baseline report for monitoring. Canberra: AIHW, 2011.
31. Hage CN, Jalloul M, Sabbah M, Adib SM. Awareness
and intake of folic acid for the prevention of neural tube
defects among Lebanese women of childbearing age.
Matern Child Health 2012;16(1):258–65.
32. Rasmussen MM, Clemmensen D. Folic acid
supplementation in pregnant women. Dan Med Bull
2010;57(1):A4134
33. Borland T, Babayan A, Irfan S, Schwartz R. Exploring the
adequacy of smoking cessation support for pregnant and
postpartum women. BMC Public Health 2013;13:472
34. Cui Y, Shooshtari S, Forget EL, Clara I, Cheung KF.
Smoking during pregnancy: Findings from the 2009–
2010 Canadian Community Health Survey. PLOS ONE
2014;9(1):e84640
35. Burns L, Breen C, Bower C, O’ Leary C, Elliott EJ.
Counting fetal alcohol spectrum disorder in Australia:
The evidence and the challenges. Drug Alcohol Rev
2013;32(5):461–67.
36. Laws P, Li Z, Sullivan E. Australia’s mothers and babies
2008. Canberra: Australian Institute of Health and
Welfare, 2010.
37. O’Mahony JM, Donnelly TT. How does gender influence
immigrant and refugee women’s postpartum depression
help-seeking experiences? J Psychiatr Ment Health Nurs
2013;20(8):714–25.
38. O’Mahony JM, Donnelly TT, Bouchal SR, Este D. Cultural
background and socioeconomic influence of immigrant
and refugee women coping with postpartum depression.
J Immigr Minor Health 2013;15(2):300–14.
39. Australian Health Ministers’ Advisory Council. Clinical
practice guidelines: Antenatal care – Module 1. Canberra:
Department of Health and Ageing, 2012.
http://www.ranzcog.edu.au/doc/vitamin-and-mineral-supplementation-in-pregnancy.html
http://www.ranzcog.edu.au/doc/vitamin-and-mineral-supplementation-in-pregnancy.html
http://www.ranzcog.edu.au/doc/vitamin-and-mineral-supplementation-in-pregnancy.html
http://www.ranzcog.edu.au/college-statements-guidelines.html
http://www.ranzcog.edu.au/college-statements-guidelines.html
24
Guidelines for preventive activities in general practice
9th edition
2. Genetic counselling and testing
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Genetic testing can be used for various purposes, from preconception planning (refer to Chapter 1. Preventive
activities prior to pregnancy), during pregnancy, for neonates (newborn screening), during childhood and right
through to adult-onset familial diseases (eg cancer, cardiac and neurodegenerative diseases).
In order to identify patients who may be at risk of a genetic disorder, a comprehensive family history must be taken
from all patients, and this should be regularly updated. A family history should include first-degree and second-
degree relatives on both sides of the family and ethnic background. Age of onset of disease and age of death
should be recorded where available.
Increased frequency and early onset of cancers in families, premature ischaemic heart disease or sudden cardiac
death, intellectual disability, multiple pregnancy losses, stillbirth or early death, and children with congenital
abnormalities may suggest the presence of genetically determined disease. Patients of particular ethnic
backgrounds may be at increased risk and may benefit from genetic testing for specific conditions. Possible
consanguinity (eg cousins married to each other) should be explored, for example, by asking, ‘Is there any chance
that a relative of yours might be related to someone in your partner’s family?’ General Practitioners (GPs) should
consider referral to, or consultation with, a genetic service (general or cancer genetics) for testing because test
results, which rely on sensitivity, specificity and positive predictive value, are not straightforward. Testing often
involves complex ethical, social and legal issues. The time on waiting lists for genetic services is usually longer than
one month, so direct consultation and liaison by telephone are necessary when the genetic advice could affect a
current pregnancy. On the basis of current evidence, whole genome sequencing is not recommended in low-risk
general practice populations (refer to Chapter 15. Screening tests of unproven benefit).
Clinical genetic services provide testing, diagnosis, management and counselling for a wide range of genetic
conditions. Reasons for referral include:
• diagnosis of a genetic condition
• family history of a genetic condition
• recurrence risk counselling (eg risk of recurrence in a future pregnancy)
• pregnancy counselling (eg preconception, consanguinity)
• prenatal screening and testing
• presymptomatic and predictive testing for adult-onset disorders (eg cancer)
• discussions surrounding genetic testing
• arranging of genetic testing.
Services such as paternity testing or genetic testing/management of very common genetic conditions (eg
haemochromatosis) are not provided by clinical genetic services.
Use of a simple family history screening questionnaire (FHSQ) can help identify individuals who may require a
more detailed assessment of their family history of cancer, heart disease or diabetes (refer to Appendix 2A. Family
history screening questionnaire for a published and validated FHSQ).1 This tool can be used as part of the patient
assessment at their first visit to a practice. If a patient is uncertain about their family history, they can be asked
to discuss the FHSQ with their relatives prior to completing the questionnaire. For patients with low literacy,
the FHSQ may need to be completed with the support of a healthcare professional. A positive response to any
question requires follow-up with a more detailed assessment of the family history. As family history can change, it is
recommended that the FHSQ be repeated at least three every years.
25
Guidelines for preventive activities in general practice
9th edition
Table 2.1. Genetic testing: Identifying risks
Who is at risk? What should be done? How often? References
Cystic fibrosis (CF)
Increased probability:
• Northern European or Ashkenazi
Jewish ancestry
• Family history of CF or a relative with a
known CF mutation
• Where partner is affected or a known
carrier of CF
• Partners from Northern European
or Ashkenazi Jewish backgrounds
who are consanguineous (eg cousins
married to each other)
• Men with infertility suspected or due to
congenital absence of the vas deferens
Offer referral for genetic
counselling and carrier testing
(III, B)
If patient is pregnant, contact
genetic services to organise
screening in first trimester
Test couple for carrier
status if planning
pregnancy or in first
trimester
2–5
Down syndrome
Probability:
• All pregnant women
Combined maternal serum and
ultrasound screening in first
trimester*
Maternal serum screening in
second trimester† (C)
Non-invasive prenatal test (NIPT)‡
First or second
trimester
3, 6–11
Significantly increased probability:
• Women who had a previous Down
syndrome pregnancy
• Women with positive maternal serum
screening/nuchal translucency
ultrasound, NIPT in first trimester
or maternal serum screening in
second trimester
• Parent with a chromosomal
rearrangement (eg balanced
translocation of chromosome 21)
Fetal diagnostic genetic testing
(C)
Offer referral for genetic
counselling
First or second
trimester
10
Fragile X syndrome
Increased probability
Children or adults of either sex with one or
more of the following features:
• developmental delay including
intellectual disability of unknown cause
• autistic-like features
• attention deficit hyperactivity disorder
(ADHD)
• speech and language problems
• social and emotional problems, such as
aggression or shyness
• a female with a history of primary
ovarian insufficiency or premature
menopause (aged <40 years)
• adults with ataxia, balance problems
and parkinsonism
• relative with a fragile X mutation
Deoxyribonucleic acid (DNA)
test for fragile X and karyotype/
comparative genomic
hybridisation by microarray
for other possible causes of
developmental delay
Refer to genetic services for
genetic counselling and testing
at-risk family (I, A)
(IV, B)
(IV, A)
Any age for diagnosis
Prior to pregnancy to
ascertain carrier status
and reproductive risk
3, 12, 13
14–16
17
26
Guidelines for preventive activities in general practice
9th edition
Who is at risk? What should be done? How often? References
Haemoglobinopathies and thalassaemias
Increased probability:
• People from any of the following ethnic
backgrounds: Southern European,
African, Middle Eastern, Chinese, Indian
subcontinent, Central and South-east
Asian, Pacific Islander, New Zealand
Maori, South American, Caribbean, and
some northern Western Australian and
Northern Territory Aboriginal and Torres
Strait Islander communities
Test for mean corpuscular
volume (MCV), mean corpuscular
haemoglobin (MCH) and ferritin
Haemoglobin electrophoresis
(III, B)
Blood for deoxyribonucleic acid
(DNA) studies
Arrange partner testing if: MCV
≤80 fL and/or MCH ≤27 pg and/
or abnormal haemoglobin (Hb)
electrophoresis
Test couple for
carrier status prior to
pregnancy or in first
trimester
3, 18–20
Breast and ovarian cancer Refer to Section 9.3. Breast cancer
Colon cancer Refer to Section 9.2. Colorectal cancer
Familial hypercholesterolaemia (FH)
Increased probability:
• Premature ischaemic heart disease (ie
ischaemic heart disease in men aged
<55 years and women aged <60 years)
• First-degree relative with premature
ischaemic heart disease (men aged
<55 years and women aged <60 years)
• Total cholesterol >7.5 mmol/L or low
density lipoprotein-cholesterol (LDL-C)
>4.9 mmol/L
• First-degree relative with a total
cholesterol >7.5 mmol/L or LDL-C
>4.9 mmol/L
• Tendon xanthomata or arcus cornealis
at <45 years of age
Assess their probability of
having FH using the Dutch
Lipid Clinic Network (DLCN)
criteria or Modified UK Simon
Broome (MUKSB) criteria (III,
B) (Appendix 2B. Dutch Lipid
Clinic Network Criteria for
making a diagnosis of Familial
Hypercholestroloaemia in adults)
Offer referral to a lipid disorders
clinic if DLCN score ≥3 or the
MUKSB suggests possible FH
First presentation 21, 22
27
Guidelines for preventive activities in general practice
9th edition
Who is at risk? What should be done? How often? References
Hereditary haemochromatosis (HHC)
Increased probability:
• All first-degree relatives of patients with
HHC who are C282Y homozygous or
C282Y/H63D compound heterozygous
Positive family history –
asymptomatic and symptomatic
For patients aged >18 years, test
for HFE mutations, transferrin
saturation and serum ferritin to
simultaneously assess future
and current risk of iron overload
(C). Medicare Benefits Schedule
(MBS) rebate applies if affected
relative is first-degree relative;
no MBS rebate applies for more
distant relatives
If HFE mutation tests show
C282Y homozygous or C282Y/
H63D compound heterozygous
result, arrange for all of that
patient’s first degree relatives
aged >18 years to have tests for
HFE mutations and transferrin
saturation and serum ferritin (C).
MBS rebate applies
Aged >18 years at first
presentation
Although
abnormalities in
transferrin saturation
and serum ferritin may
occur at <18 years
of age in patients
with HHC, morbidity
from significant
iron overload is
exceedingly rare
before the age of 18
years
9, 23–29
Consider in these patients:
• Patients with conditions that could be
a complication of haemochromatosis
(eg arthritis, chronic fatigue, erectile
dysfunction, early menopause,
cirrhosis, hepatocellular carcinoma,
cardiomyopathy, diabetes mellitus)
• Patients with liver disease of unknown
cause, including those with suspected
alcoholic liver disease
• Patients with a family history of
haemochromatosis, liver cancer,
unexplained early death from liver or
heart failure
• Patients with porphyria cutanea tarda
and chondrocalcinosis (‘pseudogout’)
Other patients – asymptomatic
and symptomatic
For patients aged >18 years, test
transferrin saturation and serum
ferritin
If transferrin saturation >45%
or serum ferritin >250 µg/L on
repeated testing, test for HFE
mutations. MBS rebate applies
The ideal sample for testing
transferrin saturation and serum
ferritin is early morning fasting
blood test with iron supplements
withheld for 24 hours
*First trimester Down syndrome screening:
• free beta human chorionic gonadotrophin (HCG), pregnancy associated plasma protein at 10–12 weeks (this also provides risk for
trisomy 18 and Edwards syndrome)
• nuchal translucency screen at 11 weeks, 3 days to 13 weeks, 6 days
• NIPT‡ from 10 weeks for trisomy 21, 18 and 13; not available for MBS rebate. Tests for fetal DNA in maternal blood
†Second trimester serum screening:
• beta HCG, unconjugated oestriol, alpha-fetoprotein and inhibin A, ideally at 15–17 weeks; also gives risk for Edward syndrome and
neural tube defects (NTDs)
ADHD, attention deficit hyperactivity disorder; CF, cystic fibrosis; DLCN, Dutch Lipid Clinic Network; DNA, deoxyribonucleic acid; FH,
familial hypercholesterolaemia; Hb, haemoglobin; HCG, human chorionic gonadotrophin; HHC, hereditary haemochromatosis; LDL-C,
low density lipoprotein-cholesterol; MCH, mean corpuscular haemoglobin; MCV, mean corpuscular volume; MUKSB, Modified UK
Simon Broome; NIPT, non-invasive prenatal test; NTD, neural tube defect
28
Guidelines for preventive activities in general practice
9th edition
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http://www.ranzcog.edu.au/college-statements-guidelines.html
http://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/genetics_in_family_mdicine
http://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/genetics_in_family_mdicine
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Menopause_premature_early_menopause
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Menopause_premature_early_menopause
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Menopause_premature_early_menopause
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Guidelines for preventive activities in general practice
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Appendix 2A. Family history screening questionnaire
The use of a simple family history screening questionnaire (FHSQ) can help identify individuals who may require a
more detailed assessment of their family history of cancer, heart disease or diabetes.1
This tool can be used as part of the patient’s assessment at their first visit to a practice. If patients are uncertain about
their family history, they can be asked to discuss the FHSQ with their relatives prior to completing the questionnaire.
For patients with low literacy, the FHSQ may need to be completed with the support of a healthcare professional.
A positive response to any question requires follow-up with a more detailed assessment of the family history. As
family history can change it is recommended that the FHSQ be repeated at least every three years.
This risk assessment focuses on your close relatives including parents, children,
brothers and sisters who are either living or dead. Yes No
Have any of your close relatives had heart disease before 60 years of age?
‘Heart disease’ includes cardiovascular disease, heart attack, angina and bypass surgery.
Have any of your close relatives had diabetes?
‘Diabetes’ is also known as type 2 diabetes or non-insulin dependent diabetes.
Do you have any close relatives who had melanoma?
Have any of your close relatives had bowel cancer before 55 years of age?
Do you have more than one relative on the same side of the family who had bowel cancer at
any age?
Please think about your parents, children, brothers, sisters, grandparents, aunts, uncles, nieces,
nephews and grandchildren.*
Have any of your close male relatives had prostate cancer before 60 years of age?
Have any of your close female relatives had ovarian cancer?
Have any of your close relatives had breast cancer before 50 years of age?
Do you have more than one relative on the same side of your family who has had breast cancer
at any age?
Please think about your parents, children, brothers, sisters, grandparents, aunts, uncles, nieces,
nephews and grandchildren.*
*Only first-degree and second-degree relatives need be considered in this screening questionnaire
Reproduced with permission from Emery JD, Reid G, Prevost AT, Ravine D, Walter FM. Development and validation of a family
history screening questionnaire in Australian primary care. Ann Fam Med 2014;12(3):241–49. Available at www.annfammed.org/
content/12/3/241.long
http://www.annfammed.org/content/12/3/241.long
http://www.annfammed.org/content/12/3/241.long
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Guidelines for preventive activities in general practice
9th edition
Appendix 2B. Dutch Lipid Clinic Network Criteria for making
a diagnosis of familial hypercholestrolaemia in adults
Score
Family history
First-degree relative with known premature coronary and/or vascular disease (men aged <55 years and
women aged <60 years)
or
First-degree relative with known low-density lipoprotein-cholesterol (LDL-C) above the 95th percentile
for age and sex
1
First-degree relative with tendinous xanthomata and/or arcus cornealis
or
Children aged <18 years with LDL-C above the 95th percentile for age and sex
2
Clinical history
Patient with premature coronary artery disease (ages as above) 2
Patient with premature cerebral or peripheral vascular disease (as above) 1
Physical examination
Tendinous xanthomata 6
Arcus cornealis prior to 45 years of age 4
LDL-C (mmol/L)
LDL-C ≥8.5 8
LDL-C 6.5–8.4 5
LDL-C 5.0–6.4 3
LDL-C 4.0–4.9 1
Deoxyribonucleic acid (DNA) analysis: Functional mutation in the low-density lipoprotein receptor (LDLR),
apolipoprotein B (APOB) or proprotein convertase subtilisin/kexin type 9 (PCSK9) gene
8
Stratification Total score
Definite familial hypercholesterolaemia (FH) ≥8
Probable FH 6–7
Possible FH 3–5
Unlikely FH <3
ApoB, apolipoprotein B; DNA, deoxyribonucleic acid; FH, familial hypercholesterolaemia; LDL-C, low-density lipoprotein-cholesterol;
LDLR, low-density lipoprotein receptor; PCSK9, proprotein convertase subtilisin/kexin type 9
Reproduced with permission from Elsevier from Watts GF, Sullivan DR, Poplawski N, et al. Familial Hypercholesterolaemia Australasia
Network Consensus Group (Australian Atherosclerosis Society). Familial hypercholesterolaemia: A model of care for Australasia.
Atheroscler Suppl 2011;12(2):221–63.
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Guidelines for preventive activities in general practice
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Modified UK Simon Broome criteria
1. Deoxyribonucleic acid (DNA) mutation
2. Tendon xanthomas in patient or first-degree or second-degree relative
3. Family history myocardial infarction (MI) <50 years of age in second-degree relative or <60 years of age in
first-degree relative
4. Family history of cholesterol >7.5 in first-degree or second-degree relative
5. Cholesterol >7.5 (adult) or >6.7 (aged <16 years)
6. Low-density lipoprotein-cholesterol >4.9 (adult) or >4.0 (aged <16 years)
Definite: (5 or 6) + 1
Probable: (5 or 6) + 2
Possible familial hypercholesterolaemia: (5 or 6) + (3 or 4)
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Guidelines for preventive activities in general practice
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3. Preventive activities in children and
young people
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Early intervention
Prevention and health promotion in the early years, from conception to 5 years of age, is important for an
individual’s lifelong health and wellbeing.1 It may also be an opportunity to redress health inequalities.2,3 In
adolescence, neurodevelopmental studies support the value of early intervention to prevent ongoing harm.4
Many infants and children visit their general practitioner (GP) frequently, and adolescents visit at least once a year.5
This frequent contact provides opportunities for disease prevention and health promotion.
Evidence provides moderate support for the hypothesis that ‘accessible, family-centred, continuous,
comprehensive, coordinated, compassionate and culturally effective care improves health outcomes for children
with special healthcare needs’.6 There is also evidence that supports the beneficial impact of similar care for
children without special healthcare needs.7,8
Health inequity
What are the key equity issues and who is at risk?
• Low socioeconomic status (SES) is associated with increased childhood morbidity and mortality.9 This includes
higher rates of death from neonatal hypoxia, sudden unexpected death in infancy (SUDI), prematurity-related
disorders, and accidental and non-accidental injury;10,11 hospitalisations related to asthma;12 and risk of child
abuse.13 Low SES is also associated with overweight and obesity in children.14
• While there has been a decline in infant mortality since the 1990s, infant mortality in Aboriginal and Torres
Strait Islander peoples is more than twice that of non-Indigenous children,10 in part due to pregnancy, labour
and delivery complications, and trauma and congenital malformations.15 Aboriginal and Torres Strait Islander
infants have higher rates of death from SUDI.16 They are also more likely to be born premature or with low birth
weight17,18 and are more likely to be hospitalised before 1 year of age.19
• Aboriginal and Torres Strait Islander peoples and people from socioeconomically disadvantaged backgrounds
are more likely to experience low immunisation rates.20
What can GPs do?
• Refer to the general strategies for supporting patient education and health literacy in disadvantaged groups.
• Consider advocating for and supporting community-based strategies or policies for health promoting changes
within the environments in which families live (eg school-based programs targeting nutrition and physical
activity).21–27
• Use resources supporting the provision of culturally competent care to adolescents from culturally diverse
backgrounds.28
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Guidelines for preventive activities in general practice
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Table 3.1. Age-related health checks in children and young people
Age What should be done? References
Neonatal • Promote immunisation as per recommendations in the Australian immunisation handbook
at www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-
home
• Vitamin K as per recommendations by the National Health and Medical Research Council
(NHMRC) at www.nhmrc.gov.au/guidelines-publications/ch39
Assessment
• Metabolic screen (IV, B)
• Universal hearing screen
• Physical exam as outlined in the Child Personal Health Record (C; refer to Practice Point
a in Table 3.2)
• Identify family strengths, elicit concerns and promote parental confidence, competence
and mental health (C)
Preventive counselling and advice
Injury prevention: Promote protection from accidental and non-accidental injury. This
includes protecting against the risks of:
• passive smoking
• sudden unexpected death in infancy (SUDI)
• use of appropriate restraints in motor vehicles
29
30
31
32
31, 33
2, 4, 6,
12 and 18
months; and
3 years
• Immunisation as per the Australian immunisation handbook at www.immunise.health.gov.
au/internet/immunise/publishing.nsf/Content/Handbook10-home (A)
• Immunisation includes seeking informed consent and identifying Aboriginal and Torres
Strait Islander babies, infants and toddlers
Assessment
• Physical exam as outlined in the Child Personal Health Record (C; refer to Practice Point a in
Table 3.2). This includes regular measurement, plotting and interpreting of length, weight and
head circumference on growth charts. Include body mass index (BMI) from 2 years of age
• When a baby or child is presented as a ‘problem’, assessment should include parental
mental health, family functioning, the possibility of domestic violence and adequacy of
social support (C; refer to Practice Point b in Table 3.2)
• From 12 months, ‘Lift the lip’ dental check (C; refer to Practice Point e in Table 3.2)
Health promotion
• Support breastfeeding (refer to Practice Point c in Table 3.2 for introduction of solids and
reduction of food allergy)
• Promote healthy eating in the second year of life as per Australian dietary guidelines at
www.nhmrc.gov.au/guidelines-publications/n55
• Promote physical activity as per Australian recommendations for children aged 0–5 years
• Promote healthy sleep
• www.sleephealthfoundation.org.au
• http://raisingchildren.net.au
• Enquire about developmental progress including behaviours that suggest normal hearing
and vision (refer to Practice Point d in Table 3.2)
• From 6 months of age, consider the use of tools such as Parents’ evaluation of
developmental status (PEDS) and the Early intervention referral guide (refer to Appendix
3A. ‘Red flag’ early intervention referral guide)
• Promote early interactive reading with children
• Promote secure attachment
Preventive counselling and advice
• Injury prevention: Promote protection from accidental and non-accidental injury
• The Royal Children’s Hospital Melbourne has advice for parents and carers of children from
birth to 5 years at www.rch.org.au/uploadedFiles/Main/Content/safetycentre/fact_sheets/
Growing%20Safely%20DL%20brochure_WEB%20secure
• Promote sun protection (refer to Section 9.4. Skin cancer)
31
34
35, 36
37, 38
31
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
http://www.nhmrc.gov.au/guidelines-publications/ch39
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
http://www.nhmrc.gov.au/guidelines-publications/n55
http://www.sleephealthfoundation.org.au
http://raisingchildren.net.au
http://www.rch.org.au/uploadedFiles/Main/Content/safetycentre/fact_sheets/Growing%20Safely%20DL%20brochure_
http://www.rch.org.au/uploadedFiles/Main/Content/safetycentre/fact_sheets/Growing%20Safely%20DL%20brochure_
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Guidelines for preventive activities in general practice
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Age What should be done? References
3.5–5 years • Promote immunisation as per recommendations in the Australian immunisation
handbook at www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/
Handbook10-home
• Recommendations include seeking informed consent and identifying Aboriginal and
Torres Strait Islander babies, infants and toddlers
• Use the Australian Early Development Census (AEDC) to determine the vulnerabilities of
children 0–5 years of age in your community
Available at www.aedc.gov.au/resources/resources-accessible/aedc-user-guide-local-
government
Assessment
• Physical exam (include checking vision and calculating BMI; refer to Practice Point g and
j in Table 3.2)
• ‘Lift the lip’ dental check (C; refer to Practice Point e in Table 3.2)
• Promote healthy eating, drinking and physical activity (refer to Practice Point f in
Table 3.2)
• Promote healthy sleep as per advice from 6 months of age
• If behaviour is a concern, consider the quality of family functioning and the possible
contribution of factors in the child’s wider social environment (C; refer to Practice Point h
and i in Table 3.2)
• Elicit concerns regarding development, social and emotional wellbeing (refer to Practice
Point l in Table 3.2)
Preventive counselling and advice
• Injury prevention: Promote protection from accidental and non-accidental injury
• Promote sun protection (refer to Section 9.4. Skin cancer)
39
40, 41
36
42
6–13
years
Assessment
• Measure growth and BMI routinely (B; refer to Practice Point k in Table 3.2).
• Promote oral health
• Promote healthy eating and drinking
• ‘Lift the lip’ dental check (C; refer to Practice Point e in Table 3.2). Encourage regular
dental reviews
• Promote healthy physical exercise and reduction of sedentary behaviour
• Enquire about progress at school as an index of wellbeing (C)
• When behaviour is a concern, explore possible contributing factors within the family and
the wider social environment
Preventive counselling and advice
• Injury prevention – Harm minimisation (II). The Royal Children’s Hospital Melbourne has
advice for parents of children 6–12 years of age at
www.rch.org.au/uploadedFiles/Main/Content/safetycentre/ChildSafetyHandbook
• Promote social and emotional wellbeing (C)
• Promote sun protection (refer to Section 9.4. Skin cancer)
40, 41
36
43
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
http://www.aedc.gov.au/resources/resources-accessible/aedc-user-guide-local-government
http://www.aedc.gov.au/resources/resources-accessible/aedc-user-guide-local-government
http://www.rch.org.au/uploadedFiles/Main/Content/safetycentre/ChildSafetyHandbook
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Guidelines for preventive activities in general practice
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Age What should be done? References
14–19
years
• Promote immunisation as per the Australian immunisation handbook at
www.immunise.health.gov.au (A). Note the electronic version of the handbook is regularly
updated in between editions of the hardcopy
Assessment
• Measure growth and BMI routinely (B; refer to Practice Point k in Table 3.2)
• Promote healthy eating, drinking, physical activity and sleep
• Screen sexually active young people for Sexually Transmissible Infections (STIs; refer to
Section 6.2.1. Chlamydia and other STIs)
Preventive counselling and advice
• Assess for risky behaviours (refer to Practice Point m in Table 3.2). In one study, risky
behaviours occurred in 90% of young Australians attending a general practice
• Promote oral health (also refer to Chapter 11. Oral health)
• Use models of care that facilitate the transition of young people with chronic disease
or disability from tertiary paediatric care to effective primary care with access to adult
specialist care. The NSW Agency for Clinical Innovation has models of care for transition
for most paediatric centres across Australia
• www.trapeze.org.au/content/gps
• www.aci.health.nsw.gov.au/networks/transition-care
• Ask about smoking and provide a strong anti-smoking message (III, C; refer to Section
7.1. Smoking)
44, 45
36, 43
32,46,47
64
AEDC, Australian Early Development Census; BMI, body mass index; NHMRC, National Health and Medical Research Council;
PEDS, parents’ evaluation of developmental status; SUDI, sudden unexpected death in infancy
http://www.immunise.health.gov.au
http://www.trapeze.org.au/content/gps
http://www.aci.health.nsw.gov.au/networks/transition-care
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Guidelines for preventive activities in general practice
9th edition
Table 3.2. Explanatory notes for Practice Points
Practice
Point Comment
a Physical exam
• Complete the Child Personal Health Record, which is given at birth in New South Wales,31 or refer to
relevant programs in individual states and territories
Note: parents value reviewing completed growth charts
b At present, there is insufficient evidence for either benefit or harm in screening for postnatal depression (PND).
However, PND is known to have an unfavourable impact on the quality of attachment and family functioning.
Further, there are evidence-based interventions for PND48 and improving the quality of mother–infant interaction
adversely affected by PND.49,50 GPs should be alert to the possibility of impaired parental mental health and
family dysfunction. Visit www.beyondblue.org.au/the-facts/pregnancy-and-early-parenthood
Table 10.1.2 and Section 10.3. Intimate partner violence
c The Australasian Society of Clinical Immunology and Allergy’s (ASCIA) 2016 Guidelines for allergy prevention
in infants supports the introduction of complementary ‘solid’ foods within four to six months of age and
preferably while breastfeeding.51 The introduction of allergenic food should not be delayed. However,
the ASCIA position is in conflict with the 2012 National Health and Medical Research Council (NHMRC)
guideline, which recommends exclusive breastfeeding until 6 months of age35
The new ASCIA guidelines provide:
• good evidence* that introducing peanut into the diet of infants who already have severe eczema and/or
egg allergy before 12 months of age can reduce the risk of these infants developing peanut allergy
• moderate evidence† that introducing cooked egg into an infant’s diet before 8 months of age, where there
is a family history of allergy, can reduce the risk of developing egg allergy. Raw egg is not recommended
Also refer to Table 7.3.2
*High/good/strong evidence means convincing evidence from well-conducted studies, or many well-
conducted studies results pooled into a large analysis (meta-analysis)
†Moderate evidence means evidence from reasonably well-conducted studies or well-conducted single
studies
d Developmental progress
Early intervention presupposes early detection. Prior to 3 years of age, the rate of attaining developmental
milestones varies so much that the simple application of screening ‘tools’ would excessively detect
developmental delay (false positive). This risk is reduced after 3 years of age
In the earliest years, guides to developmental progress can be used to initiate an ongoing conversation with
parents to elicit their concerns about their child’s progress52,53
Developmental milestone assessments are outlined in the Child Personal Health Record, which is provided
at birth in New South Wales
A tool, such as the Parents’ evaluation of developmental status (PEDS), can be used on a regular basis
to identify any concerns about their child’s development. The information gathered helps the GP gain a
better understanding of the progress of each child. Further information on the PEDS questionnaire can be
accessed at www.rch.org.au/ccch/peds
The value of the PEDS may be increased if used in conjunction with:
• Learn the signs – Act early at www.cdc.gov/ncbddd/actearly/index.html
• Red flags early intervention guide at www.health.qld.gov.au/cq/child-development/docs/red-flag-a3-
poster-banana (refer to Appendix 3A. ‘Red flag’ early intervention referral guide). Information on the
Ages and Stages Questionnaire is available at http://agesandstages.com
http://www.beyondblue.org.au/the-facts/pregnancy-and-early-parenthood
http://www.rch.org.au/ccch/peds
http://www.cdc.gov/ncbddd/actearly/index.html
https://www.health.qld.gov.au/cq/child-development/docs/red-flag-a3-poster-banana
https://www.health.qld.gov.au/cq/child-development/docs/red-flag-a3-poster-banana
http://agesandstages.com
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Guidelines for preventive activities in general practice
9th edition
Practice
Point Comment
e ‘Lift the lip’ screening tool for the prevention and early detection of tooth decay in children:
• Complete and also teach parents to simply lift the top lip of their child, looking for signs of tooth decay
(eg white lines on top of the teeth below the gumline, or discolouration of the teeth that cannot be
brushed off). Encourage parents to complete once a month
• Encourage dental hygiene twice a day: No toothpaste <17 months of age and low fluoride toothpaste up
to 5 years of age
• Encourage dental visits annually after 12 months of age
Also refer to Chapter 11. Oral health
f The latest Australian recommendations for healthy eating, drinking and physical exercise are summarised in
The Royal Australian College of General Practitioners’ (RACGP) Smoking, nutrition, alcohol and physical activity
(SNAP): A population guide to the behavioural risk factors in general practice, 2nd edn, in particular, Table 1554
Nutrition for babies:
www.eatforhealth.gov.au/sites/default/files/files/the_guidelines/n55e_infant_brochure
Nutrition for children:
www.eatforhealth.gov.au/sites/default/files/files/the_guidelines/n55f_children_brochure
g The American Academy of Pediatrics has recommended the annual plotting of body mass index (BMI) for all
patients aged ≥2 years. Be aware that small errors in measuring either height/length or weight cause large
errors in the position of the calculated BMI on the BMI percentile chart. This is because percentile lines are
crowded together in the preschool ages
h An Australian randomised controlled trial (RCT) demonstrated that a coordinated cross-agency system of
parenting support, which included general practice, produced meaningful effects at the population level56
i For pre-school children, family support and parenting programs continue to be the most effective method
of preventing the onset of emotional and behavioural problems, which predispose to mental illness in later
childhood and adolescence32,56
j The US Preventive Services Task Force (USPSTF) concludes with moderate certainty that vision screening
for all children at least once between 3 and 5 years of age to detect the presence of amblyopia or its risk
factors has a moderate net benefit.57 The USPSTF concludes that the benefits of vision screening for
children aged <3 years are uncertain, and that the balance of benefits and harms cannot be determined for
this age group
k The USPSTF recommends that clinicians screen children aged ≥6 years for obesity and offer them or refer
them to comprehensive, intensive behavioural interventions to promote improvement in weight status (B)45
• There is a moderate net benefit for screening children aged 6–18 years
• As a screening tool, BMI is an ‘acceptable measure for identifying children and adolescents with excess
weight’45
• ‘Overweight’ is having a BMI between the 85th and 94th percentiles for the individual’s age and gender
• ‘Obesity’ is having a BMI >95th percentile for age and gender
l Mental, emotional, behavioural disorder in Australian young people
• Fifty per cent of adult disorders have onset by 14 years of age
• Between 14% and 18% of children and young people experience mental health problems of clinical
significance
• Depression and coping with stress are priorities for:
– 16% of those aged 11–14 years
– 21% of those aged 15–19 years58
• The USPSTF recommends the screening of adolescents (aged 12–18 years) for major depressive
disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive, behavioural
or interpersonal) and follow-up (B)59
• Risk factors for major depressive disorder include parental depression, having comorbid mental health or
chronic medical conditions, and having experienced a major negative life event59
www.eatforhealth.gov.au/sites/default/files/files/the_guidelines/n55e_infant_brochure
www.eatforhealth.gov.au/sites/default/files/files/the_guidelines/n55f_children_brochure
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Guidelines for preventive activities in general practice
9th edition
Practice
Point Comment
m Assess for risky behaviours
Promoting health and minimising harm is a whole-of-community opportunity and responsibility. Celebrating
strengths, explaining confidentiality (including its limits) and using the HE2ADS3 framework60 (refer to below)
to explore with young people the context in which they live are strategies that are likely to improve the
clinician’s capacity to promote health and minimise morbidity (C):61,62
– Home
– Education/employment
– Eating and exercise
– Activities
– Drugs
– Sexuality
– Suicide
– Safety
• Young people who present frequently are at higher risk of having a mental health problem63
• Provide messages that encourage delay in initiation of potentially risky behaviours and, at the same
time, promote risk-reduction strategies if adolescents choose to engage or are already engaging in the
behaviour
• Use principles of motivational interviewing in the assessment and discussion of risky health behaviours
with adolescent patients (including safe practice for those who are sexually active)
• Be familiar with the resources in the community that provide harm reduction programs for substance
abuse, pregnancy prevention, injury prevention and road safety
• Be familiar with resources in the community that provide parenting skills training for parents of young
people
• Advocate for the introduction, further development and evaluation of evidence-based prevention and
treatment programs that use a harm reduction philosophy in schools and communities (C)
ASCIA, Australasian Society of Clinical Immunology and Allergy; BMI, body mass index; NHMRC, National Health and Medical
Research Council; PEDS, parents’ evaluation of developmental status; PND, postnatal depression; RCT, randomised controlled trial;
USPSTF, US Preventive Services Task Force
References
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[Accessed 25 May 2016].
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22. Kimbro RT, Denney JT. Neighborhood context and racial/
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27. Magnusson MB, Sjoberg A, Kjellgren KI, Lissner L.
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32. The Royal Australian and New Zealand College of
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34. Douglas PS, Hiscock H. The unsettled baby: Crying out
for an integrated, multidisciplinary primary care approach.
Med J Aust 2010 Nov 1;193(9):533–36.
35. National Health and Medical Research Council. Infant
feeding guidelines: Information for health workers.
Canberra: NHMRC, 2012.
36. National Health and Medical Research Council. Australian
dietary guidelines. Canberra: NHMRC, 2013.
37. Duursma E, Augustyn M, Zuckerman B. Reading
aloud to children: The evidence. Arch Dis Child
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38. Sim S, Berthelsen D. Shared book reading by parents
with young children: Evidence-based practice.
Australasian J Early Childhood 2014;39(1):50–55.
39. Cheng TL, Emmanuel MA, Levy DJ, Jenkins RR. Child
health disparities: What can a clinician do? Pediatrics
2015;136(5):961–68.
40. NSW Health. Early childhood oral health guidelines for
child health professionals. Sydney: Centre for Oral Health
Strategy, 2014. Available at www0.health.nsw.gov.au/
policies/gl/2014/pdf/GL2014_020 [Accessed 21
March 2016].
41. Rogers JG. Evidence-based oral health promotion
resource. Melbourne: Prevention and Population Health
Branch, Department of Health (Vic), 2011.
42. Sleep Health Foundation. Sleep shack. Blacktown, NSW:
Sleep Foundation, 2015. Available at
http://health.gov.au/internet/main/publishing.nsf/Content/neonatal-hearing-screening
http://health.gov.au/internet/main/publishing.nsf/Content/neonatal-hearing-screening
http://www.kidsfamilies.health.nsw.gov.au/media/296430/phr_blue-book_2015_web
http://www.kidsfamilies.health.nsw.gov.au/media/296430/phr_blue-book_2015_web
http://www.kidsfamilies.health.nsw.gov.au/media/296430/phr_blue-book_2015_web
http://www.sidsandkids.org/wp-content/uploads/SIDS053-Safe-Sleeping-Long-Brochure-Updates-web
http://www.sidsandkids.org/wp-content/uploads/SIDS053-Safe-Sleeping-Long-Brochure-Updates-web
http://www0.health.nsw.gov.au/policies/gl/2014/pdf/GL2014_020
http://www0.health.nsw.gov.au/policies/gl/2014/pdf/GL2014_020
40
Guidelines for preventive activities in general practice
9th edition
www.sleephealthfoundation.org.au/public-information/
more/sleepshack.html [Accessed 25 May 2016].
43. Department of Health. Australia’s physical activity and
sedentary behaviour guidelines, 2014. Canberra: DOH,
2014. Available at www.health.gov.au/internet/main/
publishing.nsf/content/health-pubhlth-strateg-phys-act-
guidelines [Accessed 21 March 2016].
44. National Institute for Health and Care Excellence. CG43
Obesity: Guidance on the prevention, identification,
assessment and management of overweight and obesity
in adults and children. London: NICE, 2006.
45. Barton M. Screening for obesity in children
and adolescents: US Preventive Services Task
Force recommendation statement. Pediatrics
2010;125(2):361–67.
46. Kendrick D. Preventing injuries in children: Cluster
randomized controlled trial in primary care. BMJ
1999;318(7189):980–83.
47. Clamp M, Kendrick D. A randomized controlled trial of
general practitioner safety advice for families with children
under 5 years. BMJ 1998;316(7144):1576–79.
48. beyondblue. Clinical practice guidelines for depression
and related disorders – Anxiety, bipolar disorder and
puerperal psychosis – in the perinatal period. A guideline
for primary care health professionals. Hawthorn, Vic:
beyondblue, 2011. Available at www.beyondblue.org.
au/health-professionals/clinical-practice-guidelines
[Accessed 21 March 2016].
49. Bakermans-Kranenburg MJ, van IJzendoorn MH,
Juffer F. Less is more: Meta-analyses of sensitivity
and attachment interventions in early childhood.
Psychological Bulletin 2003;129(2):195–215.
50. Milgrom J, Ericksen J, McCarthy RM, Gemmill AW.
Stressful impact of depression on early mother–infant
relations. Stress Health 2006;22:229–38.
51. Australasian Society of Clinical Immunology and Allergy.
Guidelines for allergy prevention in infants. Balgowlah,
NSW: ASCIA 2016. Available at www.allergy.org.au/
images/pcc/ASCIA_PCC_Guidelines_Allergy_Prevention_
Infants_2016 [Accessed 21 March 2016].
52. Glascoe FP. If you don’t ask: Parents may not tell:
Noticing problems vs expressing concerns. Arch Pediatr
Adolesc Med 2006;160:220.
53. McLean K, Goldfeld S, Molloy C, Wake M, Oberklaid
F. Screening and surveillance in early childhood health:
Rapid review of evidence for effectiveness and efficiency
of models. Ultimo, NSW: The Sax Institute, 2014.
54. The Royal Australian College of General Practitioners.
Smoking, nutrition, alcohol, physical activity (SNAP): A
population health guide to behavioural risk factors in
general practice. 2nd edn. East Melbourne, Vic: RACGP,
2015.
55. Sanders MR, Ralph A, Thompson R, et al. Every family: A
public health approach to promoting children’s wellbeing.
Brisbane: University of Queensland, 2007.
56. Brookes-Gunn J, Berlin LJ, Fuligni AS. Early childhood
intervention programs: What about the family? In:
Shonkoff JP, Meisels SJ, editors. Handbook of early
childhood intervention. 2nd edn. New York: Cambridge
University Press, 2000; p. 549–88.
57. US Preventive Services Task Force. Screening for
visual impairment in children ages 1 to 5 years: Topic
page. Rockville, MD: USPSTF, 2011. Available at www.
uspreventiveservicestaskforce.org/uspstf/uspsvsch.htm
[Accessed 25 May 2016]
58. Australian Infant Child Adolescent and Family Mental
Health Association. Improving the mental health of
infants, children and adolescents in Australia. Position
paper of the Australian Infant, Child, Adolescent
and Family Mental Health Association Ltd. Adelaide:
AICAFMHA, 2011. Available at www.emergingminds.
com.au/images/About-Us/AICAFMHA_pos_paper_final.
pdf [Accessed 25 May 2016].
59. US Preventive Services Task Force. Depression
in children and adolescents: Screening.
Rockville, MD: USPSTF, 2016. Available at www.
uspreventiveservicestaskforce.org/uspstf/uspschdepr.
htm [Accessed 25 May 2016 June].
60. Goldenring J, Rosen D. Getting into adolescent heads:
An essential update. Contemp Pediatr 2004;21:64.
61. McDermott B, Baigent M, Chanen A, et al. beyondblue
Expert Working Committee, Clinical practice guidelines:
Depression in adolescents and young adults. Hawthorn,
Vic: beyondblue, 2010.
62. Sanci L, Chondros P, Sawyer S, et al. Responding
to young people’s health risks in primary care:
A cluster randomised trial of training clinicians in
screening and motivational interviewing . PLOS ONE
2015;10(9):e0137581.
63. McNeill YL, Gillies ML, Wood SF. Fifteen year olds at risk
of parasuicide or suicide: How can we identify them in
general practice? Fam Pract 2002;19(5):461–65.
64. Stanton A, Grimshaw G. Tobacco cessation interventions
for young people. Cochrane Database Syst Rev
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http://www.sleephealthfoundation.org.au/public-information/more/sleepshack.html
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http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines
http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines
http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines
http://www.beyondblue.org.au/health-professionals/clinical-practice-guidelines
http://www.beyondblue.org.au/health-professionals/clinical-practice-guidelines
http://www.allergy.org.au/images/pcc/ASCIA_PCC_Guidelines_Allergy_Prevention_Infants_2016
http://www.allergy.org.au/images/pcc/ASCIA_PCC_Guidelines_Allergy_Prevention_Infants_2016
http://www.allergy.org.au/images/pcc/ASCIA_PCC_Guidelines_Allergy_Prevention_Infants_2016
http://www.emergingminds.com.au/images/About-Us/AICAFMHA_pos_paper_final
http://www.emergingminds.com.au/images/About-Us/AICAFMHA_pos_paper_final
http://www.emergingminds.com.au/images/About-Us/AICAFMHA_pos_paper_final
http://www.uspreventiveservicestaskforce.org/uspstf/uspschdepr.htm
http://www.uspreventiveservicestaskforce.org/uspstf/uspschdepr.htm
http://www.uspreventiveservicestaskforce.org/uspstf/uspschdepr.htm
41
Guidelines for preventive activities in general practice
9th edition
Appendix 3A ‘Red flag’ early intervention referral guide
Reproduced with permission from Queensland Health from Central Queensland Hospital and Health Service. The Red Flag: Early intervention
referral guide for children 0–5 years. Brisbane: Central Queensland Hospital and Health Service, 2016. Available at www.health.qld.gov.au/cq/
child-development/docs/red-flag-a3-poster-banana [Accessed 15 July 2016].
Parents – If there are Red Flags call your Family Doctor or Child Health Nurse
Professionals – REFER EARLY − DO NOT WAIT
Red Flag referral guidelines
6 months 9 months 12 months 18 months 2 years 3 years 4 years 5 years
Red Flags at
any stage
Social /
Emotional
Does not smile
or squeal in
response to
people
Not sharing
enjoyment with
others using eye
contact or facial
expression
Does not notice
someone new
Does not play
early turn taking
games (e.g.
peekaboo,
rolling a ball)
Lacks interest
in playing and
interacting with
others
When playing
with toys tends
to bang, drop,
or throw them
rather than use
them for their
purpose (e.g
cuddle doll,
build blocks)
No interest in
pretend play or
other children
Difficulties in
noticing and
understanding
feelings in
themselves
and others (e.g.
happy, sad)
Unwilling /
unable to play
cooperatively
Play is different
than their
friends Not achieving
indicated
developmental
milestones
Strong parent
concerns
Significant loss
of skills
Lack of response
to sound or
visual stimuli
Poor interaction
with adults or
other children
Difference
between right
and left sides of
body in strength,
movement or
tone
Loose and floppy
movements (low
tone) or stiff
and tense (high
tone)
Communication
Lack of or limited eye contact
Not starting
to babble (e.g
adah; oogoo)
No gestures
(e.g. pointing,
showing,
waving)
Not using 2 part
babble (e.g.
gaga, arma)
No babbled
phrases that
sound like
talking
No response to
familiar words
No clear words
Cannot
understand
short requests
eg. ‘Where is the
ball?’
Does not have at
least 50 words
Not putting
words together
eg. ‘push car’
Most of what is
said is not easily
understood
Speech difficult
to understand
Not using simple
sentences e.g.
big car go
Speech difficult
to understand
Unable to follow
directions with 2
steps
Difficulty telling
a parent what is
wrong
Cannot answer
questions
in a simple
conversation
Fine Motor
and Cognition
Not reaching
for and holding
(grasping) toys
Hands frequently
clenched
Unable to hold
and/or release
toys
Cannot move toy
from one hand
to another
Majority of
nutrition still
liquid/puree
Cannot chew
solid food
Unable to pick
up small items
using index
finger and
thumb
Not holding or
scribbling with a
crayon
Does not
attempt to tower
blocks
No interest in
self care skills
eg. feeding,
dressing
Difficulty
helping with
self care skills
(e.g. feeding,
dressing)
Difficulty
manipulating
small objects
e.g. threading
beads
Not toilet trained
by day
Unable to draw
lines and circles
Concerns from
teacher about
school readiness
Not independent
with eating and
dressing
Cannot draw
simple pictures
(e.g. stick
person)
Gross Motor
Not rolling
Not holding
head and
shoulders up
when on tummy
Not sitting
without support
Not moving
eg. creeping or
crawling motion
Does not take
weight well on
legs when held
by an adult
Not crawling or
bottom shuffling
Not pulling to
stand
Not standing
holding on to
furniture
Not attempting
to walk without
support
Not standing
alone
Unable to run
Unable to use
stairs holding on
Unable to throw
a ball
Not running well
Cannot walk up
and down stairs
Cannot kick or
throw a ball
Cannot jump
with 2 feet
together
Cannot pedal a
tricycle
Cannot catch,
throw or kick a
ball
Cannot balance
well standing on
one leg
Awkward
when walking,
running,
climbing and
using stairs
Ball skills are
very different to
their peers
Unable to hop
5 times on each
foot
The “Red Flag”
Early Intervention Referral Guide
for children 0 – 5 years
How to use this resource
This resource is a tool to help you to determine
whether a child may have developmental
delays. It will allow you to refer early before the
child begins to struggle to achieve tasks usually
managed by children of the same age.
Step 1:
Find the child’s age across the top of the
table below.
Step 2:
Read through the list and identify if the child is
demonstrating any of the Red Flags at their
age level.
Step 3:
If the child is between age levels (e.g. 2 yrs 5
months) check the lower age level for Red Flags
(ie. 2 yrs)
When to be concerned?
One or more Red Flags (in any area) is a sign
of delayed development.
Who to go to?
Parents:
If you have concerns about your child’s
development, please contact your
Family Doctor or
Child Health Nurse Phone: (07) 4992 7000
Health Professionals:
If you have screened and identified any
Red Flags, please contact your local Child
Development Service.
Who helps with these Red Flags?
Children aged 0 – 5 years who have a
developmental concern, may benefit from the
services from any of the following:
• Paediatrician
• Speech Pathologist
• Occupational Therapist
• Physiotherapist
• Social Worker
• Psychologist
• Dietitian
Local Child Development Service
Banana Community and Allied Health Services
Phone (07) 4992 7000
Office Hours 8.00 am to 4.30 pm
Monday to Friday
www.health.qld.gov.au/cq/child-development
Developed by: Child Development Program, Children’s Health Services in conjunction with GPpartners.
Adapted by Central Queensland Hospital and Health Service 2015. Print ID P1000 05052015 v1.0
http://www.health.qld.gov.au/cq/child-development/docs/red-flag-a3-poster-banana
http://www.health.qld.gov.au/cq/child-development/docs/red-flag-a3-poster-banana
42
Guidelines for preventive activities in general practice
9th edition
4. Preventive activities in middle age
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
The recommended specific activities for low-risk patients in the 45–64 years age group are listed in Table 4.1.
Patients should be offered these opportunistically, or at two-year to five-year intervals.
Planned health checks in general practice of middle-aged adults have been demonstrated to improve the
frequency of the management of smoking, nutrition, alcohol and physical activity (SNAP) behavioural risk factors;
screening for cervical and colorectal cancer (CRC); and hyperlipidaemia.1–3
There is also evidence that Aboriginal and Torres Strait Islander health checks improve early detection of diabetes
and provision of preventive care.4 However, there is mixed evidence for the effectiveness of interventions to address
multiple risk factors.5 These checks may be facilitated by the involvement of practice nurses.6–8 Interventions should
be tailored to the level of risk, and the use of the 5As framework (Ask, Assess, Advise and agree, Assist, Arrange
follow-up) is recommended as a guide to their delivery in primary healthcare.9
Health inequity
What are the key equity issues and who is at risk?
• Midlife, between 45 and 64 years of age, is particularly a time of determining patient risk factors and offering
screening for health conditions. Multimorbidity, particularly physical–mental health comorbidity, is an important
issue in middle aged populations. Social disadvantage can hasten the onset of multimorbidity by about 10–15
years, suggesting screening should start earlier in high-risk populations, including Aboriginal and Torres Strait
Islander peoples (eg at 30 years of age). This may be a critical time for preventive interventions to reduce later
life chronic illness.10
• The impact of income-related inequalities on the prevalence of common mental health disorders and
psychological distress is particularly seen in middle aged people.11
What can GPs do?
• Refer to the general principles of providing patient education and supporting health literacy in disadvantaged
groups.
• Be aware that disadvantaged groups may be less likely to access health checks,12 so proactive efforts to go
outside the practice (eg to workplaces) may be needed or preventive care may be built in opportunistically to
routine consultations.
• Actively manage vulnerable patients by recalling patients by phone or text messages for preventive care.
43
Guidelines for preventive activities in general practice
9th edition
Table 4.1. Age-related health checks for low-risk patients in middle age
Age What should be done Chapters
45–49 years Ask about:
• Smoking, nutrition, alcohol and physical activity (SNAP), and readiness to change
• possible depression but do not routinely screen unless staff-assisted depression care
supports are in place
• early signs of skin cancer
• preconception care
• completing a family history screening questionnaire
Measure:
• weight, height (to calculate body mass index [BMI]) and waist circumference
• blood pressure (BP)
• fasting lipids
Perform:
• Papanicolaou (Pap) test every two years (until April 2017)
• Human papillomavirus (HPV) test every five years (from May 2017)
• mammogram for women dependent on her individual degree of risk
• 23–valent pneumococcal polysaccharide vaccine (23vPPV) and influenza vaccination
for all Aboriginal and Torres Strait Islander peoples
• Influenza and diphtheria, tetanus, and acellular pertussis (dTpa adolescent/adult
version) vaccination for pregnant women
• genetic testing as part of preconception planning
Calculate:
• risk of diabetes using the Australian type 2 diabetes risk assessment tool (AUSDRISK)
• review fracture risk factors for osteoporosis for women aged >45 years of age
• absolute cardiovascular risk
Chapter 7
Chapter 10
Section 9.4
Chapter 1
Chapter 2
Section 7.2
Section 8.2
Section 8.3
Section 9.5
Section 9.3
Chapter 6
Chapter 6
Chapter 2
Section 8.4
Chapter 14
Section 8.1
50–64 years Ask about:
• SNAP and readiness to change
• possible depression but do not routinely screen unless staff-assisted depression care
supports are in place
• early signs of skin cancer
• completing a family history screening questionnaire
Measure:
• weight, height (to calculate BMI) and waist circumference
• BP
• fasting lipids
Perform:
• Colorectal cancer (CRC) screening with faecal occult blood testing (FOBT) at least
every two years
• Pap test every two years (until April 2017)
• HPV test every five years (from May 2017)
• mammography for women dependent on individual degree of risk
• 23vPPV and influenza vaccination for all Aboriginal and Torres Strait Islander peoples
• vaccination for diphtheria, tetanus (DT); dTpa should be used in place of DT when
providing booster tetanus immunisations
Calculate:
• risk of diabetes using AUSDRISK
• review fracture risk factors for osteoporosis for women aged >45 years and men aged
>50 years
• absolute cardiovascular risk
Chapter 7
Chapter 10
Section 9.4
Chapter 2
Section 7.2
Section 8.2
Section 8.3
Section 9.2
Section 9.5
Section 9.3
Chapter 6
Chapter 6
Section 8.4
Chapter 14
Section 8.1
23vPPV, 23-valent pneumococcal polysaccharide vaccine; AUSDRISK, Australian type 2 diabetes risk assessment tool; BMI, body
mass index; BP, blood pressure; DT, diphtheria, tetanus; dTpa, diphtheria, tetanus, and acellular pertussis(adolescent/adult version);
HPV, human papillomavirus; Pap, Papanicolaou; SNAP, smoking, nutrition, alcohol and physical activity
44
Guidelines for preventive activities in general practice
9th edition
Table 4.2. Preventive interventions in middle age
Intervention Technique
Health education Tailor health advice or education to the patient’s risk, stage of change and health literacy
(Chapter II. Patient education and health literacy)
Practice organisation Use clinical audit to identify patients who have not had preventive activity. Recall to
practice or opportunistically arrange a 45–49 years health assessment
References
1. Boulware LE, Marinopolous S, Phillips KA, et al.
Systematic review: The value of the periodic health
evaluation. Ann Intern Med 2007;146(4):289–300.
2. Dowell AC, Ochera JJ, Hilton SR, et al. Prevention in
practice: Results of a 2-year follow-up of routine health
promotion interventions in general practice. Fam Pract
1996 Aug;13(4):357–62.
3. Imperial Cancer Research Fund OXCHECK Study Group.
Effectiveness of health checks conducted by nurses in
primary care: Final results of the OXCHECK study. BMJ
1995;310(6987):1099–104.
4. Spurling GK, Hayman NE, Cooney AL. Adult health
checks for Indigenous Australians: The first year’s
experience from the Inala Indigenous Health Service.
Med J Aust 2009;190(10):562–64.
5. Eriksson MK, Franks PW, Eliasson M. A 3-year
randomized trial of lifestyle intervention for cardiovascular
risk reduction in the primary care setting: The Swedish
Bjorknas study. PLOS ONE 2009;4(4):e5195.
6. Raftery JP, Yao GL, Murchie P, Campbell NC, Ritchie
LD. Cost effectiveness of nurse led secondary
prevention clinics for coronary heart disease in primary
care: Follow up of a randomised controlled trial. BMJ
2005;330(7493):707.
7. Family Heart Study Group. Randomised controlled trial
evaluating cardiovascular screening and intervention in
general practice: Principal results of British family heart
study. BMJ 1994;308(6924):313–20.
8. Engberg M, Christensen B, Karlsmose B, Lous J,
Lauritzen T. General health screenings to improve
cardiovascular risk profiles: A randomized controlled trial
in general practice with 5-year follow-up. J Fam Pract
2002;51(6):546–52.
9. World Health Organization. Screening for various
cancers. Geneva: WHO, 2008. Available at www.who.
int/cancer/detection/variouscancer/en/ [Accessed 3
May 2016].
10. Barnett K, Mercer SW, Norbury M, Watt G, Wyke
S, Guthrie B. Epidemiology of multimorbidity
and implications for health care, research, and
medical education: A cross-sectional study. Lancet
2012;380(9836):37–43.
11. Lang IA, Llewellyn DJ, Hubbard RE, Langa KM, Melzer D.
Income and the midlife peak in common mental disorder
prevalence. Psychol Med 2011;41(7):1365–72.
12. Dryden R, Williams B, McCowan C, Themessl-Huber M.
What do we know about who does and does not attend
general health checks? Findings from a narrative scoping
review. BMC Public Health 2012;12(1):1–23.
45
Guidelines for preventive activities in general practice
9th edition
5. Preventive activities in older age
Older people are at increased risk of multiple chronic conditions that may impair their function and quality of life. Those
living alone, with difficulties accessing healthcare, with poor mobility and with limited financial support are particularly
vulnerable.1 Their health problems may be exacerbated by poor nutrition, poor oral health,2 lack of physical activity,3
taking multiple medications4,5 and lack of sun exposure,6 all of which can be addressed in preventive activities.
Older people may rely on the help and support of carers and family. Carers, particularly carers for people with
dementia or depression, are at risk of depression, anxiety, emotional distress, loneliness and isolation, but their
healthcare needs are often overlooked.7–11 Their need for support should be assessed when possible (C) and
appropriate referral instituted.12 Carer support resources are helpful for carer wellbeing and may delay the need for
the older person who is receiving care to be relocated to a residential facility.7,13–15
People should be advised to plan as much as possible for their care as they get older to prevent family disruption
in episodes of illness as well as unpleasant and undesired acute care interventions. This includes organising
wills, financial enduring power of attorney, and the equivalent documentation for health and care (called enduring
guardianship in some jurisdictions), and an advance care plan.16 The Royal Australian College of General
Practitioners’ (RACGP) position statement on the incorporation of advance care planning into routine general
practice is available at www.racgp.org.au/download/documents/Policies/Clinical/advancedcareplanning_
positionstatement
Medication-related problems may cause unnecessary hospital admissions, adverse drug reactions and other
adverse outcomes for older people living in the community.17 General practitioners (GPs) should review medications
in older people, particularly for vulnerable groups. Vulnerability factors include:
• recent discharge from hospital or other facility
• significant changes made to medication treatment regimen in the past three months
• high-risk drug groups (eg those with a narrow therapeutic index and those that cause xerostomia)
• confusion/cognitive impairment or dementia
• other causes of difficulty managing medications including literacy, language issues, dexterity problems, sight
impairment
• inability to manage therapeutic devices
• history of falls
• currently taking five or more regular medications
• taking >12 doses of medication per day
• patients attending multiple doctors including GPs and specialists
• disease states where medication management is an important process of care (chronic kidney disease,
congestive cardiac failure)18
• multiple chronic medical problems
• regular use of alcohol
• previous adverse drug reaction
• anticholinergic load.
GPs may consider a medication review, in particular focusing on reducing medications and anticholinergic load.
The most successful interventions were delivered by small numbers of pharmacists working in close liaison with
primary care doctors (III, C).19 The review should include consideration of the need for each medication; issues
around patient compliance and understanding of the medication; screening for side effects, particularly falls and
cognitive impairment; and consideration of the use of aids such as dosette boxes and Webster packaging. A
review of the combined anticholinergic and sedative loads of the medications may also be done, as anticholinergic
and sedative loads increase the rate of confusion and other adverse side effects.20–23 This process is often referred
to as ‘deprescribing’.24
http://www.racgp.org.au/download/documents/Policies/Clinical/advancedcareplanning_positionstatement
http://www.racgp.org.au/download/documents/Policies/Clinical/advancedcareplanning_positionstatement
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Guidelines for preventive activities in general practice
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5.1 Immunisation
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Influenza immunisation is recommended for adults aged >65 years, according to the Australian immunisation
handbook (which is regularly updated and available at www.immunise.health.gov.au/internet/immunise/publishing.
nsf/Content/Handbook10-home). However, the benefits are modest, with a number needed to treat of 71 people in
the general population for influenza vaccination to prevent a single episode of influenza in older age.25
Table 5.1. Immunisation: Preventive interventions in older age
Intervention Technique References
Vaccination: Influenza Annual influenza vaccination in the pre-flu season months (III, C) 26
Vaccination: Pneumococcal 23-valent pneumococcal polysaccharide vaccine (23vPPV) is
recommended for the prevention of invasive pneumococcal disease
(II, B)
Vaccination should be done opportunistically. One dose is currently
recommended, except for those who have a condition that predisposes
them to an increased risk of invasive pneumococcal disease
Refer to www.health.gov.au/internet/immunise/publishing.nsf/content/
older-australians
27
Vaccination: Herpes zoster A single dose of zoster vaccine is recommended for adults aged >60
years (II, B)
Also refer to Section 6.1. Immunisation
28
23vPPV, 23-valent pneumococcal polysaccharide vaccine
5.2 Physical activity
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Advice about moderate physical activity is recommended for all older people (A).29 In addition, vigorous physical
activity offers additional benefits for those without specific contraindications such as unstable, advanced or terminal
illness. For the older person, physical activity provides many benefits, as well as minimising some of the limitations
of later life.30
Benefits include:
• maintaining or improving physical function and independent living
• improving social interactions, quality of life, sleep and reducing depression
• building and maintaining healthy bones, muscles and joints, reducing the risk of injuries from falls
• reducing the risk of heart disease, stroke, high blood pressure, type 2 diabetes, some cancers and vascular
disease and Alzheimer’s dementia
• improving management of lung disease, heart disease, arthritis, osteoporosis, kidney disease, stroke, cancer,
and other chronic conditions.
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
http://www.health.gov.au/internet/immunise/publishing.nsf/content/older-australians
http://www.health.gov.au/internet/immunise/publishing.nsf/content/older-australians
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Guidelines for preventive activities in general practice
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The following are Australia’s physical activity and sedentary behaviour guidelines for older people31
(www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-phys-act-guidelines#chba):
Older people:
• should do some form of physical activity, no matter what their age, weight, health problems or abilities
• should be active every day in as many ways as possible, doing a range of physical activities that incorporate
fitness, strength, balance and flexibility
• should accumulate at least 30 minutes of moderate intensity physical activity on most, preferably all, days
• who have stopped physical activity, or who are starting a new physical activity, should start at a level that is
easily manageable and gradually build up to the recommended amount, type and frequency of activity
• who continue to enjoy a lifetime of vigorous physical activity should carry on doing so in a manner suited to their
capability into later life, provided recommended safety procedures and guidelines are adhered to.
Refer to falls risk reduction in Table 5.3.2 for more information on specific exercises.
5.3 Falls
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Approximately 30% of people aged ≥65 years report one or more falls in the past 12 months.32 Most falls are
caused by an interaction of multiple risk factors. Having one fall puts you at risk of another fall, and the more risk
factors, the greater the chance of falling. You can help your patients manage their risk and prevent further falls by
regularly asking them about falls.
Table 5.3.1. Falls: Identifying risks
Who is at risk of falls? What should be done? How often? References
Average risk:
• All people aged ≥65 years Screen for falls (I, A) Every 12 months 29, 33
Moderately high risk:
• Older people presenting with one or more falls,
who report recurrent falls or with multiple risk
factors (refer to Table 5.3.2)
Case find for risk factors
and involve in preventive
activities (I, A)
Every six months 32, 33
http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-phys-act-guidelines#chba
48
Guidelines for preventive activities in general practice
9th edition
Table 5.3.2. Falls: Preventive interventions
Intervention Technique References
Screening for
falls risk
Case finding
questions
about risk
factors to be
used in those
at moderately
high risk
Ask the following three screening questions:
1. Have you had two or more falls in the past 12 months?
2. Are you presenting following a fall?
3. Are you having difficulty with walking or balance?
If the answers to any of these are positive, complete a multifactorial risk
assessment including obtaining relevant medical history, completing a physical
examination, and performing cognitive and functional assessments
• History should include:
– detailed history of falls (eg how many falls?, at home or outdoors?,
patient perception of causes, any fear of falling)
– multiple medications, and specific medications (eg psychotropic
medications)
– impaired gait, balance and mobility
– foot pain and deformities, and unsafe footwear
– home hazards
– bifocal or multifocal spectacle use
– incontinence
– recent discharge from hospital
– chronic illness such as stroke, multiple sclerosis (MS), Parkinson’s
disease, cognitive impairment/dementia
– vitamin D deficiency/poor sun exposure if housebound or in a care
facility
• Physical examination should include:
– impaired visual acuity, including cataracts
– reduced visual fields
– muscle weakness
– neurological impairment
– cardiac dysrhythmias
– postural hypotension
– six-metre walk, balance, sit-to-stand*
• Cognitive and functional impairments should include:
– dementia/cognitive impairment assessment (eg General Practitioner
Assessment of Cognition [GPCOG])
– activities of daily living and home assessment as appropriate (eg by
occupational therapist)
– falls risk–assessment tools
– if unsteady, gait and mobility assessment by physiotherapist
There are many fall risk–assessment tools. However, reports from researchers
are variable, so no single tool can be recommended for implementation in all
settings or for all subpopulations within each setting
Also refer to Chapter 13. Urinary incontinence
32, 34–36
29, 32, 33, 37
29
38, 39
49
Guidelines for preventive activities in general practice
9th edition
Intervention Technique References
Falls risk
reduction
Prescribe or refer for a home-based exercise program and/or encourage
participation in a community-based exercise program, particularly targeting
balance and which may include strength and endurance (I)
For specific exercises to reduce the risk of falls, refer to www.racgp.org.au/
your-practice/guidelines/handi/interventions/musculoskeletal/exercises-for-
falls-prevention
Patients who report unsteadiness or are at higher risk of falls should be
referred to a health professional for individual exercise prescription. Referral
should specify fall prevention
Exercise programs targeting non–English-speaking patients may need to
address cultural norms about appropriate levels of physical activity
Exercise guidelines for fall prevention recommend the following:
• Exercise that specifically challenges balance is the most effective physical
activity intervention to prevent falls
• Exercise needs to be done for at least two hours per week and continue as
a lifetime activity
• Fall prevention exercises can be home-based or a group program.
• Walking or strength training as a single intervention does not appear to
prevent falls
Regularly review medication. Encourage patients to keep a medication review
card. Reduce dose to address side effects and dose sensitivity, and stop
medications that are no longer needed
Medications that can promote falls include psychotropic medications, and
medications with anticholinergic activity, sedation effects and hypotensive
effects or orthostatic hypotensive side effects
Also refer to Chapter 14. Osteoporosis
A home assessment should be considered for those at moderately high to
high risk of falls. Occupational therapy interventions can reduce fall hazards,
raise awareness of fall risk and implement safety strategies. Referral should
specify fall prevention
Other risk factors should be managed actively including:
• using a multidisciplinary team (eg podiatrist regarding foot problems,
optometrist regarding avoidance of multifocal lenses, physiotherapist or
nurse regarding urge incontinence)
• referring to relevant medical specialists (eg ophthalmologist for cataract
surgery, cardiologist for consideration of pacemaker)
• investigating the causes of dizziness
40–47
29, 33
41
48, 49
33
29, 33
29, 33
*Two simple tests are the repeated chair standing test and alternate step test. The repeated chair standing test
measures how quickly an older person can rise from a chair five times without using the arms. A time of >12 seconds
indicates an increased fall risk. The alternate step test measures how quickly an older person can alternate steps (left,
right, left, etc) onto an 18 cm high step a total of eight times. A time >10 seconds indicates an increased fall risk. The
Quickscreen assessment tool, developed and validated for use in an Australian population, includes these tests as well
as simple assessments of medication use, vision, sensation and balance. This is available at www.neura.edu.au/wp-
content/uploads/2016/05/QuickScreen-Information-Order-Form_1
GPCOG, General Practitioner Assessment of Cognition; MS, multiple sclerosis
http://www.racgp.org.au/your-practice/guidelines/handi/interventions/musculoskeletal/exercises-for-falls-prevention
http://www.racgp.org.au/your-practice/guidelines/handi/interventions/musculoskeletal/exercises-for-falls-prevention
http://www.racgp.org.au/your-practice/guidelines/handi/interventions/musculoskeletal/exercises-for-falls-prevention
http://www.neura.edu.au/wp-content/uploads/2016/05/QuickScreen-Information-Order-Form_1
http://www.neura.edu.au/wp-content/uploads/2016/05/QuickScreen-Information-Order-Form_1
50
Guidelines for preventive activities in general practice
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5.4 Visual and hearing impairment
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Visual acuity should be assessed from 65 years of age using the Snellen chart (B) in those with symptoms or who
request it. There is no evidence that screening of asymptomatic older people results in improved vision.50,51
Hearing loss is a common problem among older individuals and is associated with significant physical, functional
and mental health consequences. Annual questioning about hearing impairment is recommended with people aged
>65 years (B).
In some states and territories, there are legal requirements for annual assessment (eg driving aged >70 years).52
Eye disease and visual impairment increase three-fold with each decade of life after 40 years of age. They are often
accompanied by isolation, depression and poorer social relationships, and are strongly associated with falls and hip
fractures.53 It should be determined whether the patient is wearing up-to-date prescription spectacles, and whether
there is a possibility of falls because the patient is no longer capable of managing a bifocal, trifocal or multifocal
prescription. People at greater risk of visual loss are older people and those with diabetes and a family history of
vision impairment; such history should be sought. Smoking (current or previous) increases the risk of age-related
macular degeneration.54 Cataracts are the most common eye disease in Australians aged ≥65 years (42% of
cases of visual impairment), followed by age-related macular degeneration (AMD; 30%), diabetic retinopathy and
glaucoma. The leading causes of blindness in those aged ≥65 years are AMD (55%), glaucoma (16%) and diabetic
retinopathy (16%).55,56
Table 5.4.1. Visual and hearing impairment: Identifying risks
Who is at higher risk of hearing loss?
What should be
done? How often? References
People ≥65 years of age Screen for hearing
impairment (II, B)
Every 12 months 57
Table 5.4.2. Visual and hearing impairment: Preventive interventions
Intervention Technique References
Visual impairment: Case finding Use a Snellen chart to screen for visual impairment in the elderly
if requested, or indicated by symptoms or history. There is no
evidence that screening asymptomatic older people results in
improvements in vision
Also refer to Chapter 12. Glaucoma
50
Hearing impairment screening A whispered voice out of the field of vision (at 0.5 m) or finger
rub at 5 cm has a high sensitivity for hearing loss, as does a
single question about hearing difficulty
58
51
Guidelines for preventive activities in general practice
9th edition
5.5 Dementia
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
With people aged >65 years, clinicians should be alert to the symptoms and signs of dementia. These may
be detected opportunistically and assessed using questions addressed to the person and/or their carer (C).
Depression and dementia may co-exist. When a person has dementia, adequate support is required for the
person, carer and family. Counselling and education are important. Management priorities will vary from patient to
patient, but there may be a need to consider medical management of dementia, behaviour and comorbidity, legal
and financial planning, current work situation, driving, and advance care planning.59
Table 5.5.1. Dementia: Identifying risks
Who is at risk? What should be done? How often? References
Average risk:
• Those without symptoms No evidence of benefit from
screening (II, C)
N/A 60, 61
Moderate risk:
• Those with symptoms (refer to Table 5.5.2)
• Risk increases with increasing age
• A family history of Alzheimer’s disease
• People with history of repeated head trauma
• People with Down syndrome
• Those with elevated cardiovascular risk (eg heart
disease, stroke, hypertension, obesity, diabetes,
elevated homocysteine, elevated cholesterol,
smoking, sedentary lifestyle)
• Those with depression or a history of depression
• People with low levels of education
• Aboriginal and Torres Strait Islander peoples
Case finding and early
intervention (III, C)
Note that culturally safe
practices should be adopted
with this community
N/A 62–64
65
66–69
64
70–74
52
Guidelines for preventive activities in general practice
9th edition
Table 5.5.2. Dementia: Preventive interventions
Intervention Technique References
Case
finding and
confirmation
• Ask ‘How is your memory?’ and obtain information about dementia and other
cognitive problems from others who know the person (eg repeating questions,
forgetting conversations, double buying, unpaid bills, social withdrawal)
• Other symptoms may include a decline in thinking, planning and organising, and
reduced emotional control or change in social behaviour affecting daily activities.
