Antenatal and postnatal mental health: clinical management and service guidance

National Institute for Health and Clinical Excellence

Key priorities for implementation

Prediction and detection

• At a woman's first contact with services in both the antenatal and the postnatal periods, healthcare professionals (including midwives, obstetricians, health visitors and GPs) should ask questions about:
  • past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in the postnatal period and severe depression
  • previous treatment by a psychiatrist/ specialist mental health team including inpatient care
  • a family history of perinatal mental illness
• Other specific predictors, such as poor relationships with her partner, should not be used for the routine prediction of the development of a mental disorder
• At a woman's first contact with primary care, at her booking visit and postnatally (usually at 4 to 6 weeks and 3 to 4 months), healthcare professionals (including midwives, obstetricians, health visitors and GPs) should ask two questions to identify possible depression:
  • 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?
• A third question should be considered if the woman answers 'yes' to both of the initial questions:
  • is this something you feel you need or want help with?

Psychological treatments

• Women requiring psychological treatment should be seen for treatment normally within 1 month of initial assessment, and no longer than 3 months afterwards. This is because of the lower threshold for access to psychological therapies during pregnancy and the postnatal period arising from the changing risk–benefit ratio for psychotropic medication at this time

Explaining risks

• Before treatment decisions are made, healthcare professionals should discuss with the woman the absolute and relative risks associated with treating and not treating the mental disorder during pregnancy and the postnatal period. They should:
  • acknowledge the uncertainty surrounding the risks
  • explain the background risk of fetal malformations for pregnant women without a mental disorder
  • describe risks using natural frequencies rather than percentages (for example, 1 in 10 rather than 10%) and common denominators (for example, 1 in 100 and 25 in 100, rather than 1 in 100 and 1 in 4)
  • if possible use dcision aids in a variety of verbal and visual formats that focus on an individualised view of the risks
  • provide written material to explain the risks (preferably individualised) and, if possible, audiotaped records of the consultation

Management of depression

• When choosing an antidepressant for pregnant or breastfeeding women, prescribers should, while bearing in mind that the safety of these drugs is not well understood, take into account that:
  • tricyclic antidepressants, such as amitriptyline, imipramine and nortriptyline, have lower known risks during pregnancy than other antidepressants
  • most tricyclic antidepressants have a higher fatal toxicity index than selective serotonin reuptake inhibitors (SSRIs)
  • fluoxetine is the SSRI with the lowest known risk during pregnancy
  • imipramine, nortriptyline and sertraline are present in breast milk at relatively low levels
  • citalopram and fluoxetine are present in breast milk at relatively high levels
  • SSRIs taken after 20 weeks' gestation may be associated with an increased risk of persistent pulmonary hypertension in the neonate
  • paroxetine taken in the first trimester may be associated with fetal heart defects
  • venlafaxine may be associated with increased risk of high blood pressure at high doses, higher toxicity in overdose than SSRIs and some tricyclic antidepressants, and increased difficulty in withdrawal
  • all antidepressants carry the risk of withdrawal or toxicity in neonates; in most cases the effects are mild and self-limiting
• For a woman who develops mild or moderate depression during pregnancy or the postnatal period, the following should be considered:
  • self-help strategies (guided self-help, computerised cognitive behavioural therapy or exercise)
  • non-directive counselling delivered at home (listening visits)
  • brief cognitive behavioural therapy or interpersonal psychotherapy

Organisation of care

• 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 disorders, 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 full guidelines

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG45

National Institute for Health and Clinical Excellence. Antenatal and postnatal mental health: clinical management and service
guidance. Quick Reference Guide. February 2007