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Antenatal and postnatal mental health: clinical management and service guidance

Key priorities for implementation

  • The following recommendations have been identified as priorities for implementation. For the full list of recommendations, see www.nice.org.uk/guidance/cg192

Considerations for women of childbearing potential

  • Discuss with all women of childbearing potential who have a new, existing or past mental health problem:

    • the use of contraception and any plans for a pregnancy
    • how pregnancy and childbirth might affect a mental health problem, including the risk of relapse
    • how a mental health problem and its treatment might affect the woman, the fetus and baby
    • how a mental health problem and its treatment might affect parenting
  • Do not offer valproate for acute or long‑term treatment of a mental health problem in women of childbearing potential

Principles of care in pregnancy and the postnatal period

Coordinated care

 

  • Develop an integrated care plan for a woman with a mental health problem in pregnancy and the postnatal period that sets out:
    • the care and treatment for the mental health problem
    • 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 the outcomes with the woman

Treatment decisions, advice and monitoring for women who are planning a pregnancy, pregnant or in the postnatal period

Information and advice

  • Mental health professionals providing detailed advice about the possible risks of mental health problems or the benefits and harms of treatment in pregnancy and the postnatal period should include discussion of the following, depending on individual circumstances:
    • the uncertainty about the benefits, risks and harms of treatments for mental health problems in pregnancy and the postnatal period
    • the likely benefits of each treatment, taking into account the severity of the mental health problem
    • the woman's response to any previous treatment
    • the background risk of harm to the woman and the fetus or baby associated with the mental health problem and the risk to mental health and parenting associated with no treatment
    • the possibility of the sudden onset of symptoms of mental health problems in pregnancy and the postnatal period, particularly in the first few weeks after childbirth (for example, in bipolar disorder)
    • the risks or harms to the woman and the fetus or baby associated with each treatment option
    • the need for prompt treatment because of the potential effect of an untreated mental health problem on the fetus or baby
    • the risk or harms to the woman and the fetus or baby associated with stopping or changing a treatment

Starting, using and stopping treatment

  • Before starting any treatment in pregnancy and the postnatal period, discuss with the woman the higher threshold for pharmacological interventions arising from the changing risk‑benefit ratio for psychotropic medication at this time and the likely benefits of a psychological intervention
  • If a pregnant woman has taken psychotropic medication with known teratogenic risk at any time in the first trimester:
    • confirm the pregnancy as soon as possible
    • explain that stopping or switching the medication after pregnancy is confirmed may not remove the risk of fetal malformations
    • offer screening for fetal abnormalities and counselling about continuing the pregnancy
    • explain the need for additional monitoring and the risks to the fetus if she continues to take the medication
  • Seek advice from a specialist if there is uncertainty about the risks associated with specific drugs

TCAs, SSRIs, (S)NRIs

  • When choosing a tricyclic antidepressant (TCA), selective serotonin reuptake inhibitor (SSRI) or (serotonin‑) noradrenaline reuptake inhibitor [(S)NRI],* take into account:
    • the woman's previous response to these drugs
    • the stage of pregnancy
    • what is known about the reproductive safety of these drugs (for example, the risk of fetal cardiac abnormalities and persistent pulmonary hypertension in the newborn baby)
    • the uncertainty about whether any increased risk to the fetus and other problems for the woman or baby can be attributed directly to these drugs or may be caused by other factors
    • the risk of discontinuation symptoms in the woman and neonatal adaptation syndrome in the baby with most TCAs, SSRIs and (S)NRIs, in particular paroxetine and venlafaxine

Recognising mental health problems in pregnancy and the postnatal period and referral

  • At a woman's first contact with primary care or her booking visit, and during the early postnatal period, consider asking the following depression identification questions as part of a general discussion about a woman's mental health and wellbeing:
    • during the past month, have you often been bothered by feeling down, depressed or hopeless?
    • during the past month, have you often been bothered by having little interest or pleasure in doing things?
  • Also consider asking about anxiety using the 2‑item Generalized Anxiety Disorder scale (GAD‑2):
    • during the past month, have you been feeling nervous, anxious or on edge?
    • during the past month have you not been able to stop or control worrying?

Providing interventions in pregnancy and the postnatal period

  • All healthcare professionals providing assessment and interventions for mental health problems in pregnancy and the postnatal period should understand the variations in their presentation and course at these times, how these variations affect treatment, and the context in which they are assessed and treated (for example, maternity services, health visiting and mental health services)

The organisation of services

  • Clinical networks should be established for perinatal mental health services, managed by a coordinating board of healthcare professionals, commissioners, managers, and service users and carers. These networks should provide:
    • a specialist multidisciplinary perinatal service in each locality, which provides direct services, consultation and advice to maternity services, other mental health services and community services; in areas of high morbidity these services may be provided by separate specialist perinatal teams
    • access to specialist expert advice on the risks and benefits of psychotropic medication during pregnancy and breastfeeding
    • clear referral and management protocols for services across all levels of the existing stepped‑care frameworks for mental health problems, to ensure effective transfer of information and continuity of care
    • pathways of care for service users, with defined roles and competencies for all professional groups involved

*Although this use is common in UK clinical practice, at the time of publication (December 2014]), TCAs, SSRIs and (S)NRIs did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.
†An answer of 'Not at all' scores 0; 'Several days' scores 1; 'More than half the days' scores 2; 'Nearly every day' scores 3.

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/CG192

National Institute for Health and Care Excellence.Antenatal and postnatal mental health: clinical management and service guidance.
First included: June 2007.