Not everyone with dementia has memory problems as an initial symptom (C). Other
clues are missed appointments (receptionist often knows), change in compliance
with medications, and observable deterioration in grooming or dressing. Falls may
also be an indication of cognitive impairment
• Over several consultations, obtain the history from the person and family/carer, and
perform a comprehensive physical examination. Undertake cognitive assessment
using:
– Standardised Mini-Mental State Examination (SMMSE) available at www.ihpa.
gov.au/publications/standardised-mini-mental-state-examination-smmse
– General Practitioner Assessment of Cognition at www.gpcog.com.au
– clock drawing test
– Rowland Universal Dementia Assessment Scale at www.fightdementia.org.au/
understanding-dementia/rowland-universal-dementia-assessment-scale.aspx
which is a multicultural cognitive assessment scale that has been used to detect
dementia across cultures
– The Kimberley Indigenous Cognitive Assessment tool (KICA) dementia
assessment instrument (available at www.healthinfonet.ecu.edu.au/key-
resources/programs-projects?pid=509), may be used as a component of
dementia assessment for Aboriginal and Torres Strait Islander peoples living in
remote areas; and the modified KICA, may be used as a component of dementia
assessment in more urban Aboriginal and Torres Strait Islander peoples
– The Mini-Mental State Examination (MMSE), is the most widely used and
evaluated scale. However, as it is now copyrighted, it should be replaced by
the SMMSE
A suite of recommended rating tools is available at www.dementia-assessment.com.au
• Assess functional status. The Instrumental activities of daily living at
www.abramsoncenter.org/media/1456/instrumental-activities-of-daily-living.
pdf assessment tool may be used. All screening instruments used to assess
dementia in general practice have high rates of overdiagnosis (false positives) and
underdiagnosis (false negatives), so the full clinical presentation needs to be taken
into account. Reassessment after 6–12 months may be helpful
Assessment should include relevant blood tests and imaging to a exclude space-
occupying lesion or other brain disorder
Relevant tests are recommended in the Clinical practice guidelines for dementia in
Australia available at http://sydney.edu.au/medicine/cdpc/documents/resources/
LAVER_Dementia_Guidleines_recommendations_PRVW5
75–77
75
78
79
80, 81
http://www.ihpa.gov.au/publications/standardised-mini-mental-state-examination-smmse
http://www.ihpa.gov.au/publications/standardised-mini-mental-state-examination-smmse
http://www.gpcog.com.au
http://www.fightdementia.org.au/understanding-dementia/rowland-universal-dementia-assessment-scale.aspx
http://www.fightdementia.org.au/understanding-dementia/rowland-universal-dementia-assessment-scale.aspx
http://www.healthinfonet.ecu.edu.au/key-resources/programs-projects?pid=509
http://www.healthinfonet.ecu.edu.au/key-resources/programs-projects?pid=509
http://www.dementia-assessment.com.au
http://www.abramsoncenter.org/media/1456/instrumental-activities-of-daily-living
http://www.abramsoncenter.org/media/1456/instrumental-activities-of-daily-living
http://sydney.edu.au/medicine/cdpc/documents/resources/LAVER_Dementia_Guidleines_recommendations_PRVW5
http://sydney.edu.au/medicine/cdpc/documents/resources/LAVER_Dementia_Guidleines_recommendations_PRVW5
53
Guidelines for preventive activities in general practice
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Intervention Technique References
Early
intervention
and
prevention
Evidence is growing that attention to cardiovascular disease (CVD) risk factors may
improve cognitive function and/or reduce dementia risk. There is sufficient evidence
now for clinicians to recommend the following strategies for early intervention and
prevention of dementia:
• increased physical activity (eg 150 minutes per week of moderate-intensity walking
or equivalent)
• social engagement (increased number of social activities per week)
• cognitive training and rehabilitation
• diet – the Mediterranean and the Dietary Approaches to Stop Hypertension (DASH)
diets have been shown to be protective against cognitive decline
• smoking cessation
• management of vascular risk factors (refer to Chapter 8. Prevention of vascular and
metabolic disease)
• use of the risk assessment tool developed by the Collaborative Research Centre,
which is based on dementia prevention, and takes about 15 minutes to fill out and
provides a good overview for all the possible risks for dementia, for discussion with
the GP available at http://anuadri.anu.edu.au
Refer to Chapter 7. Prevention of chronic disease, Chapter 8. Prevention of vascular
and metabolic disease, and Chapter 10. Psychosocial
68, 69, 82–87
88
89, 90
91, 92
67
66, 68
CVD, cardiovascular disease; DASH, Dietary Aproaches to Stop Hypertension; KICA, Kimberley Indigenous Cognitive Assessment;
MMSE, Mini-Mental State Examination; SMMSE, Standardised Mini-Mental State Examination
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2012;9:CD007146.
34. Coleman AL, Stone K, Ewing SK, et al. Higher risk of
multiple falls among elderly women who lose visual
acuity. Ophthalmology 2004;111(5):857–62.
35. Hodge W, Horsley T, Albiani D, et al. The consequences
of waiting for cataract surgery: A systematic review. Can
Med Assoc J 2007;176(9):1285–90.
36. National Institute for Health and Care Excellence. Falls
– Assessment and prevention of falls in older people.
London: NICE, 2013.
37. Scott V, Votova K, Scanlan A, Close J. Multifactorial and
functional mobility assessment tools for fall risk among
older adults in community, home-support, long-term and
acute care settings. Age Ageing 2007;36(2):130–39.
38. Tiedemann A, Lord SR, Sherrington C. The development
and validation of a brief performance-based fall risk
assessment tool for use in primary care. J Gerontol A Biol
Sci Med Sci 2010;65(8):896–903.
39. Tiedemann A, Shimada H, Sherrington C, Murray S, Lord
S. The comparative ability of eight functional mobility
tests for predicting falls in community-dwelling older
people. Age Ageing 2008;37(4):430–35.
40. Australian Commission on Safety and Quality in Health
Care. Preventing falls and harm from falls in older
people: Best practice guidelines for Australian hospitals,
residential aged care facilities and community care.
Sydney: ACSQHC, 2009.
41. Borschmann K, Moore K, Russell M, et al. Overcoming
barriers to physical activity among culturally and
linguistically diverse older adults: A randomised controlled
trial. Australas J Ageing 2010;29(2):77–80.
42. Cameron ID, Murray GR, Gillespie LD, et al. Interventions
for preventing falls in older people in nursing care
facilities and hospitals. Cochrane Database Syst Rev
2010;1:CD005465.
43. Gillespie LD, Robertson MC, Gillespie WJ, et al.
Interventions for preventing falls in older people living
in the community. Cochrane Database Syst Rev
2009;2:CD007146.
44. Sherrington C, Whitney J, Lord S, Herbert R, Cumming
R, Close J. Effective exercise for the prevention of falls: A
systematic review and meta-analysis. J Am Geriatr Soc
2008;56(12):2234–43.
45. US Preventive Services Task Force. Prevention of falls in
community-dwelling older adults. Rockville, MD: USPSTF,
2012. Available at www.uspreventiveservicestaskforce.
org/uspstf/uspsfalls.htm [Accessed 15 December 2015].
46. Wyman JF, Croghan CF, Nachreiner NM, et al.
Effectiveness of education and individualized counseling
in reducing environmental hazards in the homes of
community-dwelling older women. J Am Geriatr Soc
2007;55(10):1548–56.
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47. Zijlstra GA, van Haastregt JC, van Rossum E, van Eijk
JT, Yardley L, Kempen GI. Interventions to reduce fear
of falling in community-living older people: A systematic
review. J Am Geriatr Soc 2007;55(4):603–15.
48. Sherrington C, Lord S, JCT C. Best-practice
recommendations for physical activity to prevent falls in
older adults: An evidence check rapid review brokered by
the Sax Institute for the Centre for Health Advancement.
Sydney: Department of Health, 2008. Available at www.
saxinstitute.org.au [Accessed 15 May 2016].
49. Tiedemann A, Sherrington C, Close JC, Lord SR.
Exercise and Sports Science Australia position statement
on exercise and falls prevention in older people. J Sci
Med Sport 2011; 14(6):489–95.
50. Smeeth L, Iliffe S. Community screening for visual
impairment in the elderly. Cochrane Database Syst Rev
2006;3:CD001054.
51. US Preventive Services Task Force. Impaired visual acuity
in older adults: Screening. Rockville, MD: USPSTF, 2016.
Available at www.uspreventiveservicestaskforce.org/
Page/Document/UpdateSummaryFinal/impaired-visual-
acuity-in-older-adults-screening#consider [Accessed 23
May 2016].
52. Austroads. Assessing fitness to drive for commercial
and private vehicle drivers. Sydney: Austroads, 2012
(as amended up to 30 June 2014). Available at www.
onlinepublications.austroads.com.au/items/AP-G56-13
[Accessed 15 December 2015].
53. Taylor H, Keeffe J. Updates in medicine: Ophthalmology.
Med J Aust 2002;176(1):29.
54. Smith W, Mitchell P, Leeder SR. Smoking and age-related
maculopathy. The Blue Mountains Eye Study. Arch
Ophthalmol 1996;114(12):1518–23.
55. Australian Institute of Health and Welfare. Australia’s
health 2006. Canberra: AIHW, 2006.
56. Tapp RJ, Shaw JE, Harper CA, et al. The prevalence of
and factors associated with diabetic retinopathy in the
Australian population. Diabetes Care 2003;26(6):1731–37.
57. US Preventive Services Task Force. Screening for hearing
loss in older adults. Rockville MD: USPSTF, 2011.
Available at www.uspreventiveservicestaskforce.org/
uspstf/uspshear.htm#top [Accessed 15 December 2015].
58. Moyer VA. Screening for hearing loss in older adults:
US Preventive Services Task Force recommendation
statement. Ann Intern Med 2012;157(9):655–61.
59. The Royal Australian College of General Practitioners,
NSW Health. Care of patients with dementia in general
practice: Guidelines. Sydney: Department of Health,
2003.
60. Boustani M, Peterson B, Hanson L, et al. Screening for
dementia in primary care: A summary of the evidence for
the US Preventive Services Task Force. Ann Intern Med
2003;138(1):927–37.
61. National Collaborating Centre for Mental Health.
Dementia: A NICE-SCIE Guideline on supporting people
with dementia and their carers in health and social
care. London: National Institute for Health and Care
Excellence, 2007.
62. Gao S, Hendrie HC, Hall KS, Hui S. The relationship
between age, sex and the incidence of dementia and
Alzheimer disease: A metaanalysis. Arch Gen Psychiatry
1998;55(9):809–15.
63. Lautenschlager NT, Cupples LA, Rao VS, et al. Risk of
dementia among relatives of Alzheimer’s disease patients
in the MIRAGE study: What is in store for the oldest old?
Neurology 1996;46(3):641–50.
64. Lenoir H, Dufouil C, Auriacombe S, et al. Depression
history, depressive symptoms, and incident dementia:
The 3C Study. J Alzheimers Dis 2011;26(1):27–38.
65. Fleminger S, Oliver DL, Lovestone S, Rabe-Hesketh
S, Giora A. Head injury as a risk factor for Alzheimer’s
disease: The evidence ten years on; a partial replication.
J Neurol Neurosurg Psychiatry 2003;74(7):857–62.
66. Anstey KJ, Eramudugolla R, Hosking DE, Lautenschlager
NT, Dixon RA. Bridging the translation gap: From
dementia risk assessment to advice on risk reduction. J
Prev Alzheimers Dis 2015;2(3):189–98.
67. Anstey KJ, von Sanden C, Salim A, O’Kearney R.
Smoking as a risk factor for dementia and cognitive
decline: A meta-analysis of prospective studies. Am J
Epidemiol 2007;166(4):367–78.
68. Alzheimer’s Disease International. World Alzheimer
report 2014. Dementia and risk reduction. An analysis
of protective and modifiable risk factors. London:
Alzheimer’s Disease International, 2014.
69. Beydoun MA, Beydoun HA, Gamaldo AA, Teel A,
Zonderman AB, Wang Y. Epidemiologic studies of
modifiable factors associated with cognition and
dementia: Systematic review and meta-analysis. BMC
Public Health 2014;14:643.
70. Flicker L, Holdsworth K. Aboriginal and Torres Strait
Islander people and dementia: A review of the research.
A report for Alzheimer’s Australia. North Ryde, NSW:
Alzheimer’s Australia, 2014.
71. Broe T, Wall S. The Koori dementia care project (KDCP):
Final report. Sydney: Dementia Collaborative Research
Centres, 2013. Available at: www.dementiaresearch.org.
au/images/dcrc/output-files/1288-cb55_final_report_
with_amendments
72. Smith K, Flicker L, Lautenschlager NT, et al. High
prevalence of dementia and cognitive impairment in
Indigenous Australians. Neurology 2008;71(19):1470–73.
73. Australian Health Ministers’ Advisory Council. Standing
Committee on Aboriginal and Torres Strait Islander Health
Working Party. AHMAC cultural respect framework for
Aboriginal and Torres Strait Islander health, 2004–2009.
Canberra: AHMAC, 2004.
74. Smith K, Flicker L, Shadforth G, et al. ‘Gotta be sit down
and worked out together’: Views of Aboriginal caregivers
and service providers on ways to improve dementia
care for Aboriginal Australians. Rural Remote Health.
2011;11:1650: Available at www.rrh.org.au/articles/
subviewnew.asp?ArticleID=1650 [Accessed 26 January
2016].
75. Brodaty H, Pond D, Kemp NM, Luscombe GS, Harding
L. The GPCOG: A new screening test for dementia
designed for general practice. J Am Geriatr Soc
2002;50(3):530–34.
76. DeLepeleire J, Heyrman J, Baro F, Buntinx F. A
combination of tests for the diagnosis of dementia
http://www.dementiaresearch.org.au/images/dcrc/output-files/1288-cb55_final_report_with_amendments
http://www.dementiaresearch.org.au/images/dcrc/output-files/1288-cb55_final_report_with_amendments
http://www.dementiaresearch.org.au/images/dcrc/output-files/1288-cb55_final_report_with_amendments
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had significant diagnostic value. J Clin Epidemiol
2005;58(3):217–25.
77. Dementia Collaborative Research Centre – Assessment
and Better Care 2011. 14 Essentials for good dementia
care in general practice. Sydney: University of New South
Wales, 2011.
78. Kirby M, Denihan A, Bruce I, Coakley D, Lawlor BA. The
clock drawing test in primary care: Sensitivity in dementia
detection and specificity against normal and depressed
elderly. Int J Geriatr Psychiatry 2001;16(10):935–40.
79. Storey J, Rowland JTJ, Conforti DA, Dickson HG.
The Rowland Universal Dementia Assessment Scale
(RUDAS): A multicultural cognitive assessment scale. Int
Psychogeriatr 2004;16(1):13–31.
80. Laver K, Cumming RG, Dyer SM, et al. Clinical practice
guidelines for dementia in Australia. Med J Aust
2016;204(5):191–93.
81. Guideline Adaptation Committee. Clinical practice
guidelines and principles of care for people with
dementia. Sydney: Guideline Adaptation Committee,
2016.
82. Farooki A. Central obesity and increased risk of
dementia more than three decades later. Neurology
2009;72(11):1030–31.
83. Helzner EP, Luchsinger JA, Scarmeas N, et al.
Contribution of vascular risk factors to the progression in
Alzheimer disease. Arch Neurol 2009;66(3):343–48.
84. Peila R, White LR, Petrovich H, et al. Joint effect of the
APOE gene and midlife systolic blood pressure on late-
life cognitive impairment: The Honolulu-Asia Aging Study.
Stroke 2001;32(12):2882–89.
85. Razay G, Williams J, King E, Smith AD, Wilcock G.
Blood pressure, dementia and Alzheimer’s disease: The
OPTIMA longitudinal study. Dement Geriatr Cogn Disord
2009;28(1):70–74.
86. Stewart R, Asonganyi B, Sherwood R. Plasma
homocysteine and cognitive impairment in an older
British African-Caribbean population. J Am Geriatr Soc
2002;50(7):1227–32.
87. White L, Launer L. Relevance of cardiovascular risk
factors and schemic cerebrovascular disease to the
pathogenesis of Alzheimer disease: A review of accrued
findings from the Honolulu-Asia Aging Study. Alzheimer
Dis Assoc Disord 2006;20(3 Suppl 2):S79–83.
88. Mortimer JA, Ding D, Borenstein AR, et al. Changes
in brain volume and cognition in a randomized trial of
exercise and social interaction in a community-based
sample of non-demented Chinese elders. J Alzheimers
Dis 2012;30(4):757–66.
89. Sitzer DI, Twamley EW, Jeste DV. Cognitive training in
Alzheimer’s disease: A meta-analysis of the literature.
Acta Psychiatr Scand 2006;114(2):75–90.
90. Lampit A, Hallock H, Moss R, et al. Dose-response
relationship between computerized cognitive training
and global cognition in older adults. J Nutrit Health Aging
2013;17(9):803–04.
91. Lourida I, Soni M, Thompson-Coon J, et al.
Mediterranean diet, cognitive function, and dementia: A
systematic review. Epidemiology 2013;24(4):479–89.
92. Tangney CC, Li H, Wang Y, et al. Relation of DASH- and
Mediterranean-like dietary patterns to cognitive decline in
older persons. Neurology 2014;83(16):1410–6.
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6. Communicable diseases
General practitioners (GPs) have an important role in the prevention and management of communicable diseases.
This includes advice on prevention, immunisation, early detection and management.
The use of immunisation information systems1 such as the Australian Childhood Immunisation Register (ACIR) and
Vaccination Information and Vaccination Administration System (VIVAS) in Queensland helps raise immunisation
rates. The available information in these databases helps to create recall-and-reminder systems and individual
immunisation records within GP electronic medical records. An adult immunisation register is planned from
September 2016.2
Updates on communicable diseases and notification requirements are available from the Department of Health at
www.health.gov.au/internet/main/publishing.nsf/Content/cda-surveil-nndss-casedefs-distype.htm
Notification of particular infectious diseases to state public health units is mandatory (the law overrides all privacy
regulations). This is almost completely automated by pathology laboratories, but for clinically diagnosed infections
such as varicella and herpes zoster, the GP is required to notify the relevant authority.
6.1 Immunisation
Age Birth <2 2–3 4–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 ≥65
Immunisation is recommended from birth for all children, and at particular ages throughout life, according to the
Australian immunisation handbook (this is updated regularly at www.health.gov.au/internet/immunise/publishing.
nsf/Content/Handbook10-home).
Consent
Consent should be sought from someone with legal capacity before each vaccination. The individual providing
consent should have the intellectual capacity to understand specific information and agree voluntarily without
pressure, coercion or manipulation. The consent process should include written advice about benefits and harms
of the vaccines, risk of not having the vaccine, and what to do after receiving the vaccine. Information on providing
valid consent is available at www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-
home~handbook10part2~handbook10-2-1#2-1-3
The National Immunisation Program Schedule (NIPS) lists the recommended funded vaccines for all Australian
residents. There may be other vaccines that are not funded but are recommended in the Australian immunisation
handbook, depending on occupation or travel. There may be variability in vaccines recommended/funded (eg
hepatitis A vaccine).
Vaccination for special high-risk groups
Adults or children who develop asplenia, human immunodeficiency virus (HIV) infection or a haematological
malignancy, or who have received a bone marrow or other transplant, may not be fit for some vaccinations, or may
require additional or repeat vaccinations.
www.health.gov.au/internet/main/publishing.nsf/Content/cda-surveil-nndss-casedefs-distype.htm
http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home~handbook10part2~handbook10-2-1#2-1-3
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home~handbook10part2~handbook10-2-1#2-1-3
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Health inequity
What are the key equity issues and who is at risk?
GPs need to be aware of groups with lower levels of age-appropriate immunisation.3 Socioeconomic
characteristics associated with lower immunisation rates at 12 months4 include:
• being Aboriginal or Torres Strait Islander
• being born overseas
• no private health insurance
• being in the highest or lowest socioeconomic quintile
• being of low birth weight and singleton birth.
All of these factors were also associated with lower immunisation coverage at 24 months, with the exception of low
birth weight, which was only significant in the very low birth weight category.
What can GPs do?
Evidence supports a number of strategies in improving immunisation rates that could reduce inequities if efforts
were focused on at-risk groups:
• audit of immunisation coverage of at-risk groups in the practice
• use of recall-and-reminder systems and catch-up plans, with a focus on at-risk groups
• integrating vaccination status checks into routine health assessments for those target population groups.
Table 6.1.1. Summary of the main requirements from the National Immunisation Program
Schedule
Age Vaccine
Birth* Hepatitis B (hep B)
6–8 weeks Hepatitis B, diphtheria, tetanus, acellular pertussis (whooping cough), haemophilus
influenzae type b, inactivated poliomyelitis (polio; hepB-DTPa-Hib-IPV)
Pneumococcal conjugate (13vPCV)
Rotavirus (dose 1 of Rotarix or RotaTeq)†
4 months Hepatitis B, diphtheria, tetanus, acellular pertussis (whooping cough), haemophilus
influenzae type b, inactivated poliomyelitis (polio; hepB-DTPa-Hib-IPV)
Pneumococcal conjugate (13vPCV)
Rotavirus (dose 2 Rotarix or RotaTeq)†
6 months Hepatitis B, diphtheria, tetanus, acellular pertussis (whooping cough), haemophilus
influenzae type b, inactivated poliomyelitis (polio; hepB-DTPa-Hib-IPV)
Pneumococcal conjugate (13vPCV)
Rotavirus (dose 3 for RotaTeq recipients only)†
≥6 months Influenza annually (for those at risk of serious complications of influenza – eg Aboriginal
and Torres Strait Islander peoples)
12 months Haemophilus influenzae type b and meningococcal C (Hib-MenC)
Measles, mumps and rubella (MMR)
Pneumococcal conjugate (13vPCV) booster (only for medically at-risk groups)
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Age Vaccine
12–18 months Hepatitis A (for Aboriginal and Torres Strait Islander peoples in the Northern Territory,
Queensland, South Australia and Western Australia only)
Pneumococcal conjugate (13vPCV; for Aboriginal and Torres Strait Islander peoples in
the Northern Territory, Queensland, South Australia and Western Australia only)
18 months Measles, mumps, rubella and varicella (chickenpox; MMRV)
Diphtheria, tetanus, acellular pertussis (whooping cough; DTPa)
18–24 months Hepatitis A (for Aboriginal and Torres Strait Islander peoples in the Northern Territory,
Queensland, South Australia and Western Australia only)
4 years‡ Diphtheria, tetanus, acellular pertussis (whooping cough) and inactivated poliomyelitis
(polio; DTPa-IPV)
Measles, mumps and rubella (MMR; if MMRV vaccine was not given at 18 months of
age)
Pneumococcal polysaccharide (23vPPV; only for medically high-risk groups)
10–15 years
School-based programs +/–
GP catch-up
Hepatitis B (two adult doses for those not vaccinated against hepatitis B)
Varicella (catch up until all immunised)
Human papillomavirus (HPV; three doses over six months)
Diphtheria, tetanus and acellular pertussis (dTpa is the adult/adolescent vaccine)
15–49 years Influenza annually (for Aboriginal and Torres Strait Islander peoples)
Pneumococcal polysaccharide (23vPPV; for Aboriginal and Torres Strait Islander people
who are medically at risk)
Pregnant women Influenza
Diphtheria, tetanus and acellular pertussis (dTpa) from 28 weeks (up to 38 weeks
acceptable). Note that this is recommended for all but funding is variable
50 years and over Influenza (for Aboriginal and Torres Strait Islander peoples)
Pneumococcal polysaccharide (23vPPV; for Aboriginal and Torres Strait Islander
peoples)
65 years and over Influenza
Pneumococcal polysaccharide (23vPPV)
*Hep B vaccine (dose 1 or 0) should ideally be given to all infants within 24 hours of birth, but at most within seven days of birth.
Infants born to hepatitis B surface antigen (HBsAg)–positive mothers should be given hepatitis B immune globulin (HBIG) and a
dose of monovalent hepatitis B vaccine on the day of birth (preferably within 12 hours of birth and certainly within 48 hours). Further
information at www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
†Rotavirus vaccines are contraindicated in infants with a history of intussusception (IS), or predisposing abnormality to IS, or severe
combined immunodeficiency. Rotavirus vaccines are time limited and differ in number of doses and timing: catch-up may not be possible
‡MMR dose 2 remains at 4 years of age for children not immunised with MMRV at 18 months
www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
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Table 6.1.2. Vaccines recommended but not funded in National Immunisation Program
Age Vaccine
Soon after birth Bacillus Calmette–Guérin (BCG; Aboriginal and Torres Strait Islander peoples in higher risk areas
of the Northern Territory, Queensland, and parts of northern South Australia). Infants born to
migrants from country with high risk of tuberculosis (TB) – look up individual state and territory
guidelines
<2 years and
between 15 and 19
years of age
Meningococcal B vaccine recommended for highest incidence age groups from 6 weeks of age
Any age from 12
months
Varicella – A second dose of vaccine, at least one month after first dose, provides improved
protection from varicella
Parents and carers
of infants aged <6
months
Diphtheria, tetanus and acellular pertussis (dTpa) is recommended to protect the infant from
pertussis. To maximise the protection of infants, parents and carers should get immunised before
the birth. The dTpa vaccine can be given at any time after vaccination with diphtheria, tetanus
(DT), and may be given again five years after previous dTpa
50 years and >65
years
Travellers of any age
dTpa should be used in place of DT when providing booster tetanus immunisations ≥50 years of
age. This booster dose is recommended if no tetanus immunisation was received in the previous
10 years, or no previous dTpa
>60 years A single dose of zoster vaccine is recommended for prevention of shingles
All healthcare
workers
dTpa
Hepatitis B (and hepatitis A in some jurisdictions)
Annual influenza
Measles, mumps and rubella (MMR; if not immune)
Varicella (if not immune)
Men who have sex
with men
People who inject
drugs
Hepatitis A and B
Immunisation information resources include:
• NIPS, available at
www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/national-immunisation-program-schedule
• Australian immunisation handbook, available at www.immunise.health.gov.au/internet/immunise/publishing.nsf/
Content/Handbook10-home
• Australian Childhood Immunisation Register (ACIR), available at www.humanservices.gov.au/customer/services/
medicare/australian-childhood-immunisation-register, by email (acir@humanservices.gov.au) or telephone (1800
653 809). The ACIR can be used to obtain information on the vaccination history of individuals from birth to 7
years of age given since 1 January 1996
• National Centre for Immunisation Research & Surveillance, available at www.ncirs.edu.au
Notification of adverse events
The reporting of adverse events following vaccinations varies geographically. It is possible to report directly to the
Therapeutic Goods Administration (TGA) from anywhere in Australia by telephone on 1800 044 114, or online at
www.tga.gov.au/hp/problem-medicine-reporting-reactions.htm
www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/national-immunisation-program-schedule
www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
http://www.humanservices.gov.au/customer/services/medicare/australian-childhood-immunisation-register
http://www.humanservices.gov.au/customer/services/medicare/australian-childhood-immunisation-register
http://www.ncirs.edu.au
www.tga.gov.au/hp/problem-medicine-reporting-reactions.htm
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6.2 Sexually transmissible infections
Sexually transmissible infections (STIs) are frequently seen in general practice, especially chlamydia, which is
typically asymptomatic.5,6 It is important to detect it early in order to prevent transmission to others and minimise
potential complications, such as infertility. It may also be appropriate to screen for other STIs. The individual’s age,
sexual behaviour and community HIV or STI prevalence all influence the level of risk, and should influence the
choice of STI screening tests. For additional resources specific to Aboriginal and Torres Strait Islander peoples, The
Royal Australian College of General Practitioners’ (RACGP) National guide to a preventive health assessment for
Aboriginal and Torres Strait Islander people, 2nd edn, includes information about sexual health and blood-borne
viruses (www.racgp.org.au/your-practice/guidelines/national-guide).
Sexual health consultation
Many patients and doctors feel uncomfortable discussing sexual histories even when indicated or the patient is
requesting STI testing. Taking a sexual history is an important part of the assessment and management of STIs,
and it should not be a barrier to offering STI testing.7
A non-judgmental attitude and environment will facilitate disclosures on sexual matters.8 It is important to ask open-
ended questions and to avoid assumptions about sexual orientation, by using the term ‘partner’. Gentle enquiry
about recent sexual activity, gender, number of partners, contraception (including use of condoms), travel history,
and immunisation status helps to inform decision making. Additionally, ask about the risk for blood-borne viruses
(hepatitis B, C, and HIV), such as injecting drug use, tattooing and piercing. Investigations should be explained, and
patients should be asked for consent before tests such as HIV or hepatitis C are ordered.
Contact tracing
Contact tracing is essential in reducing the transmission of STIs and HIV. It is the responsibility of the diagnosing
clinician to facilitate the process of notifying current and past partners. This may be through a direct approach from
the patient, their treating health professional, or by using online partner notification services available such as:
• www.letthemknow.org.au
• www.thedramadownunder.info/notify (for men who have sex with men [MSM])
• www.bettertoknow.org.au (for Aboriginal and Torres Strait Islander youths).
For more information and to determine ‘how far back to trace’, refer to the contact tracing manual at the
Australasian Society of HIV, Viral Hepatitis and Sexual Health Medicine’s (ASHM) website at http://contacttracing.
ashm.org.au or the Contact Tracing Tool for General Practitioners at NSW STI Programs Unit’s website at http://
stipu.nsw.gov.au/wp-content/uploads/GP-Contact-Tracing-Tool
For HIV contact tracing, seek assistance from local sexual health services.
In the case of a notifiable condition, the patient should be informed that case notification to public health authorities
will occur. Notification should be made as set by the department of health in the relevant state or territory.
www.racgp.org.au/your-practice/guidelines/national-guide
http://www.letthemknow.org.au
http://www.thedramadownunder.info/notify
http://stipu.nsw.gov.au/wp-content/uploads/GP-Contact-Tracing-Tool
http://stipu.nsw.gov.au/wp-content/uploads/GP-Contact-Tracing-Tool
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6.2.1 Chlamydia and other STIs
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥ 80
More than 80% of chlamydia infections occur in people <29 years of age.9 Screening for chlamydia infection in
all sexually active people up to 29 years of age is recommended because of increased prevalence and risk of
complications.10 In asymptomatic, sexually active people up to 29 years of age, the overall absolute risk of infection
is approximately 5% for chlamydia and 0.5% for gonorrhoea.
The ranked risk for specific infections per 100,000 in general population/Aboriginal and Torres Strait Islander
populations:11
• Chlamydia (371/1341)
• Gonorrhoea (49/858)
• Hepatitis B (23/50)
• Syphilis (8/32)
• HIV (4/6)
A large proportion of young people will attend primary care clinics each year, and this presents the opportunity
to normalise sexual health care as part of usual general practice.10 Younger sexually active youths should not be
excluded from case finding, or identifying any safety or abuse issues. This may involve a complete psychosocial
(HE2ADS3)12 risk assessment as discussed in Table 3.2.
Women with untreated chlamydia infections have a 2–8% risk of infertility.13 Other STIs to consider screening for
in higher risk individuals are gonorrhoea, HIV and syphilis.14 The risk for gonorrhoea, HIV and syphilis is low for
heterosexuals in all major cities in Australia and New Zealand,15 but rates of gonorrhoea and syphilis are higher
among MSM. The individual’s age and sexual habits, and community STI prevalence all influence the level of risk
and should guide STI testing recommendations for patients (refer to Tables 6.2.1.1 and 6.2.1.2 for guidance).
MSM should be screened for gonorrhoea, chlamydia, syphilis and HIV every 12 months. Screening should be
performed more often if they have multiple sexual contacts. Most MSM with STIs have no symptoms.16
Aboriginal and Torres Strait Islander peoples are at higher risk and should also be screened for gonorrhoea,
chlamydia, syphilis and HIV.
Screening for hepatitis C should be provided if the patient is HIV positive or there is a history of injecting drug use,
as this increases the risk of transmission.16
All pregnant women should be screened for hepatitis B, C, HIV and syphilis.14,17,18 Consider screening pregnant
women up to 29 years of age for chlamydia (and also gonorrhoea, if the patient is at high risk).17–20
63
Guidelines for preventive activities in general practice
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Table 6.2.1.1. Sexually transmissible infections: Identifying risks
Risk assessment of asymptomatic
sexually active person What should be done? How often? References
Low–average risk:
• Heterosexual asymptomatic up to 29 years
of age requesting sexually transmissible
infection (STI) check up
Urine, cervical or genital swab
polymerase chain reaction
(PCR; or self-collected) for
chlamydia
Consider other infections
based on risk assessment
Opportunistically if
indicated (evidence
is unclear on testing
interval)
5
Medium–high risk:
• <20 years of age
• Rural and remote
As above
Consider other infections,
particularly gonorrhoea
and syphilis, based on risk
assessment
Opportunistically if
indicated (evidence
is unclear on testing
interval)
6, 10, 11,
21–26
Higher risk:
• Aboriginal or Torres Strait Islander peoples
Testing for chlamydia,
gonorrhoea, syphilis
Serology for human
immunodeficiency virus (HIV),
syphilis and, if the person is
not vaccinated or immune,
hepatitis A and B (III)
Offer hepatitis A and B
vaccination (III, B)
Every 12 months
(evidence is unclear
on testing interval)
27
Other higher risk:
• People who inject drugs
• Sex workers
Testing for chlamydia,
gonorrhoea, syphilis; Serology
for HIV, syphilis; if the person
is not vaccinated or immune,
hepatitis A and B
Offer hepatitis A and B
vaccination (III, B)
Hepatitis C testing if the
patient injects drugs
Every 12 months
(evidence is unclear
on testing interval)
Highest risk:
• Asymptomatic men who have sex with men
• Highest risk in those who:
– have unprotected anal sex
– had >10 partners in past six months
– participate in group sex or use
recreational drugs during sex
Urine, throat and rectal swab
for chlamydia PCR
Throat and rectal swab for
gonorrhoea PCR (III, B)
Serology for HIV, syphilis and,
if the person is not vaccinated
or immune, hepatitis A and B
Offer hepatitis A and B
vaccinations (III, B)
Every 12 months
and three to six
monthly in higher
risk men
5, 16, 28
Sexual contacts from the last six months of
women and men with an STI
For how far back to trace, refer to
Contact Tracing Tool for General Practice
Test and treat contacts
presumptively (II, A)
Consider other infections
based on risk assessment
such as gonorrhoea, hepatitis
B (if not vaccinated), syphilis
and HIV (III, B)
If chlamydia
infection found (and
treated), repeating
testing to check for
re-infection after
3–12 months may
be appropriate
29–32
HIV, human immunodeficiency virus; PCR, polymerase chain reaction; STI, sexually transmissible infection
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Table 6.2.1.2. Tests to detect sexually transmissible infections
Test Technique References
Nucleic acid
amplification test
most commonly by
polymerase chain
reaction (PCR)
The first 20 mL of urine passed at any time of day, and at least 20 minutes
since last voiding
PCR testing can be performed on urine, throat, endocervix rectum, or
vagina (whichever are indicated)
33
5, 15, 30, 34
Gonorrhoea
microscopy, culture
and sensitivity (MCS)
If the suspected clinical diagnosis is gonorrhoea, an MCS is required to
guide antibiotic treatment
11
MCS, microscopy, culture and sensitivity; PCR, polymerase chain reaction
Implementation
Chlamydia is the most common and curable STI in Australia. Notification rates per 100,000 increased from 35.4 in
1993 to 363 in 2011, and has been steady since; 78% of those infected are aged 15–29 years.11 Young Aboriginal
and Torres Strait Islander peoples have higher infection rates especially in regional and remote areas, with a
substantially increased risk of chlamydia, gonorrhoea and syphilis.10
Screening sexually active women <25 years of age for chlamydia on an annual basis has been shown to halve the
infection and complication rates.11,13,35
Treatment of partners and contact tracing
All partners of those infected should be tested and treated presumptively. A systematic review has shown that
providing patient-delivered partner therapy to index cases is more effective in reducing infection rates than paper-
based methods of contact tracing.36 There is no single optimal strategy for contact tracing. Getting assistance from
the local sexual health services is recommended for HIV and syphilis because it leads to more contacts being tested
and treated.35 Referral to sexual health services should be considered for problematic or repeated infections.37
It is important to ensure current sexual partners are treated simultaneously. Untreated pregnant women infected
with chlamydia have a 20–50% chance of infecting their infant at delivery.38
References
1. Community Preventive Services Task Force (USA).
Recommendation for use of immunization information
systems to increase vaccination rates. J Public Health
Manag Pract 2015;21(3):249–52.
2. Department of Health. Update: Expansion of Australia’s
immunisation registers. Canberra: DoH, 2015. Available
at www.immunise.health.gov.au/internet/immunise/
publishing.nsf/Content/news-20152310 [Accessed 13
May 2016].
3. Ward K, Chow MYK, King C, Leask J. Strategies to
improve vaccination uptake in Australia, a systematic
review of types and effectiveness. Aust N Z J Public
Health 2012;36(4):369–77.
4. Haynes K, Stone C. Predictors of incomplete
immunisation in Victorian children. Aust N Z J Public
Health 2004;28(1):72–79.
5. Australasian Society for HIV, Viral Hepatitis and Sexual
Health Medicine. HIV, viral hepatitis and STIs: A guide for
primary care. Sydney: ASHM, 2014.
6. Kong FY, Guy RJ, Hocking JS, et al. Australian general
practitioner chlamydia testing rates among young people.
Med J Aust 2011;194(5):249–52.
7. Pavlin NL, Parker R, Fairley CK, Gunn JM, Hocking
J. Take the sex out of STI screening! Views of young
women on implementing chlamydia screening in general
practice. BMC Infect Dis 2008;8:62.
8. Preswell N, Barton D. Taking a sexual history. Aust Fam
Physician 2000;29(5):533–39.
9. Department of Health. Third national sexually transmissible
infections strategy 2014–2017. Canberra: DoH, 2014.
Available at www.health.gov.au/internet/main/publishing.
nsf/Content/ohp-bbvs-sti [Accessed 23 May 2016].
10. Guy RJ, Ali H, Liu B, Hocking J, Donovan B, Kaldor J.
Genital chlamydia infection in young people: A review of
the evidence. Sydney: The Kirby Institute, 2011.
11. The Kirby Institute. HIV, viral hepatitis and sexually
transmissible infections in Australia: Annual surveillance
report 2015. Sydney: The Kirby Institute, 2015.
65
Guidelines for preventive activities in general practice
9th edition
12. Goldenring J, Rosen D. Getting into adolescent
heads: An essential update. Contemp Pediatrics
2004;21(64):64–90.
13. Hocking J, Fairley C. Need for screening for genital
chlamydia trachomatis infection in Australia. Aust N Z J
Public Health 2003;27(1):80–81.
14. Meyers D, Wolff T, Gregory K, Marion L. USPSTF
recommendations for STI screening. Am Fam Physician
2008;77(6):819–24.
15. Cook RL, Hutchison SL, Ostergaard L. Systematic
review: Noninvasive testing for Chlamydia trachomatis
and Neisseria gonorrhoeae. Ann Intern Med
2005;142(11):914–25.
16. Templeton DJ, Read P, Varma R, Bourne C. Australian
sexually transmissible infection and HIV testing guidelines
for asymptomatic men who have sex with men 2014: A
review of the evidence. Sex Health 2014;11(3):217–29.
17. Australian Health Ministers’ Advisory Council. Clinical
practice guidelines: Antenatal care – Module II. Canberra:
AHMAC, 2014.
18. The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists. Routine antenatal
assessment in the absence of pregnancy complications.
East Melbourne, Vic: RANZCOG, 2016. Available at
www.ranzcog.edu.au/college-statements-guidelines.
html#obstetrics [Accessed 28 April 2016].
19. Cheney K, Wray L. Chlamydia and associated factors
in an under 20s antenatal population. Aust NZ J Obstet
Gynaecol 2008;48(1):40–43.
20. Chen MY, Fairley CK, De Guingand D, et al. Screening
pregnant women for chlamydia: What are the predictors
of infection? Sex Transm Infect 2009;85(1):31–35.
21. Scholes D, Stergachis A, Heidrich FE, Andrilla H.
Prevention of pelvic inflammatory disease by screening
for cervical chlamydial infection. N Eng J Med
1996;334(21):1362–66.
22. Queensland Health. Indigenous sexual health service
report for Brisbane Southside. Brisbane: Communicable
Disease Unit, 2004.
23. Low N, McCarthy A, Macleod J, Salisbury C.
Epidemiological, social, diagnostic and economic
evaluation of population screening for genital chlamydial
infection. Health Technol Assess 2007;11(8):1–165.
24. Heal C, Jones B, Veitch C, Lamb S, Hodgens S.
Screening for chlamydia in general practice. Aust Fam
Physician 2002;31(8):779–82.
25. Hayman N. Chlamydia PCR screening in an Indigenous
health general practice clinic in Brisbane 2002–3.
Brisbane, 2004.
26. Uddin RN, Ryder N, McNulty AM, Wray L, Donovan B.
Trichomonas vaginalis infection among women in a low
prevalence setting. Sex Health 2011;8(1):65–68.
27. The Kirby Institute. Bloodborne viral and sexually
transmitted infections in Aboriginal and Torres Strait
Islander people: Surveillance and evaluation report.
Sydney: The Kirby Institute, 2014.
28. Whiley DM, Garland SM, Harnett G, et al. Exploring
‘best practice’ for nucleic acid detection of Neisseria
gonorrhoeae. Sex Health 2008;5(1):17–23.
29. Whittington WL, Kent C, Kissinger P, Oh MK.
Determinants of persistent and recurrent chlamydia
trachomatis infection in young women: Results
of a multicenter cohort study. Sex Transm Dis
2001;28(2):117–23.
30. Orr DP, Johnston K, Brizendine E, Katz B. Subsequent
sexually transmitted infection in urban adolescents
and young adults. Arch Pediatr Adolesc Med
2001;155(8):947–53.
31. Guy R, Wand H, Franklin N, et al. Re-testing for
chlamydia at sexual health services in Australia, 2004–08.
Sex Health 2011;8(2):242–47.
32. Centers for Disease Control and Prevention. Sexually
transmitted diseases treatment guidelines. MMWR
2006;55:38–40.
33. Kwan B, Ryder N, Knight V, et al. Sensitivity of
20-minute voiding intervals in men testing for Chlamydia
trachomatis. Sex Transm Dis 2012;39(5):405–06.
34. Watson E, Templeton A, Russell I, Paavonen J. The
accuracy and efficacy of screening tests for Chlamydia
trachomatis: A systematic review. J Med Microbiol
2002;51(12):1021–31.
35. Ferreira A, Young T, Mathews C, Zunza M, Low N.
Strategies for partner notification for sexually transmitted
infections, including HIV. Cochrane Database Syst Rev
2013;10:CD002843.
36. Trelle S, Shang A, Nartey L, Cassel J, Low N. Improved
effectiveness of partner notification for patients with
sexually transmitted infections: Systematic review. BMJ
2007;334(7589):354.
37. Burnet Insitute. Partner notification of sexually transmitted
infections in New South Wales: An informed literature
review. Melbourne: Centre for Population Health, 2010.
Available at http://stipu.nsw.gov.au/wp-content/uploads/
NSW_STI_PN_PDF [Accessed 28 January 2016].
38. Honey E, Augood C, Templeton A, et al. Cost
effectiveness of screening for Chlamydia trachomatis:
A review of published studies. Sex Transm Infect
2002;78(6):406–12.
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7. Prevention of chronic disease
The lifestyle risk factors of smoking, nutrition, alcohol and physical activity (SNAP) are common among patients
attending general practice.1 They contribute significantly to the burden of disease, largely due to their effect on
the incidence and complications of chronic diseases such as diabetes, cardiovascular disease (CVD), chronic
respiratory disease and some cancers.2 General practitioners (GPs) and their teams can make an important
contribution to managing each of the SNAP lifestyle behaviours, including smoking,3,4 dietary change,5 hazardous
drinking,6 physical activity7,8 and weight.9,10
Each of these risk factors may interact with the others throughout the lifecycle and need to be considered together
rather than separately.11 The 5As is an internationally accepted framework for organising the assessment and
management of behavioural risk factors in primary healthcare.12–14 It consists of the following:
• Ask – A systematic approach to asking all patients about their SNAP, which may occur opportunistically as they
present for other conditions and/or by recall for health checks.
• Assess – Assess readiness to change, and dependence (for smoking and alcohol).
• Advise – Provide brief, non-judgemental advice with patient education materials.
• Assist/agree – Work with the patient to set agreed goals for behaviour change; provide motivational
interviewing; refer to telephone support services, group lifestyle programs or individual providers (eg dietitian or
exercise physiologist); consider pharmacotherapy.
• Arrange – Regular follow-up visits to monitor maintenance and prevent relapse.
Progress along the pathway from assessment and advice to goal setting, referral and follow-up is associated with
increased patient motivation and behaviour change.15 A number of evidence-based preventive care guidelines are
based on the 5As framework.9
Health inequity
What are the key equity issues and who is at risk?
• The greatest burden of chronic illness is experienced by socioeconomically disadvantaged groups, including
Aboriginal and Torres Strait Islander peoples, who access preventive healthcare less frequently than other
groups.16–18 Aboriginal and Torres Strait Islander peoples have a significantly lower life expectancy at birth than
non-Indigenous Australians. This is attributable, to a significant extent, to inequities in prevalence and care for
chronic diseases.19,20 This gap appears to be widening and is the widest seen globally between Indigenous and
non-Indigenous populations.21 Multimorbidity is more common in disadvantaged groups and is associated with
higher levels of psychosocial stress.22,23
• The uptake of preventive and screening services in primary healthcare is significantly related to higher levels of
education, health motivation, and self-rated health, as well as to particular cultural groups. Immigrant groups
undergo fewer preventive consultations and screening tests, and have overall less primary care utilisation.24
Aboriginal and Torres Strait Islander peoples and socioeconomically deprived people have higher risks of
disease, but are less likely to be offered preventive interventions.25
• Socioeconomic disadvantage is associated with higher rates of smoking and alcohol use, poorer diets and
lower levels of physical activity. The higher rates are a product of social, environmental and individual factors.
• Smoking rates show significant inequities across groups. Most disadvantaged groups continue to have higher
smoking rates. Smoking status varies by education level, employment status, socioeconomic status (SES),
geographic location and Indigenous status.26,27 Nationally, the prevalence of smoking among Aboriginal and
Torres Strait Islander peoples (45%) is more than double that of non-Indigenous Australians, and is up to 82% in
remote communities.28,29 Smoking is also more prevalent in people with long-term mental illness.30
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Guidelines for preventive activities in general practice
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• Overweight and obesity rates are higher in socioeconomically disadvantaged groups and the gap is
widening.31–33 Aboriginal and Torres Strait Islander peoples have higher rates of being overweight and obese
as well as a higher incidence of vascular disease.34 Aboriginal and Torres Strait Islander communities in remote
regions face significant access barriers to nutritious and affordable food.35,36 Nutritious food tends to cost more
in rural and remote areas, and cost may also be an issue in low SES groups.37,38 Low-income groups are less
likely to be offered interventions to prevent being overweight.39
• Alcohol may produce a greater burden of harm in more socially disadvantaged groups partly through the more
hazardous pattern of drinking and partly through reduced access to resources to mitigate harm.40–43 Recognition
and treatment are also impeded by the social stigma associated with problematic use of alcohol.44–46
What can GPs do?
• Interventions targeting Aboriginal and Torres Strait Islander peoples could include individual and group
interventions delivered in primary healthcare and community settings to promote improved health literacy and
awareness of behavioural risk factors.47 Financial assistance to enable healthier food choices may be effective.48
The Centre for Excellence in Indigenous Tobacco Control (CEITC) provides resources and strategies at
www.ceitc.org.au Improvements in physical activity for Aboriginal and Torres Strait Islander patients may
be achieved by linking health advice with locally available and appropriate community sport and recreation
programs, as well as social support programs such as group activities.34,49
• Provide motivational interviewing for at-risk patients with low SES.50–52 Individual behavioural counselling is
more likely to be effective for patients from disadvantaged backgrounds if linked to community resources, and
if financial and access barriers are addressed.53,54 Interventions to improve physical activity among socially
disadvantaged patients would ideally be linked to community programs that improve the physical environment,
are culturally acceptable and address cost barriers.55–57 Supportive provider attitudes are also important in
building self-efficacy among patients from these groups.58
• Be aware that behavioural risk factors are not simply a matter of ‘individual lifestyle choices’. For example,
racism and stress may be drivers of smoking for Aboriginal and Torres Strait Islander peoples and dietary
choices may be shaped significantly by availability, cost and distribution of healthy food.
• Quality improvement activities, especially clinical audit and practice plans, can help improve the assessment and
recording of behavioural risk factors.59
7.1 Smoking
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥ 80
Smoking status and interest in quitting should be assessed and documented in the medical record for every patient
>10 years of age.3,13,60 All patients who smoke, regardless of the amount they smoke, should be offered smoking
cessation advice. This should include the following actions:
• Ask about their interest in quitting (B).
• Advise to stop smoking (A), agreeing on quit goals and offer pharmacotherapy to all patients smoking more than
10 cigarettes per day unless contraindicated, especially if there is evidence of nicotine dependence (A).
• Offer referral to a proactive telephone call-back cessation service (eg Quitline 13 7848; A).
• Follow up to support maintenance and prevent relapse using self-help or pharmacotherapy (A).
To assess nicotine dependence, ask about the:60
• number of minutes between waking and smoking the first cigarette
• number of cigarettes smoked a day (there is a high likelihood of nicotine dependence if the person smokes
within 30 minutes of waking and smokes more than 10–15 cigarettes a day)
• type of craving or withdrawal symptoms experienced in previous quit attempts.
www.ceitc.org.au
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Guidelines for preventive activities in general practice
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Table 7.1.1. Smoking: Identifying risks
Who is at risk? What should be done? How often? References
Average risk:
• Everyone >10
years of age
Ask about quantity and frequency of smoking
(I, A). Offer smoking cessation advice, set quit
goals, offer pharmacotherapy, referral and
follow-up as appropriate (II, A)
Opportunistically* (III, C) 60
High risk of
complications:
• Aboriginal and
Torres Strait
Islander peoples
• People with
smoking-related
disease
Offer smoking cessation advice. Agree on quit
goals, offer pharmacotherapy and culturally
appropriate referral and support
(II, A)
(I, A)
Opportunistically, ideally
at every visit* (III, C)
61
Patients requiring different interventions to those at average risk
• People with mental
illness
• People with other
drug-related
dependencies
Make careful use of pharmacotherapy, because
of the significant impact of nicotine and nicotine
withdrawal on drug metabolism (I, A)†
Add mood management to behavioural support in
those with current or past depression
Opportunistically, ideally
every visit* (III, C)
62
• Pregnant women Offer smoking cessation advice, agree on quit
goals, offer referral to a quit program (I, A). Also
refer to Chapter 1. Preventive activities prior to
pregnancy
At each antenatal visit
(III, C)
• Parents of young
babies and
children
Offer smoking cessation advice. If the parent is
unable to quit, advise to:
• smoke away from children
• not smoke in confined spaces with children
(eg when driving) (I, A)
Opportunistically, ideally
every visit* (III, C)
• Adolescents and
young people
Ask about smoking and provide a strong
antismoking message (III, C)
Opportunistically (III, C) 63
*Refer to Appendix 9. Effect of smoking abstinence on medications in the New Zealand smoking cessation guidelines 2007 at
www.treatobacco.net/de/uploads/documents/Treatment%20Guidelines/New%20Zealand%20treatment%20guidelines%20in%20
English%202007
†While enquiry about smoking should occur at every opportunity, be aware of patient sensitivity. Non-judgmental enquiry about
smoking is associated with greater patient satisfaction64–66
Implementation
At an individual patient level, GPs and their teams can influence smoking rates by systematically providing
opportunistic advice and offering support to all attending patients who smoke.67 Where this is insufficient,
other effective treatment strategies include referral to the Quitline,68 pharmacotherapy69,70 and motivational
interviewing.71,72 Tobacco use is most effectively treated with a comprehensive approach involving behavioural
support and pharmacotherapy. Combined pharmacotherapy and behavioural support increases the success of
smoking cessation.73
Pregnant women find it especially difficult to quit; pregnancy alters nicotine metabolism and heightens
withdrawal symptoms and the support from partners is an important element in quitting. Higher smoking rates in
disadvantaged individuals reflect greater neighbourhood disadvantage, less social support, greater negative effect
http://www.treatobacco.net/de/uploads/documents/Treatment%20Guidelines/New%20Zealand%20treatment%20guidelines%20in%20English%202007
http://www.treatobacco.net/de/uploads/documents/Treatment%20Guidelines/New%20Zealand%20treatment%20guidelines%20in%20English%202007
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Guidelines for preventive activities in general practice
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and lower self-efficacy.21,28 Removing access barriers and providing incentives to motivate patients to quit may
improve quit rates.
Patients should be reviewed within one week and again after one month of stopping smoking in order to help
increase the long-term chance of quitting.
There is a lack of consistent, bias-free evidence that acupuncture, acupressure or laser therapy have sustained
benefit on smoking cessation for longer than six months.74 There is insufficient evidence that electronic cigarettes
(e-cigarettes) help smokers to stop smoking when compared with nicotine patches or placebo.75
The CEITC provides resources and strategies at www.ceitc.org.au
7.2 Overweight
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥ 80
Body mass index (BMI) and waist circumference should be measured every two years and recorded in the
medical record (A). On its own, BMI may be misleading, especially in older people and muscular individuals, and
classifications may need to be adjusted for some ethnic groups.9 Waist circumference is a stronger predictor of
CVD and diabetes than weight alone.76,77
Patients who are overweight or obese should be offered individual lifestyle education and skills training (A).9
Restrictive dieting is not recommended for children and most adolescents who have not completed their growth
spurt.9 A modest loss of 5–10% of starting body weight in adults who are overweight is sufficient to achieve some
health benefits.9,78
http://www.ceitc.org.au
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Guidelines for preventive activities in general practice
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Table 7.2.1. Obesity-related complications: Identifying risks
Who is at risk? What should be done? How often? References
Average risk:
Adults Assess body mass index (BMI) and waist
circumference in all adults >18 years of age (I, A)
Offer education on nutrition and physical activity (I, A)
Every two years (IV, D) 78
Adolescents Assess weight and height using age-specific BMI
charts (either Centers for Disease Control and
Prevention [CDC] or World Health Organization
[WHO]; Practice Point)
Involve parents, carers and families in lifestyle change
(Practice Point)
Every two years 9
Children Aged >2 years: Assess weight and height using age
specific BMI charts (either CDC or WHO;
Practice Point)
Aged <2 years: Monitor growth using WHO growth
charts (Practice Point)
Involve parents, carers and families in lifestyle change
At times of child
health surveillance or
immunisation
9
Increased risk:
• Aboriginal and
Torres Strait
Islander peoples
and people from
the Pacific Islands
• Patients with
existing diabetes
or cardiovascular
disease, stroke,
gout or liver
disease
Assess BMI and waist circumference in all adults
aged >18 years (I, B)
Offer individual or group-based education on nutrition
and physical activity (II, A)
Every 12 months
(IV, D)
49
Identified risk:
• Adults who are
overweight or
obese
Assess weight and waist circumference (I, B)
Develop weight management plan* (II, B)
Offer behaviour-oriented interventions to assist with
weight loss (I, B)
Consider referral for:
• self-management support
• coaching in an individual or group-based diet
• physical activity program
• allied health provider (eg dietitian, exercise
physiologist, psychologist)
Every six months†
(III, C)
9, 79
• Children and
adolescents who
are overweight or
obese
Recommend lifestyle change including reducing
energy intake and sedentary behaviour, and
increased physical activity and measures to support
behaviour change (II, B)
80
*Refer to the National Health and Medical Research Council’s (NHMRC) Clinical practice guidelines for the management of overweight
and obesity in adults, adolescents and children in Australia.9 The plan should include frequent contact (not necessarily in general
practice), realistic targets and monitoring for at least 12 months
†Review impact on changes in behaviour in two weeks
BMI, body mass index; CDC, Centers for Disease Control and Prevention; NHMRC, National Health and Medical Research Council;
WHO, World Health Organization
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Table 7.2.2. Overweight and obesity: Assessment and preventive interventions
Assessment Technique References
Body mass
index (BMI)
BMI = body weight in kilograms divided by the square of height in metres. BMI of ≥25 kg/m2
conveys increased risk
Waist
circumference
An adult’s waist circumference is measured halfway between the inferior margin of
the last rib and the crest of the ilium in the mid-axillary plane over bare skin. The
measurement is taken at the end of normal expiration
≥94 cm in males and ≥80 cm in females conveys increased risk
≥102 cm in males and ≥88 cm in females conveys high risk
9
Weight
reduction in
adults (5As
approach)
Ask patients what concerns they have about their weight and if they tried to lose weight
in the past
Assess BMI, waist circumference, diet, physical activity, motivation to change and
health literacy
Advise that weight loss can have health benefits, including reduced blood pressure and
prevention of diabetes in high-risk patients. Advise the risks of being overweight and a
lifestyle program that includes reduced caloric intake (aiming for 600 kcal or 2500 kJ energy
deficit) and increased physical activity (increasing to 60 minutes at moderate intensity five
days per week), supported by behavioural counselling
Assist/Agree: Discuss goals, including a realistic initial target of 5% weight loss and
specific measurable changes to diet and physical activity. Make contact (eg visit, phone)
two weeks after commencing weight loss to determine adherence and if goals are
being met. If no response (<1 kg weight or <1 cm waist reduction) after three months,
consider alternative approaches, including referral to lifestyle programs or coaching.
These programs may be face to face or delivered by phone
Arrange: After achieving initial weight loss, advise that patients may regain weight
without a maintenance program that includes support, monitoring and relapse
prevention
Consider very low energy diets if there is no response to lifestyle programs. Bariatric
surgery may be considered in patients who fail lifestyle interventions and who have
a BMI >35 kg/m2 with comorbidities, such as poorly controlled diabetes, who are
expected to improve with weight reduction
9, 81
BMI, body mass index
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Table 7.2.3. Nutrition: Healthy weight: Body mass index (kg/m2)82
Classification Body mass index (BMI; kg/m2) Risk of morbidities
Underweight <18.5 Increased
Normal weight 18.5–24.9 Low
Overweight 25.0–29.9 Increased
Obese I 30.0–34.9 Moderate
Obese II 35–39.9 Severe
Obese III ≥40.0 Very severe
BMI, body mass index
Implementation
Consider and offer adult patients a range of treatment options. Individual education and simple behavioural
interventions are appropriate for some patients, while behavioural approaches may be more appropriate for those
with disordered eating patterns. Behaviour change techniques include goal setting, self-monitoring of behaviour
and progress, stimulus control (eg recognising and avoiding triggers that prompt unplanned eating), cognitive
restructuring (modifying unhelpful thoughts or thinking patterns) or problem-solving, and relapse prevention and
management.9
Telephone coaching has been demonstrated to be comparable with face-to-face techniques and is available in
most states.83,84
For adolescents and children, lifestyle programs should focus on parents, carers and families. Advise that weight
maintenance is an acceptable approach in most situations for children who are overweight or obese. Recommend
lifestyle changes, including reducing energy intake and sedentary behaviour, and increasing physical activity based
on current Australian dietary and physical activity guidelines.9
For more information, refer to The Royal Australian College of General Practitioners’ (RACGP) Smoking, Nutrition,
Alcohol and Physical activity (SNAP): A population health guide to behavioural risk82 and National Health and
Medical Reserach Council’s (NHMRC) Clinical practice guidelines for the management of overweight and obesity in
adults, adolescents and children in Australia.9
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7.3 Nutrition
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥ 80
Ask adults how many portions of fruits or vegetables they eat in a day and advise to follow the NHMRC’s Australian
dietary guidelines (B).85 Brief advice should be given to eat two serves of fruit and five serves of vegetables per day
(2 + 5 portions), and to limit sugar, saturated fat, salt and alcohol.
Breastfeeding should be promoted as the most appropriate method for feeding infants (and one that offers
protection against infection and some chronic diseases).85 Refer to Chapter 3. Preventive activities in children and
young people for nutrition-related recommendations.
Table 7.3.1. Nutrition-related complications: Identifying risk
Who is at risk? What should be done? How often? References
Average risk:
Adults Ask about the number of portions of fruits and
vegetables eaten per day, and the amount of
sugar (including sweetened drinks), salt and
alcohol, and saturated fat intake (II, B)
All patients should be advised to follow the
Australian dietary guidelines (www.nhmrc.gov.
au/guidelines-publications/n55), and eat at
least five serves of vegetables and two serves
of fruit per day (II, B)
Every two years
(IV, D)
9, 86
Children and adolescents Assess growth using the World Health
Organization (WHO) weight-for-age and
height-for-age charts up to 2 years of age,
and body mass index (BMI) for age charts
from 2 to 16 years of age
Advise patients to follow Australian dietary
guidelines, including eating high quantities of
vegetables, fruit, wholegrain cereals, poultry,
fish, eggs and low fat milk, yoghurt and
cheese products, and less discretionary food
choices including sugary soft drinks
At times of
child health
surveillance or
immunisation
until 5 years of
age then every
two years
85
High risk:
• Overweight or obese
• High cardiovascular disease
(CVD) absolute risk (>15%)
• A past or first-degree family
history of CVD (including stroke)
before 60 years of age. For
personal history the age does
not matter
• Type 2 diabetes or high risk for
diabetes
Provide lifestyle advice to limit intake of foods
containing saturated fat, added salt, added
sugars (including sugary drinks) and alcohol,
and increase serves of fruit and vegetables.
(Refer to Section 7.2. Overweight for dietary
recommendations for overweight and obesity;
II, B)
Provide self-help nutrition education materials
and refer to a dietitian, group diet program or
phone coaching (II, B)
Every six months
(Practice Point)
85, 87
BMI, body mass index; WHO, World Health Organization
http://www.nhmrc.gov. au/guidelines-publications/n55
http://www.nhmrc.gov. au/guidelines-publications/n55
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Table 7.3.2. Nutrition-related complications: Preventive interventions
Intervention Technique References
Vitamin supplements Vitamin supplementation is not of established value in asymptomatic
individuals* (with the exception of folate and iodine in pregnancy). Routine
screening for vitamin D deficiency is not recommended in low-risk populations
85
Dietary
recommendations
Enjoy a wide variety of foods each day, including:
• five serves of vegetables (of different types and colours, and legumes/
beans) and two serves of fruit
• grain or cereals (mostly wholegrain and/or high fibre varieties such as
breads, rice, pasta, noodles, polenta, couscous, oats, quinoa and barley)
• lean meats, fish, poultry, eggs, tofu, nuts and seeds
and
• drink plenty of water.
Take care to:
• limit saturated fat and reduce salt
• limit alcohol intake
• avoid sugary beverages including soft drink and limit fruit juices
• limit sugars and foods containing added sugars
• limit red meat (three to four times per week) and limit or avoid
processed meat
• care for food: prepare and store it safely
• encourage and support breastfeeding
For specific advice, especially patients with specific conditions, refer to a
dietitian
The National Heart Foundation of Australia has a number of nutrition position
statements at http://heartfoundation.org.au/for-professionals/food-and-
nutrition/position-statements
In children, overweight or obesity is associated with sweet drink consumption,
and dental problems are associated with consumption of fatty foods and
sweet drinks
85
88
89
Encourage
breastfeeding
Encourage and support exclusive breastfeeding until 4 to 6 months of age
(there is current controversy about when to introduce foods; refer to Practice
Point c in Table 3.2). It is recommended that breastfeeding continue until 12
months of age and thereafter as long as is mutually desired
85
*Prevalence of nutritional deficiency is high in certain groups, such as people with alcohol dependence and the elderly living alone
or in institutions.
For further information, refer to the RACGP’s SNAP guide, 2nd edn,82 and NHMRC’s Australian dietary guidelines.85
http://heartfoundation.org.au/for-professionals/food-and-nutrition/position-statements
http://heartfoundation.org.au/for-professionals/food-and-nutrition/position-statements
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7.4 Early detection of at-risk drinking
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥ 80
All patients should be asked about the quantity and frequency of alcohol intake from 15 years of age (A).6 Those
with at-risk patterns of alcohol consumption should be offered brief advice on the risk in drinking (A).90 Motivational
interviewing is both a useful and effective counselling strategy to facilitate a decrease of alcohol intake to low-risk
drinking (I, B).91–94
Table 7.4.1. Alcohol-related complications: Identifying risk
Who is at risk? What should be done? How often? References
Low risk:*
• All patients aged >15 years
Ask about the quantity and frequency of
alcohol intake (II, B)
The alcohol use disorder identification
test-consumption (AUDIT-C) tool can be
used to assess this (II, B)
Advise if drinking alcohol to drink two
drinks or less per day or less and no
more than four drinks on any one
occasion (II, B)
Every two to four years
(III, C)
6, 95
Increased risk:
• Children and adolescents
Advise children aged <15 years not to
drink (III, B)
Advise young people aged 15–17 years
to delay drinking as long as possible
(III, B)
Opportunistically (III, C) 6, 96, 97
• Older people† Inform that there is an increased risk of
potential harm from drinking (III, B)
Opportunistically (III, C) 98, 99
• Young adults, who have
a higher risk of accidents
and injuries
100, 101
• People with a family history
of alcohol dependence
102, 103
• Individuals who are
participating in or
supervising risky activities
(eg driving, boating,
extreme sports, diving,
using illicit drugs)
Advise that non-drinking is the safest
option: driving (I, A), other areas (III, C)
Opportunistically (III, C) 104–106
• Women who are pregnant
or planning a pregnancy
(refer to Chapter 1.
Preventive activities prior
to pregnancy)
Advise that non-drinking is the safest
option
At each antenatal visit (III, C) 107, 108
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Who is at risk? What should be done? How often? References
• People with a physical
condition made worse by
alcohol:
– pancreatitis
– diabetes
– hepatitis/chronic liver
disease
– hypertension
– sleep disorders
– sexual dysfunction
– other major organ
disease
Advise that non-drinking is the safest
option (II–IV, B)
Advise those with hypertension, or taking
antihypertensive medication, to limit
alcohol intake to no more than two (for
men) or one (for women) standard drinks
per day (II, B)
Opportunistically (III, C)
6
109
110, 111
6, 112
6, 113
114, 115
• People with a mental
health problem made
worse by alcohol (eg
anxiety and depression)
Assess whether there are possible
harmful interactions between their
medications and alcohol (II, A)
Opportunistically (III, C) 116–118
• People taking multiple
medications
Opportunistically (III, C) 119, 120
*There is some variability between the levels of low-risk drinking in the drinking guidelines for each country. The Australian
guidelines, to be updated in 2016, represent the modal (or most common) recommendation. Refer to www.iard.org/wp-content/
uploads/2016/02/Drinking-Guidelines-General-Population
†Older people who have a higher risk of falls and are more likely to be taking medication.121
AUDIT-C, alcohol use disorder identification test-consumption
Table 7.4.2. What advice, and to whom, should be provided?
What advice should be given to adults who drink alcohol? References
• Advise to limit their drinking to two drinks or less per day, and no more than four drinks on any one
occasion (II, B)
• Counsel everybody who consumes alcohol about the dangers of operating a motor vehicle or
performing other potentially dangerous activities after drinking (II, B)
• Provide simple advice to reduce alcohol consumption to all patients drinking at potentially risky or
high-risk levels (I, A)
• Advise pregnant women not to drink alcohol (ie there are no safe drinking levels)
6
http://www.iard.org/wp-content/uploads/2016/02/Drinking-Guidelines-General-Population
http://www.iard.org/wp-content/uploads/2016/02/Drinking-Guidelines-General-Population
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Table 7.4.3. Strategies to increase effectiveness
Intervention Technique References
Screening • Early detection of at-risk drinking may be improved by asking patients about their
drinking more frequently. New patient registration, health assessment, chronic
disease or mental health assessments and care planning are acceptable times for
enquiry
122, 123
Brief
intervention
• Screening and brief advice in general practice has been demonstrated to have
resulted in a reduction in drinking of about four to six standard drinks per week
for men
• While there is no clear dose-response curve for spending more time counselling
subjects who are drinking at risky levels, the minimum time to achieve some
impact is between five and 15 minutes. Although some have argued that
screening, of itself, constitutes a brief intervention, the impact of interventions of
less than five minutes is less clear
• Components of effective interventions include:
– motivational interviewing, especially being more person-centred and eliciting
change talk
– asking about drinking and its consequences
– personalised feedback about impact on health
– goal setting
90, 124–126
126–129
124, 130, 131
Management of
dependence or
heavy drinking
• Brief interventions and routine GP care are likely to be insufficient for patients
with alcohol dependence or heavy drinking. Such patients should be referred to a
drug and alcohol service
132
Implementation
There is some evidence from earlier systematic reviews that for every 10 hazardous drinkers treated using brief
interventions, one will reduce drinking to low-risk levels.102,133,134 For more information, refer to the RACGP’s SNAP
guide, 2nd edn.82
7.5 Physical activity
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥ 80
Ask about the patient's current level of physical activity and sedentary behaviour, and assess against current
guidelines.
Provide age-specific advice on meeting recommended levels of sedentary behaviour and physical activity.
The message that any physical activity is better than none is important. If a patient does not already engage in regular
physical activity, they can be encouraged to start by doing some, and then gradually build up to the recommended
amount.135 Advice, written physical activity materials and referral should be tailored to age (refer to Table 7.5.1).
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Table 7.5.1. Physical activity: Assessment, advice and referral
Age and risk group What should be done? How often? References
Children 0–5 years of age From birth, encourage physical activity,
particularly supervised floor-based play in safe
environments
Toddlers and pre-schoolers should be physically
active every day for at least three hours, spread
throughout the day (Practice Point)
Recommend children <2 years of age not
spend time in front of screens. From two to five
years of age recommend limiting screen time to
one hour per day (Practice Point)
At times of child
health surveillance
or immunisation
(Practice Point)
136
Children 5–17 years of age Ask questions regarding current level of activity
and sedentary behaviour, and assess against
current guidelines (II, A)
Recommend accumulating 60 minutes of a
variety of moderate or vigorous aerobic physical
activity per day (I, A) and muscle strengthening
activity three days a week (II, A)
Recommend limiting or breaking up sitting time
and use of screens to no more than two hours
a day (Practice Point)
Opportunistically 136
Adults 18–64 years of age Ask questions regarding current level of activity
and sedentary behaviour, and assess against
current guidelines (II, A)
Recommend doing some activity on most
days of the week. Accumulate 2.5–5 hours of
moderate intensity physical activity, 1.25–2.5
hours of vigorous intensity physical activity, or
a combination of these per week (III, A). Do
muscle strengthening activities at least two days
a week (I, A)
Avoid prolonged sitting and break up periods of
sitting (III, C)
Every two years
(III, C)
135
People ≥65 years of age Ask questions regarding current level of activity
and sedentary behaviour, and assess against
current guidelines (II, A)
Recommend some physical activity every day
that improves fitness, strength, balance and
flexibility (III, C)
Gradually increase amount and frequency
(Practice Point)
Accumulate at least 30 minutes of moderate
activity on most days (III, C; refer to Section 5.2.
