Care Pathway for the Management of Perinatal Mental Health

The following pathway* provides options for mental health supports and services available to Durham Region residents experiencing Perinatal Mood Disorders (PMD).

Options are categorized in a step-care approach and based on the client’s assessed needs as determined by their care practitioner and as related to their scores:

A person can enter at any step in the pathway and move up or down based on the severity of illness and response to prior interventions. Ongoing monitoring by the care practitioner is required.

Stepped care approach

Ask about the well-being of the pregnant or postpartum person at every visit to identify the need for mental health support and treatment.

Ask about mood and well-being of the pregnant or postpartum person at each visit and consider input from patient’s circle of care.

Assessment tools can be used, including the Edinburgh Perinatal/Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder (GAD-7), and Patient Health Questionnaire (PHQ-9).

Identify factors that precipitate or exacerbate mental health symptoms (e.g., lack of support, financial difficulties, domestic violence, alcohol, or substance use disorders, etc.).

Advise by providing education on perinatal mental health and arrange support to mitigate factors that are affecting mental health.

Provide information about mental health problems in pregnancy and postpartum, how common they are and that effective treatments are available. Discuss strategies to increase practical and emotional social support, improve night-time sleep and incorporate regular meals and physical activity. These factors may improve mental health on their own for those with mild or subclinical symptoms and in conjunction with mental health treatments for those with problems that are more severe.

Link to community supports. Across Ontario, the Healthy Babies Healthy Children (HBHC) program is a free program delivered through Ontario’s public health units in partnership with hospitals and other community partners to help families receive supports and services to enhance mental health, self-care, and parenting capacity in the community. Arrange assistance in addressing precipitating and perpetuating factors, including resources available in the community to provide support (e.g., accessing financial, legal, and domestic violence support, and accessing care for substance use disorders).

Assess the severity of the mental health concern.

Some mental health issues can resolve on their own with time and support, or with addressing the other risk factors or concerns. However, other issues may be more persistent and develop into a clinical mental disorder requiring more than supportive interventions. For presentations that require clinical intervention, treatment planning is guided by the severity of the illness (mild, moderate, severe, and urgent), which is assessed by considering the number, nature and persistence of symptoms and the degree of impact on quality of life.

Assist by recommending or implementing a treatment step.

A stepped-care management plan may include a range of treatment options and interventions and is adaptable to a patient’s changing needs and preferences. An individual can enter the pathway at any step and move between steps based on severity of illness and in response to interventions. Regardless of which "step" is being considered, child care support is essential in the care management plan. The HBHC program offers a home-visiting program so families can receive supports and services they need, including to enhance maternal mental health, self-care, and parenting capacity while in the community.

Arrange follow-ups to monitor recommended treatment plan. Make modifications or changes to treatment step as required.

Address barriers to treatment uptake, review risk factors and discuss progress to determine whether new level of treatment step is required.

Frequency of initial follow-up should be at minimum every two weeks during active treatment phase (12 weeks). More frequent contact may be required if there is a higher severity of illness or medication is prescribed and may be less frequent as symptoms improve. Be clear about which health professional is providing follow-up care.

Use the assessment tools to monitor symptoms. Scores on a GAD-7 <5, PHQ-9 <5 or EPDS <10 on at least two assessments that are at least two weeks apart suggest remission.

Follow patient to remission. Follow the individual on medication treatment for at least six months or longer after remission to assess need for ongoing treatment.

Screening Tools

The tools below are used internationally and have been translated into various languages and validated in diverse populations.
Tools have been formatted to be completed electronically, saved and/or printed, or shared electronically for the patient to complete.

Once completed, please select the box that corresponds to your patient’s score to view supports and resources.

Perinatal / Postnatal Depression Scale (EPDS) Generalized Anxiety Disorder-7 (GAD-7) Patient Health Questionnaire-9 (PHQ-9)

Patient assessment and scoring

EPDS score of 10 to 12.
PHQ-9 or GAD-7 score of 5 to 9.

Common mental health concerns such as depression or anxiety, where symptoms are mild or subclinical (may include patients for whom you are taking a watch and-wait approach). Access supports and resources.

