Perinatal mood and anxiety disorders — structured clinical viva

Treat the EPDS as a screen, not a diagnosis. Score 18 with a positive self-harm item mandates same-day clinical interview: full depressive/manic/psychotic screen, sleep, supports, domestic safety, substances, and dual risk (maternal suicide and infant safety/care capacity). Expand the self-harm item into ideation, intent, plan, means and protective factors.[1][6]

OCD vs psychosis. Ego-dystonic intrusive infant-harm images with horror, checking/avoidance and insight usually indicate perinatal OCD spectrum and need psychoeducation plus ERP-informed care — not automatic removal of the infant. Ego-syntonic delusions, command hallucinations, manic drive or perplexity indicate postpartum psychosis emergency pathways.[2][4]

Sertraline and breastfeeding. Discuss risk-benefit of untreated depression versus medication; sertraline is a common first-line choice with relatively favourable lactation data in pooled analyses; start sertraline 50 mg orally daily, early review, consider titration, monitor mother and infant (sedation, feeding, irritability). Combine with psychological therapy and sleep support.[3][6]

Escalation. Mother-baby unit or inpatient care if high suicide risk, psychosis, inability to care safely, or failed intensive community support. ECT for severe life-threatening depression/psychosis with need for rapid response after consent and obstetric liaison.[5][4]