Physical activity)
Every two years 137, 138
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Age and risk group What should be done? How often? References
Increased risk
• Those at higher risk include
teenage girls, older adults,
office workers, Aboriginal
and Torres Strait Islander
peoples, and people from
low socioeconomic and
non–English-speaking
backgrounds
• Those with or at high risk
of a chronic condition or
cancer (refer to Chapter 8.
Prevention of vascular and
metabolic disease, and
Chapter 9. Cancer)
Ask questions regarding current level of activity
and sedentary behaviour and assess against
current guidelines (III, C)
Provide brief interventions (refer to below)
and age-appropriate written physical activity
materials (III, C)
Refer to an exercise or physical activity
professional or program if appropriate brief
interventions within the general practice cannot
be offered (I, D) or if preferred by the patient
(Practice Point)
Programs with additional behaviour change
support may be more beneficial (III, C)
At least two
yearly and
opportunistically
(IV, D)
139–141
142, 143
Table 7.5.2. Physical inactivity interventions
Assessment and
intervention Technique References
Brief interventions to
increase levels of physical
activity
Some of the components of interventions in general practice that have
been shown to have short-term benefit in changing behaviour related to
physical activity include:
• at least two sessions of face-to-face provision of brief advice or
counselling on exercise with supporting written materials
• written prescription for exercise and/or supplementary advice or
counselling by telephone
• pedometer step target that is incremental and agreed with the patient 142, 144
Physical activity program Structured programs of physical activity education and exercise may
be delivered as individual or group program and over several sessions.
The National Heart Foundation of Australia’s program is available at
http://heartmoves.heartfoundation.org.au and some local councils have
information on local physical activity programs. Exercise physiologists are
listed at www.essa.org.au
Non–face-to-face programs using telephone or internet have been
demonstrated to be effective in adults >50 years of age
It should be noted that there is limited research examining the effectiveness
of exercise referral and none comparing exercise referrals to general
practice-based physical activity interventions
145, 146
143, 147
Implementation
Physically inactive patients may be referred to physical activity programs or classes run by local community
organisations. Those who have a chronic medical condition and complex needs may benefit from referral to an
accredited exercise physiologist or physiotherapist. For more information, refer to the RACGP’s SNAP guide,
2nd edn.82
http://heartmoves.heartfoundation.org.au
http://www.essa.org.au
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90. Kaner E, Bland M, Cassidy P, et al. Effectiveness of
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91. Kaner EFS, Dickinson HO, Beyer F, et al. The
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92. VanBuskirk KA, Wetherell JL. Motivational interviewing
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93. Lundahl B, Moleni T, Burke BL, et al. Motivational
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94. Smedslund G, Berg RC, Hammerstrom KT, et al.
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95. Reinert DF, Allen JP. The alcohol use disorders
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96. Newbury-Birch D, Walker J, Avery L, et al. Impact of
alcohol consumption on young people. A systematic
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97. Thompson KD, Stockwell T, MacDonald S. Is there a
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98. Wadd S, Papadopoulos C. Drinking behaviour and
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99. Heuberger RA. Alcohol and the older adult: A
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100. Squeglia LM, Boissoneault J, Van Skike CE, Nixon
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101. Bekkering GE, Aertgeerts B, Asueta-Lorente JF, et al.
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102. Whitlock EF, Green CA, Polen MR. Behavioral counseling
interventions in primary care to reduce risky/harmful
alcohol use. Rockville, MD: US Government, 2004.
103. Magnusson A, Goransson M, Heilig M. Early onset
alcohol dependence with high density of family history is
not ‘male limited’. Alcohol 2010;44(2):131–39.
104. Fell JC, Voas RB. The effectiveness of a 0.05 blood
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States. Addiction 2014;109(6):869–74.
105. Driscoll TR, Harrison JA, Steenkamp M. Review of the
role of alcohol in drowning associated with recreational
aquatic activity. Inj Prev 2004;10(2):107–13.
106. Suter PM, Schutz Y. The effect of exercise, alcohol or
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107. O’Leary CM, Bower C. Guidelines for pregnancy: What’s
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108. World Health Organization. Guidelines for the
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109. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy
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110. Hutchinson SJ, Bird SM, Goldberg DJ. Influence
of alcohol on the progression of hepatitis C virus
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111. Lin CW, Lin CC, Mo LR, et al. Heavy alcohol
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112. Briasoulis A, Agarwal V, Messerli FH. Alcohol
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113. Strohl KP, Brown DB, Collop N, et al. An official American
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114. Glina S, Sharlip ID, Hellstrom WJ. Modifying risk factors
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115. Grover S, Mattoo SK, Pendharkar S, Kandappan V.
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116. Sullivan LE, Fiellin DA, O’Connor PG. The prevalence
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117. Beaulieu S, Saury S, Sareen J, et al. The Canadian
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118. National Collaborating Centre for Mental Health.
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119. Moore AA, Whiteman EJ, Ward KT. Risks of combined
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120. Johnson BA, Seneviratne C. Alcohol-medical drug
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121. Deandrea S, Lucenteforte E, Bravi F, Foschi R,
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123. Tam CW, Leong L, Zwar N, Hespe C. Alcohol enquiry by
GPs – Understanding patients’ perspectives: A qualitative
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124. Kaner EF, Beyer F, Dickinson HO, et al. Effectiveness of
brief alcohol interventions in primary care populations.
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125. Moyer VA, US Preventive Services Task Force. Screening
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126. McCambridge J, Kypri K. Can simply answering research
questions change behaviour? Systematic review and
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127. Jonas DE, Garbutt JC, Amick HR, et al. Behavioral
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128. Gaume J, McCambridge J, Bertholet N, Daeppen JB.
Mechanisms of action of brief alcohol interventions
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129. McCambridge J, Rollnick S. Should brief interventions in
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130. Riper H, van Straten A, Keuken M, Smit F, Schippers
G, Cuijpers P. Curbing problem drinking with
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131. O’Donnell A, Anderson P, Newbury-Birch D, et al. The
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132. Saitz R. Alcohol screening and brief intervention in
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133. Ballesteros J, Duffy JC, Querejeta I, Arino J, Gonzalez-
Pinto A. Efficacy of brief interventions for hazardous
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134. Beich A, Thorsen T, Rollnick S. Screening in brief
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135. Brown W, Bauman A, Bull F, et al. Development of
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136. Okely AD, Salmon J, Vella SA, et al. A systematic review
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137. Sims J, Hill K, Hunt S et al. National physical activity
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138. Michael YL, Whitlock EP, Lin JS, Fu R, O’Connor EA,
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139. Bauman A, Bellew B, Vita P, Brown W, Owen N.
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140. LeFevre ML. Behavioral counseling to promote a healthful
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141. Mammen G, Faulkner G. Physical activity and the
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142. Orrow G, Kinmonth AL, Sanderson S, Sutton S.
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143. Pavey TG, Anokye N, Taylor AH, et al. The clinical
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144. Kolt GS, Schofield GM, Kerse N, Garrett N, Ashton T,
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145. Muller AM, Khoo S. Non face-to-face physical activity
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146. Goode AD, Reeves MM, Eakin EG. Telephone-delivered
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8. Prevention of vascular and
metabolic disease
Cardiovascular disease (CVD) occurs in 18% of Australians. It accounts for 36% of all deaths and 6.9% of all
disability.1 The most important behavioural and physiological risk factors for CVD are smoking, diabetes, raised
blood pressure (BP), dyslipidaemia, obesity, physical inactivity and poor diet.2 These risk factors are common in
the Australian population: 90% of adults aged >45 years have at least one modifiable risk factor and 66% have
three or more risk factors for CVD.3 In addition to these, a family history of premature heart disease in a first-degree
relative,4 history of depression, social isolation and lack of quality social support are recognised risk factors for
coronary heart disease (CHD).5
Health inequity
What are the key equity issues and who is at risk?
• CVD: Socioeconomic disadvantage is associated with higher rates of CVD.6 Aboriginal and Torres Strait Islander
peoples, people living in rural and remote areas, and people in lower socioeconomic groups, all have an
increased risk of cardiovascular disease.6 Minority groups have high risk factor rates of cardiovascular disease
globally.6,7
• Type 2 diabetes (T2D): There is a higher prevalence of T2D among Australians in the lower socioeconomic
groups.8 T2D is more than twice as common in the most disadvantaged communities.9 Certain ethnic groups
are more at risk.10 Aboriginal and Torres Strait Islander peoples are three times more likely to have diabetes than
non-Indigenous Australians, and T2D is a direct or indirect cause for 20% of Aboriginal and Torres Strait Islander
deaths.11
• CVD risk factors: Biological and behavioural risk factors play a role in increasing cardiovascular risk (refer
to Chapter 7. Prevention of chronic disease). However, while smoking, nutrition, alcohol and physical activity
(SNAP) risk factors exhibit clear socioeconomic gradients,10,12 the higher prevalence of vascular and metabolic
disease is only partly mediated by behavioural risk factors and is more consistently observed in women.13
Diabetes and CVD are more common in rural populations, and this is exacerbated by poorer access to
healthcare.14 There is evidence that men from socioeconomically disadvantaged backgrounds may be less likely
to be offered statins.15
• Chronic kidney disease (CKD): Disadvantaged groups have higher rates of CKD for which type 2 diabetic
nephropathy is a common cause.16,17 Over the past 25 years, the number of Aboriginal and Torres Strait Islander
peoples commencing renal replacement therapy was 3.5 times greater than the majority of the population.
CKD has an earlier onset in Indigenous peoples.18–20 Aboriginal and Torres Strait Islander peoples are 10 times
more likely than non-Indigenous Australians to be hospitalised for CKD, and, from 2008 to 2012, CKD was
responsible for or associated with 16% of Aboriginal and Torres Strait Islander deaths.11
What can GPs do?
• Inequities in diabetes care can be ameliorated using a structured systems-based approach to care targeting at-
risk and minority populations using diabetes registries.21
• Social disadvantage may be a factor in poor medication adherence in patients with chronic disease.22,23
Interventions that can help improve medication adherence include those that target the barriers created by
socioeconomic status (SES) and the treatment itself.23 Underuse of cardiovascular medications is common in
older adults at high risk of CVD, and may be a factor in inequity in cardiovascular outcomes.24
86
Guidelines for preventive activities in general practice
9th edition
• Effective chronic disease interventions are likely to be those that address the determinants of behavioural risk
factors that arise from root social causes such as poverty and low health literacy.6 Interventions delivered in
community settings that target families and are multifaceted to incorporate the social context are generally the
most successful.25,26
• Trust is an important element in the delivery of culturally competent health service to patients with chronic
diseases, particularly Aboriginal and Torres Strait Islander peoples. Key ways to improve healthcare delivery
are to respond to social complexity; promote empowerment, trust and rapport; and reduce discrimination and
racism. To do so requires not only practice-system change but also Aboriginal and Torres Strait Islander cultural
training of health professionals to build culturally safe environments.27,28 Continuity of care and patient-centred
care are also important. Culturally specific interventions are needed and there are ongoing initiatives to develop
these.29–33
8.1 Assessment of absolute cardiovascular
disease risk
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Aboriginal and Torres
Strait Islander peoples
Absolute CVD risk assessment combines risk factors to calculate the probability that an individual will develop
a cardiovascular event (eg myocardial infarction, stroke) or other vascular disease within a specified time frame
(usually five years). Absolute CVD risk assessment should be conducted at least every two years in all adults aged
>45 years who are not known to have CVD or to be at clinically determined high risk (B).34 This calculation requires
information on the patient’s age, sex, smoking status, total and high-density lipoprotein-cholesterol (HDL– C),
systolic blood pressure (SBP) and whether the patient is known to have diabetes or left ventricular hypertrophy
(LVH). In adults at low absolute CVD risk, blood test results within five years may be used for review of absolute
CVD risk unless there are reasons to the contrary.34
Adults >74 years of age may have their absolute CVD risk assessed with age entered as 74 years. This is likely to
underestimate five-year risk but will give an estimate of minimum risk.35 Patients with a family history of premature
CVD (in a first-degree relative – men aged <55 years, women aged <65 years)4 or obesity (body mass index [BMI]
above 30 kg/m2 or more) may be at greater risk.36–38 Similarly, patients with depression and atrial fibrillation (AF) may
also be at increased risk.34
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Guidelines for preventive activities in general practice
9th edition
Table 8.1.1. Cardiovascular disease: Identifying risk
Population group What should be done? How often? References
Adults aged >45 years
not known to have
cardiovascular disease (CVD)
or not clinically determined
to be at high risk
Calculate absolute CVD risk*
45–74 years (II, B)
Every two years†
(IV, C)
34
Aboriginal and Torres Strait
Islander peoples aged
>35 years not known to
have CVD or not clinically
determined to be at high risk
Assess absolute CVD risk
(may underestimate risk; IV, C)
Every two years
(IV, C)
*Calculate risk using the National Heart Foundation of Australia’s risk charts (refer to Appendix 8A. Australian cardiovascular disease risk
charts) or online at www.cvdcheck.org.au Blood lipid results within five years can be used in the calculation of absolute CVD risk, but
blood pressure (BP) should be measured at the time of assessment. On-therapy measures of BP and cholesterol may underestimate
absolute risk, and thus, recently recorded pre-treatment measures may be more appropriate to use if available. An electrocardiogram
(ECG) is not required to determine left ventricular hypertrophy (LVH) if it is not previously known. Other absolute CVD risk calculators have
been developed but most should not be applied to the Australian population.
†Adults with any of the following do not require absolute CVD risk assessment using the absolute risk calculator, because they are
already known to be at clinically determined high risk of CVD (IV, D):
• diabetes and >60 years of age
• diabetes with microalbuminuria (>20 μg/min or urine albumin-to-creatinine ratio (UACR) >2.5 mg/mmol for males, >3.5 mg/mmol for
females)
• moderate or severe chronic kidney disease (CKD; persistent proteinuria or estimated glomerular filtration rate [eGFR] <45 mL/min/1.73 m2)
• previous diagnosis of familial hypercholesterolaemia (FH)
• Systolic blood pressure (SBP) ≥180 mmHg or diastolic blood pressure (DBP) ≥110 mmHg
• serum total cholesterol >7.5 mmol/L
• Aboriginal or Torres Strait Islander peoples aged >74 years (Practice Point)
BP, blood pressure; CKD, chronic kidney disease; CVD, cardiovascular disease; DBP, diastolic blood pressure; ECG,
electrocardiogram; eGFR, estimated glomerular filtration rate; FH, familial hypercholesterolaemia; LVH, left ventricular hypertrophy; SBP,
systolic blood pressure; UACR, urine albumin-to-creatinine ratio
8.2 Blood pressure
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
BP should be measured in all adults from 18 years of age (A) at least every two years. BP should be interpreted in
the context of an absolute CVD risk assessment after 45 years of age (35 years of age for Aboriginal and Torres
Strait Islander peoples; B). Secondary causes of hypertension and ‘white coat’ hypertension should be considered.
http://www.cvdcheck.org.au
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Guidelines for preventive activities in general practice
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Table 8.2.1. Hypertension: Identifying risk
Who is at risk? What should be done?
How
often? References
Low absolute risk:
• <10% cardiovascular disease
(CVD) risk
Provide lifestyle advice and education (I, B)
Offer pharmacotherapy if blood pressure (BP)
persistently over 160/100 mmHg
Review BP of 140–159 mmHg after two months of
lifestyle advice
BP every
two years
(III, C)
34, 39–41
Moderate risk:
• 10–15% absolute CVD risk
Provide intensive lifestyle advice (II, B)
Consider pharmacotherapy if systolic blood
pressure (SBP) is 140–159 mmHg or diastolic
blood pressure (DBP) is 90–99 mmHg. If SBP is
130–139 mmHg or DBP is 85–89 mmHg, review
BP in six months
Offer pharmacotherapy simultaneously with lifestyle
intervention if BP persistently over 160/100 mmHg
or if family history of premature CVD or patient is
of South Asian, Middle Eastern, Maori, Aboriginal,
Torres Strait Islander or Pacific Islander descent
(III, C)
BP every
6–12
months
(III, C)
34, 38, 42
11, 36, 37,
41, 43
High risk:
• >15% absolute CVD risk
• Clinically determined high risk:
– diabetes and >60 years of age
– diabetes with microalbuminuria
(>20 μg/min or urine the urine
albumin-to-creatinine ratio
[UACR] >2.5 mg/mmol for
males, >3.5 mg/mmol for
females)
– moderate or severe chronic
kidney disease (CKD)
(persistent proteinuria or
estimated glomerular filtration
rate [eGFR] <45 mL/min/
1.73 m2)
– previous diagnosis of familial
hypercholesterolemia (FH)
– SBP ≥180 mmHg or DBP
≥110 mmHg
– serum total cholesterol >7.5
mmol/L
– Aboriginal and Torres Strait
Islander peoples aged >74
years
Provide intensive lifestyle advice (II, B)
Commence pharmacotherapy (simultaneously with
lipid therapy unless contraindicated)
Treatment goal is BP ≤140/90 mmHg in adults
without CVD, or lower (SBP <120 mmHg) in some
individuals who tolerate more intensive treatment,
and those with CKD (I, B to III, D;* ≤130/80 mmHg
in people with diabetes or microalbuminuria or
macroalbuminuria UACR >2.5 mg/mmol in males
and >3.5 mg/mmol in females)
BP every
6–12
weeks
(III, C)
34, 43
44, 45
• Existing CVD (previous event,
symptomatic CVD), stroke or
transient ischaemic attacks
(TIAs) or CKD
Provide lifestyle risk factor counselling and
commence pharmacotherapy to lower risk (I, A).
There is some evidence that a treatment goal (SBP
<120 mmHg) in some individuals who tolerate
more intensive treatment provides additional
benefit. Adverse effects need to be monitored
Every six
months
(III, C)
43, 46
*D recommendation for clinically determined high risk
BP, blood pressure; CKD, chronic kidney disease; CVD, cardiovascular disease; DBP, diastolic blood pressure; eGFR, estimated
glomerular filtration rate; FH, familial hypercholesterolaemia; SBP, systolic blood pressure; TIA, transient ischaemic attack;
UACR, urine albumin-to-creatinine ratio
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Table 8.2.2. Hypertension: Preventive interventions
Intervention Technique References
Measure
blood
pressure (BP)
Measure BP on at least two separate occasions with a calibrated mercury
sphygmomanometer, or automated device that is regularly calibrated against a mercury
sphygmomanometer. At the patient’s first BP assessment, measure BP on both arms.
Thereafter, use the arm with the higher reading. In patients who may have orthostatic
hypotension (eg elderly, those with diabetes), measure BP in sitting position and repeat
after the patient has been standing for at least two minutes
If possible, use ambulatory BP monitoring or self-measurement for patients with:
• unusual variation between BP readings in the clinic
• suspected white coat hypertension
• hypertension that is resistant to drug treatment
• suspected hypotensive episodes (eg in elderly or diabetic patients)
Risk calculation should be performed using clinical BP measurements (as the algorithms
are based on these)
34, 40
47
Lifestyle
modification
Lifestyle risk factors should be managed at all risk levels
All people, regardless of their absolute cardiovascular disease (CVD) risk assessment,
should be given dietary advice. Those at low to moderate absolute CVD risk should be
given dietary and other lifestyle advice (refer to Chapter 7. Prevention of chronic disease)
Advise to aim for healthy targets:
• Encourage any physical activity and aim for at least 30 minutes of moderate-intensity
physical activity on most, if not all, days
• Recommend smoking cessation
• Suggest a target waist measurement <94 cm for men and <80 cm for women, and a
body mass index (BMI) <25 kg/m2
• Recommend dietary salt restriction ≤4 g/day (65 mmol/day sodium)
• Encourage limiting alcohol intake to ≤2 standard drinks per day for males and ≤1
standard drink per day for females
34, 40, 48
Medications BP treatment should aim to lower BP towards (while balancing risks and benefits):
• ≤140/90 mmHg for adults without CVD (including those with chronic kidney disease [CKD])
• ≤130/80 mmHg for adults with diabetes or with microalbuminuria or macroalbuminuria
(urine albumin-to-creatinine ratio urine albumin-to-creatinine ratio [UACR] >2.5 mg/
mmol for males, >3.5 mg/mmol for females)
• In patients at high absolute risk there is some evidence that a lower treatment goal
(systolic blood pressure [SBP] <120 mmHg) in individuals who tolerate more intensive
treatment provides additional benefit. Adverse effects need to be monitored
34, 49
BMI, body mass index; BP, blood pressure; CKD, chronic kidney disease; CVD, cardiovascular disease; SBP, systolic blood pressure;
UACR, urine albumin-to-creatinine ratio
8.3 Cholesterol and other lipids
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Aboriginal and Torres
Strait Islander peoples
Adults should have their blood lipids (a fasting sample should be used when assessing elevated triglycerides [TG])50
assessed every five years starting at 45 years of age (A for males, C for females). Lipid levels should be interpreted in
the context of an absolute CVD risk assessment after 45 years of age (35 years of age for Aboriginal and Torres Strait
Islander peoples; B). Aboriginal and Torres Strait Islander adults should have lipid tests performed every five years
from 35 years of age (B).
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Table 8.3.1. Cholesterol and lipids: Identifying risk
Who is at risk? What should be done? How often? References
Low risk:
• Absolute cardiovascular disease (CVD) risk <10%
Provide lifestyle advice (I, A) Repeat lipids
every five years*
34
Moderate risk:
• Absolute CVD risk 10–15%
Provide intensive lifestyle
advice (II, B)
Consider pharmacotherapy†
if not reaching target after
six months (I, A) or if family
history of premature CVD
or patient is of Aboriginal or
Torres Strait Islander, South
Asian, Middle Eastern, Maori
or Pacific Islander descent
(II, C)
Repeat lipids
every two years
34, 36–38, 42
High risk:
• Absolute CVD risk >15%
• Patient with the following clinically determined
high-risk factors:
– diabetes and >60 years of age
– diabetes with microalbuminuria (>20 µg/min
or urine albumin-to-creatinine ratio [UACR])
>2.5 mg/mmol for males, >3.5 mg/mmol for
females)
– Chronic kidney disease (CKD); persistent
microalbuminuria or stage 4 renal failure
(estimated glomerular filtration rate [eGFR]
<30 mL/min/1.73 m2) or stage 3a renal failure
eGFR <45 mL/min/1.73 m2)
– previous diagnosis of familial
hypercholesterolaemia
– Systolic blood pressure (SBP) ≥180 mmHg or
diastolic blood pressure (DBP) ≥110 mmHg
– serum total cholesterol >7.5 mmol/L‡
– Aboriginal and Torres Strait Islander peoples
aged >74 years
Refer to Section 8.2. Blood pressure
Provide intensive lifestyle
advice (II, C)
Commence cholesterol-
lowering therapy
(simultaneously with
antihypertensive unless
contraindicated) (II, C to III,
D)§
Every 12
months (III, C)
34, 42
• Existing CVD (previous event, symptomatic CVD) Provide lifestyle risk factor
counselling and commence
pharmacotherapy to lower
risk
Every 12
months (III, C)
51
*Lipid blood test results within five years can be used to calculate absolute CVD risk every two years. Patients with diabetes, cardiac
disease, stroke, hypertension or kidney disease should have their lipids tested every 12 months (III, C)
†In Australia, pharmacotherapy with statins are only subsidised on the pharmaceutical benefits scheme (PBS) for limited criteria at
www.pbs.gov.au/info/news/2006/09/Eligibility-cholestl-lwring-meds
‡Those with low-density lipoprotein cholesterol (LDL-C) >4.0 or total cholesterol >7.5 should be reviewed for family history and clinical
features of FH52
§D recommendation for clinically determined high risk
CKD, chronic kidney disease; CVD, cardiovascular disease; DBP, diastolic blood pressure; eGFR, estimated glomerular filtration rate;
FH, familial hypercholesterolaemia; low-density lipoprotein cholesterol, LDL-C; PBS, Pharmaceutical Benefits Scheme; SBP, systolic
blood pressure; UACR, urine albumin-to-creatinine ratio
http://www.pbs.gov.au/info/news/2006/09/Eligibility-cholestl-lwring-meds
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Table 8.3.2. Cholesterol and lipids: Preventive interventions
Intervention Technique References
Blood lipids Total cholesterol, low-density lipoprotein-cholesterol (LDL-C), high-density
lipoprotein-cholesterol (HDL-C) and triglycerides (TGs)
If lipid levels are abnormal, a second confirmatory sample should be
taken on a separate occasion (as levels may vary between tests) before
a definitive diagnosis is made. A fasting sample should be used when
assessing elevated TGs
Screening tests using capillary blood samples produce total cholesterol
results that are slightly lower than on venous blood. These may be used,
providing they are confirmed with full laboratory testing of venous blood for
patients with elevated levels and there is good follow up
In adults with low absolute cardiovascular disease (CVD) risk, blood test
results within five years may be used for review of absolute CVD risk unless
there are reasons to the contrary
50, 53–55
Lifestyle modification Lifestyle risk factors should be managed at all risk levels
All people, regardless of their absolute CVD risk level, should be given
dietary advice. Those at low to moderate absolute CVD risk should be
given dietary and other lifestyle advice (refer to Chapter 7. Prevention of
chronic disease)
Advise to aim for healthy targets:
• Encourage any physical activity and aim for at least 30 minutes of
moderate-intensity physical activity on most, if not all, days
• Recommend smoking cessation
• Suggest a target waist measurement <94 cm for men and <80 cm for
women, and a body mass index (BMI) <25 kg/m2
• Recommend salt restriction ≤4 g/day (65 mmol/day sodium
• Encourage limiting alcohol intake to ≤2 standard drinks per day for
males and ≤1 standard drink per day for females
34, 40
Pharmacotherapy Lipid-lowering therapy for primary prevention should (while balancing risks
and benefits) aim towards:
• total cholesterol <4.0 mmol/L
• HDL-C ≥1.0 mmol/L
• LDL-C <2.0 mmol/L
• non-HDL-C <2.5 mmol/L
• TG <2.0 mmol/L
Refer to the Australian medicines handbook for pharmacotherpy options
34, 49
BMI, body mass index; CVD, cardiovascular disease; HDL-C, high-density lipoprotein-cholesterol; LDL-C, low-density lipoprotein-
cholesterol; TG, triglyceride
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8.4 Type 2 diabetes
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Aboriginal and Torres
Strait Islander peoples
Abnormal blood glucose is a modifiable risk factor for CVD and a diagnosis of diabetes substantially increases
a person’s absolute CVD risk score. The Australian type 2 diabetes risk assesment tool (AUSDRISK) is useful in
assessing risk of diabetes. Preventive interventions (refer to Table 8.4.3) have been shown to reduce progression to
diabetes in patients with impaired fasting glucose.
Patients at high risk should be screened for diabetes every three years from 40 years of age. Aboriginal and
Torres Strait Islander peoples should have their risk of diabetes assessed every three years from 18 years of age.
Screening should be part of a comprehensive CVD assessment including BP, lipids, smoking, physical activity, diet,
overweight and obesity.
Table 8.4.1. Type 2 diabetes: Identifying risk
Who is at risk?
What should
be done? How often? References
Increased risk:
• ≥40 years of age
• Aboriginal and Torres Strait Islander peoples aged ≥18 years
AUSDRISK*
(III, B)
Every three
years (III, C)
56
High risk:
• ≥40 years of age and being overweight or obese
(refer to Section 7.2. Overweight)
• AUSDRISK score of 12 or more
• Consider screening the following groups because they may be
at increased risk for diabetes at an earlier age or lower body
mass index (BMI):
– first-degree relative with diabetes
– high-risk race/ethnicity (Indian subcontinent or Pacific
Islanders)
– all people with a history of a previous cardiovascular event
(eg acute myocardial infarction or stroke)
– women with a history of gestational diabetes mellitus
– women with polycystic ovary syndrome
– patients on antipsychotic drugs
Fasting blood
glucose (III, B)
OR
glycated
haemoglobin
(HbA1c)
Every three
years (III, C)
57–59
• Those with impaired glucose tolerance test or impaired fasting
glucose (not limited by age)
Fasting blood
glucose (III, B)
or HbA1c
Every 12
months (III, C)
58
*The Australian type 2 diabetes risk assessment tool (AUSDRISK) is available at www.health.gov.au/preventionoftype2diabetes
BMI, body mass index; HbA1c, glycated haemoglobin
http://www.health.gov.au/preventionoftype2diabetes
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Table 8.4.2. Tests to detect diabetes*
Test Technique References
Fasting blood
glucose
Measure plasma glucose levels on a fasting sample:
• <5.5 mmol/L: Diabetes unlikely
• 5.5–6.9 mmol/L: May need to perform an oral glucose tolerance test
• ≥7.0 mmol/L (>11.1 non-fasting): Diabetes likely; repeat fasting blood sugar on
a separate day to confirm
The test should be performed on venous blood and tested in a laboratory to confirm
a diagnosis
Impaired fasting glucose is diagnosed on the basis of a result between 6.1 and
6.9 mmol/L
58
Glycated
haemoglobin
(HbA1c)
HbA1c may be used as a diagnostic test for diabetes. HbA1c of ≥48 mmol/mol (6.5%)
is diagnostic of diabetes
60, 61
Oral glucose
tolerance test
Measure the plasma glucose before (fasting) and two hours after a 75 g glucose load
is taken orally. Diabetes is diagnosed if fasting plasma glucose is ≥7.0 mmol/L or two-
hour plasma glucose is ≥11.1 mmol/L. If the two-hour plasma glucose is between 7.8
and 11.0 mmol/L, there is impaired glucose tolerance. A two-hour result <7.8 mmol/L
is considered normal
58
*Cut off levels for classifications vary by national and World Health Organization (WHO) guidelines, and are subject to change as more
evidence is developed
HbA1c, glycated haemoglobin; WHO, World Health Organization
Table 8.4.3. Type 2 diabetes: Preventive interventions
Target group Intervention References
Impaired glucose tolerance,
impaired fasting glucose and those
with an elevated Australian type
2 diabetes risk assesment tool
(AUSDRISK) score or with other
specific high-risk factors
• Increasing physical activity (eg 30 minutes brisk walking five
times a week) and/or weight loss reduces risk of developing
diabetes by 40–60% in those at high risk
• Give advice on healthy low-fat diet (<30% kcal or kilojoules
from fat and <10% from saturated fat; high fibre, low
glycaemic index with cereals, legumes, vegetables and
fruits), weight loss and increased physical activity (refer
to Smoking, nutrition, alcohol, physical activity (SNAP): A
population health guide to behavioural risk factors in general
practice, 2nd edn)
• Refer patients to a dietitian and a physical activity program
• Provide pre-conception advice to women with a history of
gestational diabetes
62–65
AUSDRISK, Australian type 2 diabetes risk assessment tool
The RACGP and Diabetes Australia’s publication General practice management of type 2 diabetes – 2016–18
provides guidance for the management of patients diagnosed with T2D.
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8.5 Stroke
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
GPs should be alert to symptoms of transient ischaemic attacks (TIAs) in those aged ≥45 years and they should
assess these patients early in order to prioritise those needing urgent investigation and management. People at
high risk should be questioned about symptoms of TIA to determine appropriate action. Adults with AF should have
their absolute CVD risk assessed and the cause of their AF determined and treated according to cardiovascular
and thromboembolic risk (II, B).
Table 8.5.1. Stroke: Identifying risk
Who is at risk? What should be done? How often? References
High absolute risk:
• Calculated >15% absolute risk,
clinically determined high risk
or pre-existing cardiovascular
disease (CVD)
• Previous stroke (especially with
co-existent atrial fibrillation
[AF] or high grade [70–99%]
symptomatic carotid stenosis)
• Previous transient ischaemic
attack (TIA)
Question about symptoms of TIA. If TIA, stratify
risk of stroke and consider anticoagulation* (I, A)
If AF, determine cause of AF and treat according
to cardiovascular and thromboembolic risk (II, B)
Manage behavioural and physiological risk
factors actively. Treat with antihypertensive
and lipid-lowering medications unless
contraindicated or clinically inappropriate (II, B)
Every 12
months (IV, C)
34, 51
66–68
Auscultation for carotid bruit Auscultating for carotid bruit in asymptomatic
people is not recommended in the general adult
population as a screening tool for stroke risk.
Screening with duplex ultrasonography in this
population is not cost-effective (yields many false
positive results). In addition, the overall benefit
of surgery is, at best, small; hence, very careful
selection of patients is needed to justify surgery
in those with severe (>60%) but asymptomatic
stenosis†
However, the presence of a carotid bruit has
been shown to be associated with increased
risk of myocardial infarction and cardiovascular
death, so may be a useful prognostic marker
when assessing cardiovascular risk generally
Screen patients with known asymptomatic
carotid artery stenosis for other treatable causes
of stroke and treat these intensively
67, 69–71
67
*Anticoagulation therapy for long-term secondary prevention should be used in people with ischaemic stroke or TIA who have
documented atrial fibrillation or cardio-embolic stroke
†Antiplatelet therapy should be considered for non-cardio-embolic stroke or TIA
AF, atrial fibrillation; CVD, cardiovascular disease; TIA, transient ischaemic attack
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Table 8.5.2. Tests to detect stroke risk
Test Technique References
Question about
transient ischaemic
attack (TIA)
ABCD2 tool
Question patient or carer regarding symptoms of sudden onset of loss of focal
neurological function such as weakness or numbness of arms or legs, speech
disturbance, double vision or vertigo
All patients with suspected TIA should have stroke risk assessment, which may
include the ABCD2 tool:
• Age: >60 years (1 point)
• BP: >140/90 mmHg (1 point)
• Clinical features: Unilateral weakness (2 points), speech impairment without
weakness (1 point)
• Duration: >60 minutes (2 points), 10–59 minutes (1 point)
• Diabetes (1 point)
Important additional information required:
• presence of atrial fibrillation (AF)
• signs that might indicate carotid disease (eg anterior circulation signs),
in people who are candidates for carotid surgery
• ≥2 TIAs within the previous seven days (crescendo TIA)
For those deemed high risk (ABCD2 tool = 4–7 and/or AF, potential carotid
disease or crescendo TIA): Urgent brain and carotid imaging (‘urgent’ is
considered immediately, but certainly within 24 hours). If carotid territory
symptoms, consider duplex ultrasound for patients who are potential candidates
for carotid revascularisation
For those deemed low risk (ABCD2 tool = 0–3 without AF, potential carotid
disease or crescendo TIA): Refer for computed tomography (CT) of brain (and
carotid ultrasound where indicated) as soon as possible (ie within 48–72 hours)
68, 72
Assess the need for
anticoagulation
A decision to anticoagulate someone with AF can be assisted by stroke
(CHA2DS2-VASc) and bleeding (HAS-BLED) scores
73, 74
AF, atrial fibrillation; CT, computed tomography; TIA, transient ischaemic attack
For further information about secondary prevention after stroke or TIA, refer to https://strokefoundation.com.au
Also refer to Chapter 15. Screening tests of unproven benefit.
https://strokefoundation.com.au
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8.6 Kidney disease
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Approximately 1.7 million Australians aged >18 years have reduced kidney function and/or albumin in the urine,75
but only 10% are aware of this.76 CKD may be a stronger risk factor for future coronary events and all-cause
mortality than diabetes.77 Early management of CKD includes CVD risk factor reduction, lifestyle changes and
prescription of angiotensin-converting-enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs).78 Patients
should be screened for kidney disease if they are at high risk (B).
Table 8.6.1. Kidney disease: Identifying risk
Who is at risk? What should be done? How often? References
High risk:
• Smoking
• Obesity (body mass index [BMI] >30 kg/m2)
• Family history of kidney failure
• Diabetes
• Hypertension
• Aboriginal or Torres Strait Islander peoples
aged >30 years
• Established cardiovascular disease (CVD),
coronary heart disease (CHD) or peripheral
vascular disease (PVD)
• History of acute kidney injury
Blood pressure (BP),
albumin-to-creatinine
ratio (ACR) and estimated
glomerular filtration rate
(eGFR; III, A)
If ACR is positive, arrange
two further samples for urine
ACR over two months (III, B)
If eGFR <60 mL/min/1.73 m2,
repeat within seven days
Every one to two
years* (IV, C)
79–88,
92–94
57, 88–91
*One year for patients with hypertension or diabetes
ACR, albumin-to-creatinine ratio; BMI, body mass index; BP, blood pressure; CHD, coronary heart disease; CVD, cardiovascular
disease; eGFR, estimated glomerular filtration rate; PVD, peripheral vascular disease
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Table 8.6.2. Tests to detect kidney disease
Test Technique References
Albuminuria Estimation of urine albumin-to-creatinine ratio (UACR), preferably on a first morning void.
Note: Dipstick urine test is not adequate to identify microalbuminuria
Albumin-to-creatinine ratio (ACR)
Females Males
Normal <3.5 mg/mmol <2.5 mg/mmol
Microalbuminuria 3.5–35 mg/mmol 2.5–25 mg/mmol
Macroalbuminuria >35 mg/mmol >25 mg/mmol
88, 90
Estimated
glomerular
filtration rate
(eGFR)
This is currently automatically reported with every test for serum creatinine using
the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula (staging
is based on both eGFR level and UACR [normoalbuminuria, microalbuminuria or
macroalbuminuria]):
• Stage 1: >90 mL/min/1.73 m2 with microalbuminuria, proteinuria or haematuria with
the presence of structural or pathological abnormalities
• Stage 2: 60–89 mL/min/1.73 m2 with microalbuminuria, proteinuria or haematuria with
the presence of structural or pathological abnormalities
• Stage 3a: 45–59 mL/min/1.73 m2
• Stage 3b: 30–44 mL/min/1.73 m2
• Stage 4: 15–29 mL/min/1.73 m2
• Stage 5: (end-stage): <15 mL/min/1.73 m2
Refer patients with Stage 4 or 5 to a renal unit or nephrologist, and consider referral at
Stage 3 or earlier if:
• persistent significant albuminuria (UACR ≥30 mg/mmol)
• a sustained decrease in eGFR of 25% or more OR a sustained decrease in eGFR of
15 mL/min/1.73 m2 within 12 months
• chronic kidney disease (CKD) with hypertension that is hard to get to target despite at
least three antihypertensive agents
Visit www.kidney.org.au/cms_uploads/docs/ckd-management-in-gp-handbook-3rd-
edition
Note: eGFR and the presence and severity of albuminuria reflects the risk of
cardiovascular disease (CVD) progression and future cardiovascular events
The eGFR may be unreliable in the following situations:
• acute changes in renal function
• patients on dialysis
• certain diets (eg vegetarian, high protein, recent ingestion of cooked meat)
• extremes of body size
• muscle diseases (may overestimate) or high muscle mass (may underestimate)
• children <18 years of age
• severe liver disease
78, 89, 95
ACR, albumin-to-creatinine ratio; CKD, chronic kidney disease; CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; CVD,
cardiovascular disease; eGFR, estimated glomerular filtration rate; UACR, urine albumin-to-creatinine ratio
8.7 Atrial fibrillation
AF is the most common heart arrhythmia; it increases in incidence with age,96,97 affecting less than 1% of patients
aged <60 years and between 5% and 15% of patients aged >80 years.98
Systematic screening for AF is not recommended; however, opportunistic screening when taking a blood pressure
or at other times appears to be cost effective.99
http://www.kidney.org.au/cms_uploads/docs/ckd-management-in-gp-handbook-3rd-edition
http://www.kidney.org.au/cms_uploads/docs/ckd-management-in-gp-handbook-3rd-edition
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31. Kritharides L, Lowe HC. Extracting the ESSENCE –
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36. van Dis I, Kromhout D, Geleijnse JM, Boer JM,
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38. Welborn TA, Dhaliwal SS, Bennett SA. Waist–hip ratio is
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39. Vasan RS, Larson MG, Leip EP, Kannel WB, Levy D.
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40. National Blood Pressure and Vascular Disease Advisory
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41. US Preventive Services Task Force. Screening for high
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42. The Royal Australian College of General Practitioners.
Smoking, nutrition, alcohol, physical activity (SNAP): A
population health guide to behavioural risk factors in
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43. National Heart Foundation. Guideline for the diagnosis
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44. Culleton B, Larson M, Wilson P, Evans J, Parfrey P, Levy
D. Cardiovascular disease and mortality in a community-
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45. Go A, Chertow G, Fan D, McCulloch C, Hsu CY.
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46. Wright JT Jr, Williamson JD, Whelton PK, et al. A
randomized trial of intensive versus standard blood-
pressure control. N Engl J Med. 2015;373(22):2103–16.
47. National Heart Foundation and High Blood Pressure
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blood pressure monitoring. Aust Fam Physician
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49. Australian Medicines Handbook. Adelaide: AMH, 2016.
50. Nordestgaard BG, Langsted A, Mora S, et al. Fasting is
not routinely required for determination of a lipid profile:
Clinical and laboratory implications including flagging
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51. National Heart Foundation of Australia and the Cardiac
Society of Australia and New Zealand. Reducing risk
in heart disease: An expert guide to clinical practice
for secondary prevention of coronary heart disease.
Melbourne: National Heart Foundation of Australia, 2012.
52. Kirke A, Watts GF, Emery J. Detecting familial
hypercholesterolaemia in general practice. Aust Fam
Physician 2012;41(12):965–68.
53. National Heart Foundation of Australia, The Cardiac
Society of Australia and New Zealand. Position
statement on lipid management 2005. Heart Lung Circ
2005;14:275–91.
54. Bradford RH, Bachorik PS, Roberts K, Williams OD,
Gotto AM Jr. Blood cholesterol screening in several
environments using a portable, dry-chemistry analyzer
and fingerstick blood samples. Lipid Research Clinics
Cholesterol Screening Study Group. Am J Cardiol
1990;65(1):6–13.
55. Bachorik PS, Cloey TA, Finney CA, Lowry DR,
Becker DM. Lipoprotein-cholesterol analysis during
screening: Accuracy and reliability. Ann Intern Med
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56. National Health and Medical Research Council. National
evidence based guidelines for case detection and
diagnosis of type 2 diabetes. Canberra: NHMRC, 2009.
57. Iseki K, Ikemiya Y, Iseki C, Takishita S. Proteinuria and
the risk of developing end-stage renal disease. Kidney Int
2003;63:1468–74.
58. Colagiuri S, Davies D, Girgis S, Colagiuri R. National
evidence based guideline for case detection and
diagnosis of type 2 diabetes. Canberra: Diabetes
Australia and the National Health and Medical Research
Council, 2009.
59. Siu AL. Screening for abnormal blood glucose and
type 2 diabetes mellitus: US Preventive Services Task
Force recommendation statement. Ann Intern Med
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60. d’Emden MC, Shaw JE, Jones GR, Cheung NW.
Guidance concerning the use of glycated haemoglobin
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(HbA1c) for the diagnosis of diabetes mellitus. Med J
Aust 2015;203(2):89–90.
61. World Health Organization. Report of a World Health
Organization Consultation – Use of glycated haemoglobin
(HbA1c) in the diagnosis of diabetes mellitus. Diabetes
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62. Knowler WC, Barrett-Connor E, Fowler S, et al.
Reduction in the incidence of type 2 diabetes with
lifestyle intervention or metformin. N Eng J Med
2002;346:393–403.
63. Pan X, Li G, Hu Y, et al. Effects of diet and exercise
in preventing NIDDM in people with impaired glucose
tolerence: The Da Qing IGT and Diabetes Study. Diabetes
Care 1997;20:537–44.
64. Tuomilehto J, Lindstrom J, Eriksson J, et al. Prevention
of type 2 diabetes melllitus by changes in lifestyle among
subjects with impaired glucose tolerance. N Eng J Med
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65. Williamson DF, Vinicor F, Bowman BA. Primary prevention
of type 2 diabetes mellitus by lifestyle intervention:
Implications for health policy. Ann Intern Med
2004;140(11):951–57.
66. National Heart Foundation of Australia. National
Heart Foundation position statement on non-valvular
atrial fibrillation and stroke prevention. Med J Aust
2001;174:234–348.
67. Goldstein LB, Adams R, Alberts MJ, et al. Primary
prevention of ischemic stroke: A guideline from the
American Heart Association/American Stroke Association
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Peripheral Vascular Disease Interdisciplinary Working
Group; Cardiovascular Nursing Council; Clinical
Cardiology Council; Nutrition, Physical Activity, and
Metabolism Council; and the Quality of Care and
Outcomes Research Interdisciplinary Working Group.
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68. Alberts MJ, Eikelboom JW, Hankey GJ. Antithrombotic
therapy for stroke prevention in non-valvular atrial
fibrillation. Lancet Neurol 2012;11(12):1066–81.
69. Sauve J, Thorpe KE, Sackett DL, Taylor W. Can bruits
distinguish high-grade from moderate symptomatic
carotid stenosis? The North American Symptomatic
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70. Pickett CA, Jackson JL, Hemann BA, Atwood JE.
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death and myocardial infarction: A meta-analysis. Lancet
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71. Floriani M, Giulini SM, Bonardelli S, Portolani N. Value
and limites of ‘critical auscultation’ of neck bruits.
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72. National Stroke Foundation. Clinical guidelines for stroke
management. Melbourne: NSF, 2010.
73. Lane DA, Lip GY. Use of the CHA(2)DS(2)-VASc
and HAS-BLED scores to aid decision making for
thromboprophylaxis in nonvalvular atrial fibrillation.
Circulation 2012;126(7):860–65.
74. Wolf PA, Abbot RD, Kannel WB. Atrial fibrillation as an
independent risk facor for stroke: The Framingham study.
Stroke 1991;22:983–88.
75. Australian Bureau of Statistics. Australian health survey:
Biomedical results for chronic diseases, 2011–12.
Canberra: ABS, 2013.
76. Australian Bureau of Statistics. Australian health survey:
First results 2011–12. Canberra: ABS, 2012.
77. Tonelli M, Muntner P, Lloyd A, et al. Risk of coronary
events in people with chronic kidney disease compared
with those with diabetes: A population-level cohort study.
Lancet 2012;380(9844):807–14.
78. Kidney Health Australia. Chronic kidney disease (CKD)
management in general practice. 3rd edn. South
Melbourne, Vic: Kidney Health Australia, 2015.
79. Wang Y, Chen X, Song Y, Caballero B, Cheskin LJ.
Association between obesity and kidney disease:
A systematic review and meta-analysis. Kidney Int
2008;73(1):19–33
80. Johnson D. Evidence-based guide to slowing the
progression of early renal insufficiency. Intern Med J
2004;34:50–57.
81. Hallan SI, Dahl K, Oien CM, et al. Screening strategies
for chronic kidney disease in the general population:
Follow-up of cross sectional health survey. BMJ
2006;333(7577):1047.
82. Fox C, Larson MG, Leip EP, Culleton B, Wilson PWF.
Predictors of new-onset kidney disease in a community-
based population. JAMA 2004;291:844–50.
83. Crowe E, Halpin D, Stevens P. Early identification and
management of chronic kidney disease: Summary of
NICE guidance. BMJ 2008;337:a1530.
84. Chadban S, Briganti EM, Kerr PG, et al. Prevalence
of kidney damage in Australian adults:
The AusDiab kidney study. J Am Soc Nephrol
2003;14(7 Suppl 2):S131–38.
85. Astor BC, Hallan SI, Miller ER, Yeung E, Coresh J.
Glomerular filtration rate, albuminuria, and risk of
cardiovascular and all-cause mortality in the US
population. Am J Epidemiol 2008;167(10):1226–34.
86. Angelantonio ED, Chowdhury R, Sarwar N, Aspelund
T, Danesh J, Gudnason V. Chronic kidney disease and
risk of major cardiovascular disease and non-vascular
mortality: Prospective population based cohort study.
BMJ 2010;341:4986.
87. Hoy W, Mathews J, McCredie D, Pugsley D, Hayhurst B.
The multidimensional nature of renal disease: Rates and
associations of albuminuria in an Australian Aboriginal
community. Kidney Int 1998;54:1296–304.
88. Methven S, MacGregor MS, Traynor JP, Hair M, St J
O’Reilly D, Deighan CJ. Comparison of urinary albumin
and urinary total protein as predictors of patient
outcomes in CKD. Am J Kidney Dis 2010;57(1):21–28.
89. Levey AS, Coresh J, Balk E, Kausz AT, Levin A. National
Kidney Foundation practice guidelines for chronic kidney
disease: Evaluation, classification, and stratification. Ann
Intern Med 2003;139(2):137–47.
90. Eknoyan G, Hostetter T, Bakris GL, et al. Proteinuria
and other markers of chronic kidney disease: A position
statement of the National Kidney Foundation (NKF)
and the National Institute of Diabetes and Digestive
and Kidney Diseases (NIDDK). Am J Kidney Dis
2003;42:617–22.
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91. Bleyer A, Shemanski LR, Burke GL, Hansen KJ.
Tobacco, hypertension, and vascular disease: Risk
factors for renal functional decline in an older population.
Kidney Int 2000;57:2072–79.
92. Scottish Intercollegiate Guidelines Network. Diagnosis
and management of chronic kidney disease: A national
clinical guideline. Edinburgh: SIGN, 2008.
93. National Aboriginal Community Controlled Health
Organisation and The Royal Australian College of General
Practitioners. National guide to a preventive health
assessment for Aboriginal and Torres Strait Islander
people. 2nd edn. East Melbourne, Vic: RACGP, 2012.
94. Kidney Health Australia. National Chronic Kidney Disease
Strategy. Melbourne: KHA, 2006.
95. Levey AS, Stevens LA, Schmid CH, et al. A new equation
to estimate glomerular filtration rate. Ann Intern Med
2009;150(9):604–12.
96. Lloyd-Jones DM, Wang TJ, Leip EP, et al. Lifetime risk for
development of atrial fibrillation: The Framingham Heart
Study. Circulation 2004;110(9):1042–46.
97. Rosamond W, Flegal K, Furie K, et al. Heart disease
and stroke statistics – 2008 update: A report from
the American Heart Association Statistics Committee
and Stroke Statistics Subcommittee. Circulation
2008;117(4):e25–146.
98. Kalman JM, Sanders P, Brieger DB, et al. National Heart
Foundation of Australia consensus statement on catheter
ablation as a therapy for atrial fibrillation. Med J Aust
2013;198(1):27–28.
99. Moran PS, Flattery MJ, Teljeur C, Ryan M, Smith SM.
Effectiveness of systematic screening for the detection
of atrial fibrillation. Cochrane Database Syst Rev
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Appendix 8A. Australian cardiovascular disease risk charts
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Reproduced with permission from the National Heart Foundation of Australia from National Vascular Disease Prevention Alliance. Absolute
cardiovascular disease risk management. Quick reference guide for health professionals. Melbourne: NVDPA, 2012.
Notes: The risk charts include values for SBP alone as this is the most informative of
conventionally measured blood pressure parameters for cardiovascular risk.
For specific groups, additional guidance includes:
The Framingham Risk Equation has not been validated for all population groups,
the assessment score should be interpreted with caution in the following groups:
• The Framingham Risk Equation may underestimate CVD risk in Aboriginal
and Torres Strait Islander peoples (EBR Grade D); adults with diabetes aged
between 45 and 60 years (EBR Grade C); adults aged over 74 years (CBR),
however, available evidence suggests that this approach will provide an estimate
of minimum cardiovascular risk.
• The Framingham Risk Equation is likely to underestimate CVD risk in adults
with socioeconomic deprivation (an independent risk factor for cardiovascular
disease) (PP) or depression (PP).
• The predictive value of the Framingham Risk Equation has not been
specifically assessed in adults who are overweight or obese (EBR Grade D).
• The increased risk of cardiovascular events and all-cause mortality, in
addition to thromboembolic disease including stroke, should be taken into
account for adults with atrial fibrillation (particularly those aged over 65 years) (PP).
Charts are based on the NVDPA’s Guidelines for the assessment of absolute
cardiovascular disease risk and adapted with permission from New Zealand
Guidelines Group. New Zealand Cardiovascular Guidelines Handbook: A Summary
Resource for Primary Care Practitioners. Second edition. Wellington, NZ: 2009.
www.nzgg.org.nz.
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9. Early detection of cancers
General practitioners (GPs) can play a key role in identifying patients who may be at increased risk of cancer, and
giving tailored advice and cancer screening. There are many risk factors for cancers that GPs can explore – most
are specific to each cancer.
9.1 Prostate cancer
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Not recommended as a preventive activity
Screening of asymptomatic (low-risk) men for prostate cancer by prostate specific antigen (PSA) testing is not
recommended because the benefits have not clearly been shown to outweigh the harms.1 This remains the case
following recent large trials.1 Therefore, GPs have no obligation to offer prostate cancer screening to asymptomatic men.
Some men may have individual concerns about prostate cancer and may put a higher value on the possible
benefits of prostate cancer screening. This requires specific discussion to address the benefits and harms
(from overdiagnosis and overtreatment) of prostate cancer screening.2 The Royal Australian College of General
Practitioners (RACGP) has produced a patient decision aid that may assist this discussion (www.racgp.org.au/
your-practice/guidelines/prostate-cancer).
If after an informed process, perhaps using a decision aid, a man still requests prostate cancer screening, a PSA
blood test is acceptable.3 Digital rectal examination (DRE) is no longer recommended as it is insufficiently sensitive
to detect prostate cancers early enough.4
Clinicians should not test for asymptomatic prostate cancer (eg by adding the PSA test to a battery of other tests)
without counselling about possible harms as well as possible benefits, and obtaining informed consent.
Table 9.1.1. Prostate cancer: Identifying risk
Who is at risk? What should be done? How often? References
Average risk:
• The risk of developing prostate cancer increases
with age and positive family history. However,
because prostate cancer is normally slow
growing, men aged >75 years or with a life
expectancy of <10 years are at reduced threat of
dying from a diagnosis of prostate cancer
• Men with uncomplicated lower urinary tract
symptoms (LUTS) do not appear to have an
increased risk of prostate cancer. The most
common cause of LUTS is benign prostate
enlargement. Early prostate cancer often does
not have symptoms
Respond to requests for
screening by informing
patients of risks and benefits
of screening using a decision
support aid (I, A)
On demand
(Practice Point)
5, 6
High risk:
• Men with one or more first-degree relatives
diagnosed <65 years of age
• Men with a first-degree relative with familial
breast cancer (BRCA1 or BRCA2)
Respond to requests for
screening by informing
patients of risks and benefits of
screening (Practice Point)
On demand
(Practice Point)
5–7
LUTS, lower urinary tract symptoms
http://www.racgp.org.au/your-practice/guidelines/prostate-cancer
http://www.racgp.org.au/your-practice/guidelines/prostate-cancer
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Table 9.1.2. Screening for prostate cancer in asymptomatic men
Not
recommended Justification References
Prostate specific
antigen (PSA)
screening
The most common adverse effect of radical prostatectomy is erectile dysfunction,
which affects most men (it is less common in younger men, those with a lower
PSA, and when nerve-sparing surgical techniques are used)
Other complications are common as well, including urinary incontinence (which
is very common in the months after treatment; however, this returns to normal in
75–90% men after two years, depending on treatment type). To a lesser extent,
urinary irritation and bowel symptoms can occur. General feelings of ‘vitality’ are
lost in about 10% of men
Both suicide and cardiovascular disease (CVD) increase enormously (eight and
11 times more respectively) in the week after men are given their diagnosis of
prostate cancer
Even diagnostic procedures performed following positive screening can be
harmful, with Australian data showing that the risk of life-threatening sepsis
needing intensive care admission is about 1% after biopsy
Despite large trials, two meta-analysis suggests that prostate cancer screening
does not save lives
For more information on benefits and harms, visit the Clinical practice guidelines
PSA testing and early management of test-detected prostate cancer at
http://wiki.cancer.org.au/australia/Guidelines:PSA_Testing/About_this_guideline
4, 8–11
12
13, 14
15
2, 8
CVD, cardiovascular disease; PSA, prostate specific antigen
Implementation
Strategy
Patients who request testing should be informed about the risks and benefits of tests for prostate cancer, and
should be assisted to make their own decision using an acceptable decision aid.16
9.2 Colorectal cancer
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Average risk
High risk 10 years prior to age of onset of affected family member
Biennial faecal occult blood test (FOBT) can reduce colorectal cancer (CRC) mortality by 16%.17 The original trials
of FOBT screening used the guaiac-based FOBT but this has been superseded by the more sensitive and specific
faecal immunochemical test. Organised screening by FOBT is recommended for the asymptomatic (average risk)
population from 50 years of age every two years (A) until 75 years of age with repeated negative findings.18,19
Increased risk is determined by family history; this should include determining the number of relatives affected by
CRC, side of family and age at diagnosis. DRE is not recommended as a screening tool (D), but is important in
evaluating patients who present with symptoms such as rectal bleeding.
Colonoscopy is not recommended as a screening test for people at average risk of CRC. No randomised
controlled trials (RCTs) have evaluated the effect of colonoscopy on CRC mortality, although trials are in progress in
Spain, Sweden and the US. Colonoscopy has indirect and direct harms, including, rarely, death from the procedure
http://wiki.cancer.org.au/australia/Guidelines:PSA_Testing/About_this_guideline
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(1 in 10,000–14,000 colonoscopies).20,21 Harm may be caused by the bowel cleanout prior to the procedure (eg
dehydration and electrolyte imbalances), the sedation used during the procedure (eg cardiovascular events), or
the procedure itself (eg infection, colonic perforations, bleeding). There is insufficient evidence about the use of
computed tomography (CT) colonography (also refer to Chapter 15. Screening tests of unproven benefit), faecal
deoxyribonucleic acid (DNA) or plasma circulating DNA tests to recommend them as alternatives to FOBT for CRC
screening.22 There is insufficient evidence to recommend the use of low-dose aspirin in people at average risk of
CRC.23
Table 9.2.1. Colorectal cancer: Identifying risk
Who is at risk? What should be done? How often? References
Category 1 – Average or slightly
increased risk:
Asymptomatic people with:
• no personal history of bowel cancer,
colorectal adenomas, inflammatory bowel
disease or family history of colorectal cancer
(CRC)
or
• one first-degree or second-degree relative
with CRC diagnosed aged ≥55 years
Faecal occult blood test
(FOBT; I, A)
Every two years from
50 years of age
(Practice Point)
17, 19, 24
Category 2 – Moderately increased risk
(1–2% of the population):
Asymptomatic people with:
• one first-degree relative with CRC diagnosed
aged <55 years
or
• two first-degree or one first-degree and one
second-degree relative(s) on the same side
of the family with CRC diagnosed at any age
(without potentially high-risk features as in
Category 3)
Colonoscopy
Sigmoidoscopy plus
double-contrast barium
enema or computed
tomography (CT)
colonography (performed
by an experienced
operator) are acceptable
if colonoscopy is
contraindicated
Consider offering FOBT
(III, B)
Every five years from
50 years of age, or
at an age 10 years
younger than the age
of first diagnosis of
CRC in the family,
whichever comes first
(Practice Point)
In intervening years
19, 25, 26
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Who is at risk? What should be done? How often? References
Category 3 – High risk
(relative risk of ~4–20%; <1% of the
population):*
Asymptomatic people with:
• three or more first-degree or second-
degree relatives on the same side of the
family diagnosed with CRC (suspected
Lynch syndrome, also known as hereditary
non-polyposis CRC [HNPCC]or other Lynch
syndrome-related cancers†
or
• two or more first- or second-degree relatives
on the same side of the family diagnosed
with CRC, including any of the following
high-risk features:
– multiple CRC in the one person
– CRC aged <50 years
– a family member who has or had Lynch
syndrome-related cancer
or
• at least one first-degree or second-degree
relative with CRC, with a large number
of adenomas throughout the large bowel
(suspected familial adenomatous polyposis
[FAP])
or
• somebody in the family in whom the presence
of a high-risk mutation in the adenomatous
polyposis coli (APC) or one of the mismatch
repair genes has been identified
• Members of proven FAP|| and Lynch
syndrome families who are shown not to carry
the family mutation are no longer at high risk
and revert to the average-risk group and still
require population-based screening
Refer for genetic screening
of affected relatives
Refer to bowel cancer
specialist to plan
appropriate surveillance
(III, B)
FAP: flexible
sigmoidoscopy
or
Colonoscopy in
attenuated FAP‡
HNPCC:
– colonoscopy
Consider offering FOBT
(III, B)
Those at risk for:
• FAP (no APC
mutation defined):
Every 12 months
from 12–15 to
30–35 years of age
and every three
years after 35 years
of age#
• Lynch syndrome:
one to two yearly
from 25 years of
age or five years
earlier than the
youngest affected
member of the
family (whichever is
earliest)
Aspirin 100 mg/day is
effective prophylaxis§
In intervening years
(Practice Point)
25, 26
*Age of starting screening varies in high-risk groups: 25 years of age for those with Lynch syndrome or five years earlier than the
earliest age of onset in the family
†Lynch syndrome-related cancers include colorectal, small bowel, endometrial, ovarian, gastric, brain and urothelial cancers
‡Attenuated FAP is characterised by a significant risk for colon cancer but fewer colonic polyps (average of 30), more proximally
located polyps, and diagnosis of CRC at a later age. Patients with 10–100 adenomas have an attenuated form of FAP, which can be
due to APC mutation (dominantly inherited) or MUTYH bi-allelic mutations (recessive). In each case the CRC risk is high
§Aspirin at 600 mg/day reduced Lynch syndrome cancer incidence by 50–68% in the Colorectal Adenoma/Carcinoma Prevention
Programme 2 (CAPP2) trial.27 Follow-up of the low-dose aspirin randomised controlled trials (RCTs)28, 29 suggests low-dose aspirin (100
mg/day) also reduces cancer incidence by half. A dose–response RCT in Lynch syndrome is open for recruitment at www.capp3.org
||FAP is an autosomal disorder caused by a germline mutation in the APC gene. APC mutation, as manifested by the development of
CRC, approaches 100% by 50 years of age in untreated subjects. FAP, however, accounts for less than 1% of all CRC cases. HNPCC
(Lynch syndrome) is due to an inherited mutation (abnormality) in a gene that normally repairs the body’s DNA. Both disorders have
an autosomal dominant mode of transmission within families and carry a very high risk for cancer. As the HNPCC gene mutation is
present in every cell in the body, other organs can also develop cancer. In untreated FAP, mutation carriers have a lifetime risk for CRC
close to 100%. In HNPCC, the risk for colorectal or other syndrome cancers is 70–90%19
#Bi-annual (six-monthly) or annual sigmoidoscopy for APC gene carriers of diagnosed FAP (colonoscopy in attenuated FAP)
APC, adenomatous polyposis coil; CAPP2, Colorectal Adenoma/Carcinoma Prevention Programme 2; CRC, colorectal cancer; CT,
computed tomography; FAP, familial adenomatous polyposis, FOBT, faecal occult blood test; HNPCC, hereditary non-polyposis
colorectal cancer; RCT, randomised controlled trials
http://www.capp3.org
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Patients who have adenomatous polyps removed at colonoscopy are then at above-average risk for the
development of metachronous adenomatous polyps and CRC. Table 9.2.2 relates to the follow up of people after
polypectomy. It is important to try and obtain information about the histology, size and number of polyps removed
as this determines the future risk of adenomas and CRC, and therefore frequency of recommended surveillance
colonoscopy.30
Table 9.2.2. Follow up after polypectomy
Polyp type and number Recommended colonoscopy screening interval
Small pale distal hyperplastic polyps only (not
adenomas)
No follow up required as no increased risk of metachronous colorectal
neoplasia
One to two small tubular (<10 mm)
adenomas
Repeat colonoscopy at five years
If that colonoscopy is normal, repeat colonoscopy at 10 years or faecal
occult blood test (FOBT) every two years
High-risk adenomas (three or more
adenomas, ≥10 mm, or with tubulovillous or
villous histology, or high-grade dysplasia)
Three-year intervals
Large and sessile adenomas removed
piecemeal
Three to six months and again at 12 months to ensure complete removal
Multiple adenomas, which is a strong
determinant of risk of metachronous
advanced and non-advanced neoplasia:
• ≥5 adenomas
• ≥10 adenomas
• 12 months
• Sooner than 12 months (because of the likelihood of missed
synchronous polyps)
Family history in addition to adenomas Intervals determined by adenoma characteristics, unless a syndromic risk
mandates more frequent surveillance
If advanced adenomas are found during
subsequent surveillance
Three-yearly schedule is prudent, but the choice should be individualised.
The interval can be lengthened if advanced adenomas are not found
People aged >75 years No surveillance as lead time for progression of an adenoma to cancer is
around 10–20 years
FOBT, faecal occult blood test
Table 9.2.3. Test to detect colorectal cancer
Test Technique References
Faecal occult
blood test (FOBT)
screening
Two main types of FOBT are available: Guaiac and faecal immunochemical tests
Immunochemical tests are preferred as they have greater sensitivity and higher
uptake (A).31 Two or three serial stools should be tested, depending on the type
and brand of test being used. Follow the manufacturer’s instructions
It is essential that any positive FOBT (including just one of the samples) is
appropriately investigated by colonoscopy (such people being at least 12 times
more likely to have colorectal cancer [CRC] than those with a negative test). With
guaiac tests, even if a subject fails to follow dietary restrictions, it is dangerous to
assume that a positive result is a result of dietary non-compliance
31, 32
CRC, colorectal cancer; FOBT, faecal occult blood test
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Implementation
Strategy
Measures to increase screening in these groups include organised approaches such as employing recall
and reminders;32,33 recommendations by the GP for the screening;33,34 addressing capacity issues, including
convenience;33,35 and minimising barriers such as cost.33,35,36 Refer to the RACGP’s Putting prevention into practice:
Guidelines for the implementation of prevention in the general practice setting (Green Book) for more information
(available at www.racgp.org.au/your-practice/guidelines/greenbook).
The National Bowel Cancer Screening Program, using a faecal immunochemical test, is being expanded and by
2020 will offer biennial screening for people aged 50–74 years. GPs are critical, not just in maximising participation,
but managing participants with a positive FOBT.34,37
Participation is under-represented by Aboriginal and Torres Strait Islander, and culturally and linguistically diverse
(CALD) peoples.38
9.3 Breast cancer
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Increasing age is a major risk factor for developing breast cancer. Other major risk factors include a personal history
of atypical hyperplasia or lobular carcinoma in situ, a strong family history of the disease or mutation in a breast
cancer predisposition gene, and previous radiotherapy (eg for previous cancer). Breast cancer risk factors that
reflect hormonal exposures in the distant past, such as age at menarche or age at first birth, are less predictive of
late-life breast cancer than factors indicating recent hormonal exposures such as high bone mass or obesity (refer
to https://canceraustralia.gov.au/clinical-best-practice/breast-cancer/breast-cancer-risk for further information).
Breast cancer risk is not normally distributed: most women have a low (<4%) lifetime risk; and the remainder 4% to
more than 80%.39,40
Prevention of breast cancer
Physical activity,41 adequate folate,42 a Mediterranean diet,43 normal BMI (in postmenopausal women only) and
decreased alcohol consumption44 are associated with a decreased risk of breast cancer in observational studies.
For women at moderate (ie 1.5–3 times the population risk) or high (ie >3 times the population risk) risk, additional
interventions such as risk-reducing medication45 (moderate and high risk) and risk-reducing surgery46 (high risk) are
available. Referral to specialist genetic assessment is available for women assessed at high risk.
Screening
The screening strategy employed for an individual woman depends on her individual degree of risk. Validated tools
are available that can assess an individual woman’s breast cancer risk (eg International Breast Cancer Intervention
Study [IBIS] tool, available at www.ems-trials.org/riskevaluator).47 For asymptomatic, low-risk women, BreastScreen
Australia recommends screening mammograms every two years for women aged 50–74 years (B).48
The benefits of screening are obvious. However, the risks must not be forgotten: assuming that screening reduces
breast cancer mortality by 15%, and that overdiagnosis and overtreatment is at 30%, then for every 2000 women
invited for screening over 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not
have been diagnosed if there had not been screening, will be treated unnecessarily.49,50 An extra 200 women will
experience important psychological distress including anxiety and uncertainty from false positive findings. The
substantial advances in treatment, and greater breast cancer awareness since the trials were carried out, mean
http://www.racgp.org.au/your-practice/guidelines/greenbook
https://canceraustralia.gov.au/clinical-best-practice/breast-cancer/breast-cancer-risk
http://www.ems-trials.org/riskevaluator
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that presented breast cancers are detected earlier and survive better, so screening today is less effective than at
the time of the trials. Recent observational studies show more overdiagnosis than in the trials and very little or no
reduction in the incidence of advanced cancers with screening.51
The decision to start screening mammogram should be an individual one. This is especially for women aged <50
years, where the benefits–harms ratio is less favourable.48
Some points:
• Screening mammogram in women aged 40–49 years may reduce the risk of dying of breast cancer, but the
number of deaths averted is much smaller than in older women, and the number of false-positive tests and
unnecessary biopsies are larger (C). Some women put a higher value on the potential benefit than the potential
harms, and may choose to begin screening between the ages of 40–49 years (C).48
• For women at average risk (ie <1.5 times population risk) of breast cancer, most of the benefit of a mammogram
will result from biennial screening during ages 50–74 years of age.48
• Of all age groups, women aged 60–69 years are most likely to avoid a breast cancer death through
mammogram screening (C).48
• All women undergoing regular screening mammogram are at risk of overdiagnosis – the detection (and then
treatment) of non-invasive and invasive breast cancer that would otherwise not have become a threat to their
health, or even apparent, during her lifetime (C).48
• Women with a parent, sibling, or child with breast cancer may benefit more than average-risk women from
beginning screening between 40 and 49 years of age (C).48
• Cancer Australia recommends considering annual mammograms from 40 years of age if the woman has a first-
degree relative <50 years of age diagnosed with breast cancer (refer to Table 9.3.1).48
• There is insufficient evidence to assess the balance of benefits and harms of screening mammogram in women
aged >75 years (I).48 Randomised trials of the benefits of screening mammogram did not include women >74
years of age. However observational studies favour extending screening mammogram to older women who
have a life expectancy of not less than 10 years.52
• There is insufficient evidence to recommend that clinical breast examination offers any benefits to women, of any
age (C).48 However, it is recommended that all women, whether or not they undergo mammogram screening,
are aware of how their breasts normally look and feel, and promptly report any new or unusual changes (such as
a lump, nipple changes, nipple discharge, change in skin colour, pain in a breast) to their GP. No one method for
women to use when checking their breasts is recommended over another.
The recommended screening strategy for women at different individual degrees of risk is outlined in Table 9.3.1.
Cancer Australia recommends that women at any age at increased risk (ie >1.5 times population risk) are offered
an individualised surveillance program by their GP and/or specialist.53 This might include regular clinical breast
examination and breast imaging with mammography and/or ultrasound and magnetic resonance imaging (MRI).