EPDS score of 13 to 18.
PHQ-9 or GAD-7 score of 10 to 14.

Common mental health concerns of mild severity that do not remit with Step 1 interventions.
Common mental health concerns of moderate severity or greater.
Access supports and resources.

EPDS score greater than 19 or question 10 has a score greater than zero.
PHQ-9 or GAD-7 score greater than 15.
Active intent to harm self/others and/or suicidal ideation.

Mild or moderate mental health concerns that do not remit with Step 2 interventions.
Severe mental health concerns (severe depression or other severe mental illnesses such as bipolar disorder or schizophrenia).
Access supports and resources.

The scope of this work does not include guidance on specific mental disorder(s) and/or substance use. In addition, specific details about recommended pharmacological (drug) treatments or their potential benefits and harms when used in pregnancy and/or lactation are not included in this resource. Links to evidence-based information are provided in the PCMCH Perinatal Mental Health Guidance document. Health care providers must perform an individualized assessment and apply clinical judgment to ensure a safe and effective plan of care. This resource does not take the place of national or provincial medical guidelines. The resources and services hyperlinked in the care pathway and guidance document are current and consistent with the intended purpose of this work, as of the date of publication.

Supports and resources

Mild

Treatment Step 1

Self-help

Guided self-help

BounceBack® 1-866-345-0224
Free skill-building program managed by the Canadian Mental Health Association (CMHA). It is designed to help adults and youth 15+ manage low mood, mild to moderate depression and anxiety, stress or worry. Delivered over the phone with a coach and through online videos, individuals will get access to tools that will support them on their path to mental wellness.

Peer support and supportive counselling

Durham Health Connection Line 905-668-2020 or toll free: 1-800-841-2729 or 311
Durham Region Health Department public health nurses provide information and support related to health topics including mental health resources and programs. Monday to Friday, 9 a.m. to 5 p.m.

Steps to Wellness: Before and After Baby - Durham Region Health Department
A free virtual group program that provides Cognitive Behavioural Therapy (CBT) for individuals experiencing symptoms of Perinatal Mood Disorder. This 9-week registered group is for pregnant and postpartum mothers with babies up to 18 months of age. Clients can self-refer by calling Durham Health Connection Line.

Healthy Babies Healthy Children - Durham Region Health Department
Healthy Babies Healthy Children (HBHC) is a home-based visiting program for families. Families that qualify are paired with a public health nurse and family visitor, together they create goals and a plan for the family to work towards. The client picks goals they would like to focus on during the program and create a plan together. A referral can be completed and faxed by a health care practitioner or clients can self refer through calling the Durham Health Connection Line. A public health nurse will call the client to talk about their needs and how we can best support them.

Rose of Durham 905-432-3622
Provides services to young and/or vulnerable parents under 30 years of age and their children. Specific programs are available for both moms and dads. Services include counselling and support services that help parents build on their strengths and focus on achieving their goals.

EarlyON Child and Family Centres
EarlyON Child and Family Centres provide opportunities for children from birth to six years of age to participate in play and inquiry-based programs, and support parents and caregivers in their roles. Families and caregivers will be able to find support, make personal connections and access a network of resources.

Community Care Durham – WeConnect Mental Health and Wellness 1-888-255-6680
A unique community-based mental health service provided by Community Care Durham (CCD) that offers group support to adults aged 16 and older, with emotional and/or mental health concerns. Offering in-person, virtual, and hybrid services. Referrals accepted via self-referral.

MindShift CBT App
Uses scientifically proven strategies based on Cognitive Behavioural Therapy (CBT) to help individuals learn to relax and be mindful, develop more effective ways of thinking, and use active steps to take charge of their anxiety. Features a community forum, enabling clients to find and offer peer-to-peer support.

Postpartum Support International (PSI) 1-800-944-4773
A call or text helpline for questions and concerns, online support groups, and a local service provider directory. Offers options for moms and dads. There is also a specialized coordinator for LGBTQIA+ parents, adoptive parents, disabled parents, grandparents, Indigenous parents, and more.

North York General Hospital (NYGH) – Postpartum Support Group
An open virtual support group for individuals who are experiencing symptoms of postpartum anxiety, postpartum depression and/or or would like support with coping with a newborn. The group is for individuals following the birth of their baby and up to one year postpartum. Participants do not need to be an NYGH patient to attend the group. The group accepts self-referrals as well as referrals from a health care provider or clinician.

North York General Hospital (NYGH) – Late Loss Support Group
An open virtual support group that gives individuals an opportunity to share experiences and connect with other parents who have experienced a recent (within the past year) late pregnancy loss or neonatal death. Late pregnancy loss is defined as 20+ weeks and includes a still birth or loss due to incompatibility with life. You do not need to be an NYGH patient to attend the group. The group accepts self-referrals as well as referrals from a health care provider or clinician.

Sunnybrook - Pregnancy and Infant Loss Network 1-888-303-PAIL (7245)
Offers a variety of peer-support services (at no cost to families) to parents and family members who have been affected by pregnancy or infant loss. Support services are offered over the phone and online and are available to residents of Ontario.

Distress Centre Durham 905-430-2522 or 1-800-452-0688
Specially trained responder volunteer team is made up of men and women 18 and older who are non-judgmental, empathetic, caring individuals who share the desire to make a significant and meaningful contribution to the Durham Region community. Volunteers provide support via phone: emotional support and encouragement, crisis management, suicide risk assessment, community resource/referral information, emergency intervention. The helpline is available 24 hours a day, seven days a week.

Mount Sinai Hospital Perinatal Mental Health Program 416-586-4800, ext. 8325
Provides mental health assessment and treatment to Mount Sinai Hospital patients and their partners during pregnancy and for up to one year postpartum. The program is inclusive of all genders, sexual orientations and family structures.

Additional resources

e-Mental Health - Directory

Directory of mental health services and organizations in Ontario and throughout Canada.
Info sheets: Information about a variety of mental health conditions and topics.
Events calendar: Information about mental health events by geographical area.

211 Ontario
Highly-trained and accredited Community Navigators provide referrals to services to connect clients to the right supports. Services are provided by phone/voice, by text, online search, email, or chat.

For fathers (many supports in the pathway steps service all family members, see descriptions for details.)

Men's Counselling Link 211
Free confidential virtual or in-person counselling offering support for those experiencing stress, relationship conflict, harmful behaviours or personal challenges. Men’s Counselling Link can also connect men with other services, like food supports, employment services or income assistance, which helps reduce stress. For male-identifying individuals 16 years of age and older in Durham Region.

Postpartum men
A website for men with concerns about depression, anxiety or other problems with mood after the birth of a child. It promotes self-help, provides important information for fathers – including a self-assessment for postpartum depression – hosts an online forum for dads to talk to each other, offers resources, gathers new information about men’s experiences postpartum, and – most importantly – helps fathers to beat the baby blues.

Heads Up Guys
A website that offers practical self-care tips, screening tools, self-guided courses, inspirational recovery stories, and an International Therapist Directory, along with guidance on how to support the men in our lives.

Canadian Centre for Men and Families
A hub that is dedicated to the health and well-being of boys, men, fathers and families. Provide peer support groups, therapy, counselling, programs and more.

Canadian Men's Health Foundation
Provides free counselling, tools, information and resources to support men’s mental health.

Moderate

Treatment Step 2

Cognitive Behavioural Therapy (CBT) and Interpersonal Psychotherapy (IPT)

Steps to Wellness: Before and After Baby - Durham Region Health Department Durham Health Connection Line 905-668-2020, toll-free: 1-800-841-2729, or dial 311.
A free virtual group program that provides Cognitive Behavioural Therapy (CBT) for individuals experiencing symptoms of Perinatal Mood Disorder. This 9-week registered group is for pregnant and postpartum mothers with babies up to 18 months of age. Clients can self-refer by calling Durham Health Connection Line.