There is government funding available for MRI screening for women <50 years of age at high risk of developing
breast cancer.54
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Table 9.3.1. Breast cancer: Managing risk
Who is at risk? What should be done? How often? References
Average or only slightly higher* risk
(>95% of the female population):
Clarify risk at http://canceraustralia.
gov.au/clinical-best-practice/
gynaecological-cancers/familial-risk-
assessment-fra-boc
55
No confirmed family history of breast cancer
• One first-degree relative diagnosed with
breast cancer aged ≥50 years
• One second-degree relative diagnosed
with breast cancer at any age
• Two second-degree relatives on the
same side of the family diagnosed with
breast cancer aged ≥50 years
• Two first-degree or second-degree
relatives diagnosed with breast cancer,
aged ≥50 years, but on different sides
(ie on each side) of the family
As a group, risk of breast cancer up to 75
years of age is between 1:11 and 1:8
Mammogram
Breast awareness (I, A)
Every two years
from 50 to 74
years of age
Regular
(Practice Point)
Moderately increased risk† (<4% of the
female population):
• One first-degree relative diagnosed with
breast cancer aged <50 years (without
the additional features of the potentially
high-risk group)
• Two first-degree relatives, on the same
side of the family, diagnosed with breast
cancer (without the additional features of
the potentially high-risk group)
• Two second-degree relatives, on the
same side of the family, diagnosed with
breast cancer, at least one aged <50
years (without the additional features of
the potentially high-risk group)
As a group, the relative risk of breast cancer
up to 75 years of age is between 1:8 and 1:4
Clarify risk at http://canceraustralia.
gov.au/clinical-best-practice/
gynaecological-cancers/familial-risk-
assessment-fra-boc
Mammogram (III, C)
Breast awareness
Consider referral to or consultation
with a family cancer clinic for further
assessment and management plan
At least every
two years from
50 to 74 years
of age
Annual
mammograms
from 40 years
of age may be
recommended
if the woman
has a first-
degree relative
aged <50 years
diagnosed with
breast cancer
(Practice Point)
55
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
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Who is at risk? What should be done? How often? References
Potentially high risk‡ or carrying a
mutation (<1% of the female population):
• Women who are at potentially high risk of
ovarian cancer
• Two first-degree or second-degree
relatives on one side of the family
diagnosed with breast or ovarian cancer,
plus one or more of the following features
on the same side of the family:
– additional relative(s) with breast or
ovarian cancer
– breast cancer diagnosed before age
40 years
– bilateral breast cancer
– breast and ovarian cancer in the same
woman
– Ashkenazi Jewish ancestry
– breast cancer in a male relative
• One first-degree or second-degree
relative diagnosed with breast cancer
aged <45 years plus another first-degree
or second-degree relative on the same
side of the family with sarcoma (bone/
soft tissue) aged <45 years
• Member of a family in which the
presence of a high-risk breast cancer
gene mutation has been established
• Refer to the Cancer Australia guidelines
at http://canceraustralia.gov.au/clinical-
best-practice/gynaecological-cancers/
familial-risk-assessment-fra-boc for
further information
As a group, risk of breast cancer up to 75
years of age is between 1:2 and 1:4
Clarify risk at http://canceraustralia.
gov.au/clinical-best-practice/
gynaecological-cancers/familial-risk-
assessment-fra-boc
Advise referral to a cancer specialist
or family cancer clinic for risk
assessment, possible genetic testing
and management plan, which might
include treatment with chemo-
prevention with selective oestrogen-
receptor modulators (SERMs [eg
tamoxifen or raloxifene] or aromatase
inhibitors [AIs; eg exemestane and
anastrozole]), which reduce the risk of
cancer in women at moderate or high
risk of breast cancer. Tamoxifen has
greater efficacy (and can be used in
premenopausal women), but raloxifene
has fewer adverse effects
An alternative treatment is mastectomy
or salpingo-oophorectomy (which has
a greater effect on ovarian cancer risk
reduction), which also reduces the risk
of breast cancer
These decisions requires careful
assessment of risk and benefits
for individual women. Information
tailored for GPs is available at https://
canceraustralia.gov.au/sites/default/
files/publications/rrm-risk-reducing-
medication-for-women-at-increased-
risk-of-breast-cancer-due-to-family-
history_504af03f31630
Ongoing surveillance strategies
may include regular clinical breast
examination, breast imaging with
mammography, magnetic resonance
imaging (MRI) or ultrasound, and
consideration of ovarian cancer risk
(III, C)
Individualised
surveillance
program
This may
include regular
clinical breast
examination,
and annual
breast
imaging with
mammography,
MRI or
ultrasound
(Practice Point)
55
46–56
*About 1.5 times the population average
†About 1.5–3 times the population average
‡More than three times the population average. Individual risk may be higher or lower if genetic test results are known
Implementation of breast cancer screening
Strategies
A systematic review of strategies for increasing the participation of women in community breast cancer screening
found five favourable active strategies: letter of invitation, mailed educational material, letter of invitation plus phone
call, phone call, and training activities plus direct reminders.57
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
http://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/familial-risk-assessment-fra-boc
https://canceraustralia.gov.au/sites/default/files/publications/rrm-risk-reducing-medication-for-women-at-increased-risk-of-breast-cancer-due-to-family-history_504af03f31630
https://canceraustralia.gov.au/sites/default/files/publications/rrm-risk-reducing-medication-for-women-at-increased-risk-of-breast-cancer-due-to-family-history_504af03f31630
https://canceraustralia.gov.au/sites/default/files/publications/rrm-risk-reducing-medication-for-women-at-increased-risk-of-breast-cancer-due-to-family-history_504af03f31630
https://canceraustralia.gov.au/sites/default/files/publications/rrm-risk-reducing-medication-for-women-at-increased-risk-of-breast-cancer-due-to-family-history_504af03f31630
https://canceraustralia.gov.au/sites/default/files/publications/rrm-risk-reducing-medication-for-women-at-increased-risk-of-breast-cancer-due-to-family-history_504af03f31630
https://canceraustralia.gov.au/sites/default/files/publications/rrm-risk-reducing-medication-for-women-at-increased-risk-of-breast-cancer-due-to-family-history_504af03f31630
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9.4 Skin cancer
Primary prevention is being ‘sun smart’ (refer to Table 9.4.1.2). Everyone, particularly children, should be advised
to adopt protective measures when ultraviolet (UV) levels are ≥3. An RCT in Queensland showed that sunscreen
applied daily reduces the incidence of melanoma and squamous cell carcinoma (SCC) in adults with a previous
history of skin cancer.58,59
Screening of asymptomatic (low-risk) people for melanoma or non-melanocytic skin cancer (NMSC) is not
recommended as there is insufficient evidence available to show that this reduces death.60 A skin cancer screening
program in one region of Germany reported temporary reductions in melanoma mortality; however, this ecological
study may be subject to several biases.61,62
Instead of screening, providing education that raises awareness of the early signs of skin cancer, particularly in
people aged >40 years is recommended. Patients can be assessed opportunistically, or when concerned generally,
or about a specific skin lesion.
9.4.1 Melanocytic skin cancer
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Advise on sun protection
and prevention
Screen increased-risk
and high-risk patients
Clinical assessment of future risk of melanoma should take into account:60
• patient’s age and sex
• history of previous melanoma or NMSC
• number of naevi (common and atypical)
• family history of melanoma
• skin and hair pigmentation
• response to sun exposure
• evidence of actinic skin damage.
There are no sufficiently well-validated risk models to assess the combined effects of all these factors.63
Skin self-examination should be encouraged for high-risk individuals every three months and clinical examination
every six months (B).63,64
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Table 9.4.1.1. Melanocytic skin cancer: Identifying risk
Who is at risk? What should be done? How often? References
Average risk:
• Medium/dark skin colour and no other risk factors
Primary preventive
advice (III, B)
Opportunistically 60
Increased risk:
• Family history of melanoma in first-degree relative
(relative risk [RR] = 1.7)
• Fair complexion, a tendency to burn rather than tan,
the presence of freckles, high naevus count (>100),
light eye colour, light or red hair colour
• Presence of actinic damage (RR = 2)
• Past history of non-melanocytic skin cancer (NMSC)
(<40 years of age higher risk)
• People with childhood high levels of ultraviolet (UV)
exposure and episodes of sunburn in childhood
(RR = 2)
Primary preventive
advice and examination
of skin (III, B)
Opportunistically 60, 65
High risk (Risk >6 times normal):
• Previous history of melanoma (RR >10)
• >5 atypical (dysplastic) naevi (RR = 6)
Preventive advice,
examination of skin (with
or without photography)
and advice on self-
examination (III, C)
Every 6–12
months (Practice
Point)
Frequency
of follow-up
examinations for
people who have
had melanoma
is based on
disease stage
66
64
RR, relative risk; NMSC, non-melanocytic skin cancer; UV, ultraviolet
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Table 9.4.1.2. Melanocytic skin cancer: Preventive interventions
Intervention Technique References
Sun
protection
advice
All people (especially children aged ≤10 years) should be advised to be ‘sun smart’:
Adopt protective measures during sun protection times (when ultraviolet [UV] levels are
≥3). These measures include use of shade; broad-brimmed, bucket or legionnaire-style
hats; protective clothing; sunglasses; and sunscreens with a sun protection factor (SPF)
≥30 (which need to be reapplied every two hours)
Sun protection times are available from the Bureau of Meteorology. Apps for Apple and
Android tablets and smartphones or desktops provide real-time electronic alerts on
recommended sun protection times, current and maximum UV levels, and information
on recommended exposure for vitamin D. They are adjustable to specific geographic
locations around Australia, and is available at www.sunsmart.com.au
60, 67
Skin
examination
Before examining the skin, it is worth asking about any new, or changes in old skin
lesions. Characteristics of suspicious naevi include asymmetry, border irregularity,
variable colour (including a surrounding coloured halo) and diameter >6 mm (mnemonic
‘ABCD’). Naevi that stand out from the others (‘ugly duckling’) are also suspicious.
Nodular melanomas (with a much worse prognosis) are characteristically elevated, firm,
growing over the past month (mnemonic ‘EFG’)
The 7-point checklist is an alternative method to assess pigmented skin lesions
and is the only one to have been validated and shown to improve the identification
of melanoma in primary care. A score of >3 is associated with an increased risk of
melanoma
Major features of the lesions (scoring 2 points each):
• change in size
• irregular shape
• irregular colour
Minor features of the lesions (scoring 1 point each):
• largest diameter 7 mm or more
• inflammation
• oozing
• change in sensation
Excision biopsy or referral should be considered for lesions where there is clear suspicion
of melanoma
Training in the use of dermatoscopy and monitoring lesions for three months where
there is diagnostic uncertainty can reduce excision rates of benign skin lesions while
maintaining sensitivity to detect melanoma
Photography aids in monitoring skin lesions by detecting changes over time, and may
reduce the excision rate of benign lesions
60, 68–70
71–73
74–76
Self-
examination
Advise patients to be aware of the specific skin changes that suggest melanoma, be
encouraged to become familiar with their skin, and be alert for new or changing skin
lesions
Encourage high-risk individuals to perform self-examination, potentially with the aid of
a partner or carer, especially of naevi. Those at high risk may benefit from the use of
self-photography. At present, the role of ‘melanoma apps’ on smart phones to support
self-monitoring is not advised given uncertainties about their image quality and accuracy
65, 77
78
SPF, sun protection factor; UV, ultraviolet
Implementation
GPs over-excise pigmented lesions in people who are younger (aged <40 years) or female, in whom they excise
more benign lesions.75 GPs should be more suspicious of skin lesions in men aged >50 years.75
http://www.sunsmart.com.au
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9.4.2 Non-melanocytic skin cancer (basal cell and squamous
cell carcinoma)
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Prevention advice
Opportunistic
case finding
High-risk individuals aged ≥40 years should be examined for NMSC opportunistically (B). Skin self-examination
should be encouraged for high-risk individuals (B). The most common preventable cause of NMSC is UV exposure.
All people, especially children, should be advised to use protective measures when UV levels are ≥3 (A).
An RCT in Queensland showed that sunscreen applied daily reduces the incidence of melanoma and SCC in adults
with a previous history of skin cancer.58 In northern Australia and some parts of southern Australia, UV exposure is
sufficiently high to require daily use of sunscreen. For daily information about UV levels, visit the SunSmart widget at
www.sunsmart.com.au/uv-sun-protection/uv/uv-widget
Table 9.4.2.1. Non-melanocytic skin cancer: Identifying risk
Who is at risk? What should be done? How often? References
Average risk:
• Those with fair to lighter than
olive skin colour, aged <40 years
without any risk factors
Preventive advice (III, B) Opportunistically 79
Increased risk:
• Fair complexion, a tendency to
burn rather than tan, the presence
of freckles, light eye colour, light
or red hair colour
• Family history of skin cancer
• Aged >40 years
• Male
• Presence of multiple solar
keratoses
• People with high levels of
ultraviolet (UV) exposure such as
outdoor workers
Preventive advice, educate
patients to present to their
GP if changes occur in a skin
lesion, and examination of
skin (III, B)
Opportunistically 79
High risk:
• Previous non-melanocytic skin
cancer (NMSC; up to 60% of
patients grow another in three
years’ time)
• Immunosuppressed (eg post-
renal or heart transplant)
• Past exposure to arsenic
Preventive advice, educate
patients to present to their
GP if changes occur in a
skin lesion, examination of
skin, and advice on self-
examination (III, B)
If initial opportunistic
assessment indicates the
need. Every 12 months, or
when patient develops new
skin lesion (Practice Point)
80
NMSC, non-melanocytic skin cancer; UV, ultraviolet
http://www.sunsmart.com.au/uv-sun-protection/uv/uv-widget
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Table 9.4.2.2. Non-melanocytic skin cancer: Preventive interventions
Intervention Technique References
Sun protection
advice
Advise all people (especially children aged ≤10 years) to adopt protective measures
when ultraviolet (UV) levels are ≥3. These measures include use of shade; broad-
brimmed, bucket or legionnaire-style hats; protective clothing; sunglasses; and use of
sunscreen with sun protection factor (SPF) ≥30 (which need to be reapplied every two
hours)
Sun protection times are available from the Bureau of Meteorology. ‘SunSmart’
applications for Apple and Android tablets and smartphones or desktops provide real-
time electronic alerts on recommended sun protection times, current and maximum UV
levels, and information on recommended exposure for vitamin D. They are adjustable to
specific geographic locations around Australia, and is available at www.sunsmart.com.
au
60, 67
Skin
examination
Precede skin examination by enquiring for relevant history (eg of lesions of concern to
patient or recent appearance or change in any lesions in the past few months or years).
Examination should identify skin lumps, ulcers or scaly patches, particularly growing,
scarred or inflamed lesions. Consider incision, shave or excision biopsy for histology (or
referral). There are many suitable means to treat non-melanocytic skin cancer (NMSC);
these include surgery, cryotherapy, curettage and cytotoxic and immune modulating
creams
Training in the use of dermoscopy can assist in diagnosis
70, 75
Self-
examination
Advise patients to be alert for skin lesion changes 79
NMSC, non-melanocytic skin cancer; SPF, sun protection factor; UV, ultraviolet
9.5 Cervical cancer
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Prevention
Human papillomavirus vaccination (B)
For maximal effect, the vaccination should be given prior to the onset of sexual activity. It has no modifying effect
on already acquired human papillomavirus (HPV) infections. It is available as part of the National Immunisation
Program Schedule for girls and boys in year 7.81,82 HPV-vaccinated women still require cervical screening as the
HPV vaccine does not protect against all the types of HPV that cause cervical cancer.
http://www.sunsmart.com.au
http://www.sunsmart.com.au
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Screening
Australia has the lowest mortality rate and the second lowest incidence of cervical cancer in the world. The
success of the cervical screening program is dependent upon the recruitment of women: 85% of women in
Australia who develop cervical cancer have either not had a Papanicolaou (Pap) test or been inadequately screened
in the past 10 years. Women aged >50 years are still under-screened.83
Australia’s National Cervical Cancer Screening Program will change from May 2017. As of that date, women aged
25–74 years, both HPV vaccinated and unvaccinated, will be invited to undertake an HPV test every five years.84
Women of any age who have symptoms (including pain or bleeding) should have appropriate clinical assessment,
which may include a cervical cytology test and an HPV test. Women between 70 and 74 years of age who have
had a regular screening test will be recommended to have an exit HPV test before leaving the cervical screening
program.
A comparison between the current program and the one starting in May 2017 is given in Box A. In the interim,
the National Cervical Cancer Screening program continues to recommend Pap test screening every two years
for women who have ever had sex and have an intact cervix, commencing from 18–20 years of age (or up to two
years after first having sexual intercourse, whichever is later).85
Box A. Comparison of the key aspects of the current national cervical screening program with
that commencing from May 2017
Current recommendations From May 2017
Who? Human papillomavirus (HPV) vaccinated and
unvaccinated women
HPV vaccinated and unvaccinated women
What? Pap test screening HPV test
How often? Every two years Every five years
Commencing? From 18–20 years of age
(or two years after first having sexual intercourse,
whichever is later)
From 25 years of age
(or two years after first having sexual
intercourse, whichever is later)
Ending? At 70 years of age for women who have had two
normal Papanicolaou (Pap) tests within the last five
years. Women >70 years of age who have never
had a Pap test, or who request a Pap test, should
be screened
Between 70 and 74 years of age
HPV, human papillomavirus; Pap, Papanicolaou
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Guidelines for preventive activities in general practice
9th edition
Table 9.5.1. Cervical cancer: Identifying risk
Who is at risk?
What should
be done? How often? References
Average risk:
• All women who have
ever been sexually active
Papanicolaou
(Pap) test
(III–2, B)
All women who have ever been sexually active should
start having Pap tests between 18 and 20 years of
age (or two years after first having sexual intercourse,
whichever is later)
Routine screening with Pap tests should be carried
out every two years for women who have no
symptoms or history suggestive of cervical pathology
(Practice Point)
Pap tests may cease at 70 years of age for women
who had two normal Pap tests within the last five
years. Women aged >70 years who have never had
a Pap test, or who request a Pap test, should be
screened
Women with female sex partners are also at risk of
developing cervical cancer and should be screened
as above
85
Increased risk:
• Persistent infection
with high-risk human
papillomavirus (HPV)
types is necessary for the
development of cervical
cancer. Other risk factors
include:
– immunosuppression
– cigarette smoking
– use of combined oral
contraception >5
years
Pap test
(Practice Point)
It is important to ensure the patient always receives
the results of her test
Low-grade squamous intraepithelial lesion (LSIL):
• A woman with a Pap test report of possible/definite
LSIL should have a repeat Pap test in 12 months
(Practice Point). If the repeat test at 12 months
shows LSIL (definite or possible) the woman should
be referred for colposcopy
• A woman aged ≥30 years with a Pap test report
of LSIL, without a history of negative smears in the
preceding two to three years, should be offered
either colposcopy or a repeat Pap test at six
months (Practice Point)
High-grade squamous intraepithelial lesion (HSIL):
• Refer for colposcopy assessment and targeted
biopsy where indicated
Glandular abnormality or adenocarcinoma:
• Refer for colposcopy by an experienced
gynaecologist or gynaecological oncologist
• If the woman is symptomatic or if she has a
clinically abnormal cervix, referral for colposcopy is
recommended
86, 87
HPV, human papillomavirus; HSIL, high-grade squamous intraepithelial lesion; LSIL, low-grade squamous intraepithelial lesion;
Pap, Papanicolaou
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Table 9.5.2. Tests to detect cervical cancer risk
Test Technique References
Papanicolaou
(Pap) test
A sample of the ectocervix (using an extended tip spatula) then the endocervix (using a
cytobrush), provides the best method of sampling and can be used in all age groups of
women (the cytobrush is not recommended for use during pregnancy)
The cervical broom can be used on its own in premenopausal women if it is possible
to sample from both sides of the transformation zone. In postmenopausal women, the
transformation zone tends to be higher in the endocervical canal
The cervical cells should be placed onto a glass slide and fixed with spray within five
seconds. If the smear is reported as technically unsatisfactory, it should not be repeated
before six weeks
In postmenopausal women with atrophic changes, it may be necessary to use vaginal
oestrogen for 14–21 days prior to the test. Refer to Chapter 15. Screening tests of
unproven benefit regarding evidence related to bimanual vaginal examination
88
Human
papillomavirus
(HPV) testing
As a primary screening tool:
• Current national guidelines do not support the use of HPV testing as a primary
screening tool. This will change from May 2017
In triage of low-grade squamous intraepithelial lesion (LSIL):
• The use of HPV testing in the triage of LSIL remains under investigation and is not
currently recommended by the National Cervical Cancer Screening guidelines
In follow-up of high-grade squamous intraepithelial lesion (HSIL):
• In women treated for HSIL, cervical cytology plus HPV testing should be performed
12 months post-treatment and annually thereafter until both tests are negative on
two consecutive occasions, at which point women can return to the routine cervical
screening interval
85, 89, 90
85, 91–93
Liquid-based
cytology
Liquid-based cytology can be used as an additional test to the conventional smear, but
not as a substitute. Its addition may be useful when repeating an unsatisfactory smear,
or added if requested by the woman
94, 95
Self-collection If patients do not agree to undergo Pap (or HPV) testing by a clinician, they can be
assisted to collect the sample themselves
84, 96
HPV, human papillomavirus; LSIL, low-grade squamous intraepithelial lesion; HSIL, high-grade squamous intraepithelial lesion
The following resources provide helpful advice:
• Recommended screening tests and the visual appearance of the cervix, www.papscreen.org.au/downloads/
resources/other/cervical_sampling_card
• HPV: A guide for practitioners, www.papscreen.org.au/downloads/resources/other/hpv-a-guide-for-
practitioners
Pelvic examination
Screening pelvic examinations for the detection of pathology in asymptomatic, non-pregnant, adult women is not
recommended because there is no evidence of benefit.98 Also refer to Chapter 15. Screening tests of unproven benefit.
Implementation
Strategy
Methods of encouraging women to undergo cervical screening include invitations, reminders, education, message
framing, counselling, risk-factor assessment, procedures and economic interventions. Evidence supports the use
of invitations and, to a lesser extent, educational materials. It is likely other methods are advantageous, but the
evidence is not as strong. Further research is required.97
http://www.papscreen.org.au/downloads/resources/other/cervical_sampling_card
http://www.papscreen.org.au/downloads/resources/other/cervical_sampling_card
http://www.papscreen.org.au/downloads/resources/other/hpv-a-guide-for-practitioners
http://www.papscreen.org.au/downloads/resources/other/hpv-a-guide-for-practitioners
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9.6 Ovarian cancer
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Not recommended as a preventive activity
Screening in asymptomatic, low-risk women is not recommended. Screening methods for ovarian cancer employ
blood tests for cancer antigen (CA) 125, or transabdominal or transvaginal ultrasound. There are three large
randomised trials on ovarian cancer screening: the United States Prostate, Lung, Colorectal and Ovarian trial (PLCO),
which reported in 2011;99 the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) in late
2015;100 and a European trial, which commenced in 2005 and has not reported yet. The UK trial found a small
reduction in ovarian deaths from CA125, and transvaginal ultrasound for routine population-based screening for
ovarian cancer. However, the results are regarded as preliminary, requiring confirmation and longer follow-up100 and, in
the meantime, the US Preventive Services Task Force (USPSTF) recommends against ovarian cancer screening.101
Table 9.6.1. Ovarian cancer: Identifying risk
Who is at risk? What should be done? How often? References
Lower risk:
• Those who have used the oral
contraception or carried a pregnancy to
term (risk of about half the population
average)
No screening 102
Higher risk:
• Family history of ovarian cancer,
especially first-degree relatives and
more than one relative (risk of about 3
times the population average)
• Presence of the genes BRCA1 or
BRCA2
No screening
Consider increased frequency of
screening for breast and colorectal
cancer (CRC)
103
104
CRC, colorectal cancer
9.7 Testicular cancer
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Not recommended as a preventive activity
There is insufficient evidence to routinely screen for testicular cancer using clinical or self-examination.105,106 Those
performing testicular self-examination are not more likely to detect early-stage tumours or have better survival than
those who do not (C).
Table 9.7.1. Testicular cancer: Identifying risk
Who is at risk? What should be done? How often? References
High risk:
Those with a history of cryptorchidism (relative
risk [RR] = 3.5–17 above average), orchidopexy,
testicular atrophy, or previous testicular cancer
(RR = 25–28)
Testicular examination
(Practice Point)
Opportunistically
(Practice Point)
106–108
RR, relative risk
122
Guidelines for preventive activities in general practice
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89. Mayrand MH, Duarte-Franco E, Rodrigues I, et al.
Canadian Cervical Cancer Screening Trial Study Group.
Human papillomavirus DNA versus papanicolaou
screening tests for cervical cancer. N Engl J Med
2007;357(16):1579–88.
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90. Koliopoulos G, Arbyn M, Martin-Hirsch P, Kyrgiou M,
Prendiville W, Paraskevaidis E. Diagnostic accuracy
of human papillomavirus testing in primary cervical
screening: A systematic review and meta-analysis of non-
randomized studies. Gynecol Oncol 2007;104(1):232–46.
91. Safaeian M, Solomon D, Wacholder S, Schiffman M,
Castle P. Risk of precancer and follow-up management
strategies for women with human papillomavirus-negative
atypical squamous cells of undetermined significance.
Obstet Gynecol 2007;109(6):1325–31.
92. Arbyn M, Paraskevaidis E, Martin-Hirsch P, Prendiville
W, Dillner J. Clinical utility of HPV-DNA detection: Triage
of minor cervical lesions, follow-up of women treated for
high-grade CIN: An update of pooled evidence. Gynecol
Oncol 2005;99(3 Suppl 1):S7–11.
93. Arbyn M, Buntinx F, Van Ranst M, Paraskevaidis E,
Martin-Hirsch P, Dillner J. Virologic versus cytologic triage
of women with equivocal Pap smears: A meta-analysis
of the accuracy to detect high-grade intraepithelial
neoplasia. J Natl Cancer Inst 2004;96(4):280–93.
94. Ronco G, Cuzick J, Pierotti P, et al. Accuracy of liquid
based versus conventional cytology: Overall results
of new technologies for cervical cancer screening:
Randomised controlled trial. BMJ 2007;335(7609):28.
95. Davey E, Barratt A, Irwig L, et al. Effect of study
design and quality on unsatisfactory rates, cytology
classifications, and accuracy in liquid-based versus
conventional cervical cytology: A systematic review.
Lancet 2006;367(9505):122–32.
96. Arbyn M, Verdoodt F, Snijders PJ, et al. Accuracy of
human papillomavirus testing on self-collected versus
clinician-collected samples: A meta-analysis. Lancet
Oncol 2014;15(2):172–83.
97. Everett T, Bryant A, Griffin MF, Martin-Hirsch PPL, Forbes
CA, Jepson RG. Interventions targeted at women to
encourage the uptake of cervical screening. Cochrane
Database Syst Rev 2011;5:CD002834.
98. Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg
TD, Clinical Guidelines Committee of the American
College of Physicians. Screening pelvic examination
in adult women: A clinical practice guideline from
the American College of Physicians. Ann Intern Med
2014;161(1):67–72.
99. Buys SS, Partridge E, Black A, et al. Effect of screening
on ovarian cancer mortality: The Prostate, Lung,
Colorectal and Ovarian (PLCO) Cancer Screening
Randomized Controlled Trial. JAMA 2011;305:2295–303.
100. Jacobs IJ, Menon U, Ryan A, et al. Ovarian cancer
screening and mortality in the UK Collaborative Trial of
Ovarian Cancer Screening (UKCTOCS): A randomised
controlled trial. Lancet 2016;387(10022):945–56.
101. US Preventive Services Task Force. Screening for ovarian
cancer: Reaffirmation recommendation statement. Am
Fam Physician 2013;87(10):Online.
102. Whittemore AS, Harris R, Itnyre J. Characteristics relating
to ovarian cancer risk: Collaborative analysis of 12 US
case-control studies. II. Invasive epithelial ovarian cancers
in white women. Collaborative Ovarian Cancer Group.
Am J Epidemiol 1992;136:1184–203.
103. Kerlikowske K, Brown JS, Grady DG. Should women
with familial ovarian cancer undergo prophylactic
oophorectomy? Obstet Gynecol 1992;80:700–07.
104. Ford D, Easton DF. The genetics of breast and ovarian
cancer. Br J Cancer 1995;72:805–12.
105. Elford RW. Screening for testicular cancer. Canadian
Task Force on the Periodic Health Examination Canadian
Guide to Clinical Preventive Health Care. Ottawa: Health
Canada, 1994; p. 892–98.
106. US Preventive Services Task Force. Screening for
testicular cancer: Recommendation statement. Rockville,
MD: Agency for Healthcare Research and Quality, 2011.
107. Dieckmann KP, Pichlmeier U. Clinical epidemiology of
testicular germ cell tumors. World J Urol 2004;22(1):2–14.
108. National Cancer Institute. Testicular cancer screening.
Bethesda, Maryland: US National Institutes of Health,
2012. Available at www.cancer.gov/cancertopics/pdq/
screening/testicular/Patient/page3 [Accessed 15 October
2015].
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10. Psychosocial
General practitioners (GPs) play an important role in the detection and management of mental illness, especially
with prevalent conditions such as depression and anxiety, and social conditions such as intimate partner violence.1
The prevalence of gender-based violence has been estimated at 27.4%.2 In the most recent (2007) Australian
National Survey of Mental Health and Wellbeing, the prevalence of any lifetime mental disorder was 45.5%, with
a 12-month prevalence of 14.4% for anxiety disorders, 6.2% for affective disorders and 5.1% for substance use
disorders.3 Patients, especially women, who experience underlying intimate partner violence, often present with
depression and anxiety.4
Health inequity
What are the key equity issues and who is at risk?
• Socioeconomic disadvantage – The National Survey of Mental Health and Wellbeing identified that ‘the
proportion of people who reported having mental problems increased as levels of socioeconomic disadvantage
increased’. In 2007–08, 16% of people living in the most disadvantaged areas had a mental or behavioural
problem, compared with 11% of people living in the least disadvantaged areas.3 The likelihood of depression
among low socioeconomic status (SES) persons is almost double that of high SES persons (most marked for
persistent depression).3,5–7 Anxiety and affective disorders are more common in unemployed people.8,9 In patients
with chronic disease and disability, lower educational level and unemployment are predictive of depression.10,11
– Practices in disadvantaged areas have a higher prevalence of depression to identify and manage. Mental
health services overall are used at lower rates by the socioeconomically disadvantaged, possibly related to
low health literacy and stigma.12–14
– Suicide and attempted suicide are consistently associated with markers of SES disadvantage including
limited educational achievement and homelessness.15,16
• Aboriginal and Torres Strait Islander peoples – Aboriginal and Torres Strait Islander peoples are known to be
at greater risk of morbidity and mortality from mental health–related conditions affecting social and emotional
wellbeing. Aboriginal and Torres Strait Islander peoples are hospitalised for mental health problems at twice the rate
of non-Indigenous Australians and experience twice the rate of suicide, rising to five times the rate in the 15–19
years age group.17 Very high psychological distress in Aboriginal and Torres Strait Islander communities may be
related to the risk factors of chronic stress and exposure to violence, racism (including within the health system18
where all concerned have a role to ensure this does not happen), and marginalisation and dispossession.19
• Culturally and linguistically diverse patients (CALD) – Differences in the way depression is understood and
presented may create barriers to accessing effective depression care for patients from non–English-speaking
and culturally diverse backgrounds.20
• Age – Income-related inequalities in the prevalence of psychological distress and common mental health
conditions are particularly common in midlife.21 With advancing age, socioeconomic inequities lead to an
increase in anxiety and depression. Young people with a low level of education have the greatest likelihood of
experiencing chronic depression and progression from anxiety to depression. Socioeconomic disadvantage is
associated with both the incidence and chronic nature of depression and anxiety symptoms in older adults.22
• Childbirth – Postpartum depression and poor childbirth outcomes are associated with socioeconomic
disadvantage.23 Postpartum depression is more common in women from CALD backgrounds and these women
are less likely to receive help.24 Immigrant women experience many barriers to accessing high-quality, equitable
care and are especially vulnerable to stress in the postpartum period, which may result in postnatal depression.25,26
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What can GPs do?
• Refer to the general principles of providing patient education and supporting health literacy in disadvantaged
groups (refer to preamble).
• Be aware of the associated stigma of mental illness if offering opportunistic screening for depression to
disadvantaged groups.
• Refer to The Royal Australian College of General Practitioners’ (RACGP) National guide to a preventive health
assessment for Aboriginal and Torres Strait Islander people for important information on offering mental health
care to Aboriginal and Torres Strait Islander patients.27
• Assist women to achieve optimal postpartum health by linking them into social and medical supports, improving
their health literacy and self-efficacy, and promoting positive coping strategies and realistic expectations.28 Early
screening and treatment of women with perinatal mental illness can alleviate symptoms and decrease comorbid
disease risk.29 Culturally appropriate, individual-level interventions may be important.30
10.1 Depression
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79+
While there is evidence that depression screening instruments have reasonable sensitivity and specificity, the
evidence for improved health outcomes and cost-effectiveness of screening for depression in primary care remains
unclear. There is evidence for routine screening for depression in the general adult population in the context of
staff-assisted support to the GP in providing depression care, case management and coordination (eg via practice
nurses; B).31 There is insufficient evidence to recommend routine screening in adults or adolescents where case
management and coordination is not available (C).31 There is insufficient evidence to recommend screening in
children.32 Clinicians should maintain a high level of awareness for depressive symptoms in patients at high risk of
depression and make appropriate clinical assessments wherever the risk is high.33
Table 10.1.1. Depression: Identifying risk
Who is at risk? What should be done? How often? References
Average risk:
• Adult population aged ≥18 years,
where no risk factors for depression
are identified
Be alert to possible depression, but
do not routinely screen unless staff-
assisted depression care supports
are in place (C)
Opportunistically 31
Increased risk:
• Past history of depression
• Family history of depression
• Other psychiatric disorders,
including substance misuse
• Chronic medical conditions
• Unemployment
• Low socioeconomic status (SES)
• Older adults with significant life
events (eg illness, cognitive decline,
bereavement or institutional
placement)
• All family members who have
experienced family violence
• Lesbian, gay and bisexual peoples
• Experience of child abuse
Recurrent screening may be more
useful in people deemed to be
at higher risk of depression (B);
however, in the case of people with
chronic diseases (eg diabetes, heart
failure, coronary heart disease),
a screen-and-treat strategy for
depression has not been shown to
improve chronic disease symptoms
nor reduce health service use
Maintain a high level of clinical
awareness of those at high risk of
depression and consider depression
when a person presents with
suggestive symptoms such as low
mood, insomnia, anhedonia, suicidal
thoughts
Opportunistically 31
33
34
35
36
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Guidelines for preventive activities in general practice
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Who is at risk? What should be done? How often? References
Increased risk
• Pregnant and postpartum women
Risk factors for depression during
pregnancy and postpartum include
poor self-esteem, child care
stress, prenatal anxiety, life stress,
decreased social support, single/
unpartnered relationship status,
history of depression, difficult infant
temperament, previous postpartum
depression, lower SES, and
unintended pregnancy
Recurrent screening may be more
useful in people deemed to be at
higher risk of depression (B)
Opportunistically 31
• Adolescents aged 12–18 years,
particularly with:
– family history of depression
– deliberate self-harm
– comorbid mental health or
chronic medical conditions
– experience of a major negative
life event (including being bullied)
The benefits of screening alone have
not been established, but screening
is recommended where access to
effective treatment and follow up is
available
Be alert for signs of depression in this
age group (B)
Consider use of HE2ADS3
assessment tool (refer to Practice
Point m in Table 3.2)
At every encounter 32, 37–39
40, 41
SES, socioeconomic status
Table 10.1.2. Test to detect depression
Test Technique References
Question
regarding mood
and anhedonia
Asking two simple questions may be as effective as longer instruments:
• ‘Over the past two weeks, have you felt down, depressed or hopeless?’
• ‘Over the past two weeks, have you felt little interest or pleasure in doing things?’
Asking a patient if help is needed in addition to these two screening questions
improves the specificity of a GP diagnosis of depression (IV)
In adolescents, consider use of HE2ADS3 assessment tool (refer to Chapter 3.
Preventive activities in children and young people)
In women in the perinatal period, the Edinburgh Postnatal Depression Scale
(EPDS) can be used to detect women requiring further assessment of possible
major depression (B in the postnatal period) at www.blackdoginstitute.org.au/docs/
CliniciansdownloadableEdinburgh or www.beyondblue.org.au/who-does-it-affect/
pregnancy-and-early-parenthood/edinburgh-postnatal-depression-scale
Refer to Section 10.3. Identification of intimate partner violence, as depression is a
common reason for presentation in those experiencing violence
42
33
43
EPDS, Edinburgh Postnatal Depression Scale
http://www.blackdoginstitute.org.au/docs/CliniciansdownloadableEdinburgh
http://www.blackdoginstitute.org.au/docs/CliniciansdownloadableEdinburgh
http://www.beyondblue.org.au/who-does-it-affect/pregnancy-and-early-parenthood/edinburgh-postnatal-depression-scale
http://www.beyondblue.org.au/who-does-it-affect/pregnancy-and-early-parenthood/edinburgh-postnatal-depression-scale
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10.2 Suicide
There is a lack of evidence for the routine screening of patients using a screening instrument (C). GPs should be
alert for higher-risk individuals and the possibility of suicide in these patients. There is evidence that detecting and
treating depression has a role in suicide prevention.44,45 For example, the incidence of suicide has decreased in
older men and women in association with exposure to antidepressants.31,46
Table 10.2.1. Suicide: Identifying risk
Who is at risk?
What should be
done? How often? References
Average risk:
• General population
No routine screening
for suicide (III, C)
N/A 47, 48
Increased risk:
• Attempted suicide is a higher risk in the
following factors:
– mental illness, especially mood disorders,
and alcohol and drug abuse
– previous suicide attempts or deliberate
self-harm
– male
– young people and older people
– those with a recent loss or other adverse
event
– patients with a family history of attempted or
completed suicide
– Aboriginal and Torres Strait Islander peoples
– widowed
– living alone or in prison
– chronic and terminal medical illness
– in the 12 months following discharge from a
psychiatric hospital
– women experiencing intimate partner
violence
– lesbian, gay and bisexual people
Be aware of risk factors
for suicide (III, C)
Opportunistically 31, 44, 48,
49
50
51
35
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Guidelines for preventive activities in general practice
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Table 10.2.2. Tests to detect suicide risk
Test Technique References
Evaluate the risk of
suicide in the presence of
risk factors
Assessment of risk involves enquiring into the extent of the person’s
suicidal thinking and intent, including the following:
• Suicidal thinking – If suicidal thinking is present, how frequent and
persistent is it?
• Plan – If the person has a plan, how detailed and realistic is it?
• Lethality – What method has the person chosen and how lethal is it?
• Means – Does the person have the means to carry out the method?
• Past history – Has the person ever planned or attempted suicide?
• Suicide of family member or peer – Has someone close to the person
attempted or completed suicide?
Consideration should also be given to:
• risk and protective factors
• mental state – hopelessness, despair, psychosis, agitation, shame,
anger, guilt, impulsivity
• substance use – current misuse of alcohol or other drugs
• strengths and supports – availability, willingness and capacity of
supports
For all patients with suicidal ideation, enquiry should be made regarding
preparatory actions (eg obtaining a weapon, making a plan, putting affairs
in order, giving away prized possessions, preparing a suicide note)
41
Screening for
psychological distress in
young people
The HE2ADS3 tool has questions that can assist in assessing suicide risk.
For example:
• Sometimes when people feel really down, they feel like hurting or even
killing themselves. Have you ever felt that way?
• Have you ever deliberately harmed or injured yourself (eg cutting,
burning or putting yourself in unsafe situations, such as unsafe sex)?
• Do you feel sad or down more than usual? How long have you felt that
way?
• Have you lost interest in things you usually like?
• On a scale of 1 to 10, with 1 being the worst you feel and 10 being
really great and positive, how would you rate your mood today?
40
10.3 Intimate partner violence
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Abused women use healthcare services more than non-abused women. They also identify healthcare providers
as the professionals they would most trust with disclosure of abuse.52 Consider asking all pregnant adult and
adolescent women about partner violence during antenatal care.1 There is insufficient evidence for screening
the general population;53 however, there should be a low threshold for asking about abuse, particularly when
the GP suspects underlying psychosocial problems.1 Training GPs to identify violence has resulted in increased
identification and referral to services.54 Inviting women who are fearful of a partner to attend counselling by trained
GPs has resulted in increased safety discussions with women and less depressive symptoms.55 There is some
evidence for the effectiveness of interventions in clinical practice to reduce partner violence.56
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Table 10.3.1. Intimate partner violence: Identifying risk
Who is at risk? What should be done? How often? References
Average risk:
• Adult population aged ≥18 years, where no
risk factors for intimate partner violence are
identified
Be alert to possible partner
violence, but do not routinely
screen (II, B)
Opportunistically 53
• Adolescents aged 12–18 years, particularly
with:
– family history of violence
– comorbid mental health conditions
– pregnancy
Consider use of HE2ADS3
assessment tool (refer to
Chapter 3. Preventive activities in
children and young people; III, B)
At every
encounter
57
Increased risk:
• Pregnant women
• People who were abused or witnessed
intimate partner violence as a child
• People with psychiatric disorders, especially
substance misuse
• Unemployed people
• People suffering poverty
Screen all pregnant women
Maintain a high level of clinical
awareness of those at high risk
of intimate partner violence
and consider intimate partner
violence when a person presents
with suggestive symptoms such
as symptoms of mental ill health,
chronic unexplained physical
symptoms, and unexplained
injuries (II, B)
Opportunistically 1, 52, 53
Table 10.3.2. Tests to detect intimate partner violence
Test Technique References
Ask about
partner
violence
Victimised women stress the importance of a trusting doctor–patient relationship,
confidentiality, and respectful and non-judgemental attitudes to achieving disclosure, as well
as acceptance of non-disclosure and a supportive response. It is crucial for safety reasons
that any questions are asked privately, when the patient is alone – not when another family
member, adult or child >2 years of age is present. It is a clinician’s responsibility to ask and
support women regardless of their response. Asking about abuse may ‘plant a seed’ for
later action
The World Health Organization (WHO) guidelines recommend that GPs should ask women
who are ‘symptomatic’ (eg show symptoms of mental ill health, chronic unexplained
physical symptoms, unexplained injuries, frequent attendance) about partner violence
Questions and statements to make if you suspect domestic violence:
• Has your partner ever physically threatened or hurt you?
• Is there a lot of tension in your relationship? How do you resolve arguments?
• Sometimes partners react strongly in arguments and use physical force. Is this
happening to you?
• Are you afraid of your partner?
• Violence is very common in the home. I ask a lot of my patients about abuse because
nobody should have to live in fear of their partners
52
1
WHO, World Health Organization
These recommendations might apply to people in same-sex relationships and male victims, but there has been
insufficient research in these areas.
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and related disorders – anxiety, bipolar disorder and
puerperal psychosis – in the perinatal period. A guideline
for primary care health professionals. Hawthorn, Vic:
beyondblue, 2011.
44. Gaynes B N, West SL, Ford CA, Frame P, Klein J, Lohr
KN. Screening for suicide risk in adults: A summary of the
evidence for the US Preventive Services Task Force. Ann
Intern Med 2004;140(10):822–35.
45. Goldney RD. Suicide prevention: A pragmatic review of
recent studies. Crisis 2005;26(3):128–40.
46. Hall W, Mant A, Mitchell PB, Rendle VA, Hickie IB.
Association between antidepressant prescribing and
suicide in Australia, 1991–2000 trend analysis. BMJ
2003;326(7397):1008–12.
47. Goldney RD. Suicide prevention. Oxford, UK: Oxford
University Press, 2008.
48. LeFevre ML, US Preventive Services Task Force.
Screening for suicide risk in adolescents, adults, and
older adults in primary care: US Preventive Services
Task Force recommendation statement. Ann Intern Med
2014;160(10):719–26.
49. US Preventive Services Task Force. The guide to clinical
preventive services 2014: Recommendations of the
US Preventive Services Task Force. Rockville, MD:
US Preventive Task Force. 2014. Available at www.
ahrq.gov/professionals/clinicians-providers/guidelines-
recommendations/guide/index.html [Accessed 1
November 2015].
50. Large MM, Nielssen OB. Suicide in Australia: Meta-
analysis of rates and methods of suicide between 1988
and 2007. Med J Aust 2010;192(8):432–37.
51. World Health Organization, Department of Reproductive
Health and Research London School of Hygiene and
Tropical Medicine, South African Medical Research
Council. Global and regional estimates of violence against
women. Prevalence and health effects of intimate partner
violence and non-partner sexual violence. Geneva: WHO,
2013.
52. World Health Organization. Responding to intimate
partner violence and sexual violence against women.
WHO clinical and policy guidelines. Geneva: WHO, 2013.
53. O’Doherty LJ, Taft A, Hegarty K, Ramsay J, Davidson LL,
Feder G. Screening women for intimate partner violence
in healthcare settings: Abridged Cochrane systematic
review and meta-analysis. BMJ 2014;348:g2913.
54. Feder G, Davies RA, Baird K, et al. Identification and
referral to improve safety (IRIS) of women experiencing
domestic violence with primary care training and support
programme: A cluster randomised controlled trial. Lancet
2011;378(9805):1788–95.
55. Hegarty K, O’Doherty L, Taft A, et al. Screening and
counselling in the primary care setting for women
who have experienced intimate partner violence
(WEAVE): A cluster randomised controlled trial. Lancet
2013;382(9888):249–58.
56. Bair-Merritt MH, Lewis-O’Connor A, Goel S, et al. Primary
care-based interventions for intimate partner violence: A
systematic review. Am J Prev Med 2014;46(2):188–94.
57. Sanci L, Chondros P, Sawyer S, et al. Responding
to young people’s health risks in primary care:
A cluster randomised trial of training clinicians in
screening and motivational interviewing. PLOS ONE
2015;10(9):e0137581.
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11. Oral health
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Good oral hygiene and a diet low in sugar help to prevent dental decay and periodontal disease, and improves oral
health in children and adults. There is evidence that the use of fluoride in water, or topically, reduces dental decay in
children.1–3 Although there is insufficient evidence to screen for oral cancer, opportunistic examination of the mouth
and lips is encouraged in increased risk groups.4
Table 11.1. Oral health: Identifying risk of dental decay, periodontal disease and oral cancer
Who is at risk? What should be done? How often? References
Increased risk:
• Lower socioeconomic groups with
difficulty accessing dental care
• Elderly (including residential care)
• Aboriginal and Torres Strait Islander
peoples
• Rural and remote populations
• Migrant groups (especially refugees);
more information is available at
http://refugeehealthnetwork.org.au/
category/oral-health
• People with reduced saliva flow (eg
head and neck radiation therapy,
Sjögren syndrome, multiple drug
therapy including psychotropic
medications)
• Smokers aged >50 years, heavy
drinkers, patients chewing tobacco or
betel nut
• Patients exposed to excessive
sunlight (lip cancer)
Examination of the mouth,
teeth and lips (IV, C)
Education regarding prevention
(I, B)
Recommendation of
professional or home
application of topical fluoride
pastes, gels or mouth rinses
(I, A)
Opportunistic examination of
the mouth and lips (Practice
Point)
At least every 12
months (more frequent
dental check-ups as
determined by dentist
and other dental health
professionals; Practice
Point)
5–7
8, 9*
*Oral cancer references
http://refugeehealthnetwork.org.au/category/oral-health
http://refugeehealthnetwork.org.au/category/oral-health
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Table 11.2. Oral health: Preventive interventions
Intervention Technique References
Education • Advise about the hazards of snacks and sweetened drinks containing high levels of
carbohydrate and acid between meals
• Advise against the use of baby bottles with any fluid apart from water at night
• Advise patients to brush teeth twice daily with fluoride toothpaste. A small pea-
sized amount of low-fluoride toothpaste should be used from 18 months to 6 years
of age. Encourage to spit not rinse
• Advise patients that adult supervision of tooth-brushing is recommended for
children until 8 years of age
• Encourage home use of high-fluoride toothpastes, gels or mouth rinses for children
>10 years of age and adults at high risk
• Advise the use of dental floss daily to prevent gingivitis and periodontal disease
• Advise the use of mouthguards for contact sports
• Advise patients of the risks of smoking, chewing tobacco, excessive alcohol
consumption and sunlight exposure
• Recommend regular dental check ups
• Additional advice can be obtained from the findings of a national consensus
workshop conducted in 2011, available at www.adelaide.edu.au/arcpoh/oral-
health-promotion/resources/national-consensus-workshop
10, 11
12
13
9
13
Oral
examination
• Inspect mouth for dental decay, stained, worn or broken teeth, and inflamed or
swollen gums
• Advise pregnant women to visit a dentist for treatment of all active dental decay
and periodontal disease
• Inspect mouth for xerostomia (dry mouth). It may present as dry and reddened
gums and increased decay rate particularly on root surfaces
• ‘Lift the lip’ of children 0–5 years of age for early identification of oral problems (also
refer to Chapter 3. Preventive activities in children and young people)
• Inspect the oral cavity – buccal mucosa, gums, tongue, floor of mouth and palate
(looking for white or red patches, ulceration or induration)
• Examine the extra-oral areas – neck lips and facial areas – looking for lumps and
swellings
14, 15
9, 16
Fluoridation • Fluoridation of public water supplies has improved dental health and reduced
dental decay
• Approximately 90% of Australians now drink fluoridated water. Details regarding
fluoride levels in Australian water supplies and recommended dosages of fluoride
are provided at www.nhmrc.gov.au/health-topics/health-effects-water-fluoridation
1, 2
17
Implementation
Health inequity
Oral disease is more prevalent among low socioeconomic groups. Significant financial barriers to accessing dental
care remain in Australia. People on low incomes are more likely to delay dental visits and less likely to receive
appropriate dental care.18
Private dental insurance is associated with higher rates of dental care, but insurance is less common in low
income groups or those in regional or remote locations. People who hold healthcare cards are less likely to receive
preventive dental care and more likely to receive extractions when visiting the dentist.18,19 Aboriginal and Torres
Strait Islander peoples are at higher risk of poor oral health.20
http://www.adelaide.edu.au/arcpoh/oral-health-promotion/resources/national-consensus-workshop
http://www.adelaide.edu.au/arcpoh/oral-health-promotion/resources/national-consensus-workshop
http://www.nhmrc.gov.au/health-topics/health-effects-water-fluoridation
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References
1. Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water
fluoridation for the prevention of dental caries. Cochrane
Database Syst Rev 2015;6:Cd010856.
2. McDonagh MS, Whiting PF, Wilson PM, et al. Systematic
review of water fluoridation. BMJ 2000;321(7265):855–
59.
3. World Health Organization. Sugars intake for adults and
children. Geneva: WHO, 2015.
4. US Preventive Services Task Force. The guide to clinical
preventive services: Recommendations of the US
Preventive Services Task Force. Rockville, MD: USPSTF,
2014. Available at www.ahrq.gov/professionals/clinicians-
providers/guidelines-recommendations/guide/index.html
[Accessed 1 November 2015].
5. National Health and Medical Research Council. Review
of water fluoridation and fluoride intake from discretionary
fluoride supplements. Canberra: NHMRC, 1999.
6. Ahovuo-Saloranta A, Forss H, Hiiri A, Nordblad A, Makela
M. Pit and fissure sealants versus fluoride varnishes
for preventing dental decay in the permanent teeth of
children and adolescents. Cochrane Database Syst Rev
2016;1:Cd003067.
7. Sievers K, Silk H. Fluoride varnish for preventing dental
caries in children and adolescents. Am Fam Physician
2016;93(9):743–44.
8. US Preventive Services Task Force. Oral cancer:
Screening. Rockville, MD: USPSTF, 2014. Available at
www.uspreventiveservicestaskforce.org/Page/Document/
UpdateSummaryFinal/oral-cancer-screening1 [Accessed
1 November 2015].
9. Smith RA, Cokkinides V, Brooks D, Saslow D, Shah M,
Brawley OW. Cancer screening in the United States,
2011: A review of current American Cancer Society
guidelines and issues in cancer screening. CA Cancer J
Clin 2011;61(1):8–30.
10. Marinho VC, Higgins JP, Sheiham A, Logan S. Fluoride
toothpastes for preventing dental caries in children
and adolescents. Cochrane Database Syst Rev
2003;1:Cd002278.
11. Walsh T, Worthington HV, Glenny AM, Appelbe P,
Marinho VC, Shi X. Fluoride toothpastes of different
concentrations for preventing dental caries in children
and adolescents. Cochrane Database Syst Rev
2010;1:Cd007868.
12. Marinho VC, Worthington HV, Walsh T, Chong LY.
Fluoride gels for preventing dental caries in children
and adolescents. Cochrane Database Syst Rev
2015;6:Cd002280.
13. National Oral Health Promotion Clearing House. Oral
health messages for the Australian public. Findings
of a national consensus workshop. Aust Dent J
2011;56(3):331–35.
14. Department of Health. Evidence-based oral health
promotion resource. Melbourne: Prevention and
Population Health Branch, 2011.
15. NSW Health. Early childhood oral health guidelines for
child health professionals. Sydney: Centre for Oral Health
Strategy, 2014. Available at www0.health.nsw.gov.au/
policies/gl/2014/GL2014_020.html [Accessed 21 March
2016].
16. Sugerman PB, Savage NW. Current concepts in oral
cancer. Aust Dent J 1999;44(3):147–56.
17. Neil A. The extent of water fluoridation coverage in
Australia. Aust N Z J Public Health 2011;35(4):392–93.
18. Sanders A. Social determinants of oral health: Conditions
linked to socioeconomic inequalities in oral health in the
Australian population. Canberra: Australian Institute of
Health and Welfare, 2007.
19. Chrisopoulos S, Harford J. Oral health and dental care in
Australia: Key facts and figures 2012. Canberra: AIHW,
2013.
20. National Aboriginal Community Controlled Health
Organisation and The Royal Australian College of General
Practitioners. National guide to a preventive health
assessment for Aboriginal and Torres Strait Islander
people. 2nd edn. South Melbourne, Vic: RACGP, 2012.
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12. Glaucoma
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Glaucomas are a group of relatively common optic neuropathies, in which there is pathological loss of retinal
ganglion cells, progressive loss of sight and associated alteration in the retinal nerve fibre layer and optic nerve head.
Evidence supports screening people at higher risk for glaucoma (A). General practitioners (GPs) have an important
role in identifying those at increased risk for glaucoma and referring them for testing. There is no consensus on the
recommended frequency of screening for at-risk groups.1,2
Table 12.1. Glaucoma: Identifying risk
Who is at risk? What should be done? How often? References
Increased risk:
• Family history of glaucoma (first-degree relatives)
• Caucasian and Asian patients aged ≥50 years
• Patients of African descent aged ≥40 years
Refer for ocular
examination 5–10 years
earlier than the age of
onset of glaucoma in the
affected relative (A)
Frequency of follow
up determined by the
individual patient’s eye
assessment
1, 2
Higher risk:
• Patients aged >50 years with:
– diabetes
– myopia
– long-term steroid use
– migraine and peripheral vasospasm
– abnormal blood pressure (BP)
– history of eye trauma
Refer for examination
of the optic nerve head
(ophthalmoscopy),
measurement of
intraocular pressure
(tonometry) and
assessment of visual fields
(perimetry)*
Frequency of follow
up determined by the
individual patient’s eye
assessment
1, 2
*This may be by an ophthalmologist or optometrist
BP, blood pressure
Table 12.2. Glaucoma: Preventive interventions
Intervention Technique References
Patient education Educate patients about glaucoma and alert them to associated risk factors,
with advice to attend regular, fully comprehensive eye examinations
1, 2
Tonometry Applanation or puff tonometry has poor sensitivity and specificity for early
detection of glaucoma. Tonometry alone is an inadequate screening tool
as it overestimates the prevalence of glaucoma
Perimetry (visual fields) Not advisable in general practice as only automated perimetry is sensitive
for detecting loss of visual field due to glaucoma
Assessment of eye structure
(ophthalmoscopy)
Indirect ophthalmoscopy performed with a slit lamp is the examination of
choice
1, 2
References
1. National Health and Medical Research Council. A guide to
glaucoma for primary health care providers – A companion
document to NHMRC Guidelines for the screening,
prognosis, diagnosis, management and prevention of
glaucoma. Canberra: NHMRC, 2010.
2. National Health and Medical Research Council. Guidelines
for the screening, prognosis, diagnosis, management and
prevention of glaucoma. Canberra: NHMRC, 2010.
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13. Urinary incontinence
Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
No evidence for screening general population
There is no evidence for screening for urinary incontinence in the general population. Instead, GPs should case-find
those at higher risk (B).
Within the general population, up to 19% of children,1 13% of men and 37% of women may be affected by some
form of urinary incontinence.2 While urinary incontinence is most common in women and increases with age,
bedwetting (enuresis) is common in children (5.5% of children also report daytime wetting).1 In men, uncomplicated
lower urinary tract symptoms do not appear to be associated with an increased risk of prostate cancer.3 Of those
sitting in a GP waiting room, 65% of women and 30% of men report some type of urinary incontinence, yet only
31% of these people report having sought help from a health professional.4 Primary care professionals are in a
position to take a more proactive approach to incontinence treatment by asking about urinary symptoms in at-risk
groups during routine appointments. There remains considerable health decrement due to urinary incontinence in
those not receiving help in a population readily accessible to primary care services.5
Table 13.1. Urinary incontinence: Identifying risk
Who is at higher risk of urinary
incontinence? What should be done? How often? References
Average risk: There is no evidence to support
screening (IV)
N/A
Higher risk:
• Prenatal and postnatal women
• Women who have had children
• Women who are overweight
• Women reporting constipation
• People with respiratory conditions,
diabetes stroke, heart conditions,
recent surgery, neurological disorders
• Frail elderly people or long-term care
residents
Case finding (IV, B)
Ask about the occurrence of urinary
incontinence
In residential aged care facilities,
residents are automatically assessed
Every 12
months
2
Table 13.2. Urinary incontinence: Preventive interventions
Intervention Technique References
Case finding Probing questions such as ‘Other people with … [state conditions of higher risk here]
have had problems with their waterworks [bladder control] …’
Simple patient survey assessment tools have been shown to be valid and reliable (A)
6
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Guidelines for preventive activities in general practice
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Intervention Technique References
Assessment Patients with urinary incontinence should be assessed to determine the diagnostic
category as well as underlying aetiology. This can usually be determined on the basis of
history, physical examination, and urinary dipstick and culture, if indicated. A post-void
residual may be required in the assessment of possible retention and/or overflow
There are four common types of incontinence:
1. Stress incontinence is the leaking of urine that may occur during exercise,
coughing, sneezing, laughing, walking, lifting or playing sport. This is more common
in women, although it also occurs in men, especially after prostate surgery.
Pregnancy, childbirth and menopause are the main contributors
2. Urge incontinence is a sudden and strong need to urinate. It is often associated
with frequency and nocturia, and is often due to having an over-active or unstable
bladder, neurological condition, constipation, enlarged prostate or history of poor
bladder habits
3. Mixed incontinence is a combination of stress and urge incontinence, and is most
common in older women
4. Overflow incontinence as a result of bladder outflow obstruction or injury. Its
symptoms may be confused with stress incontinence
Because treatments differ, urge incontinence should be distinguished from stress
incontinence (A)
To make this distinction, the International Continence Society guidelines recommend an
extensive evaluation that is too time-consuming for primary care practice
However, the 3 Incontinence Questions (3IQ) questionnaire is a simple, quick, and
non-invasive test with acceptable accuracy for classifying urge and stress incontinence,
and may be appropriate for use in primary care settings (A). The questionnaire is
provided in Appendix 13A
7
8, 9
The Continence Foundation of Australia (CFA) has a helpline available for consumers and healthcare professionals at
1800 33 00 66. Consumers can ask for specific help or for contact details of their nearest continence professional. The
CFA website has many evidence-based resources available for consumers at www.continence.org.au/resources.php
References
1. Bower W, editor. An epidemiological study of enuresis in
Australian children. Sydney: Wells Medical, 1995.
2. Continence Foundation of Australia. What is
incontinence: Key statistics. Brunswick, Vic: CFA, 2015.
Available at www.continence.org.au/pages/key-statistics.
html [Accessed 2015 September].
3. Martin RM, Vatten L, Gunnell D, Romundstad P, Nilsen
TI. Lower urinary tract symptoms and risk of prostate
cancer: The HUNT 2 Cohort, Norway. Int J Cancer
2008;123(8):1924–28.
4. Byles J, Chiarelli P, Hacker A, Bruin C. Help seeking for
urinary incontinence: A survey of those attending GP
waiting rooms. Aust Continence J 2003;9(1):8–15.
5. Shawa C, Gupta RD, Bushnell DM, Passassa R,
Abrams P, Wagg A. The extent and severity of urinary
incontinence amongst women in UK GP waiting rooms.
Fam Pract 2006;23(5):497–506.
6. Martin JL, Williams KS, Sutton AJ, Abrams KR, Assassa
RP. Systematic review and meta-analysis of methods
of diagnostic assessment for urinary incontinence.
Neurourol Urodyn 2006;25(7):674–83.
7. Staskin D, Kelleher C, Avery K, et al, editors. Committee
5: Initial assessment of incontinence. Proceedings of the
fourth international consultation on incontinence. Paris:
Health Publication Ltd, 2009.
8. Brown J, Bradley C, Subak L, Richter H, Kraus S,
Brubaker L. The sensitivity and specificity of a simple test
to distinguish between urge and stress incontinence. Ann
Intern Med 2006;144:715–23.
9. Hess R, Huang AJ, Richter HE, et al. Long-term efficacy
and safety of questionnaire-based initiation of urgency
urinary incontinence treatment. Am J Obstet Gynecol
2013;209(3):244, e1–9.
http://www.continence.org.au/resources.php
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Appendix 13A. The 3 Incontinence Questions (3IQ)
1. During the last three months, have you leaked urine (even a small amount)?
Yes No Questionnaire completed.
2. During the last three months, did you leak urine (check all that apply):
a. When you were performing some physical activity, such as coughing, sneezing, lifting, or exercise?
b. When you had the urge or feeling that you needed to empty your bladder, but you could not get to the
toilet fast enough?
c. Without physical activity and without a sense of urgency?
3. During the last three months, did you leak urine most often (check only one):
a. When you are performing some physical activities, such as coughing, sneezing, lifting, or exercise?
b. When you had the urge or feeling that you needed to empty your bladder, but you could not get to the
toilet fast enough?
c. Without physical activity or a sense of urgency?
d. About equally as often with physical activities as with a sense of urgency?
Definitions of the type of urinary incontinence are based on responses to Question 3
Response to question 3 Type of incontinence
a. Most often with physical activity Stress only or stress predominant
b. Most often with the urge to empty the bladder Urge only or urge predominant
c. Without physical activity or sense of urgency Other cause only or other cause predominant
d. About equally with physical activity and sense of urgency Mixed
Reproduced with permission from Brown JS, Bradley CS, Subak LL, et al. The sensitivity and specificity of a simple test to distinguish
between urge and stress incontinence. Ann Intern Med 2006;144(10):715–23.
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14. Osteoporosis
Age 0–9 10–14 20–24 15–19 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Women
Men
The goal of the prevention and treatment of osteoporosis is to reduce a person’s overall fracture risk, not just to
maintain bone density.
Review of fracture risk factors for postmenopausal women aged >45 years and men aged >50 years is
recommended (Practice Point). Those with increased risk should have bone density assessed (Practice Point).
Osteoporosis is a disease characterised by low bone mass and micro-architectural deterioration of bone tissue,
leading to bone fragility and increased fracture risk.1 It is diagnosed on the presence of a fragility fracture (fracture
from the equivalent of a fall from standing height or less, or a fracture that under normal circumstances would
not be expected in a healthy young man or woman). For epidemiological and clinical purposes, osteoporosis is
defined by bone mineral density (BMD) as a T-score of ≤–2.5. However, age, lifestyle factors, family history, and
some medications and diseases contribute to bone loss and increased risk of fragility fractures. Furthermore, it is
important to note that in an individual who has sustained a fragility fracture, a T-score of ≤–2.5 is not also required
to make the diagnosis of osteoporosis, the presence of a fragile fracture is sufficient. Thus, the goal of prevention
and treatment is to reduce a person’s overall fracture risk (not just maintain bone density).
Two of the most widely validated methods to estimate absolute fracture risk for osteoporotic fractures relevant to
the Australian population are available at:
• www.shef.ac.uk/FRAX
• www.garvan.org.au/promotions/bone-fracture-risk/calculator
These calculators can be used with and without measuring BMD, though the Garvan fracture risk calculator
has not been validated in an external cohort when BMD has not been used in the calculator.2 Risk estimation is
imperfect, with the tools being modest predictors of fracture risk.3,4 Risk factors (eg falls, glucocorticoid use) not
included in one or the other risk algorithm require clinical judgement to modify the risk estimate.
To date, there are no randomised controlled trials (RCTs) directly evaluating screening effectiveness, harms and
intervals, and whether screening is performed by bone density screening by dual-energy X-ray absorptiometry
(DXA) or by estimating absolute fracture risk.4 The place of absolute fracture risk assessment in the prevention and
management of osteoporosis requires further clarification as its effectiveness is yet to be tested.
http://www.shef.ac.uk/FRAX
http://www.garvan.org.au/promotions/bone-fracture-risk/calculator
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Table 14.1. Osteoporosis: Identifying risk
Who is at risk? What should be done? How often? References
Average risk:
• Postmenopausal women (aged ≥45
years)
• Men aged ≥50 years
Clinical assessment for
risk factors (Practice
Point)
Preventive advice (II, C)
Every 12 months (Practice
Point)
1, 3, 5
Increased risk:
• Aged >60 years for men and >50 years
for women plus any of:
– family history of fragility fracture
– smoking
– high alcohol intake (>4 standard drinks
per day for men and >2 for women)
– vitamin D deficiency <50 nmol
(screening for vitamin D not indicated
just for risk assessment)*
– low body weight (body mass index
[BMI] <20kg/m2)
– recurrent falls
– low levels of physical activity†
– immobility (to the extent that person
cannot leave their home or cannot do
any housework)
• Medical conditions and medications
that may cause secondary osteoporosis
including:
– endocrine disorders
(eg hypogonadism, Cushing
syndrome, hyperparathyroidism,
hyperthyroidism)
– premature menopause
– anorexia nervosa or amenorrhea for
>12 months (unrelated to pregnancy)
before 45 years of age
– inflammatory conditions
(eg rheumatoid arthritis)
– malabsorption (eg coeliac disease)
– chronic kidney or liver disease
– multiple myeloma and monoclonal
gammopathies
– human immunodeficiency virus (HIV)
and its treatment
– Type 1 and type 2 diabetes mellitus
– drugs, especially corticosteroids
(eg 7.5 mg for >3 months) used for
immunosuppression including as
part of chronic anti-rejection therapy
in organ or bone marrow transplant,
anti-epileptic, aromatase inhibitors,
anti-androgen, excessive thyroxine,
possibly selective serotonin reuptake
inhibitors (SSRIs)
Dual X-ray absorptiometry
(DXA) to measure bone
mineral density (BMD)
and management of
risk factors (II, A to III, D
depending on risk factor)
Investigate for causes of
secondary osteoporosis
if indicated by history,
examination findings or
BMD result (Practice
Point)
The optimal timing of
repeated DXA for screening
is unknown but is likely to
vary depending on baseline
BMD
Women with baseline
T-score >–1.0 may take
longer than 15 years to
transition to osteoporosis
Repeat only when it is likely
to change management
(II, C)
Where there is a specific
condition or medication
present likely to lead to
accelerated bone loss (eg
corticosteroid use [refer
to causes of secondary
osteoporosis]), consider
more frequent repeat of
DXA (Practice Point)
3, 5–8
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Guidelines for preventive activities in general practice
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Who is at risk? What should be done? How often? References
High risk of further fracture:
• Patients aged >45 years who have
sustained a low-trauma fracture
• Postmenopausal women, and older men
with a vertebral fracture. Such fractures
should be ruled out if clinically suspected
(eg from loss of height >3 cm, kyphosis,
back pain)
DXA to measure BMD
and management of risk
factors (II, A)
Investigate for causes of
secondary osteoporosis
if indicated by history,
examination findings or
BMD result (Practice
Point)
Recommend that such
individuals are initiated on
effective anti-osteoporosis
therapy unless there are
specific contraindications
DXA at presentation and no
more than every two years
(II, B).
It is appropriate to
recommend a repeat
BMD by DXA after two
years for patients at risk of
developing osteoporosis,
to assist in re-evaluation of
fracture risk
In patients with confirmed
osteoporosis, repeat BMD
is generally not required;
however, it may be
conducted before initiating
a change in, or cessation of,
anti-osteoporotic therapy
(Practice Point)
Where there is a specific
condition or medication
present likely to lead to
accelerated bone loss (eg
corticosteroid use [refer
to causes of secondary
osteoporosis]), consider
more frequent repeat of
DXA (Practice Point)
1
*Assessment of the potential clinical importance of a given serum vitamin D level should take into consideration the season in which
the test was done, as levels in an individual will be higher from late spring to autumn than in winter to early spring6,9 (Practice Point)
†There is no accepted cut-off or standard definition for defining low levels of physical activity as a risk factor for osteoporosis. Those at
risk would include people with higher levels of sedentary behaviour, (eg those who participate in no recreational exercise,10 or who are
sitting and lying for more than 20 hours per day).11 It also includes those who perform relatively low levels of weight bearing physical
activity (eg people who walk less than 60 minutes per day,11 less than 12 km per week,12 or do not walk for exercise)10
BMD, bone mineral density; BMI, body mass index; DXA, dual X-ray absorptiometry; HIV, human immunodeficiency virus; SSRI,
selective serotonin reuptake inhibitor
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Table 14.2. Osteoporosis: Preventive interventions
Intervention Technique References
Assessment of risk
factors
Take a thorough history, paying particular attention to the risk factors above plus:
• vertebral deformity (if has occurred within 5–10 years, this creates an
equivalent risk to any other fragility fracture)
• loss of height (>3 cm) and/or thoracic kyphosis (consider lateral spine X-ray
for vertebral deformity)
Preventive actions Encourage a daily dietary calcium intake that meets the age-appropriate
Australian recommended daily intake (1000 mg for adult men until 70 years of
age and women until 50 years of age, 1300 mg after this age; prevention of
bone loss [I, A] but not for fracture prevention [III-2, D])
Encourage healthy lifestyle (eg smoking cessation and limiting alcohol intake) (D)
Education and psychosocial support for risk factor modification (Practice Point)
Falls reduction strategies: Falls (I, A), and fracture risk reduction (Practice Point)
Encourage regular weight-bearing and resistance exercise for the prevention of
falls (I, A), bone loss (I, A) and fracture risk reduction (I, C)
Advise on appropriate sun exposure levels (which minimise the risk of skin
cancer) as a source of vitamin D (II, C)*
Discuss absolute risk of fracture (Practice Point)
13–19
Bone mineral
densitometry (BMD)
BMD should be measured by dual X-ray absorptiometry (DXA) scanning
performed on two sites, preferably antero-posterior spine and hip. Without
bone-losing medical conditions (eg hypogonadism, anti-gonadal therapy or
corticosteroid use), BMD is unlikely to change significantly in <2 years (II, B)
DXA should generally be repeated only when patient is at risk of reaching
treatment thresholds (average decrease in T-score is usually approximately
0.1/year if no specific bone-losing medical conditions; Practice Point)
8, 20
*Population screening for vitamin D deficiency is not recommended, but targeted testing of people who are at risk of osteoporosis
and/or who are at high risk of vitamin D deficiency should be considered. Vitamin D supplements could be considered in deficient
individuals if increasing sun exposure is contraindicated or not feasible or if deficiency is more than mild (ie <30 nmol/L) and so is less
likely to be corrected by low-risk levels of sun exposure 21 (Practice Point)
BMD, bone mineral density; DXA, dual X-ray absorptiometry
Quantitative ultrasound
An alternative imaging technique for assessing fracture risk is quantitative ultrasound, which measures parameters
such as speed of sound (SOS) and broadband ultrasound attenuation (BUA), with these values being combined
into composite parameters such as stiffness index. These parameters predict fracture to a similar degree as
DXA measures of BMD. However, there is no agreed definition of osteoporosis using quantitative ultrasound,
and it cannot be used to assess the response to osteoporosis treatment.22 Moreover, intervention trials have
predominantly been based on cases identified through DXA assessment, so their results cannot readily be applied
to individuals identified by other means.1,3 For this reason, DXA remains the recommended method of assessment.
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Implementation
Several Australian studies have shown an evidence–practice gap, where the majority of people with a fragility
fracture tend to have their fracture treated, but not the underlying osteoporosis.23,24 Those with a previous fragility
fracture have a very high risk of further fracture, and have greatest benefit from specific anti-osteoporosis treatment.
Fracture risk reductions with optimal therapy are substantial and treatment according to current guidelines is
recommended unless absolutely contraindicated. This is unlikely given the range of treatments now available.
Optimal treatment necessitates the use of a specific anti-osteoporosis treatment such as a bisphosphonate, but
also includes ensuring adequate calcium intake and correcting vitamin D deficiency.
There are inequities in the use of BMD measurement with relative underuse in men and people from rural and
remote locations.25
There is insufficient evidence to support population screening of younger women by DXA. However, if a DXA is
performed for a clinical indication, the results could be used opportunistically to improve bone health via feedback
of relative fracture risk. In women aged 25–45 years, written feedback of being at high risk compared to not at
high risk of fracture in later life (based on mean DXA hip and lumbar spine T-score being less than or greater than
or equal or zero) resulted in improved osteoporosis preventive behaviours and femoral neck BMD at two26 and 12
years.27
References
1. The Royal Australian College of General Practitioners.
Clinical practice guideline for the prevention and
treatment of osteoporosis in postmenopausal women
and older men. South Melbourne, Vic: RACGP, 2010.
2. Marques A, Ferreira RJ, Santos E, Loza E, Carmona L,
da Silva JA. The accuracy of osteoporotic fracture risk
prediction tools: A systematic review and meta-analysis.
Ann Rheum Dis 2015;74(11):1958–67.
3. Nelson HD, Haney EM, Chou R, Dana T, Fu R,
Bougatsos C. Screening for osteoporosis: Systematic
review to update the 2002 US Preventive Services Task
Force Recommendation. Rockville, MD: USPSTF, 2010.
4. Rubin KH, Friis-Holmberg T, Hermann AP, Abrahamsen
B, Brixen K. Risk assessment tools to identify women
with increased risk of osteoporotic fracture: Complexity
or simplicity? A systematic review. J Bone Miner Res
2013;28(8):1701–17.
5. US Preventive Services Task Force. Screening for
osteoporosis: Clinical summary of US Preventive Services
Task Force Recommendation: Rockville, MD: USPSTF,
2011.
6. Nowson CA, McGrath JJ, Ebeling PR, et al. Vitamin D
and health in adults in Australia and New Zealand: A
position statement. Med J Aust 2012;196(11):686–87.
7. Maurel DB, Boisseau N, Benhamou CL, Jaffre C. Alcohol
and bone: Review of dose effects and mechanisms.
Osteoporos Int 2012;23(1):1–16.
8. Gourlay ML, Fine JP, Preisser JS, et al. Bone-density
testing interval and transition to osteoporosis in older
women. N Engl J Med 2012;366(3):225–33.
9. Bolland MJ, Grey AB, Ames RW, et al. The effects of
seasonal variation of 25-hydroxyvitamin D and fat mass
on a diagnosis of vitamin D sufficiency. Am J Clin Nutr
2007;86(4):959–64.
10. Cummings SR, Nevitt MC, Browner WS, et al. Risk
factors for hip fracture in white women. Study of
Osteoporotic Fractures Research Group. N Engl J Med
1995;332(12):767–73.
11. Coupland C, Wood D, Cooper C. Physical inactivity is an
independent risk factor for hip fracture in the elderly. J
Epidemiol Community Health 1993;47(6):441–43.
12. Krall EA, Dawson-Hughes B. Walking is related to
bone density and rates of bone loss. Am J Med
1994;96(1):20–26.
13. National Osteoporosis Foundation. Clinician’s guide to
prevention and treatment of osteoporosis. Washington,
DC: National Osteoporosis Foundation, 2014.
14. Ebeling PR, Daly RM, Kerr DA, Kimlin MG. Building
healthy bones throughout life: An evidence-informed
strategy to prevent osteoporosis in Australia. Med J Aust
2013;199(7 Suppl):S1.
15. Bolland MJ, Leung W, Tai V, et al. Calcium intake and risk
of fracture: Systematic review. BMJ 2015;351:h4580.
16. Tai V, Leung W, Grey A, Reid IR, Bolland MJ. Calcium
intake and bone mineral density: Systematic review and
meta-analysis. BMJ 2015;351:h4183.
17. Gillespie LD, Robertson MC, Gillespie WJ, et al.
Interventions for preventing falls in older people living
in the community. Cochrane Database Syst Rev
2012;9:CD007146.
18. Howe TE, Shea B, Dawson LJ, et al. Exercise
for preventing and treating osteoporosis in
postmenopausal women. Cochrane Database Syst Rev
2011;7:CD000333.
19. Kemmler W, Haberle L, von Stengel S. Effects of exercise
on fracture reduction in older adults: A systematic review
and meta-analysis. Osteoporos Int 2013;24(7):1937–50.
20. Frost SA, Nguyen ND, Center JR, Eisman JA, Nguyen TV.
Timing of repeat BMD measurements: Development of
an absolute risk-based prognostic model. J Bone Miner
Res 2009;24(11):1800–07.
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21. Winzenberg T, van der Mei I, Mason RS, Nowson C,
Jones G. Vitamin D and the musculoskeletal health of
older adults. Aust Fam Physician 2012;41(3):92–99.
22. Schousboe JT, Shepherd JA, Bilezikian JP, Baim S.
Executive summary of the 2013 International Society for
Clinical Densitometry Position Development Conference on
bone densitometry. J Clin Densitom 2013;16(4):455–66.
23. Barrack CM, McGirr EE, Fuller JD, Foster NM, Ewald
DP. Secondary prevention of osteoporosis post minimal
trauma fracture in an Australian regional and rural
population. Aust J Rural Health 2009;17(6):310–15.
24. National Institute of Clinical Studies. Evidence – Practice
gaps report. Melbourne: NICS, 2005.
25. Ewald DP, Eisman JA, Ewald BD, et al. Population rates
of bone densitometry use in Australia, 2001-2005,
by sex and rural versus urban location. Med J Aust
2009;190(3):126–28.
26. Winzenberg T, Oldenburg B, Frendin S, De Wit L, Riley
M, Jones G. The effect on behavior and bone mineral
density of individualized bone mineral density feedback
and educational interventions in premenopausal women:
A randomized controlled trial [NCT00273260]. BMC
Public Health 2006;6:12.
27. Wu F, Laslett L, Wills K, Oldenburg B, Jones G,
Winzenberg T. Effects of individualised bone density
feedback and educational interventions on osteoporosis
knowledge and self-efficacy in young women: A 12-yr
prospective study. Plenary poster P11, ANZBMS
23rd Annual Scientific Meeting; Hilton on the Park,
Melbourne, 2013.
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15. Screening tests of unproven benefit
The following are not recommended as screening tests in low-risk or asymptomatic general practice populations.
These tests may have a separate value as diagnostic tests or as tests to monitor disease progression.
Table 15.1. Screening tests not recommended in low-risk general practice populations
Screening test Condition Reason not to use References
Genomic sequencing Genetic risk Limited evidence on the balance of benefits and harms,
ethical issues and uncertain utility in an asymptomatic
adult
1–5
Genetic testing –
methylenetetrahydrofolate
reductase (MTHFR)
Venous
thrombo-
embolism
The MTHFR test has minimum clinical utility and is
not recommended in the evaluation of thrombophilia,
recurrent pregnancy loss, or assessment of risk of
coronary artery disease or any other condition
6
Genetic testing –
apolipoprotein E (ApoE)
Alzheimer’s
disease
ApoE testing is not recommended to assess risk of
Alzheimer’s disease due to its poor predictive value and
the lack of preventive options
6
Vascular
Coronary computed
tomography angiography*
(CCTA)
Coronary
artery disease
(CAD)
No randomised controlled trial (RCT) evidence. RCTs of
therapy show no effect on coronary artery progression
May be of benefit in those at moderate risk of CAD –
but not in:
• asymptomatic persons
• subjects with known significant CAD
• subjects with a high pre-test probability of CAD
7–11
Computed tomography (CT)
calcium scoring†
Coronary heart
disease (CHD)
Usually not appropriate in a low-risk asymptomatic
population, but may be of possible value in risk
reclassification in those at moderate risk
8, 9, 11–13
Serum homocysteine CHD Value as a risk factor for CHD is uncertain and
published RCTs show no evidence of benefit by
lowering levels
14–18
Exercise electrocardiogram
(ECG)
CHD Low yield and high false-positive rate given low
prevalence in asymptomatic population
14, 19–22
High sensitivity C-reactive
protein (hsCRP)
Cardiovascular
disease (CVD)
Insufficient evidence to support the role of hsCRP in
preventive screening of asymptomatic patients
14, 22–29
Ankle:brachial index (ABI) Peripheral
vascular
disease
Current evidence is insufficient to assess benefits
and costs of using ABI to screen for peripheral
vascular disease
28, 30–37
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Screening test Condition Reason not to use References
Carotid artery ultrasound Asymptomatic
carotid artery
stenosis
It is no longer justifiable to screen for the presence of
asymptomatic carotid artery stenosis to select patients
for carotid procedures. There is no current evidence
of patient benefit. However, there is evidence of harms
from screening, including significant procedural risk
and cost
Carotid stenting cannot be recommended because
it causes about twice as many strokes or deaths as
carotid endarterectomy (CEA), a risk that is not offset
by the CEA risk of myocardial infarction
Also, asymptomatic carotid artery stenosis patients
with particularly high ipsilateral stroke risk who benefit
from CEA, in addition to current optimal medical
treatment alone, have not been identified. Evidence
is insufficient to allow reliable risk stratification. For
example, degree of stenosis within the 50–99%
range, asymptomatic stenosis progression, plaque
echolucency and transcranial Doppler embolus
detection are not specific enough to identify patients
likely to benefit from CEA
A research priority is to find out if screening to detect
asymptomatic carotid artery stenosis improves medical
treatment and patient outcomes over screening for,
and optimal treatment of, other established vascular
risk factors
38–43
Cancer
Magnetic resonance
imaging (MRI)
Breast cancer Ongoing surveillance strategies for women at high
risk of breast cancer may include imaging with MRI.
A Medicare rebate is available for MRI scans for
asymptomatic women <50 years of age at high risk of
breast cancer
There is no evidence for MRI as a stand-alone
screening test for women at average risk of breast
cancer
44–51
Thermography Breast cancer Thermography is associated with high false-positive
and false-negative rates. There is insufficient evidence
to support the use of thermography in breast cancer
screening or as an adjunctive tool to mammography
52, 53
Single nucleotide
polymorphism (SNP) testing
Breast cancer Use of a SNP‐based breast cancer risk assessment
test should only be undertaken after an in‐depth
discussion led by a clinical professional familiar with the
implications of genetic risk assessment and testing,
including the potential insurance implications
Genetic testing should be offered only with pre-test
and post-test counselling to discuss the limitations,
potential benefits, and possible consequences
46, 54–56
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Screening test Condition Reason not to use References
Cancer antigen (CA)125/
transvaginal ultrasound
Ovarian cancer There is no evidence to support the use of any
test – including pelvic examination, CA125, or
other biomarkers, ultrasound (including transvaginal
ultrasound), or combination of tests – for routine
population-based screening for ovarian cancer
CA125 is limited by poor sensitivity in early-stage
disease and low specificity. The specificity of
transvaginal ultrasound is low. The low prevalence of
ovarian cancer means that even screening tests that
have very high sensitivity and specificity have a low
positive predictive value for disease detection
The recently reported UK Collaborative Trial of Ovarian
Cancer Screening (UKCTOCS) trial of transvaginal
ultrasound +/– CA125 found no significant difference in
mortality over 0–14 years
Secondary analyses suggest a possible benefit of
screening using transvaginal ultrasound and CA125,
but further follow-up is needed before firm conclusions
can be reached on the long-term efficacy and cost-
effectiveness of ovarian cancer screening
46, 57–61
Optical colonoscopy or
computed tomography (CT)
colonography‡
Colorectal
cancer (CRC)
These have good sensitivity for cancer and advanced
polyps, and are more acceptable than colonoscopy,
but there is no current evidence of the reduction of
CRC mortality. There are several trials under way to
assess effectiveness and cost effectiveness of this as a
screening strategy
Neither optical colonoscopy nor CT colonography are
recommended for primary screening because there is
no current RCT evidence of effectiveness in relation to
any harms
62–69
Whole-body CT or MRI Cancer Whole-body imaging has not been shown to improve
quality of life and/or decrease mortality. It is associated
with additional radiation exposure and a high number
of false positive results. There are no RCTs of whole-
body imaging to detect cancer or CVD
70–77
Lung disease
Spirometry Chronic
obstructive
pulmonary
disease
(COPD)
Screening with spirometry in the absence of symptoms
has no net benefit
Opportunistic case-finding should be considered in
high-risk individuals. These include those aged >40
years, plus either:
• symptoms (chronic cough, increased sputum
production, wheezing or dyspnoea)
• history of exposure to relevant environmental factors
such as cigarette smoke
Several questionnaires§ are useful and if positive,
should be followed by spirometry by a trained
professional (consensus statement)
78–83
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Screening test Condition Reason not to use References
Endocrine
Thyroid function tests Thyroid
dysfunction
Despite the relatively high incidence of subclinical
hypothyroidism in older women (up to 17%), there is a
lack of convincing data from controlled trials that early
treatment reduces lipid levels, symptoms or the risk for
CVD in patients with mild thyroid dysfunction detected
by screening
There is no evidence supporting an increased risk for
stroke associated with subclinical thyroid dysfunction
More research is needed to determine the clinical
benefits associated with thyroid screening
84–89
Chronic disease prevention
Vitamin D Vitamin D
deficiency
Current evidence is insufficient to assess the balance
of benefits and harms of screening for vitamin D
deficiency in asymptomatic adults
90–97
Heel ultrasound Osteoporosis While there is some evidence that heel ultrasound in
combination with femoral neck bone densitometry
better predicts hip fracture, there are no RCTs showing
any benefit of using heel ultrasound as the primary
screening tool for osteoporosis, nor is its usefulness as
a pre-screening tool in tandem with dual-energy X-ray
absorptiometry (DXA) proven
98–103
Infection
Mid-stream urine (MSU)
culture
Asymptomatic
bacteriuria
(elderly)
Identifying and treating non-pregnant adults with
asymptomatic bacteriuria does not improve outcomes
and may increase antibiotic resistance. The only two
exceptions to this are pregnancy and a patient who is
about to undergo a urological procedure
104, 105
Other tests
Enquiry about sleep Obstructive
sleep apnoea
(OSA)
The prevalence of undiagnosed OSA is high and it is
associated with considerable morbidity. While there are
some screening tools that are available, there are no
large-scale RCTs showing the benefit or cost-benefit of
routine screening for OSA in primary care
Case-finding for OSA may be beneficial in commercial
vehicle drivers and pilots, but it has not been mandated
by any government authority
106–109
Bimanual pelvic exam During a
routine
Papanicolaou
(Pap) test in an
asymptomatic
woman
A bimanual examination performed as part of routine
Pap smear examination is of no proven benefit, but
studies are limited
It has been shown to be not an effective screening
method for ovarian cancer detection
110–113
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*CCTA involves the use of multi-slice CT and intravenously administered contrast material to obtain detailed images of the blood vessels
of the heart. It has been used as an alternative to conventional invasive coronary angiography for evaluating CAD and coronary artery
anomalies. CCTA requires high doses of ionizing radiation, with an average dose of 8.1 milliSieverts for patients weighing 75 kg. This
dose is approximately two to three times higher than the average radiation dose administered to patients during conventional coronary
angiography
†CT calcium scoring (also known as Coronary Calcium Scan and Coronary Artery Calcium Scoring). A good summary on CT calcium
score can be found at www.aetna.com/cpb/medical/data/200_299/0228.html [Accessed 26 May 2016]
‡There are no current Medicare Benefits Schedule (MBS) rebates for performing cardiac CT in asymptomatic individuals.
§Refer to the Lung Foundation website at http://lungfoundation.com.au/health-professionals/clinical-resources/copd/targeted-copd-
case-finding-using-copd-screening-devices-in-the-community
ABI, ankle:brachial index; ApoE, apolopoprotein E; CA, cancer antigen; CAD, coronary artery disease; CCTA, coronary computed
tomography angiography; CEA, carotid endarterectomy; CHD, coronary heart disease; CT, computed tomography; CVD,
cardiovascular disease; DXA, dual-energy X-ray absorptiometry; hsCRP, high sensitivity C-reactive protein; MBS, Medicare Benefits
Schedule; MRI, magnetic resonance imaging; MSU, mid-stream urine; MTHFR, methylenetetrahydrofolate; OSA, obstructive sleep
apnoea; Pap, Papanicolaou; RCT, randomised controlled trial; SNP, single nucleotide polymorphism; UKCTOCS, UK Collaborative Trial
of Ovarian Cancer Screening
Table 15.2. Screening tests of indeterminate value
Screening test Condition Reason not to use References
Vitamin D Pregnancy Pregnant women with one or more risk
factors for low vitamin D levels should have
their serum 25-hydroxy vitamin D levels
measured at their first antenatal visit
Risk factors for low vitamin D levels are
lack of skin exposure to sunlight, dark
skin, southerly latitude, conditions affecting
vitamin D metabolism and storage (including
obesity) and, for infants, being born to
a mother with low vitamin D levels and
exclusive breastfeeding combined with at
least one other risk factor.
92, 114–17
Vascular
Ultrasound Abdominal aortic
aneurysm (AAA)
National screening of men aged 65 years
has been successfully introduced in the UK
and parts of Scandinavia for AAA. However,
it is unclear what the impact of the lower-
than-expected prevalence (<2%) of AAAs
will be on the long-term benefit
The US Preventive Services Task Force
(USPSTF) recommends screening of older
male smokers. Limiting screening to this
sub-group has raised some ethical issues
and may influence cost-effectiveness
Unpublished recent data from the Western
Australian trial of screening for AAA suggests
that the magnitude of the benefit from
screening men aged ≥65 years does not
warrant the introduction of a national AAA
screening program in Australia at this stage
118–23
http://www.aetna.com/cpb/medical/data/200_299/0228.html
http://lungfoundation.com.au/health-professionals/clinical-resources/copd/targeted-copd-case-finding-using-copd-screening-devices-in-the-community
http://lungfoundation.com.au/health-professionals/clinical-resources/copd/targeted-copd-case-finding-using-copd-screening-devices-in-the-community
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Screening test Condition Reason not to use References
B-type natriuretic peptide
(BNP)
Congestive
cardiac failure
The evidence for screening for heart failure
using BNP is mixed despite its sensitivity
and prognostic significance. It may be useful
in excluding the condition in suspected
heart failure. A recent, pragmatic, un-
blinded randomised controlled trial (RCT)
has shown some benefit for BNP screening
in high-risk groups, but large scale trials
are needed to confirm these findings and
establish feasibility and cost effectiveness
25, 124–30
Cancer
Low-dose chest
computed tomography
Lung cancer A large trial in the US has shown that
patients selected for high lung cancer
risk have reduced lung cancer and total
mortality within a carefully conducted LDCT
screening program in the context of a
structured program of selection, screening,
evaluation, and management of the relatively
high number of benign abnormalities
Performing CT scans in high-risk
individuals outside well-designed and
conducted research programs may lack
any benefit and may be harmful. Low-risk
persons should not have screening CT as
the reasonably foreseeable benefits are
lower and may be substantially outweighed
by harms. More accurate data on the
identification of the appropriate target
group including the threshold for absolute
lung cancer risk, are required before any
recommendation on LDCT
131–38
Positron emission
tomography –
computed tomography
(or PET CT scan)
Lung cancer There is no current evidence of benefit for
PET screening for lung cancer
135, 139, 140
Elderly
Visual acuity Visual impairment Current evidence is insufficient to assess the
balance of benefits and harms of screening
for impaired visual acuity in older adults
141–43
AAA, abdominal aortic aneurysm; BNP, B-type natriuretic peptide; LDCT, low-dose computed tomography; PET, positron emission
tomography; RCT, randomised controlled trial ; USPSTF, US Preventive Services Task Force
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140. Sogaard R, Fischer BM, Mortensen J, Hojgaard L,
Lassen U. Preoperative staging of lung cancer with
PET/CT: Cost-effectiveness evaluation alongside a
randomized controlled trial. Eur J Nucl Med Mol Imaging
2011;38(5):802–09.
141. Chou R, Dana T, Bougatsos C. Screening older adults
for impaired visual acuity: A review of the evidence for
the US Preventive Services Task Force. Ann Intern Med
2009;151(1):44–58.
142. Smeeth L, Iliffe S. Community screening for visual
impairment in the elderly. [update of Cochrane Database
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143. Chou R DT, Bougatsos C, Grusing S, Blazina I. Screening
for impaired visual acuity in older adults: A systematic
review to update the 2009 US Preventive Services Task
Force recommendation. Rockville, MD: Agency for
Healthcare Research and Quality, 2015.
Activity/topic Frequency Notes Reference Age group
15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80
Prevention of chronic disease
Smoking Opportunistically It would be ideal to offer smoking cessation advice at every visit for those
at high risk of complications
p 67, Section 7.1
Women who are pregnant or planning
a pregnancy
Each antenatal visit p 67, Section 7.1 and
p 18, Chapter 1.
Overweight Every two years Every 12 months for Aboriginal and Torres Strait Islander patients, or those
with existing diabetes, cardiovascular disease, stroke, gout or liver disease.
Every six months for adults who are overweight or obese
p 69 Section 7.2
Nutrition Every two years Every six months for patients who are overweight or obese, or have high
cardiovascular absolute risk, a family history cardiovascular disease, type 2
diabetes or high risk of type 2 diabetes .
p 73, Section 7.3
Alcohol: Early detection of at-risk drinking Every two to four years for low-risk groups and
opportunistically for higher risk groups
All patients 15 years of age and older should be asked about the quantity
and frequency of alcohol intake
p 75, Section 7.4
Women who are pregnant or planning
a pregnancy
Each antenatal visit No drinking is the safest option p 18, Section 1
Physical activity Every two years Opportunistically for those at higher risk, including teenage girls, older
adults, office workers, Aboriginal and Torres Strait Islander patients, patients
with low socioeconomic status and non-English speaking background, or
those at high risk of a chronic condition or cancer
p 77, Section 7.5
Pre-conception care Opportunistically Consider for all women aged 15–49 years p 18, Chapter 1
Sexual health – Chlamydia and other
sexually transmissible diseases
Opportunistically if indicated All sexually active patients up to 29 years of age. Test every 12 months for
higher and highest risk groups
p 62, Section 6.2.1
Prevention of vascular disease
Absolute cardiovascular disease
risk assessment
Every two years Aged ≥35 years for Aboriginal and Torres Strait Islander patients p 86, Section 8.1
Blood pressure Every two years Every 6–12 months for patients with moderate risk and every 6–12 weeks
for patients with high risk.
p 87, Section 8.2
Cholesterol and other lipids Every five years Every two years for those with increased risk, and 12 months with
increased cardiovascular risk and existing chronic disease. Aged ≥35 years
for Aboriginal and Torres Strait Islander patients
p 89, Section 8.3
Type 2 diabetes Every three years Every 12 months for those with impaired glucose tolerance or impaired
fasting glucose. Aged 18 years and older for Aboriginal and Torres Strait
Islander patients
p 92, Section 8.4
Stroke Assess patients with high absolute risk every 12 months p 94, Section 8.5
Kidney disease Every one to two years for those at high risk Aged ≥30 years for Aboriginal and Torres Strait Islander patients p 96, Section 8.6
Cancer
Colorectal cancer Every two years from 50 years of age Earlier for those with high risk p 105, Section 9.2
Breast cancer Every two years p 109, Section 9.3
Melanocytic skin cancer Opportunistically for average and increased risk Examine every 6–12 months for those at high risk. p 113, Section 9.4.1
Non-melanocytic skin cancer Opportunistically Opportunistically for patients with increased risk including those >40 years
of age, and every 12 months for high-risk patients
p 116, Section 9.4.2
Cervical cancer (to April 2017) Every two years p 117, Section 9.5
Cervical cancer (commencing May 2017) Every five years p 117, Section 9.5
Psychosocial
Depression Every encounter for those aged 12–18 years and
opportunistically for those aged ≥18 years
Intimate partner violence Opportunistically; maintain a high level of clinical
awareness for patients at increased risk
Every encounter for adolescent women and screen all pregnant women p 130, Section 10.3
Elderly
Immunisation Refer to Section 5.1 or the Australian immunisation
handbook
p 46, Table 5.1
Physical activity Every two years Advise moderate physical activity p 46, Section 5.2 and
p 78, Table 7.5.1
Falls risk Every 12 months Every six months if the patient has a history of falls or multiple risk factors p 47, Section 5.3
Vision and hearing Every 12 months
Oral health At least every 12 months and encouraged to attend
annual dental visits
More frequently for those at increased risk p 134, Chapter 11
Glaucoma Frequency of follow-up determined by the patient’s
eye assessment
Patients at increased risk p 137, Chapter 12
Osteoporosis
Postmenopausal women Every 12 months for average risk Increased risk for women aged ≥50 years with risk factors p 141, Chapter 14
Men Every 12 months for average risk Increased risk for women aged ≥50 years with risk factors p 141, Chapter 14
Family history screening questionnaire First visit to a practice and then at least every three years p 24, Chapter 2
Preventive activities over the lifecycle – Adults Patient name: Date of birth: Date:
Low-average risk Increased risk
159Guidelines for preventive activities in general practice 9th edition
Activity/topic Frequency Reference Age group
Neonatal 2,4,6 & 12 months 18 months & 3 years 3.5–5 years 6–13 years 14–19 years
Immunisation Refer to the Australian immunisation handbook p 58, Table 6.1.1
Assessment
Metabolic screen p 33, Chapter 3, Table 3.1
Hearing p 33, Chapter 3, Table 3.1
Physical examination As outlined in the Child Personal Health Record (Blue Book) p 33, Chapter 3, Table 3.1
Body mass index Measure routinely from 2 years of age p 37, Table 3.2 Practice Point k
Vision At least once between 3 and 5 years of age p 37, Table 3.2 Practice Point j
Oral health Lift the lip’ check from 12 months of age and encourage
annual dental visits. Opportunistic examination of higher
risk groups
p 37, Table 3.2 Practice Point e
Chlamydia and other sexually
transmissible infections
Patients who are sexually active p 62, Section 6.2.1
Family and social environment When a child presents with behavioural or emotional
problems
p 33, Table 3.1
Depression Every encounter p 38, Table 3.2 Practice Point m
Risky behaviours p 38, Table 3.2 Practice Point m
Intimate partner violence Opportunistically at every encounter for adolescent women p 131, Table 10.3.1
Health promotion
Support breastfeeding p 74, Table 7.3.2
Nutrition p 32, Chapter 3, Table 3.1
Physical activity p 37, Table 3.2 Practice Point f
Healthy sleep p 32, Chapter 3, Table 3.1
Interactive reading p 32, Chapter 3, Table 3.1
Developmental progress As outlined in the Child Personal Health Record (Blue Book) p 36, Table 3.2 Practice Point d
Preventive counselling and advice
Smoking Ask about passive smoking during the neonatal period.
It should be asked oportunistically in adolescents and
young people
p 67, Section 7.1
Sudden unexpected death in infancy p 32, Chapter 3, Table 3.1
Social/emotional wellbeing p 32, Chapter 3, Table 3.1
Injury prevention p 32, Chapter 3, Table 3.1
Sun protection Opportunistically
Early detection of at-risk drinking Every two to four years all patients aged ≥15 years
Opportunistically for children aged <15 years (increased risk)
p 75, Section 7.4
Preventive activities over the lifecycle – Children Patient name: Date of birth: Date:
160 Guidelines for preventive activities in general practice 9th edition
Low-average risk Increased risk
Healthy Profession.
Healthy Australia.
Mental Health Care in
the Perinatal Period
Australian Clinical
Practice Guideline
October 2017
http://cope.org.au/
Australian Clinical Practice Guideline | 2
The Centre of Perinatal Excellence (COPE) is an independent, not-for-profit organisation. Since COPE’s establishment in June
2013, it has been the policy of the COPE Board not to accept funding from, nor partner with pharmaceutical companies. None of
COPE’s activities are funded by pharmaceutical companies. This allows COPE to retain independence and impartiality and promote
evidence-based approaches to perinatal mental health.
Copyright statement
This work is copyright. You may download, display, print and reproduce this material (in whole or in part) in unaltered form only
(retaining this notice) for your personal use or internal use within your organisation, but only if you or the organisation do not use the
reproduction for any commercial purpose and retain this notice as part of that reproduction. Apart from any use as permitted under the
Copyright Act 1968 and this notice, all other rights are expressly reserved.
Inquiries
Requests and inquiries concerning reproduction and rights should be sent to Communications Branch, Department of Health,
GPO Box 9848, Canberra ACT 2601 or copyright@health.gov.au
Disclaimer
This is a general guide to appropriate practice, to be followed subject to the relevant clinician’s judgement in each individual case.
COPE has taken all reasonable steps to ensure that the Guidelines is based on, and accurately represent, the best available published
evidence on key areas of antenatal care.
However, COPE does not accept any legal liability for any loss, damage, costs or expenses that may result from reliance on the
information and recommendations contained in this Guideline.
Systematic literature review
The systematic literature review that provides the evidence base for this Guideline was conducted by Hereco.
Technical writing
Ampersand Health Science Writing was responsible for drafting and editing the Guideline in consultation with the EWG.
Expiry of the Guideline
This Guideline was submitted to the National Health and Medical Research Council (NHMRC) in August 2017 and approved in
October 2017. Approval for the Guideline by the NHMRC is granted for a period not exceeding 5 years, at which date the approval
expires. The NHMRC expects that all guidelines will be reviewed no less than once every 5 years. Readers should check with COPE for
any reviews or updates of this Guideline.
Suggested citation
Austin M-P, Highet N and the Expert Working Group (2017) Mental Health Care in the Perinatal Period: Australian Clinical Practice
Guideline. Melbourne: Centre of Perinatal Excellence.
Funding
COPE acknowledges the funding provided by the Australian Government Department of Health for the development of this guideline.
Publication approval
The guideline recommendations on pages 7-12 of this document were approved by the Chief Executive Officer of the National Health
and Medical Research Council (NHMRC) on 17 October 2017 under section 14A of the National Health and Medical Research Council
Act 1992. In approving the guideline recommendations, NHMRC considers that they meet the NHMRC standard for clinical practice
guidelines. This approval is valid for a period of five years.
NHMRC is satisfied that the guideline recommendations are systematically derived, based on the identification and synthesis of the best
available scientific evidence, and developed for health professionals practising in an Australian health care setting.
This publication reflects the views of the authors and not necessarily the views of the Australian Government.
© 2017 Commonwealth of Australia as represented by the Department of Health
Forward | 3
Foreword
The Centre of Perinatal Excellence (COPE) and the Expert Working Group are pleased to issue Mental Health Care in the Perinatal
Period: Australian Clinical Practice Guideline. The purpose of the Guideline is to support health professionals in providing evidence-
based care. While the focus of the Guideline is on women, the effects of maternal mental health on infants and families and the
emerging evidence on paternal perinatal mental health are acknowledged.
The Guideline is relevant to the care of all women in the perinatal period. In addition to screening and psychosocial assessment, the
Guideline provides guidance on care for women with depressive and anxiety disorders, severe mental illnesses (schizophrenia, bipolar
disorder and postpartum psychosis) and borderline personality disorder at this time.
The Guideline includes discussion of:
• supporting emotional health and wellbeing of women
• screening for symptoms of depression and anxiety and assessment for psychosocial factors that affect mental health
• assessing mother-infant interaction and the safety of the woman and infant
• referral and care pathways for women who require further assessment or care
• care planning for women with diagnosed mental health conditions
• psychological approaches to prevention and treatment of depressive and anxiety disorders
• prescribing in pregnant and breastfeeding women, in terms of potential risks (harm to fetus/infant) and benefits
• potential areas for future development to support the sustainable and measurable implementation of best practice.
The Guideline does not cover:
• the diagnosis or specifics of managing mental health conditions in the perinatal period
• routine assessment of specific social and lifestyle factors that affect perinatal outcomes and may also be associated with mental
health.
It is hoped that the implementation of the recommendations in this Guideline will:
• increase rates of screening for depressive and anxiety disorders and reduce the severity of disorders (through early identification)
and hence the need for specialist care
• lead to consistent approaches to assessment of psychosocial risk
• support the development of clear referral pathways for health professionals to refer women to suitably qualified health professionals
and/or online treatments for the provision of timely recommended psychological treatments
• support a safe and balanced use of pharmacological treatments in the perinatal period.
Summary resources and companion documents for women and their families, and for specific groups of health professionals, will be
developed from the Guideline.
As the organisation overseeing the development of the Guideline, COPE will monitor the uptake of the Guideline to assess its
contribution to changes in practice and potentially to health outcomes.
Professor Marie-Paule Austin Dr Nicole Highet
Chair, Expert Working Group Co-Chair, Expert Working Group
Australian Clinical Practice Guideline | 4
Contents
Foreword 3
Summary 6
Summary of recommendations and practice points 7
Introduction 13
PART A – BACKGROUND INFORMATION 15
1 Mental health conditions in the perinatal period 16
1.1 Understanding the woman’s context 16
1.2 Prevalence and impact of maternal mental health conditions in the perinatal period 16
1.3 Perinatal mental health in men 18
2 Enabling effective mental health care in the perinatal period 20
2.1 Therapeutic relationship 20
2.2 Care provision 21
2.3 Support and information 22
2.4 Continuity of care 22
PART B – SCREENING AND PSYCHOSOCIAL ASSESSMENT 23
3 Considerations before screening and psychosocial assessment 24
4 Acceptability of screening and psychosocial assessment 25
4.1 Acceptability of screening among health professionals and women 25
4.2 Barriers to routine perinatal screening, follow-up assessment and treatment 25
4.3 Facilitators of screening and subsequent mental health care 25
5 Screening for depressive and anxiety disorders 27
5.1 Screening for depression 27
5.2 Culturally appropriate screening for depression 29
5.3 Screening for anxiety 29
6 Assessing psychosocial factors that affect mental health 31
6.1 Psychosocial assessment tools 31
6.2 Other considerations in psychosocial screening 32
7 Assessing mother-infant interaction and safety of the woman and infant 34
7.1 Mother-infant interaction 34
7.2 Risk to the infant 35
7.3 Risk of suicide 35
8 Implementing psychosocial assessment and screening 38
8.1 Incorporating psychosocial assessment and screening into routine practice 38
8.2 General approaches post-assessment 38
8.3 Referral and care pathways 38
8.4 Supporting emotional health and wellbeing 39
8.5 Women with complex presentations 40
9 Practice summary – screening and assessment 41
Contents | 5
PART C – PREVENTION AND TREATMENT 43
10 General principles in prevention and treatment 44
10.1 Care planning 44
10.2 Use of pharmacological treatments 45
10.3 Postnatal care and support 47
11 Depressive and anxiety disorders 49
11.1 Women at risk of depressive or anxiety disorders 49
11.2 Women with mild to moderate depression or anxiety 49
11.3 Women with moderate to severe depressive or anxiety disorder 51
12 Severe mental illnesses: schizophrenia, bipolar disorder and postpartum psychosis 54
12.1 Preconception planning 54
12.2 Considerations in providing antenatal and postnatal care 54
12.3 Psychosocial and psychological treatments 54
12.4 Pharmacological therapies 55
13 Borderline personality disorder 58
13.1 Considerations in providing antenatal and postnatal care 58
13.2 Psychosocial support and psychological treatments 59
13.3 Pharmacological treatments 60
14 Electroconvulsive therapy 61
15 Practice summary – prevention and treatment 62
PART D: AREAS FOR FUTURE RESEARCH 66
APPENDICES 68
A Membership of the expert working group and subcommittees 69
Membership of the Expert Working Group 69
Membership of the Harms Expert Subcommittee 71
Membership of the Borderline Personality Disorder and Schizophrenia Subcommittee 71
Guideline development team 72
B Administrative report 73
B1 Scope and purpose 73
B2 Stakeholder involvement 78
B3 Rigour of development 79
B4 Clarity of presentation 82
B5 Applicability 82
B6 Editorial independence 84
B7 Public consultation 85
B8 Dissemination and implementation 87
C Linking evidence to recommendations 88
D Psychosocial assessment and screening 102
Edinburgh Postnatal Depression Scale 103
Antenatal Risk Questionnaire 105
Glossary 110
Abbreviations and acronyms 113
References 114
Australian Clinical Practice Guideline | 6
Summary
Studies in Australia and around the world have found that up to one in ten women experience depression during pregnancy and one
in seven women in the year following birth. Anxiety disorders are also prevalent (around one in five women in both the antenatal and
postnatal periods) and comorbidity with depression is high. Severe mental illnesses – schizophrenia, bipolar disorder and borderline
personality disorder – are much less common than depression and anxiety disorders. All of these conditions have the potential to have
a negative impact on maternal and infant outcomes. This is more likely to occur when a mental health condition is combined with
serious or multiple adverse psychosocial circumstances.
The importance of a woman’s physical and mental health should be central to every aspect of maternity care. As well as affecting a
woman’s emotional welfare and happiness, mental health conditions affect her experience of pregnancy and parenting, are associated
with a degree of increased risk of obstetric and neonatal complications and can profoundly affect a woman’s ability to bond with her
baby and the infant’s psychological adaptation over the longer term. Fetal exposure to an untreated maternal mental health condition
can also have a negative impact on the infant’s wellbeing.
Mental health conditions in the perinatal period often go undetected and untreated, imposing a great burden on women, their families,
the health system and society more broadly. This Guideline therefore recommends repeated assessment of psychosocial risk and
screening for symptoms of depressive and anxiety disorders for all women in the perinatal period. This approach is critical to providing
women with access to early intervention if needed. While referral and care pathways vary with setting (e.g. general practice, maternity
services) and location (e.g. metropolitan, rural and remote), it is important that women are provided with access to timely, appropriate
services post-assessment, ongoing psychosocial support and appropriate treatments.
While women with pre-existing severe mental illness may already be under the care of a GP and/or psychiatrist, specific consideration
must be given to planning their care due to the complexity of these conditions and the substantial challenges for primary care
professionals involved in their management.
Care planning for a woman with a mental health condition ideally begins before conception; requires close multidisciplinary
collaboration; and a particular focus on continuity of care across the different health and other government sectors.
Interventions to support women with mental health conditions in the perinatal period range from psychosocial support, through
structured and systematic psychological interventions to pharmacological treatment, depending on the severity of a woman’s
symptoms or condition. Interventions are decided with the woman and her significant other(s)1 based on risk-benefit analysis, which
takes into account the benefit to the woman and the fetus or newborn versus the potential for harm.
The way in which different health professionals use this Guideline will vary depending on their knowledge, skills and role, as well as the
setting in which care is provided. Whatever the setting and circumstances, perinatal mental health care should be culturally responsive
and family-centred. It should involve collaborative decision-making with the woman and her significant other(s) if the woman agrees,
which includes full discussion of the potential risks and benefits of any treatments offered. Health professionals providing care should
have appropriate training and skills and should work together to provide continuity of care for women and their families.
This Guideline provides a reliable and standard reference for health professionals providing care to women in the perinatal period. By
providing a summary of the currently available evidence on effective approaches to mental health care at this time, it aims to improve a
woman’s experience of pregnancy and early parenthood, her emotional wellbeing, her safety and outcomes for all families.
1. In this Guideline, ‘significant other(s)’ includes individuals in a woman’s support network and may include partner, co-parent, members of her
immediate or extended family and/or close friends.
Summary of recommendations and practice points | 7
Summary of recommendations
and practice points
The table below lists the recommendations and practice points included in this Guideline. This information is also provided as a separate
document and is available on the COPE website.
Four types of guidance are included:
• evidence-based recommendations (EBR) – a recommendation formulated after a systematic review of the evidence, with a clear
linkage from the evidence base to the recommendation using GRADE methods and graded either:
> ‘strong’ – implies that most/all individuals will be best served by the recommended course of action; used when confident that
desirable effects clearly outweigh undesirable effects or, conversely, when confident that undesirable effects clearly outweigh
desirable effects (shaded in burgundy) or
> ‘conditional’ – implies that not all individuals will be best served by the recommended course of action; used when desirable
effects probably outweigh undesirable effects; used when undesirable effects probably outweigh desirable effects (shaded in
burgundy)
• consensus-based recommendation (CBR) – a recommendation formulated in the absence of quality evidence, after a systematic
review of the evidence was conducted and failed to identify sufficient admissible evidence on the clinical question (shaded in blue)
• practice point (PP) – advice on a subject that is outside the scope of the search strategy for the systematic evidence review, based
on expert opinion and formulated by a consensus process (shaded in pink).
Recommendations and practice points
PART B: SCREENING AND ASSESSMENT
Training for screening and psychosocial assessment
i CBR
All health professionals providing care in the perinatal period should receive training in woman-centred
communication skills, psychosocial assessment and culturally safe care.
ii CBR
Complete the first antenatal screening as early as practical in pregnancy and repeat screening at least once later
in pregnancy.
iii CBR
Complete the first postnatal screening 6–12 weeks after birth and repeat screening at least once in the first
postnatal year.
iv CBR
For a woman with an EPDS score between 10 and 12, monitor and repeat the EPDS 2–4 weeks later as her score
may increase subsequently.
v CBR Repeat the EPDS at any time in pregnancy and in the first postnatal year if clinically indicated.
vi CBR
For a woman with a positive score on Question 10 on the EPDS undertake or arrange immediate further
assessment and, if there is any disclosure of suicidal ideation, take urgent action in accordance with local
protocol/policy.
vii CBR
When screening Aboriginal and Torres Strait Islander women, consider language and cultural appropriateness of
the tool.
viii CBR
Use appropriately translated versions of the EPDS with culturally relevant cut-off scores. Consider language and
cultural appropriateness of the tool.
1 EBR
Use the Edinburgh Postnatal Depression Scale (EPDS) to screen women for a possible depressive
disorder in the perinatal period.
Strong
Screening for depression
2 EBR Arrange further assessment of perinatal woman with an EPDS score of 13 or more. Strong
Australian Clinical Practice Guideline | 8
Assessing risk of suicide
Assessing psychosocial risk
Assessing mother-infant interaction
Supporting emotional health and wellbeing
Screening for anxiety
ix CBR
Be aware that anxiety disorder is very common in the perinatal period and should be considered in the broader
clinical assessment.
xi CBR
Undertake psychosocial assessment in conjunction with a tool that screens for current symptoms of depression/
anxiety (i.e. the EPDS).
xii CBR Consider language and cultural appropriateness of any tool used to assess psychosocial risk.
x CBR
As part of the clinical assessment, use anxiety items from screening tools (e.g. EPDS items 3, 4 and 5, Depression,
Anxiety and Stress Scale (DASS) anxiety items and Kessler Psychological Distress Scale (K-10) items 2, 3, 5 and 6)
and relevant items in structured psychosocial assessment tools (e.g. Antenatal Risk Questionnaire (ANRQ)).
3 EBR If using a tool to assess psychosocial risk, administer the ANRQ. Strong
a PP Assess psychosocial risk factors as early as practical in pregnancy and again after the birth.
b PP
Ensure that health professionals receive training in the importance of psychosocial assessment and use of a
psychosocial assessment tool.
c PP
Ensure that there are clear guidelines around the use and interpretation of the psychosocial tool/interview in
terms of threshold for referral for psychosocial care and/or ongoing monitoring.
i PP At every antenatal or postnatal visit, enquire about the woman’s emotional wellbeing.
d PP
Discuss with the woman the possible impact of psychosocial risk factors (she has endorsed) on her mental health
and provide information about available assistance.
j PP
Provide women in the perinatal period with advice on lifestyle issues and sleep, as well as assistance in planning
how this advice can be incorporated into their daily activities during this time.
e PP
Assess the mother-infant interaction as an integral part of postnatal care and refer to a parent-infant therapist as
available and appropriate.
h PP
When a woman is identified as at risk of suicide (through clinical assessment and/or the EPDS), manage
immediate risk, arrange for urgent mental health assessment and consider support and treatment options.
f PP
Seek guidance/support from Aboriginal and Torres Strait Islander health professionals or bicultural health workers
when assessing mother-infant interaction in Aboriginal and Torres Strait Islander or migrant and refugee women,
to ensure that assessment is not informed by unconscious bias.
g PP
Assess the risk of harm to the infant if significant difficulties are observed with the mother-infant interaction, the
woman discloses that she is having thoughts of harming her infant and/or there is concern about the mother’s
mental health.
Summary of recommendations and practice points | 9
ix CBR
Be aware that anxiety disorder is very common in the perinatal period and should be considered in the broader
clinical assessment.
xi CBR
Undertake psychosocial assessment in conjunction with a tool that screens for current symptoms of depression/
anxiety (i.e. the EPDS).
xii CBR Consider language and cultural appropriateness of any tool used to assess psychosocial risk.
x CBR
As part of the clinical assessment, use anxiety items from screening tools (e.g. EPDS items 3, 4 and 5, Depression,
Anxiety and Stress Scale (DASS) anxiety items and Kessler Psychological Distress Scale (K-10) items 2, 3, 5 and 6)
and relevant items in structured psychosocial assessment tools (e.g. Antenatal Risk Questionnaire (ANRQ)).
3 EBR If using a tool to assess psychosocial risk, administer the ANRQ. Strong
a PP Assess psychosocial risk factors as early as practical in pregnancy and again after the birth.
b PP
Ensure that health professionals receive training in the importance of psychosocial assessment and use of a
psychosocial assessment tool.
c PP
Ensure that there are clear guidelines around the use and interpretation of the psychosocial tool/interview in
terms of threshold for referral for psychosocial care and/or ongoing monitoring.
i PP At every antenatal or postnatal visit, enquire about the woman’s emotional wellbeing.
d PP
Discuss with the woman the possible impact of psychosocial risk factors (she has endorsed) on her mental health
and provide information about available assistance.
j PP
Provide women in the perinatal period with advice on lifestyle issues and sleep, as well as assistance in planning
how this advice can be incorporated into their daily activities during this time.
e PP
Assess the mother-infant interaction as an integral part of postnatal care and refer to a parent-infant therapist as
available and appropriate.
h PP
When a woman is identified as at risk of suicide (through clinical assessment and/or the EPDS), manage
immediate risk, arrange for urgent mental health assessment and consider support and treatment options.
f PP
Seek guidance/support from Aboriginal and Torres Strait Islander health professionals or bicultural health workers
when assessing mother-infant interaction in Aboriginal and Torres Strait Islander or migrant and refugee women,
to ensure that assessment is not informed by unconscious bias.
g PP
Assess the risk of harm to the infant if significant difficulties are observed with the mother-infant interaction, the
woman discloses that she is having thoughts of harming her infant and/or there is concern about the mother’s
mental health.
xv CBR
If a mother with a severe postnatal episode requires hospital admission, avoid separation from her infant with
co-admission to a specialist mother-baby unit where facilities are available and appropriate.
v PP
In planning postnatal care for women with schizophrenia, bipolar disorder, severe depression or borderline
personality disorder, take a coordinated team approach to parent and infant mental health care and pre-arrange
access to intensive maternal child health care.
w PP
When caring for mothers with severe mental illness, including borderline personality disorder, it is important to
ensure that child protection risks are understood and addressed, if necessary.
m PP
For women with schizophrenia, bipolar disorder or borderline personality disorder, a multidisciplinary team
approach to care in the perinatal period is essential, with clear communication, advance care planning, a written
plan, and continuity of care across different clinical settings.
r PP
Discuss treatment (medication and psychological) options that would enable a woman to breastfeed if she wishes
and support women who choose not to breastfeed.
PART C: PREVENTION AND TREATMENT
General principles in prevention and treatment
General principles in the use of pharmacological treatments
Postnatal care and support
xiii CBR
Provide all women with information about the importance of enquiring about, and attending to, any mental health
problems that might arise across the perinatal period.
xiv CBR
Arrange observation of infants exposed to psychoactive medications in pregnancy for the first three days
postpartum.
k PP
If a woman agrees, provide information to and involve her significant other(s) in discussions about her emotional
wellbeing and care throughout the perinatal period.
p PP
Discuss the potential risks and benefits of pharmacological treatment in each individual case with the woman and,
where possible, her significant other(s).
l PP
Provide advice about the risk of relapse during pregnancy and especially in the early postpartum period to
women who have a new, existing or past mental health condition and are planning a pregnancy.
q PP
Ensure that women are aware of the risks of relapse associated with stopping medication and that, if a medication
is ceased, this needs to be done gradually and with advice from a mental health professional.
n PP Wherever possible, assessment, care and treatment of the mother should include the baby.
s PP
Ideally, treatment with psychoactive medications during pregnancy would involve close liaison between a treating
psychiatrist or, where appropriate, the woman’s GP, and her maternity care provider(s). In more complex cases, it
is advisable to seek a second opinion from a perinatal psychiatrist.
o PP
Where possible, health professionals providing care in the perinatal period should access training to improve their
understanding of care for women with schizophrenia, bipolar disorder and borderline personality disorder.
t PP
When exposure to psychoactive medications has occurred in the first trimester – especially with anticonvulsant
exposures – pay particular attention to the 18–20 week ultrasound due to the increased risk of major
malformation.
u PP
Plan for pharmacological review in the early postpartum period for women who cease psychotropic medications
during pregnancy.
Australian Clinical Practice Guideline | 10
DEPRESSIVE AND ANXIETY DISORDERS
Psychosocial support and psychological approaches
Complementary therapies
Pharmacological treatments for depressive and anxiety disorders
4 EBR Provide structured psychoeducation to women with symptoms of depression in the perinatal period. Strong
5 EBR
Advise women with symptoms of depression in the postnatal period of the potential benefits of a
social support group.
Conditional
7 EBR
Advise women with depression or anxiety disorder in the postnatal period of the possible benefits
of directive counselling.
Conditional
8 EBR
Advise women that omega-3 fatty acid supplementation does not appear to improve depression
symptoms but is not harmful to the fetus or infant when taken during pregnancy or while
breastfeeding.
Conditional
9 EBR
Consider the use of selective serotonin reuptake inhibitors (SSRIs) as first-line treatment for
moderate to severe depression and/or anxiety in pregnant women.
Conditional
10 EBR Use SSRIs as first-line treatment for moderate to severe depression in postnatal women. Strong
6 EBR
Recommend individual structured psychological interventions (cognitive behavioural therapy or
interpersonal psychotherapy) to women with mild to moderate depression in the perinatal period.
Strong
xvi CBR
Advise women with symptoms of depression in the perinatal period of the potential benefits of facilitated
self-help.
xvii CBR
Advise women with diagnosed post-traumatic stress disorder of the potential benefits of post-traumatic birth
counselling if they are experiencing depressive symptoms.
xix CBR
Advise pregnant women that the evidence on potential harms to the fetus from St John’s Wort is limited and
uncertain and its use during pregnancy is not recommended.
xviii CBR
For women who have or are recovering from postnatal depression and are experiencing mother–infant
relationship difficulties, consider provision of or referral for individual mother–infant relationship interventions.
xx CBR
Advise pregnant women that potential harms to the fetus from Gingko biloba have not been researched and its
use during pregnancy is not recommended.
xxi CBR
Consider the short-term use of benzodiazepines for treating moderate to severe symptoms of anxiety while
awaiting onset of action of an SSRI or tricyclic antidepressants (TCA) in pregnant or postnatal women.
x PP
Before choosing a particular SSRI for pregnant women, consider the woman’s past response to SSRI treatment,
obstetric history (e.g. other risk factors for miscarriage or preterm birth) and any factors that may increase risk of
adverse effects.
y PP
Before prescribing SSRIs to women who are breastfeeding, consider the infant’s health and gestational age at
birth.
z PP Use caution in repeated prescription of long-acting benzodiazepines around the time of the birth.
aa PP Use caution in prescribing non-benzodiazepine hypnotics (z-drugs) to pregnant women for insomnia.
bb PP
Doxylamine, a Category A drug in pregnancy, may be considered for use as a first-line hypnotic in pregnant
women who are experiencing moderate to severe insomnia.
Summary of recommendations and practice points | 11
4 EBR Provide structured psychoeducation to women with symptoms of depression in the perinatal period. Strong
5 EBR
Advise women with symptoms of depression in the postnatal period of the potential benefits of a
social support group.
Conditional
7 EBR
Advise women with depression or anxiety disorder in the postnatal period of the possible benefits
of directive counselling.
Conditional
8 EBR
Advise women that omega-3 fatty acid supplementation does not appear to improve depression
symptoms but is not harmful to the fetus or infant when taken during pregnancy or while
breastfeeding.
Conditional
9 EBR
Consider the use of selective serotonin reuptake inhibitors (SSRIs) as first-line treatment for
moderate to severe depression and/or anxiety in pregnant women.
Conditional
10 EBR Use SSRIs as first-line treatment for moderate to severe depression in postnatal women. Strong
6 EBR
Recommend individual structured psychological interventions (cognitive behavioural therapy or
interpersonal psychotherapy) to women with mild to moderate depression in the perinatal period.
Strong
xvi CBR
Advise women with symptoms of depression in the perinatal period of the potential benefits of facilitated
self-help.
xvii CBR
Advise women with diagnosed post-traumatic stress disorder of the potential benefits of post-traumatic birth
counselling if they are experiencing depressive symptoms.
xix CBR
Advise pregnant women that the evidence on potential harms to the fetus from St John’s Wort is limited and
uncertain and its use during pregnancy is not recommended.
xviii CBR
For women who have or are recovering from postnatal depression and are experiencing mother–infant
relationship difficulties, consider provision of or referral for individual mother–infant relationship interventions.
xx CBR
Advise pregnant women that potential harms to the fetus from Gingko biloba have not been researched and its
use during pregnancy is not recommended.
xxi CBR
Consider the short-term use of benzodiazepines for treating moderate to severe symptoms of anxiety while
awaiting onset of action of an SSRI or tricyclic antidepressants (TCA) in pregnant or postnatal women.
x PP
Before choosing a particular SSRI for pregnant women, consider the woman’s past response to SSRI treatment,
obstetric history (e.g. other risk factors for miscarriage or preterm birth) and any factors that may increase risk of
adverse effects.
y PP
Before prescribing SSRIs to women who are breastfeeding, consider the infant’s health and gestational age at
birth.
z PP Use caution in repeated prescription of long-acting benzodiazepines around the time of the birth.
aa PP Use caution in prescribing non-benzodiazepine hypnotics (z-drugs) to pregnant women for insomnia.
bb PP
Doxylamine, a Category A drug in pregnancy, may be considered for use as a first-line hypnotic in pregnant
women who are experiencing moderate to severe insomnia.
Psychological intervention for women with moderate to severe anxiety and depressive disorders
SEVERE MENTAL ILLNESSES
Antipsychotics
Anticonvulsants
xxii CBR
Advise women with moderate to severe anxiety and depressive disorders that psychological interventions are a
useful adjunct, usually once medications have become effective.
11 EBR Consider the use of antipsychotics for treating psychotic symptoms in pregnant women. Conditional
12 EBR Do not prescribe sodium valproate to women of childbearing age. Strong
xxiv CBR
If women commence or continue antipsychotic treatment during pregnancy, monitor them for excessive weight
gain and the development of gestational diabetes and refer them for advice on weight management as required.
xxiii CBR
Use caution when prescribing any antipsychotic to pregnant women, particularly for women with a propensity for
weight gain and metabolic syndrome
xxv CBR Do not initiate use of clozapine in pregnant women.
cc PP
Use clozapine with caution in women who are breastfeeding and monitor the infant’s white blood cell count
weekly for the first six months of life.
dd PP
Given their teratogenicity, only consider prescribing anticonvulsants (especially valproate) to women of
child-bearing age if effective contraception is in place.
ee PP
Once the decision to conceive is made, if the woman is on valproate wean her off this over 2–4 weeks, while
adding in high-dose folic acid (5 mg/day) which should continue for the first trimester.
xxix CBR Where possible, avoid the use of lithium in women who are breastfeeding.
xxvii CBR
If anticonvulsants are prescribed to a woman who is breastfeeding, arrange close monitoring of the infant and
specialist neonatologist consultation where possible.
xxvi CBR
Use great caution in prescribing anticonvulsants as mood stabilisers for pregnant women and seek specialist
psychiatric consultation when doing so.
xxviii CBR
If lithium is prescribed to pregnant women, ensure that maternal blood levels are closely monitored and that there
is specialist psychiatric consultation.
ff PP
If lithium is prescribed to a pregnant woman, reduce the dose just prior to the onset of labour and aim to
recommence treatment immediately after the birth at a pre-pregnancy dose.
Australian Clinical Practice Guideline | 12
BORDERLINE PERSONALITY DISORDER
ELECTROCONVULSIVE THERAPY
xxx CBR
Where possible and appropriate, provide women with borderline personality disorder with structured
psychological therapies that are specifically designed for this condition and conducted by adequately trained and
supervised health professionals.
xxxi CBR
As far as possible, do not use pharmacological treatments as the primary therapy for borderline personality
disorder, especially in pregnant women.
xxxii CBR
Consider electroconvulsive therapy (ECT) when a postnatal woman with severe depression has not responded to
one or more trials of antidepressants of adequate dose and duration.
xxxiii CBR
Consider ECT as first-line treatment for postnatal women with severe depression especially where there is a
high risk of suicide or high level of distress; when food or fluid intake is poor; and in the presence of psychotic or
melancholic symptoms.
gg PP
For women with borderline personality disorder who have often experienced complex trauma, trauma-informed
care and specific support for health professionals in dealing with challenging behaviours is a priority.
hh PP
Advise women with borderline personality disorder who are planning a pregnancy, of the additional challenges of
parenting associated with their emotional dysregulation, and the importance of ongoing support during and after
pregnancy.
ff PP
Encourage pregnant or postnatal women with borderline personality disorder to undertake mindfulness and/or
relaxation training to assist in managing their emotional dysregulation.
jj PP
In pregnant women, ECT should be only be undertaken in conjunction with close fetal monitoring (using
cardiotocography to monitor fetal heart rate) and access to specialist maternal-fetal medical support.
Introduction | 13
Introduction
The perinatal period (considered here as the period from conception to the end of the first postnatal year) is a time of great change in
a woman’s life. For most women and their families, pregnancy, childbirth and parenting are a time of great joy and happiness. However,
this period is associated with a significantly increased risk for onset and relapse of mental health conditions – higher than at many
other times in a woman’s life. As well, detection of mental health conditions is poor at this time, such that, in the absence of routine,
standardised screening, up to three-quarters of women meeting DSM criteria for depressive and anxiety disorders are not identified
(Spitzer et al 2000; Coates et al 2004) and only one in ten women requiring mental health care receives it (Bowen et al 2012).
This Guideline therefore has a primary focus on early identification of women experiencing psychosocial problems and mental health
conditions in the perinatal period, so that they receive the timely support and care they need. This approach aims to improve a woman’s
experience of pregnancy and early parenthood, her emotional wellbeing and her safety. As suicide in the perinatal period was a leading
cause of maternal deaths in Australia in 2008–2012 (Humphrey et al 2015) and the rate of maternal deaths due to psychosocial health
problems is rising (Humphrey 2016), the Guideline also aims to promote the safety of women in the perinatal period.
This approach is also beneficial to the wellbeing of families. Most women who experience mental health conditions are able to parent
effectively and the majority of infants are not specifically disadvantaged. However, mental health conditions in their more severe form
are often associated with impaired functioning, especially in relation to a woman’s ability to care for her infant and the formation of
secure infant attachment, which may in turn be associated with poorer social, cognitive, and behavioural outcomes in the child (1st 1001
Days APPG 2015).
Aim and scope of the Guideline
This Guideline aims to summarise the current evidence for screening for depressive and anxiety symptoms and risk factors and
preventing and treating a range of mental health conditions in the perinatal period. It builds on the foundation laid by Australia’s first
clinical practice guideline on mental health in the perinatal period, developed by beyondblue (beyondblue 2011) and broadens the
scope to include schizophrenia and borderline personality disorder as well as depressive and anxiety disorders, bipolar disorder and
postpartum psychosis. The previous Guideline played a key role in guiding best practice under Australia’s National Perinatal Depression
Initiative (2008–13). Since this time there have been advances in both research and innovation and it is through the development of
this Guideline that best practice will be informed and supported in the Australian context, and foundations for sustainability built. It is
hoped that the Guideline will also encourage further research to inform practice.
To support health professionals in providing evidence-based care, the Guideline summarises current evidence on approaches to the
assessment of psychosocial risk factors (associated with or exacerbating mental health conditions) and screening for common mental
health symptoms. It also covers the perinatal-specific aspects of prevention and treatment of mental health conditions.
The following are beyond the scope of the Guideline:
• the process of diagnosis or specifics of managing mental health conditions in the perinatal period – appropriate guidelines for the
general population should be used
• topics for which the evidence has been reviewed in the development of the Pregnancy Care Guidelines.
> assessment for smoking and substance use
> assessment and first-line response for family violence (noting that the same process applies beyond the antenatal period)
> other aspects of maternity care.
While the impact of the transition to parenthood on partners/co-parents is an emerging area of research, this was considered beyond
the scope of the Guideline. However, a brief summary of the evidence on perinatal mental health in men is included in Section 1.3.
Intended audience
The Guideline is intended for all health professionals caring for women and families during the perinatal period. This includes but is
not limited to midwives, general practitioners (GPs), obstetricians, neonatologists, paediatricians, maternal and child health nurses,2
paediatric nurses, Aboriginal and Torres Strait Islander health workers, allied health professionals, mental health practitioners
(psychologists, psychiatrists, mental health nurses, perinatal and infant mental health professionals), consumers and carers and those
working with families in the community (e.g. social workers, child protection agencies), hospital and legal systems.
The way in which different professionals use this Guideline will vary depending on their knowledge, skills and role, as well as the setting
in which care is provided. It is anticipated that Part B on screening and assessment will be of greatest relevance to health professionals
in the primary care setting, while Part C on prevention and treatment will provide guidance to health professionals involved in both
primary and specialist care. Practical guidance for specific health professional groups and information for consumers and carers will be
derived from this Guideline, and will be available from the COPE website.
2. Also referred to as child and family health nurses in some jurisdictions.
xxx CBR
Where possible and appropriate, provide women with borderline personality disorder with structured
psychological therapies that are specifically designed for this condition and conducted by adequately trained and
supervised health professionals.
xxxi CBR
As far as possible, do not use pharmacological treatments as the primary therapy for borderline personality
disorder, especially in pregnant women.
xxxii CBR
Consider electroconvulsive therapy (ECT) when a postnatal woman with severe depression has not responded to
one or more trials of antidepressants of adequate dose and duration.
xxxiii CBR
Consider ECT as first-line treatment for postnatal women with severe depression especially where there is a
high risk of suicide or high level of distress; when food or fluid intake is poor; and in the presence of psychotic or
melancholic symptoms.
gg PP
For women with borderline personality disorder who have often experienced complex trauma, trauma-informed
care and specific support for health professionals in dealing with challenging behaviours is a priority.
hh PP
Advise women with borderline personality disorder who are planning a pregnancy, of the additional challenges of
parenting associated with their emotional dysregulation, and the importance of ongoing support during and after
pregnancy.
ff PP
Encourage pregnant or postnatal women with borderline personality disorder to undertake mindfulness and/or
relaxation training to assist in managing their emotional dysregulation.
jj PP
In pregnant women, ECT should be only be undertaken in conjunction with close fetal monitoring (using
cardiotocography to monitor fetal heart rate) and access to specialist maternal-fetal medical support.
http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-antenatal-care-index
Australian Clinical Practice Guideline | 14
Development of the Guideline
The development of this Australian Guideline was undertaken by the Centre for Perinatal Excellence (COPE), with funding from
the Australian Government Department of Health and developed in accordance with National Health and Medical Research Council
(NHMRC) guideline development processes (see Appendix B). Drawing on the company membership of COPE, this involved convening
an Expert Working Group comprising members with specific expertise in mental health care, as well as representatives of maternity
care (including general practice, obstetrics, midwifery and maternal and child health), consumer and carer organisations and Aboriginal
and Torres Strait Islander health care (see Appendix A). Expert subcommittees were also convened to provide specific advice on
borderline personality disorder, bipolar disorder and schizophrenia and harms associated with pharmacological treatments (see
Appendix A) and formal consultation with a wide range of experts, stakeholders and consumer representatives was undertaken. A
systematic literature review, which identified and critically appraised the evidence, provided the basis for the Guideline (see Appendix C).
Implementation and review
As Australia’s peak body in perinatal mental health, COPE will facilitate implementation of the Guideline through its membership, online
channels and innovative approaches to dissemination, including training programs and summary documents for health professionals
and consumers (which will be available from the COPE website). It is anticipated that the Guideline will be updated periodically to
include higher-level evidence as it becomes available, ideally with a major review of the evidence within 5 years.
Structure of the Guideline
Part A: Background information is a concise review that includes discussion of an individual woman’s context, the prevalence and
impact of mental health conditions in the perinatal period (Chapter 1), and factors relevant to enabling effective mental health care in
the perinatal period (Chapter 2).
Part B: Screening for symptoms and psychosocial assessment discusses considerations before psychosocial assessment and screening
(Chapter 3), the acceptability of mental health assessment (Chapter 4), the process of screening for symptoms of depressive and
anxiety disorders (Chapter 5), assessing psychosocial factors that affect mental health (Chapter 6), and of assessing mother-infant
interaction and the safety of the woman and infant (Chapter 7). Considerations for implementing psychosocial assessment and
screening in practice are also outlined (Chapter 8).
Part C: Prevention and treatment discusses general principles in prevention and treatment (Chapter 10), the evidence for the
prevention and treatment of depressive and anxiety disorders (Chapter 11), treatment of severe mental illnesses (schizophrenia, bipolar
disorder and postpartum psychosis; Chapter 12), borderline personality disorder (Chapter 13) and electroconvulsive therapy (Chapter
14).
Part D: Areas for future research Identifies current gaps in the literature and potential areas for development to support the sustainable
and measurable implementation of best practice.
Appendices provide further information about the development of the Guideline, including the findings of the systematic literature
review and the public consultation process and provide copies of the tools used for psychosocial assessment and screening.
Practice summaries are included in Parts B and C (Chapters 9 and 15).
Part A –
Background information
Australian Clinical Practice Guideline | 16
1 Mental health conditions in the
perinatal period
1.1 Understanding the woman’s context
Every person has a right to health care that takes into consideration his or her individual social and emotional situation (UN General
Assembly 1948; UN General Assembly 2007). While many Australian women experience economic security, educational attainment
and good health, there are still many women living in poverty, subsisting on pensions or low-income occupations, restricted by
under-employment and experiencing poor health outcomes (AWHN 2008). Gender inequalities persist, with women economically
less secure, maintaining the primary carer role, and subject to violence (including physical and sexual assault, as well as emotional,
psychological and financial abuse) (AWHN 2008).
The experience of pregnancy and parenthood differs for each woman and is influenced by the stability of her relationships and social
network. While the biggest risk factor for developing perinatal mental health conditions is a previo mental health history, the presence
of psychosocial risk factors may be associated with greater risk of onset, relapse or exacerbation of mental health conditions. Women
who feel isolated either by distance, culture, or both, are more likely to develop distress or mental health conditions in the perinatal
period (Austin et al 2015). The likelihood is also greater for women who have experienced life stressors (e.g. family problems, family
violence or loss, disability) or multiple trauma (Austin et al 2015). Assessment for specific psychosocial risk factors is discussed in
Chapter 6.
Some groups of women have greater exposure to life stressors, trauma or lack of support.
• Aboriginal and Torres Strait Islander respondents to the 2012–13 Health Survey indicated that, in the last year they, their family and/
or friends had experienced the death of a family member or close friend (37%), serious illness (23%), mental health condition (16%)
or alcohol-related problems (14%) – this is in addition to disrupted cultural wellbeing and the continuing intergenerational effects of
trauma and loss (AIHW 2015). A South Australian study of Aboriginal women found that almost one in four women reported ‘high’ to
‘very high’ psychological distress (Kessler-5 ≥12) in the first 12 months postpartum (Weetra et al 2016).
• Migrant women (including refugees, asylum seekers) experience higher rates of perinatal depression than their non-migrant
counterparts in the destination country, with previous depression and poor social support strongly increasing risk. Social isolation
faced by migrant communities may be exacerbated by language and cultural barriers and can pose a significant hardship for new
mothers (Fellmeth et al 2017). Refugee women are at heightened risk of psychological morbidity (Yelland et al 2014).
• Women experiencing intimate partner violence during pregnancy were four times more likely to report depressive symptoms and
ten times more likely to report anxiety symptoms during pregnancy (Brown et al 2008). Two in five women reporting depressive
symptoms in the first year postnatally were experiencing intimate partner violence (Woolhouse et al 2012). Among Aboriginal
women, one in two women who reported violence during pregnancy reported ‘high’ to ‘very high’ psychological distress postnatally
(Weetra et al 2016).
• Lesbian, gay, bisexual, trans, and/or intersex parents can face discrimination or have their roles, methods of conception, or abilities to
parent questioned.
Many of these factors are beyond the scope of this Guideline but taking them into account (including in psychosocial assessment) is
important and will lead to a fuller understanding of the individual woman’s situation. Consultation with relevant organisations (e.g. local
Aboriginal Health Services or Migrant Health Centres) is advisable.
1.2 Prevalence and impact of maternal mental health conditions in the perinatal
period
1.2.1 Depressive and anxiety disorders
• Depressive disorders in the perinatal period are symptomatically the same as those at other times and range from mild to severe.
• Anxiety disorders at this time include generalised anxiety disorder, obsessive compulsive disorder, panic disorder, social phobia,
specific phobia and post-traumatic stress disorder and are often reported as equally prevalent as depressive disorder in the perinatal
period (Fairbrother et al 2016).
• Australian and other studies have reported the 4-year period prevalence3 of antenatal depression as up to one in ten women (Buist &
Bilsztra 2006) and the 12-month period prevalence of postnatal depression as one in six (in the first postnatal year) (Woolhouse et al
2012).
3. Period prevalence is the prevalence over a specific time period (e.g. from a longitudinal study) and point prevalence is that at a specific point of time
(e.g. from a cross-sectional study).
Mental health conditions in the perinatal period | 17
• Primary anxiety disorders are prevalent and their comorbidity with depression is very high (Wisner et al 2013) – for example the
three-month postnatal period prevalence for any anxiety disorder was reported as one in six in one study (Fairbrother et al 2016),
while another (Giardinelli et al 2012) reported a point prevalence of anxiety disorder of one in five in the third trimester of pregnancy.
• Depression may arise in pregnancy or pre-date the perinatal period. In a subset of women in a large US study of women assessed
at 6 weeks postnatally, two in five episodes of depression began postnatally, one in three during pregnancy and one in four before
pregnancy (Wisner et al 2013). An Australian study found that, for most mothers with postnatal depression, onset occurred after
weeks postpartum (Woolhouse et al 2012).
• Australian studies have reported persistence of maternal depressive symptoms beyond the first year postpartum, with more mothers
reporting depressive symptoms at 4 years follow-up than in the first 12 months postpartum (Woolhouse et al 2015), symptoms
persisting from pregnancy to 4 years postpartum in one in eleven women (Giallo et al 2017b) and symptoms persisting from the first
year to 6–7 years postpartum in one in six women (Giallo et al 2014a).
• Depression with or without anxiety in the perinatal period is associated with maternal suicide (Humphrey et al 2015).
• Obstetric complications in depressed women (independent of antidepressant use) are slightly increased including risk of preterm
birth, low birth weight, gestational hypertension and perinatal death (Grigoriadis et al 2013).
• Anxiety disorders during pregnancy may have a negative influence on obstetric, fetal and perinatal outcomes, including more
pregnancy symptoms (nausea and vomiting); more medical visits; increased alcohol or tobacco consumption or unhealthy
eating habits; pre-eclampsia and preterm birth; and postnatal depression and mood disorders (Marc et al 2011). High levels of
maternal anxiety during pregnancy are associated with increased exposure of the fetus to maternal cortisol and risk of adverse
neurodevelopmental outcomes (O’Donnell et al 2012).
• In Australia in 2012, the total disability adjusted life years (DALYs) attributable to maternal perinatal depression was 4,991 in the
antenatal period and 11,584 in the postnatal period (PANDA 2012), which represents a significant disease burden and is likely an
underestimate. Direct financial costs (to individuals, private health insurance and governments) associated with maternal postnatal
depression were estimated as $60.68M and indirect costs (due to lost productivity) as $86.59M (PANDA 2012).