Ontario Shores - LOVE YOU by Shoppers Drug Mart Women's Clinic 1-877-767-9642 | Make a referral
Email: centralizedreferral@ontarioshores.ca
Short term, focused consultation, and treatment to women with perinatal mood disorders and other reproductive issues that affect a woman's mental health. Referrals are accepted from any health care professional.

Family Services Durham 311
Provides individual, couple and family counselling and psychotherapy to people who live or work in Durham Region. We provide help for a variety of problems. Service is offered in-person, by telephone or by video. The fee for service is set during the intake process based on household income.

Catholic Family Services of Durham 905-725-3513
A psychotherapy-focused organization that works with individuals, couples and families to address the challenges they’re facing and find a path to a more hopeful future. Services are available in both English and French. A low-cost, fee-for-service agency, no one is turned away because of the fee.

Durham Counselling Walk-in Clinic (for youth 19 years and under and family) 289-509-0603 extension 3203
The Durham Counselling Walk-in Clinic (DCWIC) is a free, confidential counselling clinic providing service for children and youth ages 3- 19 years (up until their 20th birthday) and their families. Counselling sessions are available in-person and virtually.

North York General Hospital (NYGH) – Postpartum Support Group
An open virtual support group for individuals who are experiencing symptoms of postpartum anxiety, postpartum depression and/or or would like support with coping with a newborn. The group is for individuals following the birth of their baby and up to one year postpartum. Participants do not need to be an NYGH patient to attend the group. The group accepts self-referrals as well as referrals from a healthcare provider or clinician.

North York General Hospital (NYGH) - Late Loss Support Group
An open virtual support group that gives individuals an opportunity to share experiences and connect with other parents who have experienced a recent (within the past year) late pregnancy loss or neonatal death. Late pregnancy loss is defined as 20+ weeks and includes a still birth or loss due to incompatibility with life. Clients do not need to be an NYGH patient to attend the group. The group accepts self-referrals as well as referrals from a healthcare provider or clinician.

Sunnybrook Health Sciences Centre - Women's Mood & Anxiety Clinic: Reproductive Transitions
Assessment and treatment of perinatal mood and anxiety disorders with expertise in the use of both psychotropic medication and psychotherapy during pregnancy and postpartum.

Sunnybrook - Pregnancy and Infant Loss Network 1-888-303-PAIL (7245)
Offers a variety of peer-support services (at no cost to families) to parents and family members who have been affected by pregnancy or infant loss. Support services are offered over the phone and online and are available to residents of Ontario.

Lakeridge Health - Pinewood Centre - Umbrellas Program 1-833-392-7363
Intensive community treatment services for pregnant and early parenting women providing support regarding their substance use, co-occurring mental health symptoms. Client goals are personalized with programs that support each client’s readiness to change.

Referrals to other agencies and residential programs can be made. Services include assessment, case management and individual and group counselling.

Available to:

Pregnant and/or early parenting women with substance use concerns
Pregnant or parenting a child 0 to 6 months effective until January 2024 (standing criteria is pregnant or parenting 0 months to 3 years)

Adult Integrated Mental Health Services (AIMHS) - Lakeridge Health | Make a referral
Outpatient community mental health program that is part of Lakeridge Health. Provides goal-oriented and time-limited psychoeducation, treatment, and psychotherapy to adults over age 18. A variety of treatment options are offered, including psychoeducation groups and group programs that are more process oriented.

Brock Community Health Centre 1-705-432-3322
The Primary Health Care Program consists of a team of physicians, nurse practitioners, nurses, and other allied health professionals (social worker, dietitian, physiotherapist) who work in collaboration with other programs offered by Brock CHC. Services include preventative health care, treatment of chronic and episodic illnesses, mental health counselling, service navigation and referrals, access to phlebotomy, and more. All Brock CHC services are free. Office locations in Cannington and Beaverton.

Canadian Mental Health Association Durham 1-844-436-8760
A Mental Health and Primary Care Hub that promotes and enhances the mental, emotional, and physical well-being of the community, through education, collaboration, advocacy, and the provision of a broad range of direct services.