1.2.2 Severe mental illness
• Severe mental illness includes psychotic disorders (schizophrenia and postpartum psychosis) and bipolar disorder. These are much
less common than depressive and anxiety disorders, with a prevalence of around 1 in 100 in the general population for schizophrenia
and bipolar disorder (Mitchell et al 2013; Galletly et al 2016) and 1 in 1,000 pregnancies for postpartum psychosis.
• People with schizophrenia or bipolar disorder (in the general population) suffer from high rates of other mental health conditions,
including depression and anxiety disorders (Merikangas et al 2011; Galletly et al 2016).
• Population studies demonstrate an increased risk of new onset psychiatric episodes, especially psychoses, in the first few months
postpartum (Munk-Olsen et al 2006), while risk of relapse of pre-existing mood disorder (often following the cessation of medication
in pregnancy) increases significantly across the perinatal period (Viguera et al 2000; Cohen et al 2006; Viguera et al 2007),
especially for bipolar disorder (Munk-Olsen et al 2009).
• Women with bipolar disorder are more likely than women with no history of a mental health condition to experience some adverse
pregnancy outcomes, including gestational hypertension, antepartum haemorrhage, severe fetal growth restriction (<2nd–3rd
centile) (although this may be related to smoking) and neonatal morbidity (Rusner et al 2016).
• Women with diagnosed schizophrenia or bipolar disorder are more likely than women in the general pregnant population to have
obstetric complications (pre-eclampsia, gestational diabetes) (Nguyen et al 2013). Relapse of these conditions during pregnancy
is common, with 22.5% of diagnosed women in one study being admitted to a psychiatric hospital during pregnancy (38.6% with
schizophrenia and 10.7% with bipolar disorder) (Nguyen et al 2013). Women with schizophrenia had a high rate of involvement of
statutory child welfare services (50%).
1.2.3 Borderline personality disorder (and emotional dysregulation)
• Borderline personality disorder is characterised by a pervasive pattern of instability of emotions, relationships, sense of identity and
poor impulse control and is consistently associated with severe functional impairment.
• Estimates of the prevalence of borderline personality disorder range from 1% among all Australian adults and 3.5% among Australians
aged 24–25 years (NHMRC 2012). A more recent study (Quirk et al 2016) estimated prevalence among women aged ≥25 years to be
2.7% (95%CI: 1.4–4.0).
• Emotional dysregulation refers to poorly modulated emotional responses and is also referred to as mood or affective instability. It
has been measured by a number of well-validated scales, including the Difficulties in Emotional Regulation Scale (Gratz & Roemer
2004). While it is associated with depressive and anxiety disorders, it is considered a core feature of borderline personality disorder
(Glenn & Klonsky 2009; Kroger et al 2011).
Australian Clinical Practice Guideline | 18
• Emotional dysregulation and borderline personality disorder are associated with a history of childhood trauma (including sexual
abuse), and/or experience of dysfunctional parenting in a substantial proportion of cases (Fossati et al 2016).
• Women with borderline personality disorder in the perinatal period experience considerable psychosocial impairment – they may
anticipate birth as traumatic and frequently request early delivery, comorbidity with substance abuse is common and rates of referral
to child protective services high (Blankley et al 2015).
• Women with borderline personality disorder during pregnancy have been found to be at increased risk of gestational diabetes,
premature rupture of the membranes, chorioamnionitis, venous thromboembolism, caesarean section and preterm birth (Pare-Miron
et al 2016).
• Mothers with borderline personality disorder are often parenting in the context of significant additional risk factors, such as
depression, substance use and low support (Petfield et al 2015). Levels of parenting stress are high, and self-reported competence
and satisfaction are low (Petfield et al 2015).
• Mothers with borderline personality disorder symptoms – including emotional dysregulation – are more likely than women without
symptoms to engage in maladaptive interactions with their children characterised by insensitive, overprotective, and hostile
parenting (Eyden et al 2016). Adverse outcomes among children included borderline personality disorder symptoms, internalising
(including depression) and externalising problems, insecure attachment patterns and emotional dysregulation (Eyden et al 2016).
1.3 Perinatal mental health in men4
1.3.1 Psychosocial factors associated with men’s perinatal mental health
Recent Australian research has identified the following psychosocial risk factors for poor mental health among men during the perinatal
period:
• individual factors such as past history of mental health problems, poor physical health, limited engagement in self-care behaviour
and attitudinal barriers to help-seeking for mental health problems (Giallo et al 2013; Seymour et al 2013; Giallo et al 2014b; Giallo et
al 2017a)
• couple and family factors including relationship difficulties, partner mental health problems and inadequate social support (Giallo et
al 2013; Seymour et al 2013)
• employment factors including limited access to flexible job conditions and parental leave, high work-family conflict and financial
difficulties (Giallo et al 2013; Giallo et al 2014b; Cooklin et al 2015)
• child factors including sleep and self-regulation problems, difficult and reactive temperament (Seymour et al 2013; Cook et al 2017).
Additionally, Australian research with fathers of refugee background identified changing gender roles as a stressor for men (Riggs et al
2016).
1.3.2 The context of becoming a father
The transition to parenthood for fathers carries expectations of joy and wonder. However, the demands of the new baby and the
challenge in reconfiguring relationships and identity can bring exhaustion, confusion and stress, leading fathers to experience
depression and anxiety (Asenhed et al 2014).
1.3.3 Depression and anxiety among fathers
Mood disorders among fathers have not been well studied but the emerging evidence suggests that the individual and social costs of
paternal perinatal depression and anxiety are significant. Reviews have identified prevalence of:
• one in ten for paternal depression between the first trimester and 1 year postpartum (Paulson & Bazemore 2010)
• one in six for anxiety during the prenatal period and up to one in five during the postnatal period, although there was wide variation
between studies (Leach et al 2016).
Paternal depression may influence a fathers’ parenting and therefore the wellbeing of his infant into the future. Depressed fathers in
the USA, for example, were four times more likely to spank their one-year-old infants and less than half as likely to read to them as
non-depressed fathers (Davis et al 2011). Studies following infants whose fathers showed signs of postnatal depression through to
childhood show that these children are three times more likely to exhibit behaviour problems as a preschooler and twice as likely to
receive a psychiatric diagnosis by 7 years of age (Ramchandani & Psychogiou 2009; Fletcher et al 2011). Severe mental illness among
fathers has been shown to pose a risk to an infant’s physical and emotional wellbeing (Fletcher et al 2013).
4. The systematic review conducted to inform the development of this Guideline was limited to maternal mental health in the perinatal period. This
section was prepared by Richard Fletcher with input from Anne Sved-Williams, Catherine Rawlinson, Tracey Fay Stammbach and Virginia Schmied.
More recent evidence provided through the public consultation process has been incorporated.
Mental health conditions in the perinatal period | 19
Fathers’ mental health will impact on, and be affected by, the mental health of their partner. Among couples recruited during
pregnancy, antenatal paternal depression predicted significant worsening in mothers’ overall symptom severity during the first six
months postnatally (Paulson et al 2016). Australian studies have found that fathers’ postnatal depression is particularly affected by
the couple relationship and the mother’s mental health problems (Matthey et al 2000; Dudley et al 2001). Not surprisingly, when both
fathers and mothers are depressed their children are at higher risk of behavioural impairment (Paulson et al 2006).
1.3.4 Screening for depression and anxiety
Several qualitative studies of fathers in the perinatal period conducted in Australia and internationally (Rowe et al 2013; Darwin et al
2017; Rominov et al 2017) have identified that fathers want to be included in perinatal health care and engaged by health professionals
about their health and wellbeing.
The Edinburgh Postnatal Depression Scale has been validated for fathers with a lower cut-off of 5/6 recommended (Cox et al 1987;
Matthey et al 2001). However, as fathers may express their low mood in behaviours, such as anger and irritation, that may differ
from those for women, alternative scales have been introduced to some settings to better identify distress (Fletcher et al 2015). An
important question in consideration of screening fathers is where screening is to take place. Fathers attending the ultrasound, antenatal
preparation classes or the birth report that they have few opportunities to raise their concerns and nurses find including fathers when
screening mothers a challenge (Elmir & Schmied 2016; Rollans et al 2016).
1.3.5 Treatment and support mechanisms for fathers
In recognition of male-female differences in accessing mental health services, programs using cognitive behavioural therapy, group
work, and blended delivery have attempted to tailor their content and delivery to better engage men. However, few adaptations,
and no programs addressing paternal mental health have been evaluated (O'Brien et al 2016). The Perinatal Anxiety and Depression
Australia (PANDA) telephone counselling service accepts calls from men, either on their own behalf or in regard to their partner and
approximately 7% (2,600 in 2013) of callers are male but again, no evaluation of the service for men have been published (Shafiei et al
2014).
The widespread adoption of mobile technology may present an alternative route for assessing and supporting new fathers. The
provision of timely, relevant information for fathers throughout the antenatal and postnatal period can be effectively achieved through
the use of technology (beyondblue 2016; Fletcher et al 2016). The costs of failing to assess and address paternal perinatal depression
and anxiety are high. Developing effective support for new fathers will require innovative solutions to the design and delivery of
information, assessment and treatment options.
Australian Clinical Practice Guideline | 20
2 Enabling effective mental health
care in the perinatal period
The principles underlying effective provision of mental health care in the perinatal period include:
• establishing a therapeutic relationship
• providing care that is recovery-oriented and trauma-informed
• providing culturally safe support and information
• ensuring continuity of care, where possible.
2.1 Therapeutic relationship
Providing psychosocial care during the perinatal period involves establishing and maintaining a therapeutic relationship between the
health professional and the woman and her significant other(s). Continuity of carer is likely to improve of facilitate the therapeutic
relationship. Key aspects of the therapeutic relationship include development of trust, confidence, mutuality, active listening and
empowerment (Simpson & Creehan 2008).
It is important for health professionals to:
• understand the normal range of emotions common to various stages during the perinatal period so they can better identify anxiety
and depressive symptoms if they occur
• allow adequate time to assess, listen and build rapport
• ascertain and address any misconceptions or need for information, encourage women to express their feelings about pregnancy and
motherhood, validate any concerns and support their emotional state
• maintain a non-judgemental attitude and address any feelings of stigma (very common)
• assess women’s support systems, including the attitudes and availability of her significant other(s) and support network.
Where mental health treatment is required, the collaborative process continues, with the setting of mutually agreed goals and tasks and
regular support to help the woman to achieve those goals. If mental health referral is necessary, the process should be managed in an
empowering, supportive way.
2.1.1 Engaging women in mental health care
Factors that improve a woman’s experience of accessing and engaging with mental health care in the perinatal period include being
given the opportunity to develop trusting relationships with health care professionals who acknowledge and reinforce the woman’s role
in caring for her baby in a non-judgmental and compassionate manner, and foster hope and optimism about treatment (Megnin-Viggars
et al 2015). High quality information for women, their families and healthcare professionals, and the provision of individualised care and
treatment, are also crucial (Megnin-Viggars et al 2015).
2.1.2 Cultural safety
Cultural safety is based on the basic human rights of respect, dignity, empowerment, safety and autonomy (Phiri et al 2010). Cultural
safety is the final step on a continuum of care that includes cultural awareness, cultural sensitivity, cultural knowledge, cultural respect
and cultural competence. Cultural safety is the recipient’s own experience and cannot be defined by the caregiver (CATSINaM 2014).
The concept of ‘cultural safety’ focuses on social position to explain health status rather than on the ‘values, beliefs and traditions’
of a particular group (Williamson & Harrison 2010). This approach considers the dynamic nature of culture and the diversity within
groups, avoids stereotyping and identifies the needs of the individual receiving care. Strategies to ensure culturally safe care include
optimising communication (e.g. through the use of accredited interpreters), building sound relationships, acknowledging women’s
cultural preferences (Phiri et al 2010) and reflecting on and analysing how power relationships and history have affected the health of
individuals (Kruske et al 2006).
Enabling effective mental health care in the perinatal period | 21
2.1.3 Aboriginal and Torres Strait Islander women
Health professionals working with Aboriginal and Torres Strait Islander peoples are often confronted with extremely complex
presentations encompassing mental health problems, cultural disconnection and multiple stressors in the form of poverty or poor
housing, child removal, as well as trauma, abuse and loss (AIHW 2014). This level of complexity requires:
• different models of engagement and new approaches and ways of thinking about mental health – trauma-informed care (see below)
is particularly important when working with this population
• greater understanding about the determinants of mental health and wellbeing
• recognition of factors consistently identified by Aboriginal and Torres Strait Islander people as critical to the design and delivery
of effective services and programs aimed at improving their mental health and social and emotional wellbeing – these include
Indigenous definitions of health and wellbeing as holistic, underscored by connections to culture, family, community and country
• changes in the cultural competence of mental health systems, services, professions, disciplines and individual professionals.
The Pregnancy Care Guidelines (DoH 2018) include a chapter on optimising care for Aboriginal and Torres Strait Islander women, which
is applicable to both the antenatal and postnatal periods.
2.2 Care provision
2.2.1 Recovery-oriented mental health care
The principles of recovery-oriented mental health care are:
• individual uniqueness – recovery is about having opportunities, living a meaningful, satisfying and purposeful life and being a valued
community member; outcomes are personal and unique with an emphasis on social inclusion and quality of life; individuals are
central to the care they receive
• real choices – individuals make choices about how they want to lead their lives; are supported to build on their strengths and take as
much responsibility for their lives as they can; duty of care is balanced with support for individuals to take positive risks and make
the most of new opportunities
• attitudes and rights – involves listening to, learning from and acting upon communications from individuals; promotes and protects
their rights; supports individuals to maintain social, recreational, occupational and vocational activities; instils hope in an individual
about his or her future
• dignity and respect – involves courtesy, respect and honesty in all interactions; having sensitivity and respect for the values, beliefs
and culture of each individual; and challenging discrimination
• partnership and communication – involves working in partnership with individuals and their carers; valuing the importance of sharing
information and communicating clearly; and working together in positive and realistic ways to help individuals realise their own
hopes, goals and aspirations
• evaluating recovery – involves individuals and their carers tracking their own progress and services using the individual’s experiences
of care to inform quality improvement activities.
2.2.2 Trauma-informed care
Most people attending mental health services are survivors of psychological and emotional trauma. Trauma-informed care is grounded
in an understanding of and responsiveness to the impact of trauma, with an emphasis on physical, psychological, and emotional safety
for both providers and survivors and creating opportunities for survivors to rebuild a sense of control and empowerment (Kezelman &
Stavropoulos 2012). Core principles of trauma-informed care are (Kezelman & Stavropoulos 2012):
• ensure physical and emotional safety
• maximise trustworthiness through task clarity, consistency, and interpersonal boundaries
• maximise consumer choice and control
• maximise collaboration and sharing of power
• prioritise empowerment and skill-building.
http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-antenatal-care-index
Australian Clinical Practice Guideline | 22
2.3 Support and information5
Key points to discuss with women are that mental health conditions are not uncommon and that treatments are available.
In any health interaction, a woman has the right to (CHF 2004):
• determine what treatment she accepts or chooses not to accept
• be given easily understandable explanations in her first language of the details of her specific health problem, any proposed
treatments or procedures and the results of any tests performed
• have access to all health information about herself and her baby
• be treated with respect and dignity and know that, in the majority of cases, her health information will be kept confidential.
Health professionals and women need to communicate and collaborate in a team approach (Kryzanauskas 2005). The woman’s input
– and that of her significant other(s) when she chooses – is an important part of this process (NHMRC 2010). Consistency of information,
especially if this is provided by different professionals, is very important.
Making a choice or consenting should be an ongoing process of discussion between a woman and the health professionals involved in
her care.
2.3.1 Implications of low health literacy for maternal mental health surveillance and support
Health literacy refers to the degree to which an individual can obtain, communicate, process and understand basic health information
and health services to make appropriate decisions. Low health literacy is inextricably linked to poor mental health outcomes. It is
important that health services tailor care to populations likely to have low health literacy, including Aboriginal and Torres Strait Islander
families and families of refugee background, for example by involving Aboriginal and Torres Strait Islander or bicultural workers in
facilitating conversations and in brokering trusting relationships with health professionals involved in their care.
2.4 Continuity of care
The benefits of midwifery continuity of care and carer when providing maternity services are well-documented (Sandall et al 2016;
WHO 2016). Continuity of care involves a shared understanding of care pathways by all professionals involved, with the aim of reducing
fragmentation and conflicting advice. Continuity of carer is when a named professional, who is known by the woman, provides all her
care as appropriate, thus enabling the development of a relationship. Factors that may improve continuity of care include sharing of
information (e.g. through documenting of all assessments), collaborative development of management plans, developing linkages and
networks and adapting successful approaches to care (e.g. case conferencing, shared care approaches).
5. This section is adapted from (Australian Health Ministers' Advisory Council 2012).
Part B –
Screening and
psychosocial assessment
This section describes screening, which aims to detect signs and
symptoms of depressive and anxiety disorders and psychosocial
assessment, which aims to identify the presence of psychosocial
factors that are known to be associated with an elevated likelihood
of mental health conditions in the perinatal period.
Australian Clinical Practice Guideline | 24
3 Considerations before screening
and psychosocial assessment
Key considerations for service provision are outlined below.
• Systems for follow-up and support – Before screening and assessment is carried out, systems need to be in place to ensure that
appropriate health professionals are available to provide follow-up care if required and to assist if there are concerns for the safety of
the woman, the fetus or infant or other children in the woman’s care. Health professionals will greatly benefit from identifying other
professionals from whom they can seek advice, clinical supervision or support regarding mental health care in the perinatal period.
This could potentially be supported through electronic referral pathways or directories.
• Who attends assessment – Women need to feel safe during screening and assessment, so consideration should be given to other
people who may be present. While the presence of significant others is often helpful, sensitivity is required about whether it is
appropriate to continue with psychosocial assessment while they are in the room. Screening for family violence (see the
Pregnancy Care Guidelines) should only be conducted when alone with the woman. Postnatal assessments with baby and
partner present provide an opportunity to view the mother-infant relationship and partner relationship (see Section 7.1).
• Informed consent – An explanation of the purpose of screening and assessment should be given before they take place and It is
important to stress that this is part of routine care and results will generally remain confidential. Consent can be readily integrated
with consent processes for existing routine antenatal and postnatal care procedures. If a woman does not consent to assessment
and/or screening, this should be explored and documented and assessment and screening offered at subsequent consultations.
• Confidentiality – It should also be explained that confidentiality may not be kept if there is a perceived risk of harm to the woman or
her baby as there is a duty of care for this to be communicated to key others. However, in this situation, only information relevant to
the risk will be shared.
• Follow-up to screening – Decision-making about the need for and type of follow-up mental health care is based on clinical
presentation and responses at interview and/or structured assessment, and the woman’s preferences. The initial assessment in the
primary setting is not diagnostic, rather its aim is to ensure that women who would like help with their distress or symptoms, or who
need further assessment for a possible psychiatric condition, will receive the care (including diagnostic assessment) they need.
• Ongoing care and support – Most women will not need further monitoring or mental health assessment, while many of those
who need it will not accept it, at least initially. Providing ongoing exploration of their symptoms and information and encouraging
continuing contact with an appropriate health professional may support women in seeking further assistance. Screening and
assessment is likely to be easier and more effective when a woman has a relationship with her care provider. Ideally, ongoing mental
health care in the perinatal period is provided by a woman’s regular GP. However, it is acknowledged that not all women have access
to this type of care or choose it when it is available. Women should be assisted in identifying a health professional with the skills and
knowledge to provide appropriate and culturally safe ongoing care.
http://cope.org.au/health-professionals-3/clinical-practice-guidelines/
Acceptability of screening and psychosocial assessment | 25
4 Acceptability of screening and
psychosocial assessment
Mental health screening that occurs as a component of routine antenatal and postnatal care is acceptable to women and health
professionals and, while barriers exist, is considered a feasible approach to perinatal mental health care (Austin & Kingston 2016;
Venkatesh et al 2016).
4.1 Acceptability of screening among health professionals and women
• Studies have reported high levels of acceptability of perinatal mental health screening among health professionals in Australia (Reay
et al 2011; Bowen et al 2012; Austin et al 2013; Bales et al 2015), Canada (Kingston et al 2015b), the United States (Chew-Graham et al
2009; Miller et al 2009) and as reported in systematic reviews (El-Den et al 2015).
• Vulnerable women also report high acceptability, including those with high depression scores at the time of screening (Gemmill et al
2006), women of non-English-speaking background (Matthey et al 2005), those with a previous diagnosis or treatment history for
mental condition (Kingston et al 2015b) and those experiencing family violence (Matthey et al 2005).
• Fewer than 4% of women refuse health professional-initiated screening (Chew-Graham et al 2009; Miller et al 2009; Austin et al
2010). These rates may be even lower as womens' ability to be honest about emotional health is strongly associated with their
comfort with the mode of assessment (Kingston et al 2015b).
• A recent Canadian study found that 99% of pregnant women who had not been screened would have been comfortable with health
professional-initiated screening, and 97% of those who had been screened reported the same (Kingston et al 2015b). Demographics,
type of health professional and history of diagnosis or treatment for mental condition were unrelated to whether pregnant women
found screening acceptable or not (Kingston et al 2015b).
4.2 Barriers to routine perinatal screening, follow-up assessment and treatment
• Barriers to screening and referral among health professionals include lack of time, education and linkages with mental health
resources (Kim et al 2010; Byatt et al 2012). It is recognised that each of these barriers may be alleviated by using innovative
approaches to screening, information provision and e-referral pathways.
• Barriers among women include stigma, significant others normalising their emotional difficulties, desiring to manage mental health
problems on their own, preferring to discuss feelings with significant others, not knowing what emotions are 'normal' and perceiving
that the health professional is disinterested or lacks time (Highet et al 2014; Kingston et al 2015a; Kingston et al 2015b). This may be
improved by the provision of timely, relevant information and education about emotional and mental health in the perinatal period.
• While 30% of Australian women give birth in the private sector, most of them will not be offered routine psychosocial assessment
(Reilly et al 2013b) or screening for depression, although a study in a private hospital setting found that when assessment and
screening were conducted almost one in ten women required referral for further assessment and clinical support (Kohlhoff et al
2016). Thus, although many women may prefer private care, when it comes to mental health care, these women may in fact be
disenfranchised.
• Screening is often not available, accurate or appropriately administered for women of non-English speaking backgrounds due to the
lack of validated screening tools in other languages, and/or the accuracies and costs associated with interpreter services. In a recent
screening and treatment program at a metropolitan hospital in Melbourne, fewer than 4% of non-English speaking women were
offered perinatal screening in a maternity setting (compared to 49% of English-speaking women) (Highet & Bilbao 2015).
• Research suggests that only half of women who screen positive follow up with a subsequent mental health assessment (Kim et al
2010; Reay et al 2011) and 30–85% (Marcus et al 2003; Woolhouse et al 2009; Reay et al 2011; Bowen et al 2012; Bales et al 2015)
do not engage in treatment. This may be improved by consumers as well as health professionals having access to timely and
appropriate referral pathways.
4.3 Facilitators of screening and subsequent mental health care
• Health professionals in settings that have implemented an infrastructure for routine psychosocial assessment and mental health
screening as part of a system of assessment-referral-care have found it to be a feasible, effective approach (Sword et al 2008;
Mitchell & Coyne 2009; Flynn et al 2010; Reay et al 2011).
• Screening rates can increase if health professionals are educated about perinatal mental health and trained in the use of a validated
tool (Goldin Evans et al 2015). Increases in screening rates are associated with e-screening, in which women self-assess and receive
advice about whether they should seek further assessment based on the score provided.
Australian Clinical Practice Guideline | 26
• The provision of specific MBS items that mandate and incentivise screening, and the requirement for Royal Australian and New
Zealand College of Obstetricians and Gynaecologists (RANZCOG) trainees to have perinatal mental health training as a core
competency, would go a long way towards addressing the imbalance between screening in the public and private maternity sectors.
• Medicare items 16590 and 16591 have been amended to further support mental health assessment to be undertaken after 28 weeks
gestation. A new Medicare item (16407) has been introduced to include mental health assessment between 4 and 8 weeks after
the birth. These items will support screening in line with best practice – particularly in the private sector where screening rates are
significantly lower (when compared with the public maternity sector).
• Women are more likely to accept mental health screening when there is continuity of carer, the health professional is sensitive
and interested, and women are reassured that mental health care is part of routine antenatal care, that other women experience
emotional problems during pregnancy and that help is available (Kingston et al 2015a). Being informed about screening in advance
also improves women’s acceptance of screening (Brealey et al 2010).
• Women who are not asked about emotional health are far less likely to seek formal mental health care during pregnancy (AOR 0.09,
95% CI 0.04 to 0.24) or postpartum (AOR 0.07, 95%CI 0.02 to 0.13) (Reilly et al 2014).
• Formal referral following assessment increases the number of women who engage in treatment – women who do not receive
a formal referral are less likely to engage in treatment in pregnancy (AOR 0.26, 95% CI 0.15–0.45) and postpartum (AOR 0.14,
0.07-0.27) (Reilly et al 2013a).
CONSENSUS-BASED RECOMMENDATION
i. All health professionals providing care in the perinatal period should receive training in woman-centred communication
skills, psychosocial assessment and culturally safe care.
Screening for depressive and anxiety disorders | 27
5 Screening for depressive and
anxiety disorders
‘Screening’ entails the application of a validated test (or questionnaire) to identify people who may be experiencing a particular
disorder. Screening tools are not diagnostic. The administration of a screening tool for depressive or anxiety disorder is part
of a multicomponent program which must include clear rules for further assessment of women who are screening positive;
appropriate staff training in screening methods; adequate mental health referral pathways and effective treatments.
Accurately identifying women experiencing symptoms of depression and anxiety enables referral for more formal mental health
assessment and suitable follow-up, with a view to improving outcomes for women. The screening process is informed by the
considerations outlined in Chapter 3.
The context for screening has changed in the years since the release of the initial guideline on mental health in the perinatal
period (beyondblue 2011), with:
• increased awareness of the prevalence of not only antenatal and postnatal depression but also anxiety
• further research conducted into the effectiveness of screening tools and how they may be integrated into comprehensive
screening programs
• the increased range and availability of innovative methods of screening (e.g. using electronic tools).
5.1 Screening for depression
5.1.1 Summary of the evidence
Assessment of screening tools for depression included consideration of sensitivity (the proportion of people with the condition
who have a positive result; true positive rate) and specificity (the proportion of people without the condition who have a
negative result; true negative rate). Sensitivity and specificity were defined as: high >0.90; moderate 0.70–0.90 and low <0.70.
Further details are included in Tables C2 and C3, Appendix C.
Antenatal screening
The systematic review identified evidence on four screening tools for depression in the antenatal period – the Edinburgh
Postnatal Depression Scale (EPDS), the depression module of the Patient Health Questionnaire (PHQ-9), the Whooley Questions
and the Kessler Psychological Distress Scale (K-10).
A score of 13 or more on the EPDS has moderate sensitivity and high specificity for detecting possible major depression6 in
pregnant women (high quality). A score of 10 or more has moderate sensitivity and specificity (moderate quality; NICE 2015).
It is uncertain whether the other tools (at relevant cut-offs) have adequate sensitivity or specificity to detect possible depressive
disorders in pregnant women (very low to low quality; NICE 2015).
Postnatal screening
The systematic review identified evidence on the effectiveness of five screening tools for depression in the postnatal period
– the EPDS, PHQ-9, shorter versions of the PHQ-9 (PHQ-2), the Whooley Questions and the K-10.
A score of 13 or more on the EPDS has moderate sensitivity and high specificity for detecting possible major depression in the
postnatal period (high quality). A score of 10 or more has moderate sensitivity and specificity (high quality; NICE 2015).
It is uncertain whether the other tools (at relevant cut-offs) have adequate sensitivity or specificity to detect possible depressive
disorders in pregnant women (very low to low quality; NICE 2015).
6. While the DSM criteria for diagnosing minor or major depression are not suitable for diagnosis in the perinatal period, they were used to measure
outcomes in the studies.
Australian Clinical Practice Guideline | 28
Non-technical characteristics of screening tools
Assessment of the non-technical characteristics of the tools found that ease of administration and implementability were high for all
tools, acceptability was high for the EPDS and unknown but likely to be good for the other tools. The EPDS is the only one of the tools
for which effectiveness (defined as positive impact on depressive symptoms, services referred or used and impact on a woman’s mental
health) is rated ‘good’ and that has been validated in other languages.
Appendix D includes the EPDS and information on calculating a woman’s score.
5.1.2 Other considerations in screening for depression
Timing of screening
The timing of screening should reflect available resources and existing contacts between the woman and the health professionals caring
for her:
• an obvious contact point is the first antenatal visit, however, it is acknowledged that the time available at this visit and the number of
other assessments undertaken may limit opportunities for assessment of mental health
• postnatal assessment may be integrated into routine maternal and infant checks.
Timing of repeat screening is based on results of the initial screen and clinical indications.
Mode of assessment
The EPDS is a self-report tool and is usually completed by the woman, preferably without consultation with others. It may at times be
appropriate for the health professional to verbally administer the questionnaire whether face to face or by phone. Electronic screening,
in which women complete the EPDS electronically and receive advice on whether further assessment is advisable based on their overall
score, anxiety items and response to question 10, is an emerging practice.
Risk of harm
Regardless of the total EPDS score, perinatal women who score positive on Question 10 may be at risk of harming themselves and/or
their children and further assessment is necessary. Section 7.3 provides guidance on assessing the risk of self-harm or suicide.
EVIDENCE-BASED RECOMMENDATIONS STRONG
1. Use the EPDS to screen women for a possible depressive disorder in the perinatal period.
2. Arrange further assessment of perinatal woman with an EPDS score of 13 or more.
CONSENSUS-BASED RECOMMENDATIONS
ii. Complete the first antenatal screening as early as practical in pregnancy and repeat screening at least once later in
pregnancy.
iii. Complete the first postnatal screening 6–12 weeks after birth and repeat screening at least once in the first postnatal
year.
iv. For a woman with an EPDS score between 10 and 12, monitor and repeat the EPDS in 2–4 weeks as her score may
increase subsequently.
v. Repeat the EPDS at any time in pregnancy and in the first postnatal year if clinically indicated.
CONSENSUS-BASED RECOMMENDATION
vi. For a woman with a positive score on Question 10 on the EPDS, undertake or arrange immediate further assessment and,
if there is any disclosure of suicidal ideation, take urgent action in accordance with local protocol/policy.
Screening for depressive and anxiety disorders | 29
Women who decline screening
As discussed in Section 4.1, some women may not accept the offer of screening for a range of reasons. In such situations, the woman
may prefer to complete the EPDS electronically and will receive advice on whether further assessment is recommended. As the
therapeutic relationship develops, subsequent offers of the EPDS may be accepted.
5.2 Culturally appropriate screening for depression
5.2.1 Aboriginal and Torres Strait Islander women
For Aboriginal and Torres Strait Islander women, EPDS score may be influenced by the woman’s understanding of the language used,
mistrust of mainstream services or fear of consequences of depression being identified (i.e. involvement of child protection services).
Translations of the EPDS developed in consultation with women from Aboriginal communities have been found to identify a slightly
higher number of women experiencing symptoms of depression (Hayes et al 2006; Campbell et al 2008). A recent adaptation of the
EPDS assessed in the Kimberley includes an additional component of psychosocial assessment, acknowledging the contribution that
stressful events and social health issues play in maternal mental health (Marley et al 2017). Many elements of the approach taken to
adapting this instrument (i.e. the way in which questions are asked, implementation by Aboriginal health workers) are likely to have
broader relevance to urban as well as remote and regional Aboriginal and Torres Strait Islander communities.
If use of the EPDS is considered inappropriate, involvement of Aboriginal health worker may facilitate assessment of symptoms of
depressive or anxiety disorders.
5.2.2 Migrant and refugee women
Scores used to identify possible depression in migrant and refugee women are generally lower than those used in the general Australian
population. Specific scores are given in translated versions of the tool.
Cultural practices (such as attending the consultation with a family member) and the perceived degree of stigma associated with
depression may also influence the performance of the EPDS.
5.3 Screening for anxiety
The systematic review identified evidence on the accuracy of screening tools for identifying possible anxiety disorders in the:
• perinatal period – the full EPDS (Grigoriadis et al 2011; Simpson et al 2014), items 3, 4 and 5 of the EPDS (EPDS-3A) (Grigoriadis et al
2011; Simpson et al 2014) and the Generalised Anxiety Disorder 7-Item Scale (GAD-7) (Simpson et al 2014).
• antenatal period – the full EPDS (Tran et al 2011), the General Health Questionnaire (GHQ) (using 12, 28 or 30 items) (Sharp 1988;
Kitamura et al 1989; Aderibigbe & Gureje 1992; Abiodun et al 1993; Kitamura et al 1994; Tran et al 2011), the Hospital Anxiety and
Depression Scale (HADS) (Abiodun et al 1993), K-10 (Spies et al 2009) and the State-Trait Anxiety Inventory (STAI) (Grant et al
2008).
• postnatal period – the full EPDS (Navarro et al 2007; Tran et al 2011), the GHQ (using 12 or 30 items) (Nott & Cutts 1982; Kitamura et
al 1994; Navarro et al 2007; Tran et al 2011).
CONSENSUS-BASED RECOMMENDATION
vii. When screening Aboriginal and Torres Strait Islander women, consider language and cultural appropriateness of the tool.
CONSENSUS-BASED RECOMMENDATION
viii. Use appropriately translated versions of the EPDS with culturally relevant cut-off scores. Consider language and cultural
appropriateness of the tool.
Australian Clinical Practice Guideline | 30
CONSENSUS-BASED RECOMMENDATIONS
ix. Be aware that anxiety disorder is very common in the perinatal period and should be considered in the broader clinical
assessment.
x. As part of the clinical assessment, use anxiety items from other screening tools (e.g. EPDS items 3, 4 and 5, DASS anxiety
items and K-10 items 2, 3, 5 and 6) and relevant items in structured psychosocial assessment tools (e.g. ANRQ).
The evidence was heterogeneous in terms of study characteristics and cut-off values used and firm conclusions could not be drawn.
In the absence of a free, practical screening tool for anxiety disorders with adequate evidence in the perinatal period, clinical judgment
must be used. This may include consideration of items 3, 4 and 5 of the EPDS (Matthey et al 2013a; Matthey et al 2013b).
Assessing psychosocial factors that affect mental health | 31
6 Assessing psychosocial factors
that affect mental health
Psychosocial assessment allows identification of circumstances (past and present) that affect a woman’s mental health and is
conducted in addition to screening for symptoms of depression and/or anxiety. The number and type of psychosocial factors identified
influences the care pathway, with more approaches or interventions needed to support women who are experiencing multiple
psychosocial factors. The presence of complex risk factors will require a coordinated multidisciplinary approach to the woman’s care
plan.
Psychosocial assessment can be undertaken as part of the clinical interview and/or using a structured psychosocial assessment tool.
Different approaches can be taken to suit the setting, health professional confidence and skill set, as well as time constraints. Structured
questionnaires are useful in providing a comprehensive, time-efficient overview of the woman’s circumstances, especially when the
health professional is not experienced in undertaking a detailed psychosocial assessment as part of the broader clinical evaluation.
6.1 Psychosocial assessment tools
6.1.1 Summary of the evidence
Tools developed with the aim of identifying psychosocial factors in the antenatal and postnatal periods, for which there is moderate
to high quality evidence include the Antenatal Psychosocial Health Assessment (ALPHA), the AnteNatal Risk Questionnaire (ANRQ)
and the Pregnancy Risk Questionnaire (PRQ). Evaluation of these tools for their technical performance and acceptability found the
following.
ALPHA
The ALPHA (Carroll et al 2005) is a 34-item questionnaire, which does not generate a total risk score but asks the clinician to score
their level of concern on a 7-point scale. Broadly it assesses: relationship with partner, substance use, social support, recent stressful life
events, attitude to pregnancy, lack of self-esteem, previous history of depression or during pregnancy, having witnessed or experienced
abuse as a child, and quality of relationship with parents in childhood.
The ALPHA has limited psychometric properties, is moderately acceptable to users and is effective in identifying family violence (OR
2.7; 95%CI 1.1 to 6.9) (moderate quality) and ‘high level of psychosocial concern’ on the health professional’s part (OR 2.8; 95%CI 0.7 to
11.7). The ALPHA does not have adequate capacity to identify women at increased risk of postnatal depression but ‘may be particularly
useful for raising and discussing sensitive (psychosocial) issues’ (Blackmore et al 2006).
PRQ
The Pregnancy Risk Questionnaire PRQ (Austin et al 2005) the longer antecedent to the ANRQ (see below), is an 18-item tool covering
similar domains to those of the ALPHA.
It has acceptable psychometric properties and is effective in predicting cases of postnatal depression and anxiety (OR 9.18; p <0.001)
(moderate quality), with sensitivity 0.44, specificity 0.92, positive predictive value 0.235 and negative predictive value 0.968. The PRQ
is considered too lengthy for routine use in the public health setting (Austin et al 2005).
ANRQ
The ANRQ (Austin et al 2013; Reilly et al 2015) is a 13-item structured questionnaire with categorical (yes/no) and dimensional
(1 to 5) responses, which generates a total psychosocial risk score (cumulative risk) as well as identifying specific risk factors that
independently put the woman at greater psychosocial risk (past history of trauma or significant mental health condition). The ANRQ
covers relationship with partner, social support, recent stressful life events, anxiety or perfectionism, past history of depression or other
mental health conditions (and treatment for same), having experienced abuse as a child or as an adult, and quality of relationship with
mother in childhood.
PRACTICE POINT
a. Assess psychosocial risk factors as early as practical in pregnancy and again after the birth.
Australian Clinical Practice Guideline | 32
The ANRQ has acceptable technical performance in identifying women at greater risk of postnatal depression and anxiety disorder (OR
6.3 [95% CI 3.5 to 11.5]; sensitivity 0.62; specificity 0.64; positive predictive value 0.3; negative predictive value 0.87) and has a positive
effect on rates of referral for mental health assessment (moderate quality). Ease of administration and acceptability among women are
high.
A cut-off score of 23 or more is recommended but women with a significant mental health history or history of abuse are at increased
risk of poor psychosocial outcome irrespective of the total ANRQ score. As the items on the ANRQ are applicable to both pregnancy
and postnatal women, it can be used postnatally using the same cut-off score.
Appendix D includes the ANRQ and guidance on its use in clinical practice, scoring and interpretation of results.
6.2 Other considerations in psychosocial screening
As a clinically useful psychosocial assessment tool needs to be brief and to cover the key risk domains, it cannot be fully comprehensive
and should be used to “start the conversation” so that particular domains can then be explored further as needed.
6.2.1 Further exploration and interpretation of psychosocial assessment
Psychosocial risk items endorsed by the woman (whether through use of a structured tool or as part of a broader interview) need to
be further explored and documented. The results of the evaluation need to be conveyed to the woman and then (in consultation with
the woman) be translated into a tangible approach to referral or monitoring. This will be reliant on the availability of adequate referral
pathways.
6.2.2 Education about psychosocial risk factors
Given the potential impact that psychosocial risk factors may have on a woman’s mental health and the wellbeing of her baby/other
children, it is important that all women are provided with information about the nature of the different risk factors that may increase
her likelihood of experiencing a mental health condition in the perinatal period. In turn this provides an opportunity to identify supports
(protective factors) to assist in the prevention of mental health conditions, and/or raise awareness of the importance of early symptom
recognition to facilitate early detection and intervention.
EVIDENCE-BASED RECOMMENDATION STRONG
3. If using a tool to assess psychosocial risk, administer the ANRQ.
CONSENSUS-BASED RECOMMENDATION
xi. Undertake psychosocial assessment in conjunction with a tool that screens for current symptoms of depression/anxiety
(i.e. the EPDS).
PRACTICE POINTS
b. Ensure that health professionals receive training in the importance of psychosocial assessment and the use of a
psychosocial assessment tool.
c. Ensure that there are clear guidelines around the use and interpretation of the psychosocial tool/interview in terms of
threshold for referral for psychosocial care and/or ongoing monitoring.
PRACTICE POINT
d. Discuss with the woman the possible impact of psychosocial risk factors (she has endorsed) on her mental health and
provide information about available assistance.
Assessing psychosocial factors that affect mental health | 33
6.2.3 Culturally appropriate assessment of psychosocial risk
The psychosocial assessment tools described above are only available in English and no published evidence has been identified
describing their use in Aboriginal and Torres Strait Islander or migrant and refugee women. A more conversational approach to
psychosocial assessment may be needed in these groups, with a focus on developing rapport and trust.
A South Australian study (of Aboriginal women) found that women were happy to be asked about social health issues, including
family and community violence, when questions were asked by Aboriginal community women in an interview or when women were
given the option to self-complete a questionnaire (Weetra et al 2016). Similarly, involvement of multicultural health workers may be a
consideration in assessment of migrant and refugee women.
Consideration should also be given to psychosocial risk and protective factors that are not covered in the tools but may be relevant to
specific groups (see Section 1.1).
6.2.4 Assessment of specific social and lifestyle factors
Routine assessment of specific social and lifestyle factors that affect perinatal outcomes and may also be associated with mental health
is described in the Pregnancy Care Guidelines (DoH 2018). This includes:
• family violence
• lifestyle factors including nutrition, physical activity, substance use and smoking.
CONSENSUS-BASED RECOMMENDATION
xii. Consider language and cultural appropriateness of any tool used to assess psychosocial risk.
http://cope.org.au/health-professionals-3/clinical-practice-guidelines/
Australian Clinical Practice Guideline | 34
7 Assessing mother-infant
interaction and safety of the
woman and infant
7.1 Mother-infant interaction7
The following table provides a list of prompts to assess difficulties in the mother-infant relationship. The list is not exhaustive and is
not intended to be used as a checklist or formal assessment tool. Rather, it indicates areas of functioning that are important to the
mother-infant relationship. If any concerns arise, consulting with and/or referring to the appropriate specialist service is a consideration.
Table 7.1: Indications of potential difficulties and protective factors in the mother-infant interaction
Psychosocial risk factors
Infant factors
Infant behaviour of concern (observed or reported)
• Unresolved family of origin issues
• History of physical/sexual abuse, family violence, childhood
neglect
• Past pregnancy loss or excess pregnancy concern
• Unplanned or unwanted pregnancy
• Was the mother able to touch the baby on the day of birth?
• Did the mother have responsibility for infant care during the
first week of life?
• Who is involved in the baby’s care?
• Availability of emotional/social/practical support
• How much time does the mother spend away from the baby?
• Is the mother excessively worried about the baby?
• Is baby achieving normal developmental milestones?
• Is the baby growing adequately?
• Are there feeding difficulties, reflux, gastric distress, sleep
difficulties?
• Is the mother thoughtful about her baby?
• Can the mother describe the baby’s daily routine?
• Is the mother able to reflect on the baby’s needs?
• Does the mother express empathy for the baby?
• Does the mother engage in enjoyable activities with the baby?
• Does the mother play/talk appropriately with the baby?
• Does she delight in her baby?
• Does the baby ever make her feel uncomfortable, unhappy or
enraged?
• Is the mother excessively worried about the baby?
• Does the mother cope with the baby’s distress?
• Does she respond and attend appropriately to the baby’s
cues?
• Are her responses consistent?
• Is she protective of the baby?
• Current maternal psychopathy
• Antenatal or postnatal mood disorder
• Psychosis
• Diagnosed personality disorder
• Suicidal or homicidal ideation
• Negative symptoms (low motivation, anhedonia, blunted
affect, poverty of thought/speech)
• Medication side-effects
• Substance abuse
• Engaging in dangerous or risk-taking behaviours (e.g. alcohol
or drug misuse)
Relationship factors (observed or reported)
Maternal factors
Protective factors
• Gaze avoidance
• Flat affect
• Lack of crying
• Limited vocalising
• Emotionally under-responsive
• Interacts too easily with strangers (age-dependent)
• Unsettled sleep or feeding
• Difficult to console when distressed
• Irritable, constant crying
• Difficulty separating from parent (age-dependent)
• Mother is sensitive to the baby
• Mother is able to monitor the baby’s well-being adequately
• Mother is responsive to the baby
• Mother is able to cope with flexibility in her routine
• Mother has a close relationship with at least one other adult
• Mother is thoughtful about what might be going on in the
baby’s mind
7. This section is adapted from (Stefan et al 2009).
Assessing mother-infant interaction and safety of the woman and infant | 35
PRACTICE POINTS
e. Assess the mother-infant interaction as an integral part of postnatal care and refer to a parent-infant therapist as
available and appropriate.
f. Seek guidance/support from Aboriginal and Torres Strait Islander health professionals or bicultural health workers when
assessing mother-infant interaction in Aboriginal and Torres Strait Islander or migrant and refugee women, to ensure that
assessment is not informed by unconscious bias.
7.2 Risk to the infant
If there are observed difficulties with the mother-infant interaction and/or if the woman has a significant mental health condition,
further assessment is required. Risk of harm to the infant can be related to suicide risk in the mother but can also be a separate issue.
It should be noted that expressions of fear of harming the baby may be a sign of anxiety rather than intent, but should always be
assessed further.
The nature of the enquiry will depend on a range of factors, including the setting and the extent of the therapeutic relationship. The
following are examples of questions that could be asked, taken from the Postpartum Bonding Questionnaire (Brockington et al 2006)
and adapted to the perinatal context.
• Have you felt irritated by being pregnant or by your baby?
• Have you had significant regrets about becoming pregnant or having the baby?
• Does the baby feel like it’s not yours at times?
• Have you wanted to harm your unborn child or shake or slap your baby?
• Have you ever harmed your baby?
Action will depend on the answers to these questions. It is preferable that the mother and infant remain together but, if there is a
perceived risk of harm to the infant, involvement of others (e.g. father or co-parent) in caring for the infant or alternative arrangements
are advisable.
Notification to the relevant child protection agency may be necessary. All health professionals should be familiar with the legislation
concerning reporting of concerns about children at risk of harm from abuse or neglect in their State or Territory. Health services and
child and maternal agencies will generally have internal policies setting out these requirements.
7.3 Risk of suicide8
Suicide risk assessment requires clinical judgement, a sense of the woman in context, understanding of the baby/infant as both a
protective factor and a risk factor, and awareness of how mental health symptoms might affect impulsivity.
7.3.1 Assessing the risk of suicide
Assessment of risk involves making enquiry into the extent of suicidal thoughts and intent, including:
• suicidal thoughts – if suicidal thoughts are present, how frequent and persistent are they?
• plan – if the woman has a plan, how detailed and realistic is it?
• lethality – what method has the woman chosen; how lethal is it?
• means – does the woman have the means to carry out the method?
Consideration should also be given to:
• risk and protective factors
• mental state – hopelessness, despair, psychosis, agitation, shame, anger, guilt, impulsivity
• history of suicidal behaviour
• family history of suicidal behaviour
• substance use – current misuse of alcohol or other drugs
• strengths and supports – availability, willingness and capacity of supports.
Whenever assessing a woman for risk of suicide, enquiry should be made about her capacity to care for the infant and any thoughts of
harm to the infant.
PRACTICE POINT
g. Assess the risk of harm to the infant if significant difficulties are observed with the mother-infant interaction, the woman
discloses that she is having thoughts of harming her infant and/or there is concern about the mother’s mental health.
8. This section has been developed based on resources available through the Australian National Suicide Prevention Strategy (NSPS) website —
www.livingisforeveryone.com.au
http://www.livingisforeveryone.com.au
Australian Clinical Practice Guideline | 36
7.3.2 Managing immediate risk
The following diagram represents some general principles for responding to suicide risk. Care and referral pathways will need to be
adapted to individual circumstances and local resources and will be informed by clinical judgement, including assessment of impulsivity.
The safety of the baby must also be considered as there may also be a risk of infanticide.
Figure 7.1: General responses to identified risk of suicide
7.3.3 Additional considerations in managing identified risk of suicide
• Low risk – Seek to understand what precipitates the fleeting thoughts. If triggers are core to the woman’s current perinatal
experience (e.g. sense of maternal failure; shame about negative thoughts towards infant; interpersonal conflict), ensure a safety
plan is specific to the issues.
• Medium risk – Assess context of current suicidal thoughts (e.g. previous suicide ideation or behaviours and outcomes). Establish
factors that might contribute to escalation of risk (e.g. unsettled baby; conflict with partner). If triggers relate to the woman’s current
perinatal experience (and cannot be immediately resolved), carers for infant/children and mother need to be located.
• High risk – Locate a support person to care for infants/children. A mother can deny intent yet be at high risk. A woman with
significant perinatal mental health decline, inability to sleep, distorted thinking, inability to care for self or infant with fleeting
thoughts her family would be better off without her can be just as at risk as a woman with intent.
Ask
• Suicidal thoughts • Plan • Lethality • Means • Suicide History
Consider mental health of mother and risk to the infant at all times
Fleeting thoughts of self-harm or
suicide but no current plan or means
Low risk
• Discuss availability of support
and treatment options
• Arrange follow-up consultation
(timing of this will be based on
clinical judgement)
• Identify relevant community
resources and provide contact
details
Medium risk
• Discuss availability of support
and treatment options
• Organise re-assessment within
one week
• Have contingency plan in place
for rapid re-assessment if
distress or symptoms escalate
• Develop a safety plan with the
woman
High risk
• Ensure that the woman is in an
appropriately safe and secure
environment
• Organise re-assessment within
24 hours and monitoring for this
period
• Follow-up outcome of
assessment
• Monitor risk to infant
Suicidal thoughts and intent but no
current plan or immediate
Continual/specific suicidal thoughts,
intent, plan and means
Assessing mother-infant interaction and safety of the woman and infant | 37
7.3.4 Developing a safety plan
A safety plan is a prioritised list of coping strategies and sources of support that women can use when they experience suicidal
thoughts. Developing a safety plan involves assisting the woman to identify:
• warning signs that she may be at risk of imminent suicide (e.g. feeling trapped, worthless or hopeless) and actions to protect herself
and the infant
• internal coping strategies that decrease the level of risk
• people within the woman’s network who can assist in times of need
• health professionals and agencies that can be contacted for help.
Safety plans should be frequently revisited and modified as needed.
PRACTICE POINT
h. When a woman is identified as at risk of suicide (through clinical assessment and/or the EPDS), manage immediate risk,
arrange for urgent mental health assessment and consider support and treatment options.
Australian Clinical Practice Guideline | 38
8 Implementing psychosocial
assessment and screening
Routine assessment of all women in the perinatal period is critical to providing them with access to early intervention and improving
outcomes for women and their families. While referral and care pathways vary with setting (e.g. general practice, maternity services)
and the location (e.g. metropolitan, rural and remote), it is important that women are provided with access to timely, appropriate
services post-assessment and ongoing psychosocial support.
8.1 Incorporating psychosocial assessment and screening into routine practice
Recommended psychosocial assessment and depression screening (e.g. with the EPDS) can be conducted by a variety of health
professionals depending on where a woman seeks antenatal and postnatal care.
• General practice – In the general practice setting, screening and psychosocial assessment may be conducted by the general
practitioner or a practice nurse.
• Midwifery and maternal and child health care – Midwives in public or private practice and maternal and child health nurses9 are
well-placed to conduct screening and psychosocial assessment in the antenatal and postnatal periods, respectively.
• Obstetric practice – Obstetricians in public or private practice are responsible for ensuring that screening with the EPDS and
psychosocial assessment take place. Regardless of who conducts the assessments (e.g. the obstetrician or a practice midwife),
the woman’s GP and the hospital at which the woman will give birth need to be notified if there are any concerns and relevant
information included in the woman’s discharge summary.
8.2 General approaches post-assessment
Screening and psychosocial assessment provide an indication of a woman’s general mental health status and the presence of
psychosocial risk factors but do not provide a diagnosis. Initial steps following these assessments include determining whether
comprehensive mental health assessment is required (which may lead to a psychiatric diagnosis) and identifying supports and
services tailored to the woman’s needs. The following points illustrate a range of situations and the types of approaches that may be
appropriate:
• women with moderate to severe symptoms will require comprehensive mental health assessment – subsequent management will
most likely involve pharmacological treatment, ongoing psychosocial support and possibly psychological therapy once medication(s)
have become effective (see Section 11.2.3)
• women with a past history of a severe mental health condition will require comprehensive mental health assessment before
conception or in the antenatal period and additional support (particularly in the early postnatal period)
• women with mild to moderate symptoms may require comprehensive mental health assessment and may also benefit from some
form of psychological therapy (see Section 11.2) in addition to psychosocial support
• women experiencing mild depressive or anxiety symptoms in the early postnatal period may benefit from practical and emotional
support (e.g. advice on parenting, unsettled infants, sleep deprivation) and monitoring to determine the effectiveness of such
support
• women without current symptoms but experiencing significant psychosocial risk (e.g. a recent separation) may benefit from
ongoing psychosocial support.
Women with a pre-existing mental health condition may already be under the care of a GP, psychologist and/or psychiatrist (depending
on the nature and severity of their condition). However, comprehensive mental health assessment is required if the woman has, or is
suspected to have, a recurrence or new onset of severe mental health condition, suicidal thoughts or evidence of harm to herself or
infant, or if other children in her care may be at risk of harm.
8.3 Referral and care pathways
The general principles for referral are the same in all settings. However, referral pathways will depend on the setting and the access to
services available in the area. Whatever pathway is chosen, there is a need for documentation, coordinated care and inter-professional
communication as well as clear communication with the woman and her significant other.
9. Also referred to as child and family health nurses in some jurisdictions.
Implementing psychosocial assessment and screening | 39
Consideration needs to be given to the urgency of the referral, particularly when women have severe symptoms or suicidal thinking.
Women with severe mental health conditions may need to be referred directly to the local mental health team for urgent assessment or
even scheduled to the local psychiatric facility.
In rural and remote settings, mental health services may not be locally available and waiting times can be long. In such cases, advice
may need to be sought from a GP, visiting psychiatrist, telehealth or mental health support line (e.g. those provided by non-government
organisations).
For women from Aboriginal and Torres Strait Islander or migrant and refugee populations, involvement of a culturally appropriate
worker (e.g. Aboriginal and Torres Strait Islander health worker, cultural liaison officer, interpreter) is advisable.
• General practice – Where possible a GP will diagnose and develop a management plan for depressive and anxiety disorders. Women
with symptoms suggestive of more serious low prevalence conditions should be referred directly to a psychiatrist. Once a psychiatric
diagnosis is established, and where psychological therapy is deemed the best treatment approach, a GP may develop a mental
health treatment plan to allow the woman to access the relevant Medicare items for psychological therapy.
• Midwifery – For midwives, referral pathways will differ depending on whether they are in the private or public sector, independent,
involved in a group midwifery practice, working through an Aboriginal Medical Service or hospital-based. Midwives in a hospital-
based setting may provide ongoing care and support to the family, seeking the advice of an in-house, psychiatrist and/or allied
health professional (e.g. mental health nurse, psychologist) and/or social worker as required. Midwives in other settings may refer
women to a GP or private mental health service providers.
• Obstetrics – For obstetricians in the public sector, referral pathways will usually be established with in-house social workers and
allied mental health clinicians. Women may be referred back to their GP if there is shared care. For obstetricians in private practice,
referral is likely to be to the woman’s GP or directly to a psychologist or a psychiatrist, depending on the individual situation and
availability. Only GPs and psychiatrists can provide a mental health care plan to access subsidised psychological care.
• Postnatal care – Most women will see a maternal and child health nurse in the postnatal period. In this setting, referral will likely be
to a GP for further referral for counselling or psychological assessment. A maternal and child health nurse may provide ongoing care
and support to the family, seeking the advice of a GP and/or allied mental health professional as required.
Addressing individual psychosocial risk factors is beyond the scope of this Guideline. In some situations, referral of women to other
agencies (e.g. child protection, alcohol and drug, family violence and other support services) may be necessary.
8.4 Supporting emotional health and wellbeing
8.4.1 Ongoing psychosocial support
Whether or not referral is required, primary and maternity care professionals have an ongoing role in the psychosocial care of women in
the perinatal period. Regular enquiry about emotional wellbeing provides a woman with opportunities for discussion about how she is
managing and allows health professionals to determine whether repeat depression screening or other assessments are indicated.
8.4.2 Lifestyle advice
All women in the perinatal period will benefit from advice on healthy diet in accordance with the Australian Dietary Guidelines (NHMRC
2013), physical activity and sleep patterns. During pregnancy or following the birth of a baby, these aspects of a woman’s life may be
disrupted and can contribute to impaired mental health. Lifestyle advice for the general population will need to be adapted to suit
the woman’s particular circumstances, taking into consideration the demands of the pregnancy or baby and other family needs. For
example, regardless of whether women follow healthy sleep habits, their nights will be disrupted during the early postnatal period
and they should be encouraged to take opportunities to rest during the day (e.g. when the baby is asleep). When specific advice
on nutrition is required (e.g. if there is excessive gestational weight gain), referral to an accredited practising dietitian may be a
consideration.
PRACTICE POINT
i. At every antenatal or postnatal visit, enquire about the woman's emotional wellbeing.
PRACTICE POINT
j. Provide women in the perinatal period with advice on lifestyle issues and sleep, as well as assistance in planning how this
advice can be incorporated into their daily activities during this time.
Australian Clinical Practice Guideline | 40
8.4.3 Electronic perinatal mental health support
There is emerging evidence of the efficacy of using e-mental health support in both prevention and treatment of perinatal mental
health difficulties (Danaher et al 2012; Danaher et al 2013; Milgrom et al 2016). There is a range of options, including apps to support
mental health and emotional wellbeing for individuals and couples during the perinatal period or for individuals who are experiencing
suicidal thoughts, feelings, distress or crisis; and moderated online forums where people can connect with others with similar
experiences and receive and provide advice and support. Many of these are provided by non-government organisations.
8.4.4 Psychological preparation for parenthood
Including psychological preparation for parenthood as a routine part of antenatal care has a positive effect on women’s mental
health postnatally (Australian Health Ministers' Advisory Council 2014). This type of education focuses on coping, problem-solving
and decision-making skills; recognising distress and seeking help; cognitive restructuring; and psychosocial issues associated with
parenthood.
8.5 Women with complex presentations
When a woman has comorbidities – such as more than one mental health condition, a significant maternal-fetal or medical condition,
challenging personality traits, major psychosocial stressors (e.g. adolescent pregnancy, poverty, family violence or substance use)
– inter-professional collaboration is strongly recommended.
There are several options for how this might take place, depending on the setting. In the public sector, multidisciplinary case-planning
meetings may be the most efficient approach. In the private sector, collaboration may take the form of a mental health treatment plan,
a chronic disease management plan, case conferencing and/or regular contact between health professionals.
Processes for monitoring outcomes and the continuing safety of the infant or family should be put in place, particularly when women
are at risk of loss to follow-up or there is a concern about risk to the infant or mother.
Practice summary — screening and assessment | 41
9 Practice summary –
screening and assessment
Before assessment
Antenatal period
Establish referral pathways
Assess for depressive symptoms
(EPDS)
Assess psychosocial risk factors
Provide lifestyle advice
Seek informed consent
Assess for anxiety symptoms
Enquire about emotional wellbeing
Assess maternal safety
Psychological preparation for
parenthood
Identify appropriate health professionals available to provide follow-up care and to assist if
there are concerns for the safety of the woman, fetus or infant
Identify other professionals from whom you can seek advice, clinical supervision or support
regarding mental health care in the perinatal period
As early as practical in pregnancy
As early as practical in pregnancy
At least once during pregnancy
When conducting EPDS
Every antenatal visit
Based on EPDS Q10 and clinical
judgement
At least once during pregnancy
Arrange further assessment for women with a score
of 13 or more
Repeat at least once in pregnancy and whenever
clinically indicated
Further explore psychosocial risk as needed
Focus on healthy eating, physical activity and sleep
hygiene
Refer to relevant items of the EPDS, DASS or K-10
Determine whether repeat assessments are required
Manage immediate risk and arrange specific
assessment
Focus on coping, problem-solving and
decision-making skills and psychosocial issues
Explain the purpose of the assessment and screening – emphasise that this is part of routine
care and results will generally remain confidential
Comments
When Actions
Australian Clinical Practice Guideline | 42
Postnatal period
Assess for depressive symptoms
(EPDS)
Assess for anxiety symptoms
Enquire about emotional wellbeing
Assess psychosocial risk factors
Assess mother–infant interaction
Assess infant safety
Assess maternal safety
Provide lifestyle advice
6–12 weeks after birth
When conducting EPDS
Every antenatal and postnatal visit
6–12 weeks after birth
Difficulties with mother-infant
interaction observed
At postnatal contacts
Based on EPDS Q10 and clinical
judgement
Early postnatal period
Arrange further assessment for women with a score
of 13 or more
Repeat at least once in the first postnatal year and
whenever clinically indicated
Refer to relevant items of the EPDS
Determine whether repeat assessments are required
Further explore psychosocial risk as needed
Manage immediate risk and refer for mother-infant
intervention
If there are concerns, consult with or refer to
appropriate specialist service
Manage immediate risk and arrange specific
assessment
Focus on healthy eating, physical activity and sleep
hygiene
When Comments
Part C –
Prevention
and treatment
This section outlines the current evidence on the effectiveness of
psychosocial, psychological, pharmacological and complementary
therapies in preventing and treating mental health conditions in the
perinatal period. For pharmacological, physical and complementary
therapies, information on potential harms to the fetus or infant is
also included. Interventions are defined in the Glossary.
Australian Clinical Practice Guideline | 44
10 General principles in prevention
and treatment
Approaches to prevention and treatment of specific mental health conditions are discussed in detail in Chapters 11 to 13. This chapter
outlines general principles in promoting emotional wellbeing.
10.1 Care planning
Care planning for a woman with a mental health condition in the perinatal period sets out (NICE 2015):
• the care and treatment for the mental health condition
• the roles of all healthcare professionals, including who is responsible for:
> coordinating the integrated care plan
> the schedule of monitoring
> providing the interventions and agreeing on the outcomes with the woman.
The healthcare professional responsible for coordinating the care plan should ensure that (NICE 2015):
• everyone involved in a woman’s care is aware of their responsibilities
• there is effective sharing of information with all services involved and with the woman herself
• mental health (including mental wellbeing) is taken into account as part of all care plans
• all interventions for mental health conditions are delivered in a timely manner, taking into account the stage of the pregnancy or age
of the baby.
10.1.1 Providing information and advice
All women should be given culturally relevant information on mental health problems in pregnancy and the postnatal period, including
their prevalence, risk factors and symptoms (NICE 2015).
Additional information provided to women with mental health conditions and their significant other(s) should include (NICE 2015):
• the potential benefits of psychological interventions and pharmacological treatment
• the possible consequences of no treatment
• the possible harms associated with treatment
• what might happen if treatment is changed or stopped, particularly if pharmacological treatments are stopped abruptly.
CONSENSUS-BASED RECOMMENDATION
xiii. Provide all women with information about the importance of enquiring about, and attending to, any mental health
problems that might arise across the perinatal period.
PRACTICE POINT
k. If a woman agrees, provide information to and involve her significant other(s) in discussions about her emotional
wellbeing and care throughout the perinatal period.
General principles in prevention and treatment | 45
PRACTICE POINT
l. Provide advice about the risk of relapse during pregnancy and especially in the early postpartum period to women who
have a new, existing or past mental health condition and are planning a pregnancy.
PRACTICE POINT
p. Discuss the potential risks and benefits of pharmacological treatment in each individual case with the woman and, where
possible, her significant other(s).
10.1.2 Preconception planning
Discussion with all women of childbearing potential who have a new, existing or past mental health condition should cover (NICE 2015):
• the use of contraception and any plans for a pregnancy
• how pregnancy and childbirth might affect a mental health condition, including the risk of relapse
• how a mental health condition and its treatment might affect the woman, the fetus and baby
• how a mental health condition and its treatment might affect parenting.
10.1.3 Planning care for women with severe mental illness
There are specific considerations in planning care for women with severe mental illness, with priority being given to ensuring that
mental health professionals involved in their care take into account the complexity of these conditions and the challenges of living with
severe mental illness. Where available, involvement of specialist perinatal mental health services is advisable.
10.2 Use of pharmacological treatments
While approaches to the pharmacological prophylaxis and treatment of mental health conditions during the perinatal period are not
likely to differ from approaches at other times, the potential for harm to the fetus and the breastfed infant must be carefully balanced
with the potential harm to mother and fetus or infant if the mother remains untreated. In view of this, medications should only be
prescribed after careful deliberation with the woman (and her significant other[s]). Ongoing monitoring and evaluation will be required.
It should be noted that the information on pharmacological treatments in this section is based on the best available evidence, up to
September 2016 (the cut-off for the systematic literature review conducted for this Guideline). The evidence base is evolving as new
research frequently emerges.
10.2.1 Quality of the evidence
The evidence on harm to the fetus from pharmacological treatments is of low to very low quality as it is beset by methodological
limitations, the greatest being reliance on observational studies (as RCTs cannot be conducted on ethical grounds in pregnant women).
Other limitations include: a lack of adequate comparison groups (e.g. an unmedicated depressed group); study samples being
heterogeneous and underpowered; and significant risk of bias and imprecision in outcome measures.
10.2.2 Discussing risks and benefits
Whenever pharmacological treatment is prescribed to women who are planning a pregnancy, pregnant or breastfeeding, a risk/benefit
analysis needs to be performed with consideration given to the risks for the mother as well as the risks to the fetus, and the risks to
either of non-treatment.
PRACTICE POINT
m. For women with schizophrenia, bipolar disorder or borderline personality disorder, a multidisciplinary team approach to
care in the perinatal period is essential, with clear communication, advance care planning, a written plan, and continuity
of care across different clinical settings.
n. Wherever possible, assessment, care and treatment of the mother should include the baby.
o. Where possible, health professionals providing care in the perinatal period should access training to improve their
understanding of care for women with schizophrenia, bipolar disorder and borderline personality disorder.
Australian Clinical Practice Guideline | 46
Discussion about the possible risks of mental health conditions or the benefits and harms of treatment in pregnancy and the postnatal
period should include the following, depending on individual circumstances (NICE 2015):
• the likely benefits of each treatment, taking into account the severity of the mental health condition
• the woman’s response to any previous treatment
• the background risk of harm to the woman and the fetus or baby associated with maternal mental health conditions and the risk to
mental health and parenting associated with no treatment
• the possibility of the sudden onset or relapse of symptoms of mental health conditions in pregnancy and the postnatal period,
particularly in the first few weeks after childbirth (e.g. in women with bipolar disorder)
• the risks or harms to the woman and the fetus or baby associated with each treatment option
• the need for prompt instigation of treatment and monitoring for treatment response because of the potential effect of an untreated
mental health condition on the fetus or baby and woman’s ability to transition optimally to the parenting role
• the risk of harm to the woman and the fetus or baby associated with stopping or changing a treatment
• the side effects of any medication taken by the woman (especially those that increase the risk of gestational diabetes due to weight
gain).
When discussing the benefits and risks of treatment with a woman and her significant other(s) (NICE 2015):
• acknowledge the woman’s central role in reaching a decision about her treatment and that the role of the professional is to inform
that decision with balanced and up-to-date information and advice
• use absolute risk values based on a common denominator (that is, numbers out of 100 or 1,000) rather than relative risk values to
more accurately reflect risk to the woman
• acknowledge and describe, if possible, the uncertainty around any estimate of risk, harm or benefit
• use high-quality decision aids in a variety of numerical and pictorial formats that focus on a personalised view of the risks and
benefits
• consider providing records of the consultation, in a variety of visual, verbal or audio formats, to the woman, her significant other(s)
and other health professionals involved in her care.
10.2.3 Planning for breastfeeding
Breastfeeding should be discussed with women who may need pharmacological treatment in pregnancy or in the postnatal period
(NICE 2015). This may include the benefits of breastfeeding, the potential risks associated with taking medication when breastfeeding
and with stopping some medications in order to breastfeed.
PRACTICE POINT
q. Ensure that women are aware of the risks of relapse associated with stopping medication and that, if a medication is
ceased, this needs to be done gradually and with advice from a mental health professional.
PRACTICE POINT
r. Discuss treatment (medication and psychological) options that would enable a woman to breastfeed if she wishes and
support women who choose not to breastfeed.
General principles in prevention and treatment | 47
10.2.4 Pharmacological treatment during pregnancy
Information about specific mental health conditions and their pharmacological treatments is included in Chapters 11 to 13. This section
provides guidance on specific considerations in the use and monitoring of effects of pharmacological treatments in pregnancy.
When pharmacological treatment is started in the perinatal period, considerations include (NICE 2015):
• seeking advice, preferably from a specialist in perinatal mental health
• choosing the medication with the lowest risk profile for the woman, fetus and baby, taking into account a woman’s previous
response to medication and changes in pharmacodynamics in pregnancy, which may necessitate dose adjustment
• using the lowest effective dose (this is particularly important when the risks of adverse effects to the woman, fetus and baby may be
dose-related), but note that sub-therapeutic doses may lead to ineffective treatment of the mental health episode
• use a single drug, if possible, in preference to two or more drugs
• take into account that dosages may need to be adjusted in pregnancy.
10.3 Postnatal care and support
10.3.1 Observation of the newborn
Due to the risk of poor neonatal adaptation syndrome associated with the use of some pharmacological treatments in pregnancy,
monitoring of exposed newborns is required.
10.3.2 Support in the early postnatal period
The early postnatal period is a time of emotional change for most women. Some women may experience distress or symptoms of
depression if they feel overwhelmed and unable to manage. They may also experience disappointment and grief if something has gone
wrong or their expectations of the pregnancy and birth are not realised. Early intervention, in the form of support or specific care, can
help women to adjust and prevent more serious mental health conditions from developing. The early postnatal period is also the time
when symptoms of postpartum psychosis emerge.
Women with severe mental illness may find the early postnatal period particularly distressing for many reasons, particularly as their
bond with the baby may be compromised. Ensuring partner, family or paid (e.g. nanny) support is important, particularly overnight so
the woman can sleep. Sleep deprivation is a common trigger for relapse so prevention is worthwhile.
As there is a risk of major malformation associated with the use of some antipsychotics and anticonvulsants in the first trimester (see
Chapter 12), it is important that the 18–20 week ultrasound is conducted so that major malformations may be identified. This enables
women and their significant other(s) to consider their options (e.g. receive counselling regarding the option of termination) and plan for
additional care if the pregnancy continues (e.g. specialist management of the pregnancy and the baby).
PRACTICE POINT
s. Ideally, treatment with psychoactive medications during pregnancy would involve close liaison between a treating
psychiatrist or, where appropriate, the woman’s GP and her maternity care provider(s). In more complex cases, it is
advisable to seek a second opinion from a perinatal psychiatrist.
PRACTICE POINTS
t. When exposure to psychoactive medications has occurred in the first trimester – especially with anticonvulsant
exposures – pay particular attention to the 18–20 week ultrasound due to the increased risk of major malformation.
u. Plan for pharmacological review in the early postpartum period for woman who cease psychotropic medications during
pregnancy.
CONSENSUS-BASED RECOMMENDATION
xiv. Arrange observation of infants exposed to psychoactive medications in pregnancy for the first three days postpartum.
Australian Clinical Practice Guideline | 48
Women with borderline personality disorder are especially likely to have difficulties in the emotional care of the infant and will benefit
from programs from early infancy to promote attachment, improve parenting sensitivity and reduce the risk of poor child outcomes
(Newman 2015).
10.3.3 Women requiring hospital care in the postnatal period
The early postnatal period is a time when relapse of severe mental health conditions is common and when some women who have
not previously had symptoms experience postpartum psychosis. When symptoms are severe enough to warrant hospital admission,
co-admission with the baby will assist with the development of mothercraft skills and a positive relationship with the baby. This
approach may not be appropriate for women who are severely unwell and incapable of caring for the baby and/or the safety of the
baby may be compromised.