Women’s College Hospital - Parents Matters Group
POSTPARTUM MATTERS (formerly known as Mother Matters) is an eight-week online support group run by the Reproductive Life Stages (RLS) Program at Women’s College Hospital. It is for women and gender-diverse individuals who have a baby under the age of one year. The group is facilitated by a therapist from the RLS Program. It takes place on a confidential online discussion board, giving you the opportunity to share your thoughts, feelings, and experiences, while learning from and supporting others going through a similar life transition. Each week a new topic will be explored, relating to issues that commonly emerge during the first year of life with a new baby.

Specialized groups for Black parents and young parents are available in addition to groups open to all. Access to the program is by self-referral.

Metis Nation of Ontario - Mental Health and Addictions Services 1-800-263-4889 extension 7
Helps Métis Citizens of all ages in Ontario. Offers support in person, over the phone, or by video call. Service providers include mental health and addiction professionals. Help is provided in both English and French.

Hope for Wellness 1-855-242-3310
24/7 support to all Indigenous people across Canada. Experienced and culturally competent counsellors can be reached by telephone and online chat. Services available in English and French, upon request Cree, Ojibway and Inuktitut (are not available 24/7).

Postpartum Support International (PSI) 1-800-944-4773
A call or text helpline for questions and concerns, online support groups, and a local service provider directory. Offers options for moms and dads. There is also a specialized coordinator for LGBTQIA+ parents, adoptive parents, disabled parents, grandparents, Indigenous parents and more.

MindShift CBT App
Uses scientifically proven strategies based on Cognitive Behavioural Therapy (CBT) to help individuals learn to relax and be mindful, develop more effective ways of thinking, and use active steps to take charge of their anxiety. Features a community forum, enabling clients to find and offer peer-to-peer support.

BounceBack® 1-866-345-0224
Free skill-building program managed by the Canadian Mental Health Association (CMHA). It is designed to help adults and youth 15+ manage low mood, mild to moderate depression and anxiety, stress or worry. Delivered over the phone with a coach and through online videos, individuals will get access to tools that will support them on their path to mental wellness.

Durham Community Health Clinic - Counselling Services 1-877-227-3217
Durham Community Health Centre (DCHC)’s counselling team offers brief counselling services (6-12 sessions) to individuals, families and couples, and evidence-based psychotherapy groups. Helps clients with a range of challenges, from day-to-day problems to mild to moderate mental health concerns. A doctor’s referral is not required to access counselling services. DCHC’s therapists provide counselling services at no cost to clients of the centre. As part of a community health centre, DCHC strives to address inequities in health care.

Mount Sinai Hospital Perinatal Mental Health Program 416-586-4800, ext. 8325
Provides mental health assessment and treatment to Mount Sinai Hospital patients and their partners during pregnancy and for up to one year postpartum. The program is inclusive of all genders, sexual orientations and family structures.

Additional resources

Health 811 Ontario
Connect with a registered nurse day or night for free, secure, and confidential health advice.

ConnexOntario 1-866-531-2600
ConnexOntario is a 24/7 confidential phone, chat, texting and email service that helps people in Ontario who need support and information about mental health, gambling and addiction services available in their community.

Community Family Services of Ontario 1-866-979-8298 | Make a referral
Provide counselling and therapy to individuals, couples, and their families who have diverse life issues. These problems may include self-confidence, education, marriage, career, parenting, interpersonal or intergenerational relationships, or more emotional aspects of one’s life. Help clients identify their concerns and problems, develop strategies to cope with and address their issues, in a respectful, empathetic manner.

Hope + Me Mood Disorders Association of Ontario 1-888-486-8236
Hope + Me offers free support and recovery programs to people with mood disorders and their friends and family. Offers services such as: virtual peer support groups, peer support and counselling services and more.

e-Mental Health - Directory
Directory of mental health services and organizations in Ontario and throughout Canada.

Info Sheets: Information about a variety of mental health conditions and topics.
Screening Tools: Find out if you or a loved one has a mental health concern with our free, online screening tools.
Events Calendar: Information about mental health events by geographical area.
Database of research studies.