As the number of specialised mother-baby units in Australia is limited, health services should prioritise their establishment.
PRACTICE POINTS
v. In planning postnatal care for women with schizophrenia, bipolar disorder, severe depression or borderline personality
disorder, take a coordinated team approach to parent and infant mental health care and pre-arrange access to intensive
maternal child health care.
w. When caring for mothers with severe mental illness, including borderline personality disorder, it is important to ensure
that child protection risks are understood and addressed, if necessary.
CONSENSUS-BASED RECOMMENDATION
xv. If a mother with a severe postnatal episode requires hospital admission, avoid separation from her infant with
co-admission to a specialist mother-baby unit where facilities are available and appropriate.
Depressive and anxiety disorders | 49
11 Depressive and anxiety disorders
A range of psychosocial, psychological and pharmacological therapies have been evaluated for their effect in preventing and treating
depressive and anxiety disorders in the perinatal period. This section summarises the current evidence on therapies that have been
found to be effective.
11.1 Women at risk of depressive or anxiety disorders
Among psychosocial and psychological approaches to preventing depressive and anxiety disorders in the perinatal period that have
been evaluated, many appear to have no preventive effect (low to high quality). Those that have shown some preventive effect are:
• psychoeducation that is informed by psychological principles and uses techniques from cognitive behavioural therapy (CBT) and
interpersonal psychotherapy (IPT) (individual or face-to-face) (low quality; NICE 2015)
• mindfulness-based cognitive therapy among pregnant women with a history of severe depression who are not currently depressed
(Dimidjian et al 2016).
11.2 Women with mild to moderate depression or anxiety
11.2.1 Psychosocial support
Psychoeducation
Structured psychoeducation improves depression symptoms among women in the perinatal period (high quality; NICE 2015).
Physical activity
Among pregnant women with a diagnosis of depression, integrated yoga (with Tai Chi) may improve depression mean scores (very low
quality; Gong et al 2015).
Among women in the postnatal period with symptoms of depression, physical activity (e.g. pram walking exercise program) may
improve depression mean scores (very low quality; NICE 2015).
11.2.2 Psychological approaches
Individual structured psychological interventions
Individual structured psychological interventions (CBT or IPT) in the perinatal period reduce depression diagnosis (high quality) and
depression mean scores (moderate quality) and may improve depression symptoms (low quality) among women with symptoms or a
diagnosis of depression (NICE 2015).
Social support
Involvement in a social support group may improve depression symptoms among women in the postnatal period (low quality; NICE
2015).
EVIDENCE-BASED RECOMMENDATION STRONG
4. Provide structured psychoeducation to women with symptoms of depression in the perinatal period.
EVIDENCE-BASED RECOMMENDATION CONDITIONAL
5. Advise women with symptoms of depression in the postnatal period of the potential
benefits of a social support group.
EVIDENCE-BASED RECOMMENDATION STRONG
6. Recommend individual structured psychological interventions (cognitive behavioural therapy or
interpersonal psychotherapy) to women with mild to moderate depression in the perinatal period.
Australian Clinical Practice Guideline | 50
Facilitated self-help versus treatment as usual
Facilitated self-help based on cognitive behavioural principles and using a workbook or internet delivery with online or telephone
support for women with symptoms of depression (NICE 2015):
• may improve anxiety symptoms during pregnancy (very low quality)
• improves depression mean scores in the postnatal period (high quality)
• may improve depression symptoms in both pregnancy and the postnatal period (very low quality).
Post-traumatic birth counselling
Among women in the postnatal period with a diagnosis of post-traumatic stress disorder (PTSD), individual post-traumatic birth
counselling may improve depression symptoms and PTSD mean scores (low quality; NICE 2015).
Mother–infant relationship interventions versus treatment as usual or enhanced treatment as usual
Among women with depression, individual mother–infant interventions may improve mother–infant attachment problems (very low
quality) and mother-infant behavior management problems (low quality; NICE 2015).
11.2.3 Complementary therapies
Omega-3 fatty acids
Omega-3 fatty acid supplements do not appear to improve depression symptoms (very low quality; NICE 2015). However, there is no
evidence of harms to the fetus when they are taken during pregnancy, with risk of early preterm birth (<34 weeks) (moderate quality)
and preterm birth (<37 weeks) slightly reduced (high quality; Kar et al 2016) and no association with increased risk of intrauterine
growth restriction (moderate quality) (Saccone et al 2015). Taken during pregnancy and breastfeeding, these supplements did not
reduce cognitive, language or motor development in the infant or child (Gould et al 2013). There was no evidence for an increased risk
of postpartum haemorrhage in the studies assessed.
Directive counselling
Among women in the postnatal period with a diagnosis of depression, directive counselling – which includes supportive listening,
problem-solving and goal setting – may improve depression and anxiety symptoms (low quality; NICE 2015).
CONSENSUS-BASED RECOMMENDATION
xvi. Advise women with symptoms of depression in the perinatal period of the potential benefits of facilitated self-help.
CONSENSUS-BASED RECOMMENDATION
xvii. Advise women with diagnosed post-traumatic stress disorder of the potential benefits of post-traumatic birth
counselling if they are experiencing depressive symptoms.
CONSENSUS-BASED RECOMMENDATION
xviii. For women who have or are recovering from postnatal depression and are experiencing mother–infant relationship
difficulties, consider provision of or referral for individual mother–infant relationship interventions.
EVIDENCE-BASED RECOMMENDATION CONDITIONAL
7. Advise women with depression or anxiety disorder in the postnatal period of the possible
benefits of directive counselling.
EVIDENCE-BASED RECOMMENDATION CONDITIONAL
8. Advise women that omega-3 fatty acid supplementation does not appear to improve depression
symptoms but is not harmful to the fetus or infant when taken during pregnancy or while breastfeeding.
Depressive and anxiety disorders | 51
St John’s Wort
No evidence was identified on the effectiveness of St John’s Wort in treating depression in the perinatal period and no conclusions
on its safety could be drawn due to the inadequate quality of the evidence. St John’s Wort is known to interact with SSRIs (increased
serotonergic effects) and anticonvulsants (reduced blood levels) (TGA 2001).
Ginkgo biloba
No evidence was identified on either the effectiveness of Gingko biloba in treating depression in the perinatal period or on potential
harms to the fetus.
Acupuncture
There is very low quality evidence that depression-specific acupuncture is more effective than non-depression-specific acupuncture in
improving response to treatment (NICE 2015).
11.3 Women with moderate to severe depressive or anxiety disorder
For many women with moderate to severe anxiety or depressive disorders, the first-line treatment is likely to be pharmacological, with
psychological therapies introduced once medication(s) have become effective.
11.3.1 Pharmacological treatments
Antidepressants during pregnancy
There is high quality RCT evidence of the efficacy of antidepressants in the treatment of depression and anxiety in the general
population (NICE 2009; updated 2016). The evidence on their specific effectiveness in pregnancy is limited (but is not expected to be
any different to that in the general population) and, while any increases in absolute risk of less optimal birth outcomes or harm to fetus
are small, the quality of evidence is poor (see also Section 10.2.1).
Neonatal mortality
First trimester use of selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs) does not appear to be
associated with an increased risk of neonatal mortality (very low quality; Ban et al 2012).
Major or cardiac malformations
Use of SSRIs in the first trimester is not associated with major (Simon et al 2002; Ban et al 2014; Berard et al 2015) or cardiac (Margulis
et al 2013; Ban et al 2014; Huybrechts et al 2014; Berard et al 2015; Furu et al 2015; Petersen et al 2016) malformations (very low
quality). There does not appear to be an association between major malformation in the newborn and first trimester use of TCAs (very
low quality; Simon et al 2002; Ramos et al 2008; Ban et al 2014) or venlafaxine (very low quality; Oberlander et al 2008a).
Small-for-gestational age
There does not appear to be an association between use of SSRIs at any time during pregnancy and the newborn being small for
gestational age (low quality; Oberlander et al 2006).
Miscarriage and preterm birth
The risk of miscarriage is increased with use of SSRIs or SNRIs in the first 20 weeks of pregnancy and first trimester use of TCAs (low
quality; Ban et al 2012; Almeida et al 2016). Assessment of the evidence on individual SSRIs found an association between increased
risk of miscarriage and paroxetine (low quality) but not fluoxetine, sertraline or fluvoxamine (very low quality; Nakhai-Pour et al 2010).
SSRI use in late pregnancy is associated with a slight increase in risk of preterm birth (low quality; Grzeskowiak et al 2012).
CONSENSUS-BASED RECOMMENDATION
xix. Advise pregnant women that the evidence on potential harms to the fetus from St John’s Wort is limited and uncertain
and that use of this treatment during pregnancy is not recommended.
CONSENSUS-BASED RECOMMENDATION
xx. Advise pregnant women that potential harms to the fetus from Gingko biloba have not been researched, and that use
of this treatment during pregnancy is not recommended.
Australian Clinical Practice Guideline | 52
Neonatal outcomes
There are small increases in absolute risk associated with use of SSRIs for:
• convulsions in the newborn (low quality; Hayes et al 2012)
• persistent pulmonary hypertension in the newborn (low quality; Huybrechts et al 2015)
• respiratory distress or difficulty in the newborn (very low quality; Malm et al 2015)
• poor neonatal adaptation syndrome with use in the third trimester compared with use of SNRIs in the same period (very low quality;
Kieviet et al 2015).
Childhood neurobehavioural outcomes
Maternal use of SRIs during pregnancy does not appear to be associated with reduced IQ or increased risk of behavioural problems in
children aged 3–6 years (very low quality; Nulman et al 2015).
Maternal birth outcomes
Maternal use of SSRIs, SRIs and serotonin-norepinephrine reuptake inhibitor (SNRIs) at any time during pregnancy appears to be
associated with increased risk of postpartum haemorrhage (inadequate to very low quality; Jiang et al 2016).
Antidepressants in the postnatal period
There is high quality evidence for efficacy of antidepressants in the general population (NICE 2009; updated 2016). Compared to
placebo, treating postnatal depression with an SSRI is associated with good response and remission in a significant proportion of
women at 6–8 weeks post-treatment. Effectiveness does not differ significantly between SSRIs and TCAs (Molyneaux et al 2014; NICE
2015).
Compared to fetal exposure during pregnancy, exposure to SSRIs and TCAs through breast milk is very low and there is an even greater
need to treat depression postnatally (given its effect on the woman’s ability to care for the infant and on mother–infant attachment).
If SSRIs are prescribed, consider the woman’s past response to SSRI treatment and whether she has risk factors for miscarriage (e.g.
thyroid dysfunction) or preterm birth (e.g. previous preterm birth, active smoking during pregnancy), factors that may increase risk of
postpartum haemorrhage and the half-life of the treatment (e.g. risk of poor neonatal adaptation syndrome is increased with SSRIs
with a short half-life such as paroxetine).
The effects of exposure to SSRIs may be increased in preterm or otherwise unwell infants.
EVIDENCE-BASED RECOMMENDATION CONDITIONAL
9. Consider the use of SSRIs as first-line treatment for moderate to severe depression and/or
anxiety in pregnant women.
EVIDENCE-BASED RECOMMENDATION STRONG
10. Use SSRIs as first-line treatment for moderate to severe depression in postnatal women.
PRACTICE POINT
x. Before choosing a particular SSRI for pregnant women, consider the woman’s past response to SSRI treatment, obstetric
history (e.g. other risk factors for miscarriage or preterm birth) and any factors that may increase risk of adverse effects.
PRACTICE POINT
y. Before prescribing SSRIs to women who are breastfeeding, consider the infant’s health and gestational age at birth.
Depressive and anxiety disorders | 53
Benzodiazepines and non-benzodiazepine hypnotics
Benzodiazepines are an accepted treatment for anxiety symptoms and panic attacks in the general population. There is evidence that
their use in pregnancy is not associated with increased risk of major malformation in the newborn (very low quality; Oberlander et al
2008b). There is uncertainty about the association with other outcomes due to the inadequate quality of the evidence.
11.3.2 Psychological interventions
The evidence on effective psychological therapies is summarised in Section 11.2.2.
There is evidence of an increased risk of respiratory difficulty in the newborn following repeated late pregnancy exposure to
long-acting benzodiazepines (very low quality; Wikner et al 2007). The risk of poor neonatal adaptation syndrome is increased with
use of benzodiazepines with short-acting or long-acting benzodiazepines (due to accumulation).
There is a lack of evidence regarding potential harms to the fetus associated with the use of non-benzodiazepine hypnotics (z-drugs)
in pregnant women.
Antihistamines
CONSENSUS-BASED RECOMMENDATION
xx. Consider the short-term use of benzodiazepines for treating moderate to severe symptoms of anxiety while awaiting
onset of action of an SSRI or TCA in pregnant or postnatal women.
CONSENSUS-BASED RECOMMENDATION
xxii. Advise women with moderate to severe anxiety and depressive disorders that psychological interventions are a useful
adjunct, usually once medications have become effective.
PRACTICE POINT
z. Use caution in repeated prescription of long-acting benzodiazepines around the time of the birth.
PRACTICE POINT
aa. Use caution in prescribing non-benzodiazepine hypnotics (z-drugs) to pregnant women for insomnia.
PRACTICE POINT
bb. Doxylamine, a Category A drug in pregnancy, may be considered for use as a first-line hypnotic in pregnant women who
are experiencing moderate to severe insomnia.
Australian Clinical Practice Guideline | 54
12 Severe mental illnesses:
schizophrenia, bipolar disorder
and postpartum psychosis
This chapter provides guidance specific to schizophrenia, bipolar disorder and postpartum psychosis. It should be read in conjunction
with the advice in Chapter 10, which includes general principles on prevention and treatment.
12.1 Preconception planning
Preconception planning should start at diagnosis of a severe mental illness among women of childbearing age. Many of these women
will have poor health literacy and will need clear explanations of the importance of contraception if the woman is not planning a
pregnancy, the effects of some medications on fertility, the risk of relapse in pregnancy or after the birth (particularly if medications are
stopped) and the complexities of raising a child in the context of severe mental illness. These comments are particularly applicable to
women with schizophrenia and more severe bipolar disorder.
Preconception planning should include discussion of pharmacological treatments to be used after the birth, which will involve
decision-making by the woman about whether she will breastfeed (e.g. if it is planned that lithium be used postnatally).
12.2 Considerations in providing antenatal and postnatal care
12.2.1 Antenatal care
In addition to the general principles outlined in Chapter 10, key considerations in providing antenatal care to women with severe mental
illness include:
• monitoring for early signs of relapse, particularly as medication is often ceased (by the woman and/or her doctor) before or during
pregnancy
• education about nutrition and ceasing smoking, illicit substance use and alcohol intake in pregnancy
• monitoring for excessive weight gain and gestational diabetes in women taking antipsychotics, with consideration given to referral to
an appropriate health professional if excessive weight gain is identified
• referral for multi-dimensional care planning early enough in the pregnancy (particularly if the pregnancy is unplanned) to build
trusting relationships and develop a safety net for mother, baby and significant others.
12.2.2 Postnatal care
Careful monitoring is required in the first month after birth for women with severe mental illness, especially those with bipolar disorder,
with regular review in the following months. Sleep preservation is an important consideration.
If relapse of severe mental illness occurs, co-admission to a mother and baby unit is recommended. In some instances, it may be
necessary for women to cease breastfeeding if they are too unwell, require night-time sedation, or sleep disruption (to feed the infant)
would have an adverse effect on their mental state.
Access to specialist intervention to support parenting skills, including the role of partners and significant others, and attend to the
mother-infant attachment is a consideration for women with severe mental illness and their families. Such an approach can best be
taken in specialist mother-baby units, however, availability of publicly funded mother-baby units that cater to both the woman and her
baby is variable across Australian jurisdictions.
12.3 Psychosocial and psychological treatments
Psychoeducation and supportive therapy that includes family and significant others is most important for women with severe mental
illness. CBT and other psychological interventions (see Section 11.2) can be beneficial in managing secondary depression or anxiety,
which are frequently associated with severe mental illness.
Severe mental illnesses: schizophrenia, bipolar disorder and postpartum psychosis | 55
12.4 Pharmacological therapies
12.4.1 Antipsychotics
Antenatal period
There is high quality RCT evidence of efficacy of antipsychotics in the general population (NICE 2014; NICE 2014; updated 2016) and
it is important to appropriately treat antenatal psychosis. Compared to SSRIs, the evidence base for use of antipsychotics (as a class
of drugs) in pregnancy is still very limited. Based on low to very low quality evidence, antipsychotics (as a whole) in pregnancy do not
appear to be associated with adverse pregnancy or neonatal outcomes or birth defects (Lin et al 2010; Huybrechts et al 2016).
The available evidence for specific antipsychotics, suggests that:
• first-trimester use of risperidone may be associated with an increase in absolute risk of major malformation and cardiac
malformation (low quality; Huybrechts et al 2016)
• there may be an association between increased absolute risk of miscarriage and use of flupenthixol or quetiapine just prior to or
during pregnancy (very low quality; Sorensen et al 2015).
Weight gain is associated with most antipsychotics, particularly olanzapine, in the general (non-pregnant) population and the use of
such agents during pregnancy increases the risk of gestational diabetes (OR 2.32 [1.53 to 3.52]) (NICE 2015) with consequent negative
impacts on the newborn (e.g. high birthweight) and the woman’s reproductive health (e.g. increased risk of gestational diabetes in
subsequent pregnancies).
Clozapine crosses the placenta, which may increase the risk of agranulocytosis in the newborn (Mehta & Van Lieshout 2017).
Postnatal period
The evidence on the safety of clozapine in breastfeeding women is limited.
EVIDENCE-BASED RECOMMENDATION CONDITIONAL
11. Consider the use of antipsychotics for treating psychotic symptoms in pregnant women.
CONSENSUS-BASED RECOMMENDATIONS
xxiii. Use caution when prescribing any antipsychotic to pregnant women, particularly for women with a propensity for weight
gain and metabolic syndrome.
xxiv. If women commence or continue antipsychotic treatment during pregnancy, monitor them for excessive weight gain and
the development of gestational diabetes and refer them for advice on weight management as required.
CONSENSUS-BASED RECOMMENDATION
xxv. Do not initiate use of clozapine in pregnant women.
PRACTICE POINT
cc. Use clozapine with caution in women who are breastfeeding and monitor the infant’s white blood cell count weekly for the
first six months of life.
Australian Clinical Practice Guideline | 56
12.4.2 Anticonvulsants
While anticonvulsants are used in the treatment of bipolar disorder in the general population (Malhi et al 2015), most of the information
on their safety profile in pregnancy is in epileptic women.
Preconception
There is a risk of major malformation if conception occurs while a woman is taking anticonvulsants (Weston et al 2016). Several of these
medications are folate antagonists.
Antenatal period
There is evidence of substantial increases in absolute risk of major malformation and cardiac malformation in the newborn (Weston
et al 2016) and adverse cognitive outcomes in the child (e.g. increased risk of below average intelligence quotient [IQ]) (Bromley et al
2014) (very low to low quality) associated with the use of sodium valproate in pregnancy.
There is evidence that use of carbamazepine during pregnancy may be associated with an increased risk of major malformation in the
newborn (very low quality; Weston et al 2016) and uncertainty about whether lamotrigine may also have an association with increased
risk of birth defects.
Postnatal period
Due to the need to treat symptoms in the postnatal period (i.e. due to their potential effect on the woman’s ability to care for the infant
and on mother–infant attachment), consideration may be given to prescribing anticonvulsants for bipolar disorder. There is uncertainty
about the passage into breastmilk of some anticonvulsants (e.g. lamotrigine) and adverse effects in the infant.
PRACTICE POINTS
dd. Given their teratogenicity, only consider prescribing anticonvulsants (especially valproate) to women of child-bearing age
if effective contraception is in place.
ee. Once the decision to conceive is made, if the woman is on valproate wean her off this over 2–4 weeks, while adding in
high-dose folic acid (5 mg/day) which should continue for the first trimester.
EVIDENCE-BASED RECOMMENDATION STRONG
12. Do not prescribe sodium valproate to women of childbearing age.
CONSENSUS-BASED RECOMMENDATION
xxvi. Use great caution in prescribing anticonvulsants as mood stabilisers for pregnant women and seek specialist psychiatric
consultation when doing so.
CONSENSUS-BASED RECOMMENDATION
xxvii. If anticonvulsants are prescribed to a woman who is breastfeeding, arrange close monitoring of the infant and specialist
neonatologist consultation where possible.
Severe mental illnesses: schizophrenia, bipolar disorder and postpartum psychosis | 57
12.4.3 Lithium
Antenatal period
Maternal lithium requirements increase as pregnancy progresses, so monitoring of levels is advised and dose adjustment may be
required. There is evidence that first trimester use of lithium in pregnancy may be associated with an increased risk of cardiac
malformation in the newborn (very low quality; Diav-Citrin et al 2014).
Postnatal period
There is potential for high passage of lithium into breastmilk and risk of infant toxicity.
There is a sudden increase in lithium level at parturition as the woman’s fluid balance shifts and returns to pre-pregnancy levels.
CONSENSUS-BASED RECOMMENDATION
xxviii. If lithium is prescribed to pregnant women, ensure that maternal blood levels are closely monitored and that there is
specialist psychiatric consultation.
CONSENSUS-BASED RECOMMENDATION
xxix. Where possible, avoid the use of lithium in women who are breastfeeding.
PRACTICE POINT
ff. If lithium is prescribed to a pregnant woman, reduce the dose just prior to the onset of labour and aim to recommence
treatment immediately after the birth at a pre-pregnancy dose.
Australian Clinical Practice Guideline | 58
13 Borderline personality disorder
Borderline personality disorder is a long-term, complex condition that waxes and wanes, has broad impact on socio-occupational
function (especially parenting) and has substantial treatment and prognostic implications (NHMRC 2012). Borderline personality
disorder often co-exists with depression, anxiety and substance use disorders. It can also be very difficult to differentiate borderline
personality disorder from bipolar and post-traumatic stress disorders (NHMRC 2012). There is significant overlap between borderline
personality disorder and bipolar disorder type 2 in terms of affective instability and impulsivity; however they remain distinct disorders
(Henry et al 2001).
Borderline personality disorder is associated with high levels of morbidity and mortality (lifetime rates of approximately 70% for acts of
self-injury, 80% for suicide attempts and 10% for suicide) (Kroger et al 2011). There is growing consensus that emotional dysregulation
(also referred to as affective instability; see Section 1.2.3) is a core feature of borderline personality disorder, and was found to be the
one DSM-III-R criterion distinguishing individuals with borderline personality disorder from those without (Clifton & Pilkonis 2007).
Women with emotional dysregulation will find parenting very challenging (see Section 13.1.3). It is also clear that there are significant
risks for children of women with borderline personality disorder of the inadvertent intergenerational transfer of mental health problems
from mother to child (Eyden et al 2016).
The label ‘borderline personality disorder’ should be used with caution as it often has negative connotations (especially for health
professionals) and may be associated with substantial stigma. Conversely, it is important to identify women with such a condition, as
they, their family and treating health professionals will need additional resources and support over the perinatal period and beyond.
13.1 Considerations in providing antenatal and postnatal care
Women who have borderline personality disorder have often experienced sexual, physical or emotional abuse or neglect in childhood.
In addition to emotional dysregulation, their behaviour is characterised by efforts to overcome their fear of abandonment; intense and
unstable relationships; engaging in impulsive activities (e.g. substance use); talking about or engaging in self-harm and/or suicidal
behaviours; inappropriate, intense anger or difficulty controlling anger; and transient, stress-related paranoid ideation or severe
dissociative symptoms. These symptoms are particularly difficult to manage in the primary health care setting and the behaviours
targeted at staff may make it difficult for health professionals to work optimally with them. Continuity of carer (the same person or
small group of people) is likely to be helpful for women with this condition.
13.1.1 Preconception planning
While in Australia borderline personality disorder is becoming better recognised, formally diagnosed and discussed with women,
many women with emotional dysregulation and/or their treating health professionals may not be aware that the diagnosis makes
preconception planning challenging. A first step may be a diagnostic discussion when there is clarity that this approach is likely to be
therapeutic.
Multidisciplinary care
As borderline personality disorder is associated with several adverse obstetric and neonatal outcomes (see Section 1.2.3), women with
the disorder should be monitored closely by a multidisciplinary health care team before and during their pregnancies (Pare-Miron et
al 2016). This approach would aim to optimise management of challenging symptoms and behaviours and address the frequency of
comorbid substance misuse and other conditions.
Planning for support during and after pregnancy
Considerations in preconception planning include the woman’s capacity for parenting, her support network and other support available
in the antenatal period, the need for additional support and parenting interventions in the postnatal period (see Section 13.1.3) and
treatment to assist in managing emotional dysregulation and preparing for pregnancy and parenting (see Section 13.2).
PRACTICE POINT
gg. For women with borderline personality disorder who have often experienced complex trauma, trauma-informed care and
specific support for health professionals in dealing with challenging behaviours is a priority.
PRACTICE POINT
hh. Advise women with borderline personality disorder who are planning a pregnancy, of the additional challenges of
parenting associated with their emotional dysregulation, and the importance of ongoing support during and after
pregnancy.
Borderline personality disorder | 59
13.1.2 Antenatal care
Health professionals involved in the antenatal care of women with borderline personality disorder should be aware that women who
have experienced physical or sexual abuse or complex traumas may experience distress when touched (e.g. when vaginal examination
is conducted), that birth may be anticipated as traumatic and that early or caesarean delivery is frequently requested. The woman’s
emotional dysregulation may cause distress for herself, her family and treating health professionals. A team approach for all health
professionals involved in a woman’s care, with good open regular communication, is likely to be beneficial to her care.
13.1.3 Postnatal care
The early postnatal period can be particularly distressing for women with borderline personality disorder as they may find normal infant
crying intrusive and unsettling. Issues arising for women with borderline personality disorder in the perinatal period reflect possible
unresolved early trauma (Newman 2015).
Women with borderline personality disorder are more likely to have difficulties in the emotional care of the infant and in promoting
secure attachment (Newman 2015) (see Section 10.1.3). These mothers are also more likely than others to have experienced sexual
trauma and exploitation in relationships and to be experiencing domestic violence (Newman 2015).
Intensive maternal and child health care (i.e. maternal and child health care for families requiring additional support) is advisable
and targeted mother–infant therapy (individual or with a group of women with similar requirements for help with their emotional
dysregulation) may be considered after other more acute symptoms are controlled. It is important to ensure that child protection risks
are understood and addressed, if necessary.
13.2 Psychosocial support and psychological treatments
Psychological and psychosocial therapies are the preferred treatment for borderline personality disorder.
13.2.1 Psychological therapies
A range of structured psychological therapies have been evaluated in the treatment of borderline personality disorder in the general
population (NHMRC 2012; Cristea et al 2017). These include CBT, IPT, dialectical behaviour therapy (DBT), mentalisation-based therapy
(MBT), schema-focussed psychotherapy (SFT), systems training for emotional predictability and problem solving (STEPPS) and
transference-focussed psychotherapy (TFP).
DBT is effective in treatment of borderline personality disorder, with effects including a decrease in inappropriate anger, a reduction
in self-harm and an improvement in general functioning (Stoffers et al 2012). While other treatments have been less evaluated, overall
findings support a substantial role for psychotherapy in treating borderline personality disorder.
In clinical trials, the duration of treatment for borderline personality disorder ranged from 13 weeks to several years (NHMRC 2012). In
clinical practice, some therapies (e.g. DBT) are usually continued for substantially longer periods.
13.2.2 Psychosocial support
While specialist psychological treatments are the preferred treatment for borderline personality disorder, these take time to have an
effect and other more generic psychological approaches are also required so that women are assisted in managing their emotional
dysregulation and are better prepared for pregnancy and early parenthood.
CONSENSUS-BASED RECOMMENDATION
xxx. Where possible and appropriate, provide women with borderline personality disorder with structured psychological
therapies that are specifically designed for this condition and conducted by adequately trained and supervised health
professionals.
PRACTICE POINT
ii. Encourage pregnant or postnatal women with borderline personality disorder to undertake mindfulness and/or relaxation
training to assist in managing their emotional dysregulation.
Australian Clinical Practice Guideline | 60
13.3 Pharmacological treatments
Overall, pharmacological treatments do not appear to be effective in altering the nature and course of borderline personality disorder
(NHMRC 2012). However, they may be useful in the short-term in controlling more acute symptoms.
The risks associated with the use of pharmacological treatments in the perinatal period is discussed in Sections 10.2 (general
principles), 11.3.1 (antidepressants and benzodiazepines) and 12.3 (mood stabilisers and antipsychotics). In addition to these risks, if a
pharmacological treatment is prescribed to a woman with borderline personality disorder, consideration should be given to avoiding
medications that may be lethal in overdose (because of the high risk of suicide) or are associated with substance dependence.
CONSENSUS-BASED RECOMMENDATION
xxxi. As far as possible, do not use pharmacological treatments as the primary therapy for borderline personality disorder,
especially in pregnant women.
Electroconvulsive therapy | 61
14 Electroconvulsive therapy
Electroconvulsive therapy (ECT) is a safe and effective treatment for the more severe forms of depression10. In practice, it is usually
reserved for people who have not responded to several trials of medication. ECT is recommended as first-line treatment in severe
melancholic depression, particularly when the patient refuses to eat or drink and/or there is a high suicide risk, when the patient has
very high levels of distress, has psychotic depression, catatonia or has previously responded to ECT (Malhi et al 2015). It may also be
considered in the treatment of mania, severe mixed episodes of bipolar disorder and psychosis.
ECT may be prescribed by a perinatal psychiatrist for pregnant women who meet the criteria above. Specific considerations include the
risk of induction of premature labour associated with ECT and the risk of reduced fetal heart rate associated with maternal anaesthesia
(Lakshmana et al 2014).
For pregnant women, cardiotocography is required pre-ECT, during ECT and in recovery and should be monitored by an expert health
professional who can deliver the baby if necessary. For women in the third trimester, advice on obstetric anaesthesia is required.
In all situations, it is essential to have care plans and clear communication about ECT between obstetric care providers and the woman’s
psychiatrist.
A decision to prescribe ECT must involve obtaining informed consent from the woman and her significant carer(s) where possible
(Lakshmana et al 2014). Involving carers and families is critical in situations where the woman is clinically unable to provide informed
consent due to her psychiatric condition. This decision must weigh up risks associated with ECT (e.g. short-term memory loss), the
risks of not undertaking ECT and maintaining status quo and the risks of alternative treatments for the woman and, if ECT is conducted
during pregnancy, the fetus and pregnancy. This process needs to be documented as per consent guidelines of the hospital/health
service.
CONSENSUS-BASED RECOMMENDATION
xxxii. Consider ECT when a postnatal woman with severe depression has not responded to one or more trials of antidepressants
of adequate dose and duration.
xxxiii. Consider ECT as first-line treatment for postnatal women with severe depression especially where there is a high risk
of suicide or high level of distress; when food or fluid intake is poor; and in the presence of psychotic or melancholic
symptoms.
PRACTICE POINT
jj. In pregnant women, ECT should be only be undertaken in conjunction with close fetal monitoring (using
cardiotocography to monitor fetal heart rate) and access to specialist maternal-fetal medical support.
10. The use of ECT is regulated through the Mental Health Act in each jurisdiction.
Australian Clinical Practice Guideline | 62
15 Practice summary –
prevention and treatment
General principles in prevention and treatment of mental health conditions in the perinatal period
Action
Provide psychoeducation
Preconception planning
Plan for breastfeeding where feasible
Arrange appropriate observation of
the newborn
Involve significant other(s)
Discuss risks and benefits of
medications
Discuss risk of relapse
Liaise with other health professionals
involved in a woman’s care
Offer and facilitate the 18–20 week
ultrasound
Arrange co-admission of mother and
baby to a mother-baby unit, where
possible
All women
Women of childbearing age with new,
existing or past severe mental health
condition
Women who will need
pharmacological treatment during
the postnatal period
Mothers of infants exposed to
any psychotropic medication in
pregnancy
All women
Women on regular medication who
fall pregnant and then consider
medication cessation
Women being prescribed/considering
medications in the perinatal period
Women who would benefit from
pharmacological treatment during
pregnancy
Women exposed to lithium,
anticonvulsants and antipsychotics
Women with a severe postnatal
episode
Mental health problems are common in the perinatal
period and can be treated
Risk of relapse is substantial in pregnancy and
especially in the early postnatal period
Examine the best treatment options for a woman
who wishes to breastfeed
Poor neonatal adaptation syndrome is associated
with the use of some psychotropic treatments in
pregnancy
Provide information and involve in discussions about
the woman’s emotional wellbeing and care
Risk is high if medications are ceased and this
needs to be done slowly and with advice from a
psychiatrist or GP
Where possible, involve significant other(s). Describe
absolute risk (i.e. X in 1,000) when discussing
risk of birth defects above the risk in the general
population.
This involves clear communication between
professionals providing antenatal and maternity
care and treating psychiatrists and psychologists. In
more complex cases, seek advice from a perinatal
psychiatrist
Identifies malformations and enables women and
significant other(s) to consider options and plan for
additional care
Assists with monitoring safety of the infant, the
development of mothercraft skills and a positive
relationship with the baby
For whom Comments
Take a team approach
Undertake training
Health professionals involved in care
of women with severe mental illness
Perinatal health professionals involved
in care of women with severe mental
illness
Clear communication and continuity of care and
carer across clinical settings is needed
Improves understanding of care for women with
severe mental illness
Practice summary — prevention and treatment | 63
Psychosocial and psychological therapies
Lifestyle and psychosocial support
Healthy diet and regular, suitable
physical activity
Social support group
Psychologically informed
psychoeducation
Enhanced maternal and child
health care
Mindfulness or relaxation training
All women
Women with symptoms of depression
and/or anxiety
Women with symptoms of depression
and/or anxiety
Women with borderline personality
disorder
Women with borderline personality
disorder
Good nutrition and physical activity are associated
with emotional wellbeing
Enables mutual support by bringing women into
contact with other women who are having similar
experiences
Structured education (often in groups) on
preparation for childbirth, practical aspects of
childcare and mental health
The early postnatal period can be particularly
distressing, with difficulties in care and emotional
parenting of the infant
Assists in managing emotional dysregulation
For whom Comments
Psychological therapy
Complementary therapies
Structured psychological
interventions
Complementary therapies (e.g. omega
3 fatty acids, St John’s Wort)
For whom
For whom
Comments
Comments
Facilitated self-help
Directive counselling
Mother-infant interventions
Women with mild to moderate
depression
Women who enquire about
complementary therapies
Women with postnatal depression
experiencing mother–infant
difficulties
Women with moderate to severe
depression
Women with severe mental
illness
Women with borderline personality
disorder
CBT or IPT provided to individuals by a trained
health professional
Omega-3 fatty acids may be used in pregnancy but
not as sole treatment for depression. St John’s Wort
and Gingko biloba are not recommended.
As an adjunct once medications have become
effective
CBT can be beneficial in managing secondary
depression or anxiety
Interventions specifically designed for borderline
personality disorder
Women with symptoms of mild to
moderate depression
Women with mild to moderate
depression or anxiety disorder
Based on cognitive behavioural principles
– workbook or internet delivery with online
or telephone support
Involves supportive listening, problem-solving and
goal setting
Post-traumatic birth counseling Women who experience traumatic
birth and have depression symptoms
or PTSD
Involves explaining what happened during birth;
giving women an option to discuss labour, birth, and
post-birth experiences; answering any questions
Women with severe mental illness,
borderline personality disorder
Involves observation of mother–infant interactions,
feedback, modelling and cognitive restructuring
Provided individually or to groups of women with
similar requirements
Australian Clinical Practice Guideline | 64
Increase in absolute risk of adverse outcomes associated with pharmacotherapy during pregnancy
Outcome Medication Increase in absolute risk Timing
Antidepressants and anxiolytics
Antipsychotics
Miscarriage
Respiratory distress or
difficulty
Preterm birth
Neonatal convulsions
SSRIs
SNRIs
TCAs
From 81 to 109 per 1,000
From 81 to 138 per 1,000
From 81 to 107 per 1,000
SSRIs
SSRIs
From 60 to 161 per 1,000 Late pregnancy
From 3 to 4 per 1,000
(1 prescription filled)
From 3 to 15 per 1,000
(3 prescriptions filled)
3rd trimester
Major malformation
Cardiac malformation
Miscarriage
Risperidone
Risperidone
From 33 to 42 per 1,000 First trimester
From 15 to 25 per 1,000 First trimester
Late pregnancyPersistent pulmonary
hypertension
SSRIs From 3 to 4 per 1,000
First 20 weeks
Sodium valproate
Carbamazepine
From 28 to 88 per 1,000
From 28 to 42 per 1,000
During pregnancy
Flupenthixol
Quetiapine
From 136 to 211 per 1,000
From 136 to 224 per 1,000
During or just prior to
pregnancy
SSRIs
Benzodiazepines
From 32 to 45 per 1,000
From 32 to 72 per 1,000
During pregnancy
Late pregnancy
Lithium
Cardiac malformation Lithium From 6 to 29 per 1,000 During pregnancy
Anticonvulsants
Major malformation
First trimester
Cardiac malformation Sodium valproate From 6 to 29 per 1,000 During pregnancy
Practice summary — prevention and treatment | 65
Therapeutic Goods Administration categorisation of medicines
Category
A
B1
B2
B3
C
D
X
Medicines which have been taken by a large number of pregnant women and women of childbearing age without any
proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been
observed.
Medicines which have been taken by only a limited number of pregnant women and women of childbearing age,
without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus
having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage.
Medicines which have been taken by only a limited number of pregnant women and women of childbearing age,
without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus
having been observed. Studies in animals are inadequate or may be lacking, but available data shows no evidence of an
increased occurrence of fetal damage.
Medicines which have been taken by only a limited number of pregnant women and women of childbearing age,
without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus
having been observed. Studies in animals have shown evidence of an increased occurrence of fetal damage, the
significance of which is considered uncertain in humans.
Medicines which, owing to their pharmacological effects, have caused or may be suspected of causing, harmful effects
on the human fetus or neonate without causing malformations. These effects may be reversible. Accompanying texts
should be consulted for further details.
Medicines which have caused, are suspected to have caused or may be expected to cause, an increased incidence of
human fetal malformations or irreversible damage. These medicines may also have adverse pharmacological effects.
Accompanying texts should be consulted for further details.
Medicines which have such a high risk of causing permanent damage to the fetus that they should not be used in
pregnancy or when there is a possibility of pregnancy.
Part D –
Areas for future
research
Part D – Areas for future research | 67
Since the 2011 Australian clinical practice guideline (beyondblue 2011) there have been considerable advances in research and
innovation. While much of this new research was captured by the systematic review conducted for this Guideline and informed
recommendations, research in emerging areas is ongoing and has not yet been published. This includes:
• exploration of digital approaches to screening – these include a standalone digital platform for screening and automated reporting
across primary, maternity and postnatal settings, which will facilitate reporting at national, state and local levels; an electronic model
of assessment integrated into existing maternity sector databases; and web-based applications for self-assessment of psychosocial
risk and possible depression
• development of electronic information for consumers and carers by a range of organisations, with many of these linked to the
Australian Government mental health portal, Head to Health
• internet-based interventions specific to mental health in the perinatal period
• electronic referral pathways, which have the potential to benefit consumers through better coordinated care and health professionals
through improved two-way communication, resulting in fewer errors and greater administrative efficiency.
It is anticipated that this research will inform future iterations of this Guideline. The following section highlights potential areas for
future development to support the sustainable and measurable implementation of best practice.
Areas for further research identified through public consultation process
• Models of maternity care to determine the most effective ways to prevent and manage perinatal mental health conditions
• Effectiveness and cost-effectiveness of screening programs (including e-screening)
• Integrated approaches to screening/inquiry regarding women’s mental health, experience of intimate partner violence and other
social health issues
• Effectiveness of screening and service models for women experiencing intimate partner violence/family violence
• Tailoring of screening/inquiry and first line responses for Aboriginal women and women of refugee and migrant backgrounds to
ensure that approaches are culturally safe, relevant and effective for these communities, and most importantly, to ensure that
programs do not contribute to further trauma or harm for women and children
• The benefits of more frequent and staged maternal mental health surveillance in the early years of parenting (e.g. at 3, 6, 12 and 18
months and again at 4 years postpartum)
• Impact of including child outcomes on cost-effectiveness models
• Effective screening, interventions and support for perinatal mental health problems among men, including consideration of changing
gender roles
• Couple and family-based interventions for perinatal mental health problems.
Representative
Expertise
Organisation Representing
Appendices
Membership of the expert working group and subcommittees | 69
Representative Expertise
Organisation
Representing
Institutional
Affiliation(s) Location
Prof Marie-Paule Austin
(Chair)
Dr Nicole Highet
(Co-chair)
Dr James Best
Dr Helen Lindner
Mr Andrew Davis
Prof Rhonda Marriott
Ms Suzanne Higgins
Perinatal Psychiatrist,
Former Chair
beyondblue Clinical
Guideline, researcher
and clinician working
across private and public
perinatal settings
Royal Australian and
New Zealand College of
Psychiatrists (RANZCP)
University of New
South Wales, St John of
God Healthcare, Royal
Hospital for Women,
Black Dog Institute
Sydney, NSW
Executive Director
(COPE), former Co-Chair
& Director beyondblue
Clinical Guideline, online
training programs &
resources. Expertise in
consumer/carer research,
advocacy, policy &
implementation.
Centre of Perinatal
Excellence (COPE)
(Guideline developer)
Centre of Perinatal
Excellence (COPE)
Melbourne, VIC
General Practitioner
Health psychologist and
former member of the
EWG for beyondblue
perinatal guideline
Royal Australian College
of General Practitioners
(RACGP)
Australian Psychological
Society (APS)
GPMaroubra
Australian Psychological
Society (APS)
Mabroubra, NSW
Melbourne, VIC
Carer Representative
and volunteer at PANDA
Midwife, researcher
and specialist in
Aboriginal and Torres
Strait Islander perinatal
mental health
Carer Representative
Congress of Aboriginal
and Torres Strait
Islander Nurses and
Midwives (CATSINaM)
None
Murdoch University
Melbourne, VIC
Perth, WA
Credentialed Mental
Health Nurse with
additional qualifications
in midwifery, maternal
and child health and
perinatal and infant
mental health. Clinical
and management
experience in Perinatal
and Infant Mental
Health service delivery.
Australian College of
Mental Health Nurses
(ACMHN)
St John of God
Healthcare
Geelong, VIC
A Membership of the expert working
group and subcommittees
Membership of the Expert Working Group
Australian Clinical Practice Guideline | 70
Representative Expertise
Organisation
Representing
Institutional
Affiliation(s) Location
Ms Creina Mitchell
Ms Jenni Richardson
Dr Vijay Roach
Ms Terri Smith
(from 28 April 2017)
Dr Jan Taylor
Clinician, researcher and
educator in maternal
and child health with
expertise and interest in
perinatal mental health
Maternal & Child Family
Health Australia
Griffith University Brisbane, QLD
National Helpline and
Programs manager and
consumer advocate
for mental health and
suicide prevention
Consumer
representative Perinatal
Anxiety and Depression
Association (PANDA)
Perinatal Anxiety and
Depression Association
(PANDA)
Fitzroy, VIC
Obstetrician with
dedicated expertise in
perinatal mental health.
Chair of the Gidget
Foundation Australia
(perinatal mental health
support organisation)
and carer.
We would also like to acknowledge the contribution of the proxy representatives in the development of the Guideline.
• Dr Anne Sved Williams (proxy for Professor Marie-Paule Austin)
• Julie Ferguson (proxy for Ms Suzanne Higgins)
• Dr Louise Roufiele (proxy for Dr Helen Lindner)
• Dr Agnes Wilson (proxy for Dr Vijay Roach)
• Dr Catherine Chamberlain (proxy for Professor Rhonda Marriott)
Royal Australian
College of Obstetricians
and Gynaecologists
(RANZCOG)
Royal North Shore
Hospital
Sydney, NSW
CEO, Perinatal Anxiety
and Depression
Australia (PANDA)
CEO, Perinatal Anxiety
and Depression
Australia (PANDA)
Perinatal Anxiety and
Depression Australia
(PANDA)
Fitzroy, VIC
Register midwife,
midwifery academic
with expertise in
perinatal mental health.
Former member of the
beyondblue EWG.
Australian College of
Midwives (ACM)
University of Canberra Canberra, ACT
Membership of the expert working group and subcommittees | 71
Membership of the Harms Expert Subcommittee
Representative Expertise
Institutional
Affiliation Location
Prof Marie-Paule Austin
(Chair)
Prof Phillip Boyce
Prof Megan Gallbally
Dr Anne Sved-Williams
Dr Debra Kennedy
Dr Tram Nguyen
Chair Perinatal Mental Health Unit,
Professorial Fellow and Consultant
Psychiatrist
University of New South Wales,
Black Dog Institute
Sydney, NSW
Professor of Psychiatry, Perinatal
Psychiatrist
University of Sydney and
Westmead Hospital
Wentworthville, NSW
Foundation Chair in Perinatal
Psychiatry & Perinatal Psychiatrist
Perinatal Psychiatrist
Head, Medical Unit
University of Notre Dame, Fiona
Stanley Hospital
Helen Mayo House Family Unit
Perth, WA
Glenside, SA
Director, Mothersafe Royal Hospital for Women Sydney, NSW
Consultant Psychiatrist, Centre
for Women’s Mental Health
The Royal Women’s Hospital Melbourne, VIC
Membership of the Borderline Personality Disorder and Schizophrenia Subcommittee
Representative Expertise
Institutional
Affiliation Location
Prof Marie-Paule Austin
(Chair)
Prof Phillip Boyce
Prof Anne Buist
Prof Louise Newman
Dr Sylvia Lim-Gibson
Dr Tram Nguyen
Dr Anne Sved-Williams
Chair Perinatal Mental Health Unit,
Professorial Fellow and Consultant
Psychiatrist
University of New South Wales,
Black Dog Institute
Sydney, NSW
Perinatal Psychiatrist & Professor of
Psychiatry
University of Sydney and
Westmead Hospital
Wentworthville, NSW
Perinatal Psychiatrist & Director,
North-East Women’s Mental Health
Parent Infant Program
Director, Centre of Women’s
Mental Health
Austin Hospital and University of
Melbourne
The Royal Women’s Hospital
Heidelberg West, VIC
Melbourne, VIC
Perinatal Psychiatrist and Conjoint
Senior Lecturer UNSW
Royal Hospital for Women and
University of New South Wales
NSW
Consultant Psychiatrist, Centre
for Women’s Mental Health
Perinatal Psychiatrist
Head, Medical Unit
The Royal Women’s Hospital
Helen Mayo House Family Unit
Melbourne, VIC
Glenside, SA
Australian Clinical Practice Guideline | 72
Dr Nicole Highet, Founder & Executive Director
Guideline developer – COPE
Systematic literature review – Hereco health research consulting
Technical writing – Ampersand Health Science Writing
Dr Sarah Norris Dr Kristina Harvey
Ms Jenny Ramson
Dr Sue Campbell Dr Jennifer Ring
Ms Sherin Chikhani Ms Rosie Wade
Guideline development team
Administrative report | 73
B Administrative report
The development of this Guideline has followed the key principles and processes outlined in Procedures and Requirements for Meeting
the 2011 NHMRC Standard for Clinical Practice Guidelines (NHMRC 2011) and the 2016 NHMRC Standards for Guidelines.
B1 Scope and purpose
Objective
Health intents
The Guideline aims to guide health professionals in the identification of the more common mental health conditions (depression and
anxiety) and the prevention and treatment of these conditions through a range of treatment approaches that includes psychosocial and
psychological therapies, pharmacological, complementary and physical therapies.
In addition, the Guideline addresses the management of low prevalence, more severe mental illnesses – namely schizophrenia, bipolar
disorder, postpartum psychosis, and borderline personality disorder. For each of these conditions the Guideline provides guidance in
the provision of psychosocial and psychological therapies, pharmacological and physical therapies.
Expected benefits/outcomes
The Guideline aims to:
• identify current and effective tools for the detection of women most at risk of perinatal mental health conditions (psychosocial
assessment) as well as those experiencing symptoms of the more common conditions (screening tools)
• assess the evidence for interventions used in managing mental health disorders, with a focus on the impact of exposure of the fetus
to systemically active treatments (i.e., medications, complementary therapies and some physical therapies).
It is intended that this will inform local, state and national policy surrounding the timely implementation of appropriate tools to
ensure early identification of womens’ needs and timely, safe (for mother and baby) and effective intervention. Early detection and
management of perinatal mental health conditions will have significant health and economic benefits for the woman, her family and the
broader community.
Target population
The target population for the Guideline is women who are pregnant or in the first postnatal year.
Questions
The clinical research questions in this Guideline update are grouped under five headings, with each defined as follows:
• Psychosocial assessment: use of multidimensional validated tools/instruments to identify factors related to an individual woman
that might place her at higher risk of susceptibility to a perinatal mental health condition
• Screening: use of validated tools/instruments for the detection of signs or symptoms of a perinatal mental health condition (but not
a formal diagnosis)
• Prevention: an intervention in the ante- or postnatal period delivered with the purpose of reducing the development of a mental
health condition in a woman not previously diagnosed.
• Treatment: intervention in the ante- or post-natal period delivered with the purpose of reducing the impact of a mental health
condition in a woman with a diagnosis of that condition.
• Harms: adverse effects on the fetus or breast-feeding infant of an intervention delivered to the mother in the ante- or post-natal
period, respectively,
The clinical research questions are summarised in the table below. As shown in the table, some questions were addressed via the
systematic review (SR), others by narrative or descriptive review.
https://www.nhmrc.gov.au/guidelines-publications/information-guideline-developers/2016-nhmrc-standards-guidelines
Australian Clinical Practice Guideline | 74
Main question
Sub-questions
What is the most appropriate method for psychosocial assessment of women at risk of mental health
problems in the perinatal period?
What is the performance (defined as reliability, validity and predictive accuracy) of validated
multidimensional tools for perinatal psychosocial assessment? [addressed via systematic review]
What are the non-technical characteristics (defined as number of items, time to administer, complexity
of scoring, training requirements, and available languages) of validated multidimensional tools for
perinatal psychosocial assessment? [addressed via descriptive review]
What is the acceptability to pregnant or post-partum women, health professionals, and the general
public of validated multidimensional tools for perinatal psychosocial assessment? [addressed via
narrative review]
What is the effectiveness (defined as impact on detection, care sought or received, and mental health
outcomes) of perinatal psychosocial assessment with validated multidimensional tools? [addressed via
narrative review]
What are the implications (for resourcing, workforce, and models of care) of implementing perinatal
psychosocial assessment (via different modes of delivery) with a validated multidimensional tool?
[addressed via narrative review]
Table B.1: Clinical research questions
Psychosocial assessment
Depression screening
Main question What is the most appropriate method for screening women for depression in the perinatal period?
Sub-questions What is the performance (defined as reliability, sensitivity, specificity, positive likelihood ratio, and
negative likelihood ratio) of validated tools for perinatal depression screening? [addressed via
systematic review]
What are the non-technical characteristics (defined as number of items, time to administer, complexity
of scoring, training requirements, and available languages) of validated tools for perinatal depression
screening? [addressed via descriptive review]
What is the acceptability to pregnant or post-partum women, health professionals, and the general
public of screening for perinatal depression? [addressed via narrative review]
What is the effectiveness (defined as impact on detection, care sought or received, and mental health
outcomes) of screening for perinatal depression? [addressed via narrative review]
What are the implications (for resourcing, workforce, and models of care) of implementing perinatal
depression screening (via different modes of delivery) with a validated tool? [addressed via narrative
review]
Administrative report | 75
Main question
Sub-questions
What is the most appropriate method for screening women for anxiety in the perinatal period?
What is the performance (defined as reliability, sensitivity, specificity, positive likelihood ratio, and
negative likelihood ratio) of validated tools for perinatal anxiety screening? [addressed via systematic
review]
What are the non-technical characteristics (defined as number of items, time to administer, complexity
of scoring, training requirements, and available languages) of validated tools for perinatal anxiety
screening? [addressed via descriptive review]
What is the acceptability to pregnant or post-partum women, health professionals, and the general
public of screening for perinatal anxiety? [addressed via narrative review]
What is the effectiveness (defined as impact on detection, care sought or received, and mental health
outcomes) of screening for perinatal anxiety? [addressed via narrative review]
What are the implications (for resourcing, workforce, and models of care) of implementing perinatal
anxiety screening (via different modes of delivery) with a validated tool? [addressed via narrative
review]
Anxiety screening
Treatment interventions
Main question What is the efficacy and safety of interventions for the treatment of mental health problems in women in
the antenatal or postnatal period?
Sub-questions What is the efficacy and safety of psychosocial interventions for the treatment of mental health
problems in women in the antenatal or postnatal period? [addressed via systematic review]
What is the efficacy and safety of psychological interventions for the treatment of mental health
problems in women in the antenatal or postnatal period? [addressed via systematic review]
What is the efficacy and safety of online interventions for the treatment of mental health problems in
women in the antenatal or postnatal period? [addressed via systematic review]
What is the efficacy and safety of pharmacological interventions for the treatment of mental health
problems in women in the antenatal or postnatal period? [addressed via systematic review]
What is the efficacy and safety of complementary interventions for the treatment of mental health
problems in women in the antenatal or postnatal period? [addressed via systematic review]
What is the efficacy and safety of physical interventions for the treatment of mental health problems in
women in the antenatal or postnatal period? [addressed via systematic review]
Australian Clinical Practice Guideline | 76
Main question
Sub-questions
What is the efficacy and safety of interventions for the prevention of mental health problems in women
in identified as being at risk of developing a mental health problem in the antenatal or postnatal period?
What is the efficacy and safety of psychosocial interventions for the prevention of mental health
problems in women identified as being at risk of developing a mental health problem in the antenatal or
postnatal period? [addressed via systematic review]
What is the efficacy and safety of psychological interventions for the prevention of mental health
problems in women identified as being at risk of developing a mental health problem in the antenatal or
postnatal period? [addressed via systematic review]
What is the efficacy and safety of online interventions for the prevention of mental health problems in
women identified as being at risk of developing a mental health problem in the antenatal or postnatal
period? [addressed via systematic review]
What is the efficacy and safety of pharmacological interventions for the prevention of mental health
problems in women identified as being at risk of developing a mental health problem in the antenatal or
postnatal period? [addressed via systematic review]
What is the efficacy and safety of complementary interventions for the prevention of mental health
problems in women identified as being at risk of developing a mental health problem in the antenatal or
postnatal period? [addressed via systematic review]
What is the efficacy and safety of physical interventions for the prevention of mental health problems in
women identified as being at risk of developing a mental health problem in the antenatal or postnatal
period? [addressed via systematic review]
Prevention interventions
Harms: Pharmacological intervention
Main question What are the harms that occur as a result of perinatal exposure to pharmacological interventions used
for the treatment of mental health problems?
Sub-questions What are the harms that occur to the fetus as a result of perinatal exposure to pharmacological
interventions used for the treatment of mental health problems? [malformations; addressed via
systematic review]
What are the harms that occur to the infant as a result of perinatal exposure to pharmacological
interventions used for the treatment of mental health problems? [pregnancy and birth outcomes]
What are the harms that occur to the child as a result of perinatal exposure to pharmacological
interventions used for the treatment of mental health problems? [neurodevelopmental outcomes]
What are the harms that occur to the mother as a result of perinatal exposure to pharmacological
interventions used for the treatment of mental health problems? [postpartum haemorrhage]
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Main question
Sub-questions
Sub-questions
What are the harms that occur as a result of perinatal exposure to a complementary interventions used
for the treatment of mental health problems?
What are the harms that occur to the fetus as a result of perinatal exposure to complementary
interventions used for the treatment of mental health problems? [malformations; addressed via
systematic review]
What are the harms that occur to the infant as a result of perinatal exposure to complementary
interventions used for the treatment of mental health problems? [pregnancy and birth outcomes;
addressed via systematic review]
What are the harms that occur to the child as a result of perinatal exposure to complementary
interventions used for the treatment of mental health problems? [neurodevelopmental outcomes;
addressed via systematic review]
What are the harms that occur to the mother as a result of perinatal exposure to complementary
interventions used for the treatment of mental health problems? [postpartum haemorrhage; addressed
via systematic review]
Harms: complementary intervention
Harms: Physical intervention
Main question What are the harms that occur as a result of perinatal exposure to physical interventions used for the
treatment of mental health problems?
What are the harms that occur to the fetus as a result of perinatal exposure to physical interventions
used for the treatment of mental health problems? [malformations; addressed via systematic review]
What are the harms that occur to the infant as a result of perinatal exposure to physical interventions
used for the treatment of mental health problems? [pregnancy and birth outcomes]
What are the harms that occur to the child as a result of perinatal exposure to physical interventions
used for the treatment of mental health problems? [neurodevelopmental outcomes]
What are the harms that occur to the mother as a result of perinatal exposure to physical interventions
used for the treatment of mental health problems? [postpartum haemorrhage; addressed via systematic
review]
Population
The Guideline applies to pregnant or postnatal women, with the postnatal period being defined as the 12 months following birth.
Specifically, the investigations/ interventions of interest are assessed in the following populations:
• psychosocial assessment – all pregnant or postnatal women
• screening – all pregnant or postnatal women not already referred for mental health assessment
• psychosocial, psychological, physical, pharmacological and complementary interventions - pregnant or postnatal women who have
an existing mental health disorder, or are considered to be at risk of developing a mental health disorder.
As the guideline also provides an assessment of the harms associated with interventions, the population also encompasses the fetus,
infant or child.
Attention is also given to women with a history of mental health issues who might be planning a pregnancy.
Australian Clinical Practice Guideline | 78
B2 Stakeholder involvement
Group membership
On commissioning of this Guideline, the Executive Director of COPE wrote to all company members, inviting their respective
organisation to nominate a representative for the EWG. In doing so, each organisation was asked to consider representatives with
expertise in the area of perinatal mental health.
Company members are as follows:
• Australian College of Mental Health Nurses (ACMHN)
• Australian College of Midwives (ACM)
• Australian Psychological Society (APS)
• Maternal Child and Family Health Nursing Association (MCaFNA)
• Perinatal Anxiety and Depression Australia (PANDA)
• Royal Australian College of General Practitioners (RACGP)
• Royal Australian New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
• Royal Australian and New Zealand College of Psychiatrists (RANZCP)
• The Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM)
Formation of the Expert Working Group
The nominated members assigned to the EWG from their respective affiliations are detailed in Appendix A.
Target population preferences and views
Capturing consumer perspectives
The establishment of the EWG with dedicated consumer and carer representation was considered fundamental to the inclusion of
consumer and carer perspectives in the development of this Guideline. In particular the appointment of representatives from Australia’s
peak perinatal consumer body (PANDA) ensured that the perspectives of many consumers were included at the EWG level. It is also
noted that a number of representatives brought to the table expertise and insights from the lived experience of perinatal mental health.
In addition, the perspectives of consumers and carers were sought through the consultation process, whereby organisations and EWG
representatives with access to consumers promoted the consultation process.
Capturing perspectives of specific groups
Aboriginal and Torres Strait Islander perspectives were captured through the inclusion of an EWG representative from Aboriginal and
Torres Strait Islander background, who was also a health professional with a specialist background in perinatal mental health. As with all
other members of the EWG, the representative was nominated on behalf of a specific organisation (Congress of Aboriginal and Torres
Strait Islander Nurses and Midwives; CATSINaM).
Target users
The Guideline is intended for all health professionals caring for women and families during the perinatal period. This includes but is
not limited to midwives, general practitioners (GPs), obstetricians, neonatologists, paediatricians, maternal and child health nurses,11
paediatric nurses, Aboriginal and Torres Strait Islander health workers, allied health professionals, mental health practitioners
(psychologists, psychiatrists, mental health nurses, perinatal and infant mental health professionals), consumers and carers and those
working with families in the community (e.g. social workers, child protection agencies), hospital and legal systems.
The Guideline will be used by each of the professional groups in accordance with their role in the management of perinatal health.
For example, those involved at the front-end of maternity care provision (GPs, midwives and obstetricians) will be informed about
best practice screening and assessment tools to identify and respond to identified mental health problems in pregnancy. Professionals
involved in the provision of treatment for mental health conditions (psychiatrists, psychologists, GPs) will likely refer to the information
surrounding safe and effective treatments for perinatal mental health conditions. Consumers and carers will also refer to the Guideline
to obtain information about the assessment of risk and symptom detection, as well recommended safe and effective treatments for
perinatal mental conditions.
11. Also referred to as child and family health nurses in some jurisdictions.
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B3 Rigour of development
Search methods
Searches were conducted in the MEDLINE, Embase and PsychINFO databases, and also in CINAHL for psychosocial assessment and
screening (via the OVID and/or Embase.com interfaces), various databases of the Cochrane Library, and included examination of the
reference lists of included SRs and individual studies. Searches were conducted between June 2016 and April 2017.
The full search strategy is outlined in Appendix A to the Technical Report, which is available on the COPE website.
Evidence selection criteria
The main inclusion/exclusion criteria for each of the research question types were as follows. More detailed PICO (Population,
Intervention, Comparator, Outcomes) criteria used to inform the literature search are included in more detail in the Technical Report
Part B (pp 3–5; PICO p8, 10, 12), Part C (pp 2–5) and Part D (pp 2–5).
Psychosocial assessment and screening
• Target population – all pregnant or postnatal women (psychosocial assessment), or pregnant or postnatal women with no known
diagnosis of depression or anxiety (screening)
• Study design – prospective, controlled studies reporting predictive accuracy (psychosocial assessment) or diagnostic accuracy
(screening)
• Comparisons – subsequent manifestation of mental health issues (psychosocial assessment), orany standard clinical/diagnostic
interview as a reference standard (screening)
• Language – limited to English.
Effectiveness of interventions
• Target population – pregnant or postnatal women diagnosed with a mental health problem, or considered to be at risk of developing
a mental health problem
• Study design – SRs of RCTs, or individual RCTs if no SR or SR out of date
• Interventions – Psychosocial, psychological, pharmacological, complementary or physical therapies used to treat or prevent mental
health problems in pregnant or postnatal women
• Comparisons – no treatment/placebo/treatment as usual or active treatment
• Language – limited to English.
Harms of interventions
• Target population – pregnant or postnatal women diagnosed with a mental health problem, or considered to be at risk of developing
a mental health problem, or a fetus, infant or child of a mother exposed to a pharmacological, complementary or physical therapy
• Study design – SRs of RCTs (if available), SRs of observational studies, or individual observational studies if no SR or SR out of date
or unsuitable
• Comparisons – no treatment/exposure or active treatment
• Language – limited to English.
Strengths and limitations of the evidence
The strengths and limitations of the evidence have been considered from the perspective of the individual studies and the body of
evidence aggregated across all the studies. Wherever possible validated methods have been used to assess:
• study design(s)
• study methodology limitations (sampling, blinding, allocation concealment, analytical methods)
• appropriateness/relevance of primary and secondary outcomes considered
• consistency of results across studies
• direction of results across studies
• magnitude of benefit versus magnitude of harm
• applicability to practice context.
GRADE methodology was used to determine the quality of the evidence available for each intervention/outcome. The majority of
the evidence for fetal harms was considered generally to be of very low or inadequate quality. It should be noted that the category
‘inadequate’ was added for the review to better reflect the broad range of quality that would have been considered very low if GRADE
methods had been adhered to. A discussion of this adaptation of GRADE methodology can be found in Part D of the Technical Report
(Section D2.5.1).
Australian Clinical Practice Guideline | 80
In addition, no GRADE methods could be identified for the assessment of psychometric instruments. Consequently, a hybrid method
was developed for quality appraisal of psychosocial assessment instruments. This method was based on accepted psychometric
properties and QUADAS-2 principles and is described in detail in Part B of the Technical Report (Sections B4.1 and B5.2).
Formulation of recommendations
As evidence reviews on specific topics were completed they were considered by the EWG and the relevant expert committee(s) as
appropriate. The interpretation and implications of the review findings were discussed, and then evidence-based recommendations
(EBRs) developed once consensus was reached. The strength of the EBRs was agreed at this point. Once a group of related EBRs and
CBRs was developed, the EWG deliberated on the need for practice points to highlight important aspects of care.
The expert committees provided specific expertise to support the EWG. The Harms Expert Committee carried out the initial review of
the harms systematic reviews and proposed recommendations for consideration and approval by the EWG.
Once recommendations had been developed across all types of intervention, the Low Prevalence Expert Committee proposed
recommendations relevant to women with bipolar disorder, postpartum psychosis, schizophrenia or borderline personality disorder
in the perinatal period. This process involved explicit consideration of relevant, recent Australian Guidelines for mood disorder,
schizophrenia, and borderline personality disorder in general populations.
Consideration of harms and benefits
The evidence reviews explicitly considered health benefits and harms. The trade-off between benefits and harms is articulated in the
rationale for each evidence-based recommendation.
Recommendations on the use of psychosocial and psychological interventions were based primarily on evidence of the effectiveness,
because they do not cause direct harm to the fetus, infant or child.
Recommendations on the use of pharmacological, complementary and selected physical interventions were to be based on a trade-
off between effectiveness and harm; however, there was very little evidence of effectiveness for these interventions in the perinatal
population. The only evidence available was for antidepressants (suggesting it may improve postnatal depression) and omega-3 fatty
acids (where it appeared to have no effect on depression).
The harms most likely to effect recommendations were major and cardiac malformations, and neurodevelopmental harms. Due to its
strong association with major and cardiac malformation, and adverse cognitive outcome, as well as a lack of evidence of effectiveness
in pregnant or postpartum women with, or at risk of developing, a mental health problem, the prescribing of sodium valproate in all
women of childbearing age, was strongly recommended against. The evidence of harm associated with carbamazepine, and the lack of
evidence for lamotrigine led to a consensus-based recommendation to prescribe anticonvulsants with great caution during pregnancy.
While there were a number of pregnancy and birth outcomes found to be associated with pharmacological therapies (including
miscarriage, preterm birth, poor neonatal adaptation syndrome, respiratory distress, convulsions and persistent pulmonary
hypertension), these were not directly captured in any recommendations; instead, a Practice Point notes that the potential risks of
treatment (including the risk of relapse), as well as the benefits, be discussed with women.
There was little evidence available on the side effects of the pharmacological, complementary and physical interventions assessed;
these treatments are all used regularly in clinical practice and as such their side-effect profiles are well established. However, based on
a known side-effect of clozapine, agranulocytosis, a consensus-based recommendation states that its use should not be initiated during
pregnancy due to the potential harm to the infant.
Link between evidence and recommendations
See Appendix C.
External review
Independent AGREE appraisal
Two independent methodologists were engaged to critically appraise the Guideline using the AGREE-II instrument. This involved
assessing the Guideline over a number of domains using the AGREE-II User’s Manual. The appraisal from both reviewers was generally
positive, with combined domain scores as follows.
• Scope and purpose (96%) – the draft Guideline described its objective, research questions and target population. However one
reviewer felt that the expected benefits for the child could have been covered in greater detail and that more specific PICO criteria
might have been a useful inclusion.
• Stakeholder involvement (93%) – the draft Guideline outlined that it was developed by a group of individuals from relevant health
professions, consumer views had been sought and the target users were specifically identified. One reviewer felt that a wider range
of health professionals could have been involved.
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• Rigour of development (97%) – the draft Guideline outlined the systematic methods used to search for evidence, the selection
criteria employed, the strengths and limitations of the evidence, the methods for formulating recommendations and the health
benefits and risks considered Recommendations were explicitly linked to the evidence. A procedure for updating the Guideline and
discussion of external review (to be undertaken) was included. One reviewer made suggestions to improve clarity in the technical
report about the search and study exclusion process and found that the process of updating between the previous and current
Guideline was not clear. The reviewer also noted inconsistencies in numbering and wording of some recommendations between
Guideline sections. One reviewer noted that it was unclear who had provided feedback through public consultation or the scope of
changes made in response.
• Clarity of presentation (100%) – the recommendations in the draft Guideline were specific, unambiguous and easily identifiable and
management options were discussed.
• Applicability (92%) – the draft Guideline included advice and tools to assist with putting the recommendations into practice and
described facilitators and barriers to implementation of recommendations (although one reviewer found that some barriers included
in the body of the Guideline were not acknowledged in the appendix and that further information on resource implications should
be included in the body of the document). One reviewer noted that digital screening will be able to be monitored, the other that
the ability to measure uptake of screening across and within jurisdictions will be crucial for designing and applying implementation
strategies.
• Editorial independence (100%) – the draft Guideline included a complete list of competing interests of guideline development group
members and specifically stated that the views of the funding body had not influenced content.
Both reviewers recommended the use of the Guideline (100 and 93%), with some modifications. One reviewer noted that overall, the
Guideline and the accompanying documents are a substantial body of work, of high quality, and from an evidence-based perspective;
they are written clearly, with explicit links between evidence and recommendations, and the developers should be commended. The
other reviewer noted that the Guideline is comprehensive and clearly written but that navigation around the accompanying documents
was difficult at times.
In response to the AGREE appraisals, the Guideline was revised in the following ways:
• cross-reference to PICO criteria in the technical report was included in Section B3 of Appendix B
• a sentence was included in the introduction to clarify that the Guideline development process involved a new review and included a
broader range of mental health conditions
• numbering in the summary of recommendations was revised and some consensus-based recommendations revised for consistency
with the body of the document
• description of the outcomes of the public consultation process in Section B7 of Appendix B was completed
• further information on resource implications was included in the body of the document
• discussion of barriers was expanded and further discussion of digital screening included in Section B5 of Appendix B.
In addition, the following changes were made to the Technical Report:
• Table A3-1 was expanded to provide more detail of the databases and location of search strings by question (and intervention type)
and amended to reduce confusion between question types and questions
• Relevant parts of Table A3-1 were reproduced in the literature search methodology sections of Part B (Section B3), Part C (Section
C2.3) and Part D (Section D2.3)
• Changes were made to the numbering of search strings in the appendices to reduce confusion
• Text was added to clarify that literature searches were conducted to identify systematic reviews published from 2009 onwards
• Tables containing ‘PRISMA’ flow information were relabelled from ‘Exclusion of studies’ to ‘Study inclusion/exclusion’.
Independent peer review
Peer review was sought from clinicians with expertise in perinatal care. No substantive changes were made to the Guideline as a result
of peer review.
Updating procedures
The developer is aware of the current requirement of the NHMRC for Guidelines to be updated at an interval no greater than 5 years.
The developer commits to this timeframe, subject to appropriate funding. However, given the rapid emergence of relevant evidence
in recent years, the developer is exploring ways in which the Guideline might be updated within a shorter timeframe, ideally in
response to the publication of evidence that has the potential to change current recommendations or inform the development of new
recommendations. The developer plans to update the current Guideline with methodology consistent with the principles and standards
of the NHMRC current at the time of update.
Australian Clinical Practice Guideline | 82
B4 Clarity of presentation
Specific and unambiguous recommendations
The evidence-based and consensus- based recommendations were worded based on the following principles:
• recommendations are succinct and action-oriented
• the action recommended is clearly articulated and matches the strength of the body of evidence
• women to whom the recommendation relates are identified
• where relevant, timing of the action is included.
Where there is uncertainty about the best care options, this is outlined in the text.
Management options
The Guideline addresses multiple management options and these are clearly articulated via the structure of the Guideline and the
wording of the recommendations and practice points.
Identifiable key recommendations
The evidence-based recommendations, consensus-based recommendations and practice points are clearly identified by colour coding
and use of separate numbering systems. The strength of the evidence is also clearly identified. A summary of recommendations is
included.
B5 Applicability
Facilitators and barriers
Facilitators
There are a number of facilitators to guideline application which include the following.
Engagement of key stakeholders in the Guideline development
• Peak bodies that provide aspects of perinatal health and mental health care have been involved in the development of the Guideline
from the outset.
Infrastructure of peak bodies
• Each of the Colleges will play a key role in communicating the Guideline to their members and advocating for their implementation
through communication with College members in newsletters, academic publications in journals and presentation at conferences.
The infrastructure of the health system
• The framework of maternity, postnatal and primary care provision provides a vehicle for all aspects of guideline implementation from
consumer education through to screening and assessment and treatment provision. The health and community care landscape has
been taken into account when considering the Guideline application across maternity, postnatal, general practice, public and private
healthcare settings as well as the range of services available across jurisdictions.
The history of the National Perinatal Depression Initiative (NPDI)
• The Commonwealth Government’s investment into the NPDI with States and Territories (2008-15) has provided some valuable
history and infrastructure to implementation of the Guideline. Current investment is variable across States and Territories. For
example, while some States (e.g. NSW) have state-wide policies in relation to screening, in other states this has been discontinued in
the absence of funding. Awareness of the state of play across each jurisdiction and ongoing relationships and collaboration with key
Commonwealth and State Government and policy stakeholders since the NPDI, will provide an opportunity to continue to advocate
and seek support for national Guideline implementation.
The development of a perinatal mental health website to house all information for consumers, carers and health professions
• Since the release of the initial (beyondblue) Guideline, COPE (Guideline developer) has been established to provide a dedicated
focus on perinatal mental health. As part of this work, an extensive website has been developed to provide best practice information
for consumers, carers and health professionals (www.cope.org.au). The website will be updated to reflect the latest evidence for
depression, anxiety, bipolar disorder and postpartum psychosis, and be expanded to include the additional mental health conditions
that have been addressed in the current Guideline. In addition, this website will include all factsheets and screening aids (companion
documents) and house the online training program (see below).
The development of a free, online, accredited training program for health professionals
• To support implementation, a free online training program will accompany the release of the Guideline. This will facilitate education
for health professionals and include coverage of all guideline recommendations and good practice points. In addition, all companion
documents that have been developed for health professionals and consumers/carers will be embedded into the online program to
direct people to specific information on each topic.
http://www.cope.org.au
Administrative report | 83
Innovative guide for consumers and carers
• As much of the Guideline focus is on the need for education and information provision for consumers, a series of fortnightly emails
for expectant and new parents will provide emotional and mental health information relative to each stage in the perinatal period,
as well as information and links to further information and factsheets derived from the Guideline. This can be accessed at
www.readytocope.org.au
Innovative technology to facilitate screening in accordance with the Guideline
• As one of the greatest barriers to screening is time taken to do screening within tight maternity and postnatal appointments,
the Guideline developer has developed a digital screening platform that allows screening to be undertaken electronically
(http://cope.org.au/health-professionals-3/icope-digital-screening/). The feasibility trials and subsequent implementation across
a range of primary, maternity and postnatal healthcare settings demonstrate the ability of the platform (iCOPE) to save time, reduce
language barriers and improve screening rates. Programming of any additional tools recommended in the Guideline onto the iCOPE
Platform will also facilitate their application. Furthermore, the automated production of clinical reports at the time of screening
serves to guide health professionals in best practice with respect to screening outcomes and referral pathways. Consumers also can
also access a tailored report (via email or SMS) detailing outcomes and referring to more information on the COPE website.
Barriers
Barriers to application include the following.
Low screening in the private sector
• The greatest barriers to implementation are likely to be found in the private system, as many specialist obstetricians do not prioritise
perinatal mental health and focus on physical health. Medicare item numbers aim to increase rates of screening and early detection
of mental health problems and women at risk.
Lack of time to undertake screening and assessment
• As detailed above, time is a barrier and hence this is addressed through the selection of brief assessment tools and the digitisation of
screening to improve screening rates, times, accuracy and inclusiveness.
Barriers among women
• Barriers among women include stigma, significant others normalising their emotional difficulties, desiring to manage mental health
problems on their own, preferring to discuss feelings with significant others, not knowing what emotions are 'normal' and perceiving
that the health professional is disinterested or lacks time. This may be improved by the provision of timely, relevant information and
education about emotional and mental health in the perinatal period through the Ready to COPE Guide.
Lack of validated screening tools for women of non-English-speaking backgrounds
• Screening is often not available, accurate or appropriately administered for women of non-English speaking backgrounds due to the
lack of validated screening tools in other languages, and/or the accuracies and costs associated with interpreter services.
Limited uptake of referral
• Research suggests that only half of women who screen positive follow up with a subsequent mental health assessment and 30–85%
do not engage in treatment. This may be improved by consumers as well as health professionals having access to timely and
appropriate referral pathways.
Implementation advice/tools
In addition to deploying a range of approaches to raise awareness and ensure easy access to the Guideline, a range of engaging and
innovative tools and mediums will be used to disseminate the contents of the Guideline across health professional groups, consumers
and carers.
Health professionals
• Currently all Guideline information for health professionals is hosted under a specific tab on the COPE website
(www.cope.org.au/healthprofessionals) as well as being housed on the Commonwealth Department of Health website.
This will be updated and expanded to reflect changes to the Guideline.
• A range of companion documents for health professionals will be developed to enable easy access and reference to particular
elements of the Guideline, as relevant to the respective professional bodies. This is likely to include a range of fact sheets to
summarise key recommendations and practice points. These resources will be promoted widely across all College memberships and
made available through COPE and College websites.
• The development of an online (accredited) training program to inform and educate health professionals about the Guideline
recommendations and practice points. This online training program will be promoted widely across all College memberships. This is
available at www.training.cope.org.au
http://cope.org.au/readytocope/
http://cope.org.au/health-professionals-3/icope-digital-screening/
http://cope.org.au/health-professionals-3/
http://www.training.cope.org.au
Australian Clinical Practice Guideline | 84
Consumers and carers
• All information currently contained on the COPE website (www.cope.org.au) is underpinned by the previous clinical practice
guideline. As such, all website content will be reviewed to ensure it accurately reflects the new Guideline and directs people to access
the Guideline and companion documents.
• The development, promotion and dissemination of companion documents for consumers and carers will facilitate the dissemination
of Guideline information in a succinct and digestable format for consumers and carers.
• The development of Ready to COPE, innovative e-guide for consumers to receive relevant information throughout pregnancy and
the postnatal period will be developed and widely disseminated. Information pertaining to mental health is underpinned by the
clinical practice guideline, and provides an engaging and innovative approach to information dissemination for consumers and
carers. The Ready to COPE guide can be accessed at www.readytocope.org.au
Resource implications
Resource implications of each recommendation is considered in Appendix C. In summary, the recommendations are considered to have
a low requirement for additional resourcing. This is because the recommendations encompass psychometric tools or treatments that
are already in use in clinical care in Australia. If anything, it is possible that the systematic use of psychosocial assessment and screening
for depression and anxiety in the perinatal period will result in cost-savings from a whole of health system or societal perspective.
Monitoring/auditing criteria
As the peak body for perinatal mental health in Australia, COPE will continue to consult with service providers nationally to ensure
the dissemination and application of the Clinical Guideline across the country. For those utilising digital screening, this will enable the
monitoring of screening rates and outcomes across sites and settings in real time. It is noted that the ability to measure uptake of
screening across and within jurisdictions will be crucial for designing and applying implementation strategies.
Further the integration of clinical advice into the clinical reporting facilitated by the iCOPE platform will serve to inform and guide best
practice by the health professionals.
Further to this, COPE will continue to liaise with representatives of all states and territories involved in the implementation of perinatal
mental health initiatives.
B6 Editorial independence
Funding body
Financial support
COPE acknowledges that all the financial support for the development of this Guideline was received from the Commonwealth
Department of Health.
Editorial independence from funders
The commissioning of the Guideline Development to COPE as the national peak body in perinatal mental health ensures editorial
independence from the Commonwealth as the funding body.
Competing interests
Processes used for declaration and management of competing interests
At the outset of the Guideline development process, all representatives were informed of the importance of managing competing
interests and ensuring that any potential conflicts of interest were identified in advance of any meeting (as evidenced in meeting
minutes). Processes put in place to manage any potential conflicts of interest were as follows:
• All EWG members and proxies involved in the Guideline development process were required to complete a Declaration of Interest
Form (as per the NHMRC requirements). These signed and scanned forms were reviewed by the Co-Chairs of the EWG and are held
by the Guideline developer.
• On sending out agenda papers, EWG members were informed of the arising agenda items and asked to notify the Chairperson in
advance of the meeting of any potential conflicts of interest that had arisen since the most recent meeting.
• Any arising conflicts of interest were adjudicated by the Chair and Co-Chair. When a conflict of interest was declared by a EWG
member, he or she was invited to take part and contribute to discussions but was asked to leave the room (or was not involved in
email discussions) when recommendations were being formed. A conflict of interest held by the Chair was managed by the Co-Chair
and the area of conflict clearly stated. The same provisions as for other members were applied.
• If a conflict of interest was deemed to be material prior to a meeting, the member was asked to continue to contribute to the
committee, with the above measures taken to limit the introduction of bias.
http://www.cope.org.au
http://cope.org.au/readytocope/
Administrative report | 85
B7 Public consultation
The draft Guideline was released for a 30-day public consultation, as required in the NHMRC Act, 1992 (as amended), so that the final
guideline could be submitted for approval by the CEO of the NHMRC, under Item 14A Approval by CEO of guidelines for third parties,
under the Act.
Public consultation on the draft Guideline was conducted from 5 June to 4 July 2017.
The consultation draft was disseminated through COPE company members:
• Australian College of Mental Health Nurses (ACMHN)
• Australian College of Midwives (ACM)
• Australian Psychological Society (APS)
• Maternal Child and Family Health Nursing Association (MCaFNA)
• Perinatal Anxiety and Depression Australia (PANDA)
• Royal Australian College of General Practitioners (RACGP)
• Royal Australian New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
• Royal Australian and New Zealand College of Psychiatrists (RANZCP)
• The Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM).
In addition, representatives of state and territory health departments were contacted and advised of the public consultation.
A submission summary was developed that documented public submissions received and responses from the EWG. This document is
available from the COPE website.
Representative Competing interest
Prof Marie-Paule Austin
Dr James Best
Mr Andrew Davis
Ms Suzanne Higgins
Dr Helen Lindner
Prof Rhonda Marriott
Has published in the area of screening and psychosocial assessment
Developed the Antenatal Risk Questionnaire (ANRQ)
Nil
Nil
Has shares in Medibank Private
Nil
Nil
Dr Nicole Highet Developer of educational materials and digital screening and referral platforms.
Ms Creina Mitchell
Ms Jenni Richardson
Dr Vijay Roach
Ms Terri Smith
Dr Jan Taylor
Has published in the area of interventions for postnatal depression
Has developed educational materials on emotional and mental wellbeing in the perinatal period
Chairman of Gidget Foundation Australia (not-for-profit)
Nil
Nil
There was only one instance of a possible competing interest – the review of a clinical psychometric instrument (the ANRQ), which
was developed by one of the expert working group members. This was made known to all members of the EWG at the outset
of discussions. To address this issue, the member of the group was involved in the initial discussion of all available psychometric
instruments but not in further discussion or the decision-making process.
Table B2: Competing interests of EWG members
Australian Clinical Practice Guideline | 86
Over the consultation period and the following 17 days, 30 submissions were received. Of these, six were from individuals and the
remainder from organisations (including professional colleges, associations and societies; state/territory health departments; research
centres and consumer organisations). One individual submission was from a consumer with a lived experience of antenatal psychosis
and another from a consumer representative. Two pairs of submissions were duplicate or raised the same points with slightly different
wording. The Australian College of Mental Health Nurses and PANDA (a consumer organisation) advised that they would not be
providing a submission as they had been represented on the EWG and felt that their comments had been acknowledged in that forum.
Following the consultation period, submissions, a report of submissions and a revised draft of the Guideline with editorial advice
(developed by the Co-Chairs and the technical writer) were circulated to the EWG by email and feedback sought. All EWG members
provided feedback on this initial revision and there was general consensus on the suggested changes. The EWG feedback was collated
and informed the further development of the draft Guideline. Final drafts of the Guideline and submission report were then circulated to
the EWG for sign-off.
The following points list substantive comments provided in submissions and the EWG response. The submission report includes all
comments provided through submissions and The EWG reponse.
Areas for inclusion or further expansion
• Family violence – Two submissions raised the need for the Guideline to provide guidance on identifying intimate partner violence
and effective first-line responses. Another recommended that family violence be addressed separately to substance use. The
evidence on screening for family violence was not included in the systematic review and it was agreed to note in the Introduction
that assessment for family violence is outside the scope of the Guideline and to cross-reference to the Pregnancy Care Guidelines
(the evidence on assessing family violence was evaluated in the review of those Guidelines and the resulting chapter has been
revised to incorporate a submission on those Guidelines that almost duplicates one provided on this Guideline).
• LGBTI community – One submission noted that the unique needs of the LGBTI community were not included in the draft Guideline.
A point on this group has been included in Section 1.1.
• Resource implications – Two submissions noted the resource implications for mental health services. Chapter 3 notes the need
for systems for follow-up and support to be in place before screening and assessment is carried out. In addition, implications of
implementing all recommendations are included in Appendix C.
• e-health – Two submissions noted that online supports for mental health and emotional wellbeing in the perinatal period were not
discussed. This has been included in Section 8.4.3.
• Nutrition – One submission suggested that there should be a greater focus on the role of nutrition in prevention and management of
mental health conditions, the mother’s capacity to make healthy nutrition choices for herself and her child and the role of accredited
practising dietitians in mental health care in the perinatal period. This has been included where appropriate in the Guideline.
Part A – Background information
• Antenatal psychosis – One submission from an individual with a lived experience of antenatal psychosis noted that this was not
covered in the draft Guideline. A specific reference to antenatal psychosis has been included in the Guideline.
• Cultural safety – Submissions raised the need to provide more direction on supporting people who identify as Aboriginal and/or
Torres Strait Islander or who are from a culturally or linguistically diverse background and to include a practice point to ensure that
health professionals undertake cultural safety training and recognise the importance of culturally safe screening skills. This has been
included.
• Fathers’ perinatal mental health – Six submissions suggested that the appendix on perinatal mental health in partners be included in
the body of the document and one provided additional evidence on the subject. Other submissions suggested that the mental health
of the father and co-parent be considered throughout the Guideline and that the role of the father in a woman’s support network
be acknowledged. The content of Appendix E has been moved to Chapter 1, noting that this area was not covered in the systematic
review, and updated to incorporate the new evidence provided.
• Recovery-oriented mental health care – Two submissions suggested inclusion of the principles of recovery. A section on recovery-
oriented mental health care has been included in Chapter 2.
• Trauma-informed care – One submission suggested inclusion of discussion of trauma-informed care. A section on trauma-informed
care has been included in Chapter 2.
Part B – Screening and assessment
• Screening for depression – Three submissions suggested that two universal postnatal screens was demanding for health
professionals, with two (duplicate) submissions suggesting that the EPDS only be repeated when clinically indicated (as in CBR v).
A further submission suggested that the CBR to repeat the EPDS in 4–6 weeks for women with a score of 10–12 was inconsistent
with the EPDS Manual, which recommends repeat screening in 2 weeks for women with a ‘high’ score (‘high’ not defined in the
submission). One submission suggested that an EPDS score of 10–12 postnatally should trigger extra intervention from a Maternal
and Child Health Nurse. The recommendation on two universal postnatal screens was retained based on the persistence of
depressive and anxiety symptoms in the first year postpartum. The recommendation regarding women with an EPDA score of 10–12
was changed to repeat screening in 2–4 weeks.
Administrative report | 87
• Screening for anxiety – Two submissions suggested that the Perinatal Anxiety Screening Scale (PASS) be included, however the
evidence on this tool did not meet criteria for inclusion in the systematic review. Three submissions, of which two were duplicate,
suggested that the relevant items from the suggested tools be included in the recommendation. These have been included as
suggested.
• Psychosocial assessment – One submission suggested that practice points regarding the need for psychosocial assessment are
essential but that the use of a specific tool may not yet have the necessary evidence base. It also suggested that the Guideline make
it clearer that psychosocial assessment can be conducted as part of the clinical interview or using a tool. The chapter was revised to
reflect this comment.
• Risk of suicide – One submission suggested that Figure 7.1 was problematic and provided ‘red flag presentations’ from a UK report,
however the EWG agreed that the existing section was appropriate to the Australian context.
• Infant mental health – One submission suggested that guideline would benefit from further integration of perinatal psychiatry and
infant mental health as it is felt that this would reflect best practice. Another two submissions noted that there was no discussion of
the infant’s context as far as setting the scene for early brain development. The EWG noted that this is discussed in the introduction.
Part C – Prevention and treatment
• Psychological treatment for women with mild to moderate depressive or anxiety disorder – CBRs xvii and xviii – Two submissions
felt that these CBRs needed better justification for their implementation considering the low level of evidence provided. Both CBRs
were revised to better reflect the evidence base.
• Psychological treatment for women with moderate to severe depressive or anxiety disorder – One submission found that the CBR
that these disorders are best treated pharmacologically was inconsistent with the evidence and clinical experience and potentially
reflected the composition of the expert groups. The recommendation has been softened to reflect this comment.
B8 Dissemination and implementation
As Australia’s peak body in Perinatal Mental Health, the COPE, the Centre of Perinatal Excellence will provide leadership and collaborate
with its membership to support and promote the implementation of the final Guideline.
The final complete Guideline, together with a series of companion documents and resources (see above), will be disseminated broadly
through the implementation of the following strategies.
Overarching
• Production of Guideline and companion documents for health professionals and consumers, which will be available from the COPE
website.
• Placement of Guideline on key websites (COPE, Colleges, PANDA and the Commonwealth Government)
• E-dissemination of the Guideline through all professional bodies.
• National and targeted Media releases to announce the release of the new Perinatal Guideline.
Health Professionals (targeted)
• Writing and dissemination of newsletters and articles to disseminated across all professional bodies (COPE Membership) to inform
respective college members of the new Guideline and where and how to access them.
• Presentation of key recommendations at key meetings/conferences, including the Marce Australasian Conference in September 2017.
• Publication of journal articles for journals commonly referred to by health practitioners.
Consumers and carers (targeted)
• Promotion of key recommendations of interest for consumers across broad and targeted media (including broad-span and social
media channels).
• Education of all staff at the PANDA Helpline regarding the key recommendations and the implications for advice to consumers who
may be calling the helpline.
• The development of targeted social media to promote key messages and direct consumers to the guideline and companion
documents.
• Placement and links to Guideline and companion documents on partner organisation websites (e.g. beyondblue; PANDA; Pregnancy,
Birth and Baby; Healthshare; Gidget Foundation Australia).
Australian Clinical Practice Guideline | 88
C Linking evidence to
recommendations
This appendix maps the evidence statements from the Technical Report to the evidence-based recommendations in this Guideline.
Full details of the evidence, including summary of findings tables, are given in the Technical Report, which is available from the COPE
website.
Psychosocial assessment and screening
Screening for depressive and anxiety disorders
Table C2: Summary of evidence on depression screening tools in the antenatal period
Tool Quality
EPDS
0.88 (0.89 to 0.94)
0.74 (0.65 to 0.82)
0.83 (0.76 to 0.88)
0.61 (0.5 to 0.72)
Condition Sensitivity SpecificityCut-off
Major depression
Minor and major
depression
0.88 (0.86 to 0.90)
0.86 (0.83 to 0.89)
0.90 (0.88 to 0.92)
0.94 (0.92 to 0.96)
≥10
≥13
≥13
High
K-10 0.75 (0.48 to 0.93) to
1.00 (0.88 to 1.00)
Major depression 0.54 (0.44 to 0.63) to 0.81
(0.74 to 0.86)
6 Low
PHQ-9
Whooley
questions
0.74 (0.61 to 0.85) to
0.85 (0.66 to 0.96)
1.00 (0.80 to 1.00)
Major depression
Minor or major
depression
0.73 (0.38 to 0.94) to
0.84 (0.81 to 0.87)
0.68 (0.58 to 0.77)
9/10
–
Low
Low
Moderate
≥10
0.75 (0.64 to 0.84)
0.59 (0.33 to 0.82)
Minor or major
depression
Whooley plus
‘help’ question
Source: (NICE 2015).
0.88 (0.85 to 0.90)
0.91 (0.77 to 0.98)
9/10 Very low
Linking evidence to recommendations | 89
Whooley plus
‘help’ question
0.39 (0.17 to 0.64)Minor or major
depression
1.00 (0.87 to 1.00)– Very low
Table C3: Summary of evidence on depression screening tools in the postnatal period
Tool Quality
EPDS
0.95 (0.92 to 0.97)
0.83 (0.81 to 0.86)
0.80 (0.77 to 0.83)
0.68 (0.66 to 0.71)
Condition Sensitivity SpecificityCut-off
Major depression
Minor and major
depression
0.82 (0.80 to 0.84)
0.85 (0.84 to 0.86)
0.93 (0.92 to 0.94)
0.92 (0.92 to 0.93)
≥10
≥13
≥13
High
K-10 0.85 (0.66 to 0.96) Minor or major
depression
0.41 (0.25 to 0.59) 6 Low
PHQ-2
Whooley
questions
PHQ-9
0.77 (0.46 to 0.95) to
0.84 (0.71 to 0.94)
1.00 (0.81 to 1.00)
0.82 (0.68 to 0.92) to
0.89 (0.80 to 0.95)
Major depression
Minor or major
depression
Major depression
0.59 (0.53 to 0.66) to 0.79
(0.75 to 0.83)
0.64 (0.53 to 0.75)
0.65 (0.43 to 0.84) to 0.84
(0.80 to 0.87)
2 or 3
–
simple
Low
Very low
Very low
High
≥10
0.63 (0.32 to 0.86)
1.00 (0.92 to 1.00)
0.67 (0.51 to 0.80)complex
0.79 (0.73 to 0.84)
0.44 (0.39 to 0.49)
0.92 (0.89 to 094)
3 or 4
Major depression
Low
Source: (NICE 2015).
Australian Clinical Practice Guideline | 90
Implications for implementation
The use of the EPDS in the antenatal period was recommended in the previous perinatal mental health guideline. It is hoped that this
recommendation will continue to increase rates of screening, which may have implications for services providing further assessment or
treatment in primary care settings, while potentially reducing the severity of disorders (through early identification) and hence need
for medical/specialist care. The EPDS is a free tool for use in clinical and research settings, and permission has also been granted to the
Guideline developer to use it for e-screening.
It is also recommended that there is an expansion of the Medicare item number 16590 to further support screening to be undertaken
by general practitioners and specialist services (obstetricians). This will support screening in line with best practice – particularly in the
private sector where screening rates are significantly lower (when compared with the public maternity sector).
Antenatal screening
Postnatal screening
A score of 13 or more on the EPDS has moderate sensitivity and high specificity for detecting possible
major depression in pregnant women (high quality evidence).
Rationale
Based on evidence that the EPDS in the antenatal or postnatal period has moderate sensitivity and moderate to high specificity for
identifying possible depression (moderate to high quality) and that there is uncertainty about the adequacy of sensitivity or specificity
of the PHQ (very low to low quality), ‘Whooley questions (very low quality) or K-10 (low quality).
It is uncertain if the ‘Whooley questions’ have adequate sensitivity or specificity to detect possible minor
or major depression in pregnant (very low quality evidence).
A score of 10 or above on the EPDS has moderate sensitivity and moderate specificity for detecting
possible depressive disorders (minor and major depression) in pregnant women (moderate quality
evidence).
It is uncertain if the K-10 has adequate sensitivity or specificity to detect possible major depression in
pregnant women (low quality evidence).
It is uncertain if the PHQ has adequate sensitivity or specificity to detect possible depressive disorders in
pregnant women (very low to low quality evidence).
A score of 13 or more on the EPDS has moderate sensitivity and high specificity for detecting possible
major depression in postpartum women (high quality evidence).
Evidence statements: screening tool
It is uncertain if the PHQ has adequate sensitivity or specificity to detect possible depressive disorders in
postpartum women (very low to low quality evidence).
It is uncertain if the ‘Whooley questions’ have adequate sensitivity or specificity to detect possible
depression in postpartum women (very low quality evidence).
A score of 10 or above on the EPDS has moderate sensitivity and moderate specificity for detecting
possible depressive disorders (minor and major depression) in postpartum women (high quality evidence).
It is uncertain if the K-10 has adequate sensitivity or specificity to detect possible depression in
postpartum women (very low quality evidence).
RECOMMENDATION STRONG
Use the EPDS to screen women for a possible depressive disorder in the perinatal period.
References: (NICE 2015)
Linking evidence to recommendations | 91
A score of 13 or more on the EPDS has moderate sensitivity and high specificity for detecting possible major depression in pregnant
women (high quality evidence).
The ALPHA is effective at identifying family violence (moderate quality evidence).
The ANRQ is effective at predicting cases of depression (moderate quality evidence).
The PRQ is effective at predicting cases of depression (moderate quality evidence).
A score of 13 or more on the EPDS has moderate sensitivity and high specificity for detecting possible major depression in postpartum
women (high quality evidence).
Evidence statements: screening tool cut-off
Evidence statements: psychosocial assessment tool
RECOMMENDATION STRONG
Arrange further assessment of perinatal woman with an EPDS score of 13 or more.
RECOMMENDATION STRONG
If using a tool to assess psychosocial risk, administer the ANRQ.
Implications for implementation
The availability of the EPDS in many languages currently (some validated and some invalidated) supports the use of the EPDS for
women of non-English speaking backgrounds. Translated versions of EPDS are free for use in clinical and research settings, and
permission granted by the Guideline developer to use for e-screening. In addition, the Guideline developer has translated the EPDS into
other languages not previously available and has permission to make these available in electronic formats.
Implications for implementation
The ANRQ is a free tool for use in clinical and research settings (request from m.austin@unsw.edu.au), and permission has been granted
by its authors (Austin et al 2013) for the Guideline developer to use for e-screening. It forms part of the Mummatters online tool, which
can be downloaded via the internet at https://mummatters.com.au Mummatters is designed for pregnant and postnatal women to self-
assess and track their emotional wellbeing.
Rationale
Based on evidence that the ANRQ has acceptable technical performance in identifying women at increased risk of depression or
anxiety disorder (OR 6.3 [95% CI 3.5 to 11.5]), is acceptable among pregnant women (92–97%) and midwives (98%) and has a
positive effect on the rates of referral for mental health assessment (moderate quality evidence). In contrast, the ALPHA has limited
psychometric properties, is moderately acceptable to users and is effective in identifying family violence (OR 2.7; 95%CI 1.1 to 6.9) and
‘high level of psychosocial concern’ on the health professional’s part (OR 2.8; 95%CI 0.7 to 11.7) but does not have adequate capacity to
identify women at increased risk of postnatal depression (moderate quality evidence).
Psychosocial assessment
Rationale
Based on evidence that a cut-off score of 13 or more is associated with the highest sensitivity, specificity and positive likelihood ratio
and the lowest negative likelihood ratio for detecting possible major depression in the antenatal or postnatal period compared to other
cut-off scores (high quality evidence).
References: (NICE 2015)
References: (Austin et al 2005; Carroll et al 2005; Austin et al 2013; Reilly et al 2015)
https://mummatters.com.au
Australian Clinical Practice Guideline | 92
Prevention and treatment
Psychosocial support
Structured psychoeducation
Psychologically (CBT/IPT)-informed psychoeducation improves depression symptomatology (high quality evidence) at endpoint or
first measurement compared with treatment as usual or enhanced treatment as usual in women who have symptoms (or subthreshold
symptoms) of depression in the perinatal period.
Psychologically (CBT/IPT)-informed psychoeducation has inconsistent effects on depression diagnosis at endpoint or first measurement
(very low quality evidence), at intermediate follow-up (17-24 weeks post-intervention) (very low quality evidence), and at long
follow-up (25-103 weeks post-intervention) (very low quality evidence) compared with treatment as usual or enhanced treatment as
usual in women who have symptoms (or subthreshold symptoms) of depression in the perinatal period.
Psychologically (CBT/IPT)-informed psychoeducation has inconsistent effects on depression mean scores at endpoint or first
measurement (moderate quality evidence), at short follow-up (9-16 weeks post-intervention) (moderate quality evidence), at
intermediate follow-up (17-24 weeks post-intervention) (low quality evidence), and at long follow-up (25-103 weeks post-intervention)
(low quality evidence) compared with treatment as usual or enhanced treatment as usual in women who have symptoms (or
subthreshold symptoms) of depression in the perinatal period; however, the magnitude of any benefit may not be clinically significant.
Evidence statements
RECOMMENDATION STRONG
Provide structured psychoeducation to women with symptoms of depression in the perinatal period.
Implications for implementation
The need for quality psychoeducational material for pregnant women, new mothers and their families supports the need for educational
resources to be provided across maternity and healthcare settings. This has previously taken the form of education booklets and
electronic information for consumers and family members. The provision of psychoeducation resources needs to be sustained, taking
into account the needs of women from non-English speaking backgrounds.
Rationale
Based on evidence that psychologically (CBT/IPT)-informed psychoeducation improves depression symptoms among women in the
perinatal period (high quality evidence).
References: (NICE 2015)
Linking evidence to recommendations | 93
Implications for implementation
This supports the need for continued provision of support groups (e.g. mothers’ group) and the promotion of other support networks
within community settings.
Rationale
Based on evidence that involvement in a social support group may improve depression mean symptoms in women who have symptoms
of depression in the postnatal period (low quality evidence).
References: (NICE 2015)
Social support group
Social support group combined with physical exercise (a pram walking exercise program) may improve depression mean symptoms
(low quality evidence) and may have an effect on depression symptomatology (low quality evidence) compared with enhanced
treatment as usual (telephone support) in women who have symptoms of depression in the postnatal period.
Social support group may improve depression mean symptoms at endpoint or first measurement (low quality evidence) compared with
physical exercise (a pram walking exercise program) in women who have symptoms of depression in the postnatal period.
Evidence statements
RECOMMENDATION CONDITIONAL
Advise women with symptoms of depression in the postnatal period of the potential benefits
of a social support group.
Australian Clinical Practice Guideline | 94
Structured psychological interventions (individual IPT) may improve anxiety mean scores at endpoint or first measurement (low quality
evidence) compared with enhanced treatment as usual (psychoeducation booklet, monitoring and improved access to support) in
pregnant or postpartum women with a diagnosis of depression; however, the magnitude of the benefit may not be clinically significant.
RECOMMENDATION STRONG
Recommend individual structured psychological interventions (cognitive behavioural therapy or
interpersonal psychotherapy) to women with mild to moderate depression in the perinatal period.
Implications for implementation
This supports the need for: 1) clear referral pathways for health professionals to refer women to suitably qualified health professionals
and/or online treatments for the provision of timely recommended psychological treatments; 2) continued Medicare rebatable item
numbers to ensure the continued provision of psychological services to women within the perinatal period.
Rationale
Based on evidence that individual structured psychological interventions (CBT or IPT) in the perinatal period improve depression (high
quality) and depression mean scores at (moderate quality) and may improve depression symptomatology (low quality) among women
with symptoms or a diagnosis of depression.
References: (NICE 2015)
Psychological therapy
Individual structured psychological interventions
Structured psychological interventions (individual CBT or IPT) improve depression diagnosis at endpoint or first measurement (high
quality evidence) compared with treatment as usual or enhanced treatment as usual in pregnant or postpartum women with a
diagnosis of depression.
Structured psychological interventions (individual CBT or IPT) appear to have no effect on depression mean scores at intermediate
follow-up (17-24 weeks post-intervention) (very low quality evidence) compared with treatment as usual in pregnant or postpartum
women with a diagnosis of major depressive disorder or depression.
Structured psychological interventions (individual CBT) may reduce risk of self-harm mean scores at endpoint or first measurement
(low quality evidence) compared with treatment as usual in postpartum women with symptoms of depression; however, the magnitude
of the benefit may not be clinically significant.
Structured psychological interventions (individual CBT or IPT) appear to have no effect on depression diagnosis at intermediate
follow-up (17-24 weeks post-intervention) (low quality evidence) compared with treatment as usual in pregnant or postpartum women
with a diagnosis of major depressive disorder or depression.
Structured psychological interventions (individual CBT) appear to have no effect on depression symptomatology at short follow-up
(9-16 weeks post-intervention) (low quality evidence) compared with treatment as usual in pregnant or postpartum women with a
diagnosis of major depressive disorder.
Structured psychological interventions (individual CBT) improves mother–infant play frequency at endpoint or first measurement
(high quality evidence) compared with enhanced treatment as usual (home visits) in pregnant or postpartum women with a diagnosis
of major depressive episode.
Structured psychological interventions (individual CBT or IPT) improve depression mean scores at endpoint or first measurement
(moderate quality evidence) compared with treatment as usual or enhanced treatment as usual in pregnant and postpartum women
with a diagnosis of depression or symptoms of depression.
Structured psychological interventions (individual CBT) appear to have no effect on depression symptomatology at short follow-up
(9-16 weeks post-intervention) (low quality evidence) compared with treatment as usual in pregnant or postpartum women with a
diagnosis of major depressive disorder.
Structured psychological interventions (individual CBT) appear to have no effect on depression symptomatology at long follow-up
(>24 weeks post-intervention) (very low quality evidence) compared with enhanced treatment as usual non-specific emotional support
and mothercraft advice) in postpartum women with a diagnosis of major depressive disorder.
Evidence statements
Linking evidence to recommendations | 95
Directive counselling
Directive counselling may improve depression symptomatology (low quality evidence) at endpoint or first measurement compared with
treatment as usual in postpartum women with a diagnosis of minor depression or major depressive disorder.
Directive counselling appears to have no effect on depression mean scores at endpoint or first measurement (low quality evidence)
but may improve depression mean scores at long follow-up (25-103 weeks post-intervention) (low quality evidence) compared with
treatment as usual in postpartum women with a diagnosis of minor depression or major depressive disorder.
Directive counselling may improve anxiety mean scores at endpoint or first measurement (low quality evidence) compared with
treatment as usual in postpartum women with a diagnosis of minor depression or major depressive disorder.
Evidence statements
Implications for implementation
This supports the need for: 1) clear referral pathways for health professionals to refer women to suitably qualified health professionals
and/or online treatments for the provision of timely recommended psychological treatments; 2) continued Medicare rebatable item
numbers to ensure the continued provision of psychological services to women within the perinatal period.
Rationale
Based on evidence that, among women in the postnatal period with a diagnosis of minor or major depression, directive counselling may
improve depression and anxiety symptomatology (low quality).
References: (NICE 2015)
RECOMMENDATION CONDITIONAL
Advise women with depression or anxiety disorder in the postnatal period of the possible benefits
of directive counselling.
Australian Clinical Practice Guideline | 96
Complementary therapies
Omega-3 fatty acids
Treatment with omega-3 fatty acids appears to have no effect on response rate at 8 weeks post-treatment compared with placebo, in
women with antenatal or postnatal depression (very low quality evidence).
Treatment with omega-3 fatty acids does not appear to be associated with an increased risk of mild/transient side effects at 6-8 weeks
post-treatment compared with placebo, in antenatal or postnatal depression (very low quality evidence).
Maternal use of omega-3 fatty acids at any time during pregnancy is not associated with an increased risk of intrauterine growth
restriction in women with a history of intrauterine growth restriction (moderate quality evidence).
Maternal use of omega-3 fatty acids at any time during pregnancy or lactation is not associated with a reduction in motor development
at < 12 months, 12-24 months and 2-5 years (very low to moderate quality evidence).
Treatment with omega-3 fatty acids appears to have no effect on remission rate at 8 weeks post-treatment compared with placebo, in
women with antenatal or postnatal depression (very low quality evidence).
Maternal use of omega-3 fatty acids at any time during pregnancy is associated with a decreased risk of early preterm birth
(< 34 weeks), from an absolute risk of 0.3% to 0.1% (high quality evidence).
Maternal use of omega-3 fatty acids at any time during pregnancy or lactation is not associated with a reduction in cognitive
development at < 12 months, 12-24 months and 5-12 years (moderate to high quality evidence).
Maternal use of omega-3 fatty acids at any time during pregnancy may be associated with a decreased risk of neonatal mortality;
however, the finding was not statistically significant (moderate quality evidence).
Maternal use of omega-3 fatty acids at any time during pregnancy only is not associated with a reduction in motor development at
12-24 months (high quality evidence).
Maternal use of omega-3 fatty acids at any time during pregnancy only is not associated with a reduction in language development at
12-24 months and 2-5 years (moderate to high quality evidence).
Treatment with omega-3 fatty acids appears to have no effect on depression mean score at 6–36 weeks post-treatment compared with
placebo, in women with antenatal or postnatal depression (very low quality evidence).
Maternal use of omega-3 fatty acids at any time during pregnancy may be associated with a decreased risk of the infant being small for
gestational age; however, the finding was not statistically significant (moderate quality evidence).
Maternal use of omega-3 fatty acids at any time during pregnancy only is not associated with a reduction in cognitive development at
2-5 years (low to high quality evidence).
Maternal use of omega-3 fatty acids at any time during pregnancy is associated with a decreased risk of preterm birth (< 37 weeks),
from an absolute risk of 0.6% to 0.5% (high quality evidence).
Maternal use of omega-3 fatty acids at any time during pregnancy or lactation is associated with an improvement in cognitive
development at 2-5 years (high quality evidence).
Evidence statements: effectiveness
Evidence statements: harms
Linking evidence to recommendations | 97
RECOMMENDATION CONDITIONAL
Advise women that omega-3 fatty acid supplementation does not appear to
improve depression symptoms but is not harmful to the fetus or infant when taken during pregnancy
or while breastfeeding.
Implications for implementation
This supports the need for quality information provision to women and families about the role of omega-3 fatty acid supplementation
as part of psychoeducation (outlined above).
Rationale
Based on evidence that omega-3 fatty acid supplementation does not appear to have an effect on depression symptoms in the
antenatal or postnatal periods (very low quality). There is an association with a slightly reduced risk of early preterm birth (<34 weeks)
(from 3 to 1 per 1,000) (moderate quality); a slightly reduced risk of preterm birth (<37 weeks) (6 to 5 per 1,000) (high quality); a
lack of association between use during pregnancy and increased risk of intrauterine growth restriction in women with a history of
intrauterine growth restriction (moderate quality) or reduction in cognitive development at 2–5 years (low to high quality), motor
development at 12–24 months (high quality) or language development at 12–24 months and 2–5 years (moderate to high quality); and
a lack of association with reduced cognitive development at <12 months, 12–24 months and 5–12 years (moderate to high quality) or
reduced motor development at <12 months, 12–24 months and 2–5 years (very low to moderate quality) when used during pregnancy
and lactation. There was no evidence for an increased risk of postpartum haemorrhage in the studies assessed. There is a lack of effect
as prophylaxis in women at risk of postnatal depression (low quality).
References: (Gould et al 2013; NICE 2015; Saccone et al 2015; Kar et al 2016)
Australian Clinical Practice Guideline | 98
Maternal use of SSRIs at any time during pregnancy appears to be associated with an increased risk of poor neonatal adaptation
syndrome in the newborn, but due to the inadequate quality of the evidence this association is uncertain.
Maternal use of SSRIs during the third trimester of pregnancy is associated with an increased risk of convulsions in the newborn, and
the risk increases with increasing exposure, from an absolute risk of 0.3% up to 0.4% for one prescription filled, and up to 1.5% for three
prescriptions filled (low quality evidence).
Maternal use of SSRIs during the third trimester of pregnancy may be associated with an increased risk of poor neonatal adaptation
syndrome compared with maternal use of SNRIs during the same period (increase in absolute risk not estimable) (very low quality
evidence).
Maternal use of SRIs at any time during pregnancy does not appear to be associated with an increased risk of behavioural problems in
children aged 3 to 6 years (very low quality evidence).
Maternal use of SRIs at any time during pregnancy does not appear to be associated with a reduction in IQ in children aged 3 to 6
years, after controlling for maternal level of education (very low quality evidence).
Maternal use of SSRIs at any time during pregnancy may be associated with an increased risk of respiratory distress in neonates, from
an absolute risk of 3% to 5% (very low quality evidence).
Maternal use of SSRIs during late pregnancy may be associated with an increased risk of persistent pulmonary hypertension in the
newborn, from an absolute risk of 0.3% to 0.4% (low quality evidence).
There appears to be an association between maternal use of SSRIs at any time during pregnancy and an increased risk of postpartum
haemorrhage, but due to the inadequate quality of the evidence, this association is uncertain.
RECOMMENDATION CONDITIONAL
Consider the use of SSRIs as first-line treatment for moderate to severe depression and/or anxiety
in pregnant women.
Maternal use of SSRIs during the first 20 weeks of pregnancy is associated with an increased risk of miscarriage, from an absolute risk
of 8% to 11% (low quality evidence).
Maternal use of SSRIs during the first trimester of pregnancy does not appear to be associated with an increased risk of major
malformation in the newborn (very low quality evidence).
Maternal use of SSRIs at any time during pregnancy does not appear to be associated with an increased risk of the newborn being
small for gestational age (low quality evidence).
Maternal use of SSRIs during late pregnancy is associated with an increased risk of preterm birth, from an absolute risk of 6% to 16%
(low quality evidence).
Maternal use of SSRIs during the first trimester of pregnancy does not appear to be associated with an increased risk of neonatal
mortality (very low quality evidence).
Maternal use of SSRIs during the first trimester of pregnancy does not appear to be associated with an increased risk of cardiac
malformation in the newborn (very low quality evidence).
Pharmacological treatments
SSRIs during pregnancy
Evidence statements: harms
Linking evidence to recommendations | 99
Implications for implementation
This supports the need for:
1. education and training for health professionals about the safe and effective use of SSRIs in pregnant women;
2. the provision of patient information.
Rationale
Based on high quality RCT evidence of efficacy in the general population, evidence that use in pregnancy is not associated with major
and cardiac malformations (very low quality) and evidence that increases in absolute risk of other adverse outcomes are small (very
low to low quality) – miscarriage (from 81 to 109 per 1,000 with use in first 20 weeks), preterm birth (from 60 to 161 per 1,000 with use
in late pregnancy), convulsions in the newborn (from 3 to 4 per 1,000 with one prescription filled in the third trimester, and 3 to 15 with
three prescriptions filled in the third trimester), persistent pulmonary hypertension (from 3 to 4 per 1,000 with use in late pregnancy),
respiratory distress or difficulty (from 32 to 45 per 1,000 with use at any time).
References: (Simon et al 2002; NICE 2009; updated 2016; Ban et al 2012; Ban et al 2014; Berard et al 2015) (Margulis et al 2013; Ban et al 2014;
Huybrechts et al 2014; Berard et al 2015; Furu et al 2015; Petersen et al 2016) (Oberlander et al 2006) (Nakhai-Pour et al 2010) (Grzeskowiak et al 2012;
Hayes et al 2012; Almeida et al 2016) (Huybrechts et al 2015) (Malm et al 2015) (Kieviet et al 2015) (Nulman et al 2015) (Jiang et al 2016)
RECOMMENDATION STRONG
Use SSRIs as first-line treatment for moderate to severe depression in postnatal women.
Implications for implementation
This supports the need for:
1. education and training for health professionals about the safe and effective use of SSRIs in pregnant women;
2. the provision of patient information.
References: (Molyneaux et al 2014; NICE 2015) (NICE 2009; updated 2016)
Treatment with an SSRI does not appear to be associated with an increased risk of maternal adverse events at 6-8 weeks
post-treatment compared with placebo, in women with postnatal depression (very low quality evidence).
Evidence statements: effectiveness
Evidence statements: harms
SSRIs in the postnatal period
Treatment with an SSRI appears to have no effect on depression mean score at 6 weeks post-treatment compared with placebo, in
women with postnatal depression (very low quality evidence).
Treatment with an SSRI may improve response rate at 6–8 weeks post-treatment compared with placebo, in women with postnatal
depression, from a rate of 37% to 52% (very low quality evidence).
Treatment with an SSRI may improve global severity mean score at 6 weeks post-treatment compared with placebo, in women with
postnatal depression (very low quality evidence).
Treatment with an SSRI may improve remission rate at 6–8 weeks post-treatment compared with placebo, in women with postnatal
depression, from a rate of 26% to 46% (very low quality evidence).
Rationale
Based on high quality RCT evidence of efficacy in the general population; while there are few data on the efficacy of antidepressants in
perinatal samples, the available evidence suggests that SSRI use may improve response and remission rate at 6–8 weeks. Although the
perinatal specific evidence is of very low quality, this recommendation has been graded as ‘strong’ due to the minute exposure to these
antidepressants through breast milk and the greater need to treat depression postnatally (given its effect on the woman’s ability to care
for the infant and on mother–infant attachment).
Australian Clinical Practice Guideline | 100
Evidence statements: harms
Antipsychotics
Maternal use of any antipsychotics during pregnancy does not appear to be associated with an increased risk of miscarriage
(low quality evidence).
Maternal use of any antipsychotic medication during early pregnancy may be associated with an increased risk of major malformation
in the newborn, but due to the inadequate quality of the evidence any such association is uncertain.
Maternal use of any antipsychotics during pregnancy (either first, second or third trimester) does not appear to be associated with an
increased risk of preterm birth (very low quality evidence).
Maternal use of any antipsychotics during pregnancy does not appear to be associated with an increased risk of stillbirth (very low
quality evidence).
Maternal use of any antipsychotics during pregnancy does not appear to be associated with an increased risk of neonatal mortality
(very low quality evidence).
Maternal use of any antipsychotics during pregnancy (either first, second or third trimester) does not appear to be associated with an
increased risk of the newborn being small for gestational age (very low quality evidence).
Maternal use of any antipsychotics during pregnancy does not appear to be associated with an increased risk of poor neonatal
adaptation syndrome (very low quality evidence).
Maternal use of any antipsychotics during the third trimester may be associated with an increased risk of the newborn being large for
gestational age (low quality evidence).
Maternal use of any antipsychotics during the first two trimesters of pregnancy does not appear to be associated with an increased risk
of poor neonatal adaptation syndrome (very low quality evidence).
Maternal use of any antipsychotics during pregnancy a does not appear to be associated with an increased risk of respiratory distress in
newborns (very low quality evidence).
Maternal use of any antipsychotics during pregnancy does not appear to be associated with an increased risk of seizures in the
newborn (very low quality evidence).
RECOMMENDATION CONDITIONAL
Consider the use of antipsychotics for treating psychotic symptoms in pregnant women.
Implications for implementation
This supports the need for:
1. education and training for health professionals about the safe and effective use of antipsychotics in pregnant women;
2. the provision of patient information.
Rationale
Based on high quality RCT evidence of efficacy in the general population and evidence that use of most antipsychotics in pregnancy
does not appear to be associated with adverse pregnancy/birth or neonatal outcomes (very low to low quality).
References: (Lin et al 2010; NICE 2014; NICE 2014; updated 2016; Huybrechts et al 2016)
Linking evidence to recommendations | 101
Evidence statements: harms
Anticonvulsants
Maternal use of sodium valproate during pregnancy is associated with an increased risk of major malformation in the newborn, from an
absolute risk of 3% to 9% (very low quality evidence).
Maternal use of sodium valproate during pregnancy is associated with an increased risk of below average IQ (full-scale IQ score at 1 SD
level) in the child (low quality evidence).
Maternal use of sodium valproate during pregnancy is associated with an increased risk of cardiac malformation in the newborn, from
an absolute risk of 0.6% to 3.0% (very low quality evidence).
Maternal use of sodium valproate during pregnancy may be associated with a reduction in mean verbal IQ score in the child (very low
quality evidence).
Maternal use of sodium valproate during pregnancy may be associated with a reduction in mean performance IQ score in the child
(very low quality evidence).
RECOMMENDATION STRONG
Do not prescribe sodium valproate to women of childbearing age.
Implications for implementation
This supports the need for education and training for health professionals about the danger of use of sodium valproate among women
of childbearing age and provision of clear information to women.
Rationale
Based on evidence of substantial increases in absolute risk of major malformation (from 28 to 88 per 1,000), cardiac malformation
(from 6 to 29 per 1,000) and adverse cognitive outcomes (very low to low quality).
References: (Bromley et al 2014; Weston et al 2016)
Australian Clinical Practice Guideline | 102
D Psychosocial assessment and
screening
The following pages include tools for use in psychosocial assessment and screening for depression. These are followed by guides to
scoring the tools.
© 1987 The Royal College of Psychiatrists. The Edinburgh Postnatal Depression Scale (British Journal of Psychiatry 150: 782–86) reproduced with permission
Edinburgh Postnatal Depression Scale
Instructions: Please answer the following questions based on how you have been feeling over the last 7 days:
1. I have been able to laugh and see the funny side of things
5. I have felt scared or panicky for no very good reason
3. I have blamed myself unnecessarily when things went wrong
7. I have been so unhappy that I have had difficulty sleeping
9. I have been so unhappy that I have been crying
2. I have looked forward with enjoyment to things
6. Things have been getting on top of me
4. I have been anxious or worried for no good reason
8. I have felt sad or miserable
10. The thought of harming myself has occurred to me
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
Yes, quite a lot
Yes, sometimes
No, not much
No, not at all
Yes, most of the time
Yes, some of the time
Not very often
No, never
Yes, most of the time
Yes, sometimes
Not very often
No, not at all
Yes, most of the time
Yes, quite often
Only occasionally
No, never
As much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all
Yes, most of the time I haven’t been able to cope at all
Yes, sometimes I haven’t been coping as well as usual
No, I have been coping as well as ever
No, most of the time I have coped quite well
No, not at all
Hardly ever
Yes, sometimes
Yes, very often
Yes, most of the time
Yes, quite often
Not very often
No, not at all
Yes, quite often
Sometimes
Hardly ever
Never
© 1987 The Royal College of Psychiatrists. The Edinburgh Postnatal Depression Scale (British Journal of Psychiatry 150: 782–86) reproduced with permission
Calculating a score on the Edinburgh
Postnatal Depression Scale
1. I have been able to laugh and see the funny side of things
5. I have felt scared or panicky for no very good reason
3. I have blamed myself unnecessarily when things went wrong
7. I have been so unhappy that I have had difficulty sleeping
9. I have been so unhappy that I have been crying
2. I have looked forward with enjoyment to things
6. Things have been getting on top of me
4. I have been anxious or worried for no good reason
8. I have felt sad or miserable
10. The thought of harming myself has occurred to me
As much as I always could (score of 0)
Not quite so much now (score of 1)
Definitely not so much now (score of 2)
Not at all (score of 3)
Yes, quite a lot (score of 3)
Yes, sometimes (score of 2)
No, not much (score of 1)
No, not at all (score of 0)
Yes, most of the time (score of 3)
Yes, some of the time (score of 2)
Not very often (score of 1)
No, never (score of 0)
Yes, most of the time (score of 3)
Yes, sometimes (score of 2)
Not very often (score of 1)
No, not at all (score of 0)
Yes, most of the time (score of 3)
Yes, quite often (score of 2)
Only occasionally (score of 1)
No, never (score of 0)
As much as I ever did (score of 0)
Rather less than I used to (score of 1)
Definitely less than I used to (score of 2)
Hardly at all (score of 3)
Yes, most of the time I haven’t (score of 3)
been able to cope at all
Yes, sometimes I haven’t been coping (score of 2)
as well as usual
No, I have been coping as well as ever (score of 1)
No, most of the time I have coped quite well (score of 0)
No, not at all (score of 0)
Hardly ever (score of 1)
Yes, sometimes (score of 2)
Yes, very often (score of 3)
Yes, most of the time (score of 3)
Yes, quite often (score of 2)
Not very often (score of 1)
No, not at all (score of 0)
Yes, quite often (score of 3)
Sometimes (score of 2)
Hardly ever (score of 1)
Never (score of 0)
© M-P Austin. Reproduced with permission. ANRQJune04 (updated May2017)
Antenatal (Psychosocial) Risk
Questionnaire (ANRQ) – Client
V.2004 (Updated 2017) © M-P Austin
The questions below are designed to help you and your clinician understand whether you may benefit from
some extra support during this time of change. You may find some questions challenging, but please choose
the answers that best apply to you. There are no right or wrong answers.
Please complete all questions, unless instructed to SKIP a question. Once you have completed the questions,
your clinician will discuss your responses with you. If you have any concerns about any of the questions, please
let your clinician know.
Q1. Have you ever had a period of 2 weeks or more when you
felt particularly worried, miserable or depressed?
Q3. Have you had any stresses, changes or losses in the last 12
months? (e.g. only: separation, domestic violence, job loss,
bereavement etc.)
If Yes, did this:
Q1.a. Seriously interfere with your work or your
relationships with friends and family?
If Yes:
Q3.a. How distressed were you by these stresses, changes
or losses?
Q1.b. Lead you to seek professional help?
Did you see a:
psychiatrist psychologist/counsellor GP
Did you take tablets/herbal medicine? No Yes
No
If No, skip
to Q1.c.
Not
at all
A
little Somewhat
Quite
a lot
Very
much
Not
at all
A
little Somewhat
Quite
a lot
Very
much
Not
at all
A
little Somewhat
Quite
a lot
Very
much
Not
at all
A
little Somewhat
Quite
a lot
Very
much
Yes
If Yes, please answer
Q1.a., Q1.b. and Q1.c.,
No
If No, skip
to Q4.
Yes
If Yes, please
answer Q3.a.,
If yes, name of professional:
If yes, list medication(s):
If yes, please specify:
If yes, list other mental health problems:
No Yes
Q1.c. Do you have any other history of mental health
problems? (e.g. eating disorders, psychosis,
bipolar, schizophrenia) No Yes
Q2. Is your relationship with your partner an emotionally
supportive one?
Very
much
Quite
a lot Somewhat
A
little
Not
at all
No
partner
Q4. Would you generally consider yourself a worrier?
Total
Q5. In general, do you become upset if you do not have order in
your life? (e.g. regular timetable, tidy house)
© M-P Austin. Reproduced with permission. ANRQJune04 (updated May2017). The Antenatal Risk Questionnaire (ANRQ) was developed by Marie-Paule
Austin Chair of Perinatal Mental Health, University of NSW & St John of God Health Care. Reference: Austin, M. P., Colton, J., Priest, S., Reilly, N., & Hadzi-
Pavlovic, D. (2013) The Antenatal Risk Questionnaire (ANRQ): Acceptability and use for psychosocial risk assessment in the maternity setting. Women &
Birth, 26, 17-25.
No Yes
Now you are having a baby, you may be starting to think about your own childhood and what it was like:
Q7. Were you emotionally abused when you were growing up? No Yes
Q8. Have you ever been sexually or physically abused?
Q9. When you were growing up, did you feel your mother was
emotionally supportive of you?
Do you have any other concerns that you would like to talk about today?
Very
much
Quite
a lot Somewhat
A
little
Not
at all
No
Mother
Very
much
Quite
a lot Somewhat
A
little
Not
at all
Q6. Do you feel you will have people you can depend on for
support with your baby?
CL
IN
IC
AL
U
SE
O
NL
Y
Brief Scoring instructions & Interpretation of Results
• There are a maximum of 12 scored items. Based on the scoring instructions, place individual questions scores
in the score box on the right hand side.
• Add up the maximum 12 scored items and place the Total Score in the box at the top of the questionnaire.
• Total scores range from 5-60. A higher score indicates greater psychosocial risk.
Women are at increased psychosocial risk if ANY of the following criteria are met:
> Total ANRQ score of 23 or more;
> Significant mental health history: If Q1 = 5 (Yes AND [Q1.a > 4 (Quite A Lot/Very Much) OR Q1.b = 5 (Yes)];
> History of abuse: If Q7 = 5 (Yes) OR Q8 = 5 (Yes).
Instructions for women identified as at ‘increased risk’ (as per above):
• Explore psychosocial risk further as needed;
• Discuss the ANRQ and depression screening1 results with the woman and establish a care plan with her as
appropriate.
1. NOTE: The ANRQ should be administered with a depression screening measure (e.g., Edinburgh Depression Scale) to assess
for possible current depression.
© M-P Austin. Reproduced with permission. ANRQJune04 (updated May2017)
Antenatal (Psychosocial) Risk
Questionnaire (ANRQ) Clinician
Information and Scoring Template
V.2004 (Updated 2017) © M-P Austin. For permission to use please email: m.austin@unsw.edu.au
Total
Q1. Have you ever had a period of 2 weeks or more when you
felt particularly worried, miserable or depressed?
If Yes, did this:
Q1.a. Seriously interfere with your work and your
relationships with friends or family?
Q1.b. Lead you to seek professional help?
Did you see a:
psychiatrist psychologist/counsellor GP
Did you take tablets/herbal medicine? No Yes
No
0
If No, skip
to Q1.c.
Not
at all
1
A
little
2
Somewhat
3
Quite
a lot
4
Very
much
5
Yes
5
If Yes, please answer
Q1.a., Q1.b. and Q1.c.,
If yes, name of professional:
If yes, list medication(s):
If yes, list other mental health problems:
No
0
Yes
5
Q1.c. Do you have any other history of mental health
problems? (e.g. eating disorders, psychosis,
bipolar, schizophrenia) No Yes
Q2. Is your relationship with your partner an emotionally
supportive one?
Very
much
1
Quite
a lot
2
Somewhat
3
A
little
4
Not
at all
5
No
partner
5
TOTAL
SCORE
(5-60)
*SCORE Q1.A
AND Q1.B ONLY
IF Q1 = 5 (YES)
U
N
SC
O
R
ED
CL
IN
IC
AL
U
SE
O
NL
Y
No
0
Yes
5
Now you are having a baby, you may be starting to think about your own childhood and what it was like:
Q7. Were you emotionally abused when you were growing up? No
0
Yes
5
Q8. Have you ever been sexually or physically abused?
Q9. When you were growing up, did you feel your mother was
emotionally supportive of you?
Do you have any other concerns that you would like to talk about today?
Very
much
1
Quite
a lot
2
Somewhat
3
A
little
4
Not
at all
5
No
Mother
5
Not
at all
1
A
little
2
Somewhat
3
Quite
a lot
4
Very
much
5
Not
at all
1
A
little
2
Somewhat
3
Quite
a lot
4
Very
much
5
Q4. Would you generally consider yourself a worrier?
Q5. In general, do you become upset if you do not have order in
your life? (e.g. regular timetable, tidy house)
Very
much
1
Quite
a lot
2
Somewhat
3
A
little
4
Not
at all
5
Q6. Do you feel you will have people you can depend on for
support with your baby?
Q3. Have you had any stresses, changes or losses in the last 12
months? (e.g. only: separation, domestic violence, job loss,
bereavement etc.)
If Yes:
Q3.a. How distressed were you by these stresses, changes
or losses?
Not
at all
1
A
little
2
Somewhat
3
Quite
a lot
4
Very
much
5
No
0
If No, skip
to Q4.
Yes
5
If Yes, please
answer Q3.a.,
If yes, please specify:
*SCORE Q3.A
ONLY IF
Q3 = 5 (YES)
© M-P Austin. Reproduced with permission. ANRQJune04 (updated May2017). The Antenatal Risk Questionnaire (ANRQ) was developed by Marie-Paule
Austin Chair of Perinatal Mental Health, University of NSW & St John of God Health Care. Reference: Austin, M. P., Colton, J., Priest, S., Reilly, N., & Hadzi-
Pavlovic, D. (2013) The Antenatal Risk Questionnaire (ANRQ): Acceptability and use for psychosocial risk assessment in the maternity setting. Women &
Birth, 26, 17-25.
Glossary | 109
Glossary
For the purposes of this Guideline, the following terms are defined as outlined below.
Aboriginal and Torres Strait Islander peoples: It is recognised that there is no single Aboriginal or Torres Strait Islander culture or
group, but numerous groupings, languages, kinships, and tribes, as well as ways of living. Furthermore, Aboriginal and Torres Strait
Islander peoples may currently live in urban, rural or remote settings, in urbanised, traditional or other lifestyles, and frequently move
between these ways of living.
Agranulocystosis: An acute condition involving a severely lowered white blood cell count, most commonly of neutrophils. Also known
as agranulosis or granulopenia.
Anticonvulsants: Medications used in the treatment of epileptic seizures. Anticonvulsants are also used in the treatment of bipolar
disorder, as many also act as mood stabilisers.
Antidepressants: Medications used to treat moderate to severe depression and dysthymia. Antidepressants include selective serotonin
reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs) and tricyclic
antidepressants (TCAs).
Antihistamines: Medications that oppose the activity of histamine receptors and are used in the treatment of, among other things,
insomnia.
Antipsychotics: Medications most commonly, but not exclusively, used to treat psychosis.
Baseline risk: The risk of an event without treatment, intervention or exposure (e.g. risk of becoming ill without treatment or risk of
birth defects without exposure to a specific medication).
Bipolar disorder: A condition characterised by intense and sustained mood shifts usually between episodes of depression and mania.
Borderline personality disorder: A condition characterised by a pervasive pattern of instability of emotions, relationships, sense of
identity and poor impulse control that is consistently associated with severe functional impairment.
Catatonia: An abnormality of movement and behaviour arising from a disturbed mental state (typically schizophrenia).
Cognitive-behavioural therapy: Psychological therapy based on the assumption that faulty thinking patterns, maladaptive behaviours
and “negative” emotions are all inter-related. Treatment focuses on changing an individual’s thoughts (cognitive patterns) or
maladaptive behaviours in order to change emotional states. Cognitive-behavioural therapy integrates the cognitive restructuring
approach of cognitive therapy with the behavioural modification techniques of behavioural therapy.
Depression: Feelings of sadness and/or a loss of interest in activities once enjoyed, which can lead to a variety of emotional and
physical problems and decrease a person’s ability to function at work and at home. Depression symptoms vary from mild to severe.
Dialectical behaviour therapy: A cognitive behavioural treatment that was originally developed to treat chronically suicidal individuals
diagnosed with borderline personality disorder, which is now an accepted psychological treatment for this population.
Directive counselling: An intervention incorporating elements of supportive listening and history taking and techniques of problem
clarification, goal formation, problem solving and partner sessions, delivered individually or in a group format.
Electroconvulsive therapy: A procedure used to treat certain psychiatric conditions. It involves passing a carefully controlled electric
current through the brain, which affects the brain’s activity and aims to relieve severe depressive and psychotic symptoms.
Emotional dysregulation: a term used by clinicians to refer to an emotional response that is poorly modulated, and does not fall within
the conventionally accepted range of emotive response. Emotional dysregulation may be referred to as labile mood (marked fluctuation
of mood), mood swings, or mood or affective instability.
Facilitated self-help: A psychological intervention typically based on cognitive behavioural principles that seeks to equip people with
strategies and techniques to begin to overcome and manage their psychological difficulties. Self-help usually provides information in
the form of books or other written materials that include psychoeducation about the problem and describe techniques to overcome it.
A therapist or a computer-based system (stand alone or web based) assists the individual in using the materials.
Generalised anxiety disorder: Feeling anxious about a wide variety of things on most days over a long period of time (e.g. 6 months).
Interpersonal psychotherapy: A short-term supportive psychotherapy that focuses on the connection between interactions between
people and the development of psychological disorder symptoms.
Mental health (or psychiatric) condition: Condition fulfilling diagnostic criteria (depression, anxiety disorder, bipolar disorder,
postpartum psychosis), which may be mild, moderate or severe.
Mental health symptoms: Signs of mental health problems that do not in themselves constitute a clinical diagnosis.
Australian Clinical Practice Guideline | 110
Mentalisation-based therapy: An integrative form of psychotherapy, bringing together aspects of psychodynamic,
cognitive-behavioural, systemic and ecological approaches designed for the treatment of borderline personality disorder.
Mindfulness training: Mindfulness-based cognitive therapy is intended to enable people to learn to become more aware of the bodily
sensations, thoughts and feelings associated with depressive relapse, and to relate constructively to these experiences. It is based
on theoretical and empirical work demonstrating that depressive relapse is associated with the reinstatement of automatic modes of
thinking, feeling and behaving that are counterproductive in contributing to and maintaining depressive relapse and recurrence (for
example, self-critical thinking and avoidance) (NICE 2015).
Mixed depression: This term is not used in this Guideline but is used in the accompanying technical report to describe minor or major
depression.
Mood stabilisers: Medications used to treat bipolar disorder.
Mother-infant relationship interventions: Interventions that aim to improve the relationship between the mother and infant (NICE
2015). These interventions are based on a psychological theory about the nature of attachment between the mother and infant and
typically involve observations of mother–infant interactions, feedback (often video-based), modelling and cognitive restructuring. The
primary goal is to enhance maternal sensitivity to child behavioural cues and awareness of the child’s developing skills and needs.
Negative predictive value: The probability that a person who tests negative using a test does not have the condition.
Neonatal persistent pulmonary hypertension (NPPH): A serious and life-threatening, but rare, lung condition that occurs soon after
birth. Neonates with NPPH have high pressure in their lung blood vessels and are not able to get enough oxygen into their bloodstream.
Non-directive counselling: A therapeutic approach that aims to help individuals to resolve problems and to facilitate decisions based
on solutions that are appropriate for them at that time. The approach is not value-laden, biased or directive, but rather aims to allow
the individual to share his or her perspectives, values and current life circumstances.
Non-psychotic condition: A mental health condition (e.g. depressive or anxiety disorder) without psychotic symptoms.
Obsessive compulsive disorder: Ongoing unwanted/intrusive thoughts and fears that cause anxiety (obsessions) and a need to carry
out certain rituals in order to feel less anxious (compulsions).
Panic disorder: Frequent attacks and intense feelings of anxiety that seem like they cannot be brought under control; this may go on to
be associated with avoidance of certain situations (e.g. going into crowded places).
Perinatal period: The period covering pregnancy and the first year following birth.
Personality dysfunction: Longstanding maladaptive behaviours and coping styles associated with difficulties in the areas of
occupational and social function and the ability to utilise health services effectively.
Positive predictive value: The probability that a person who tests positive using a test has the condition.
Post-traumatic birth counselling: An intervention that aims to: explain to women what happened in the birth; give the woman an
option to discuss labour, birth, and post-birth experiences; and to answer any questions she has.
Post-traumatic stress disorder: Bursts of anxiety any time from one month after experiencing a traumatic event (e.g. a traumatic birth,
sexual assault or violence).
Postnatal depression: Depression experienced in the postnatal period.
Postpartum psychosis: Acute psychotic episode arising in the early postnatal period.
Practice point: For the purposes of this Guideline, these are points of advice that are based on lower quality evidence than is required
for recommendations, and/or best practice clinical judgement.
Psychodynamic therapy: A long-term method of psychological therapy involving in-depth exploration of past family relationships,
as they were perceived during an individual’s infancy, childhood and adolescence. The approach assumes dysfunctional or unwanted
behaviour is caused by unconscious, internal conflicts and focuses on gaining insight into these and developing strategies for change.
Psychoeducation: a structured educational treatment (often offered in groups), which may focus on preparation for childbirth
(antenatal) or practical aspects of childcare (postnatal) but also includes a specific mental health component with information about
common mental health conditions in the antenatal and/or postnatal period (NICE 2015). These interventions are often informed by
psychological principles and use techniques such as cognitive restructuring, pleasant event scheduling, role play, guided relaxation, and
homework exercises.
Psychosis and psychotic episode/disorder: An acute mental health episode defined by abnormality of thinking, perception and
behaviour in which the patient loses touch with reality and lacks insight into being ill.
Glossary | 111
Psychosocial: Various psychological and social factors that may have an impact on health and wellbeing in the perinatal period.
Psychotherapy: A general term for a process of treating mental and emotional conditions through an intentional interpersonal
relationship used by trained psychotherapists to aid the person in overcoming the problems of living.
Relative risk: The ratio of the risk (rate) of an outcome in an exposed group (e.g. to a specific medication) to the risk (rate) of the
outcome in an unexposed group in a specified time period.
Schema-focussed psychotherapy
Schizophrenia: A complex condition of brain function with wide variation in symptoms and signs, and in the course of the illness. The
experiential ‘core’ of schizophrenia has been described as a disturbance involving the most basic functions that give the person a
feeling of individuality, uniqueness and self-direction (Galletly et al 2016).
Sensitivity: The proportion of people with the condition who have a positive test result.
Significant other(s): Individuals who are significant to the woman and considered by the woman to be important to her care. This may
include her partner or members of her immediate or extended family. In some cases, the father of the infant may be estranged from the
mother but remain significant to the infant.
Social phobia: Intense fear of criticism, being embarrassed or humiliated, even in everyday situations (e.g. eating in public or making
small talk).
Social support group: A system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual
agreement of what is helpful and is primarily in one direction with a clearly defined peer supporter and recipient of support (NICE
2015). Peer volunteers who are mothers themselves and also have a history of antenatal or postnatal mental health problems are
recruited and trained to deliver interventions. These interventions can include befriending and mentoring. Support groups also provide
an opportunity for peer support but are usually facilitated by a healthcare professional and discussions are usually structured around
a series of pre-defined topic areas (for instance, transition to motherhood, postnatal stress management, co-parenting challenges).
However, the primary goal of these interventions is to enable mutual support by bringing women into contact with other women who
are having similar experiences and providing opportunities for sharing problems and solutions.
Sociocultural: Relating to both social and cultural factors.
Specific phobia: Fearful feelings about a particular object or situation (e.g. going near an animal, flying on a plane or receiving an
injection).
Specificity: The proportion of people without the condition who have a negative test result.
Systems training for emotional predictability and problem solving
Transference-focussed psychotherapy: An evidence-based psychodynamic therapy designed for patients with personality disorders.
Trauma-informed care: Trauma-informed care and practice is a strengths-based framework grounded in an understanding of and
responsiveness to the impact of trauma, that emphasises physical, psychological, and emotional safety for both providers and survivors,
and that creates opportunities for survivors to rebuild a sense of control and empowerment (Kezelman & Stavropoulos 2012).
Yoga: a system of gentle exercises, with the aim of attaining bodily or mental control and wellbeing (Marc et al 2011)
Australian Clinical Practice Guideline | 112
ACM Australian College of Midwives
ACMHN Australian College of Mental Health Nurses
AIHW Australian Institute of Health and Welfare
ALPHA Antenatal Psychosocial Health Assessment
ANRQ AnteNatal Risk Questionnaire
AOR adjusted odds ratio
APS Australian Psychological Society
AWHN Australian Women’s Health Network
CBR consensus-based recommendation
CBT cognitive behavioural therapy
CHF Consumers Health Forum
CI confidence interval
COPE Centre of Perinatal Excellence
DALY disability-adjusted life year
DASS Depression, Anxiety and Stress Scale
DBT dialectical behaviour therapy
DSM Diagnostic and Statistical Manual of Mental Disorders
EBR evidence-based recommendation
ECT electroconvulsive therapy
EPDS Edinburgh Postnatal Depression Scale
EPDS-3A EPDS items 3, 4 and 5
EWG Expert Working Group
GAD-7 Generalised Anxiety Disorder 7-Item Scale
GHQ General Health Questionnaire
GP general practitioner
HADS Hospital Anxiety and Depression Scale
IPT interpersonal psychotherapy
IQ intelligence quotient
K10 Kessler Psychological Distress Scale
MAOIs monoamine oxidase inhibitors
MBT mentalisation-based therapy
MCaFNA Maternal Child and Family Health Nursing Association
NHMRC National Health and Medical Research Council
NICE National Institute for Health and Clinical Excellence (UK)
NPPH neonatal persistent pulmonary hypertension
OR odds ratio
PANDA Perinatal Anxiety and Depression Australia
PHQ Patient Health Questionnaire
PP practice point
PRQ Pregnancy Risk Questionnaire
PTSD post-traumatic stress disorder
RACGP Royal Australian College of General Practitioners
RANZCOG Royal Australian and New Zealand College of
Obstetricians and Gynaecologists
RANZCP Royal Australian and New Zealand College of
Psychiatrists
RCT randomised clinical trial
SFT schema-focused psychotherapy
SNRI serotonin-norepinephrine reuptake inhibitor
SR systematic review
SSRI selective serotonin reuptake inhibitor
STAI State-Trait Anxiety Inventory
STEPPS systems training for emotional predictability and
problem solving
TCA tricyclic antidepressants
TFP transference-focussed psychotherapy
TGA Therapeutic Goods Administration
Abbreviations and acronyms
References | 113
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