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The NHS guidance body, the National Institute for Health and Care Excellence says women who have experience of or are at risk of mental health problems should get extra support before, during and after their pregnancy.

In a wide-ranging updated guideline on the clinical management of antenatal and postnatal mental health, NICE says women are at greater risk of mental health problems during and after pregnancy, and the effects for families can last for a long time. Around 12% of women experience depression and 13% experience anxiety at some point, many women will experience both. Depression and anxiety disorders also affect 1 in 5 women in the first year after childbirth. The range of  disorders which women may experience include depression, panic disorder, generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder and tokophobia (an extreme fear of childbirth), eating disorders, substance misuse, schizophrenia and bipolar disorder, with an increased risk of psychosis in the weeks after childbirth (post-partum psychosis).

Since the original guideline was published, more information is now available on using drugs to treat mental health problems during pregnancy and on stopping medication. More is known about detecting mental health problems in mothers and pregnant women.

The update will help doctors, nurses, health visitors and midwives to identify mental health problems in mothers and pregnant women.  It also offers guidance on the most appropriate drugs or other treatments to offer safely to mother and child. The guideline will also help women who have had mental health problems understand what help should be made available for them if they are planning to have a baby. It also states that women and their partners, who have had a traumatic experience such as a very difficult birth, should be offered extra support and makes clear recommendations about what should be offered to mothers who have suffered a miscarriage or whose baby is still-born.

Commenting on the newly updated guideline Professor Mark Baker, NICE Centre for Clinical Practice director, said: “Mental health problems during and after pregnancy are common. More than 1 in 10 women will experience depression at some point during their pregnancy. This increases to 1 in 5 women during the first year after giving birth. During pregnancy and the postnatal period, women may also experience other mental health problems. Giving women the right treatment at the right time can have a profound effect – not just for the mother, but her family too. The effect of getting this right can last for years.

“The guidance makes a number of new and updated recommendations, covering not only treatments, but also in providing women who are newly diagnosed or with a history of mental health problems with the information and support they need before they become pregnant.”

Professor Louise Howard, Professor in Women’s Mental Health at King’s College London and chair of the group that developed the guideline, said: “This guideline aims to highlight the full range of mental health problems that can occur during pregnancy and after childbirth, and ensure they are identified and treated promptly. These disorders are common but treatable and we hope that this guideline will help women get comprehensive holistic assessment and treatment quickly so that pregnancy, and the period after childbirth, are times of optimal mental and physical health”.

Professor Stephen Pilling, Professor of Clinical Psychology and Clinical Effectiveness, UCL and facilitator of the group that developed the guideline, said: “Having a baby is a time of huge change and any woman can find herself needing help. This updated guideline is about spotting what is not normal for each woman and making sure she gets the right treatment.

“Women with a history of mental health problems are at risk of relapse when they become pregnant, especially if they stop taking their medication. Drugs often have an important role in treating antenatal and postnatal mental health problems, but they are not always suitable and so we have again emphasised the need for rapid access to effective psychological interventions. It is critically important that a woman is able to make an informed decision about treatment and she is helped to weigh up the risks and benefits of stopping, starting or changing any treatment she is offered or currently receiving.”

Maria Bavetta, mother of two who has experienced postpartum obsessive compulsive disorder and co-founder of Maternal OCD, helped to develop the new NICE recommendations said: “Being pregnant and/or a new mum can often be challenging, with a perinatal mental health problem it can be incrediblydifficult. I believe this guideline will help to de-stigmatise mental health problems during the perinatal period and encourage all healthcare professionals at every point of contact with a mum to talk about their mental health as well as their physical health. Mothers especially need looking after so they can in turn care for themselves and their baby – this guideline sets out which treatments are recommended for mild, moderate to severe maternal mental health problems and needs to be utilised by all healthcare professionals.”

Karen, a mother who experienced postpartum psychosis, said: “When I experienced mental illness after the birth of my children – postpartum psychosis followed by depression and anxiety – it was the expertise and care of health professionals that enabled me to recover. The new guideline will help to ensure that all women whose mental health is at risk during or after their pregnancy get the support they need. The report of women's experiences of care published alongside the guideline is also essential reading – a reminder of how important it is that patients are treated with consideration, dignity and respect and involved in decisions about their own care.”

The updated guideline makes recommendations for the recognition, care and treatment of mental health problems in women during pregnancy and the postnatal period. It also includes the care of women with an existing mental health problem who are planning a pregnancy, and the organisation of mental health services. Updated recommendations include:

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; and how a mental health problem and its treatment might affect parenting.

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

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.

Pharmaceutical interventions: When choosing a tricyclic antidepressant (TCA), selective serotonin reuptake inhibitor (SSRI) or (serotonin-) noradrenaline reuptake inhibitor [(S)NRI] , take into account the reproductive safety and the uncertainty about whether any increased risk to the fetus and other problems for the woman or baby.

Traumatic birth, stillbirth and miscarriage: Discuss with a woman whose baby is stillborn or dies soon after birth, and her partner and family, the option of 1 or more of the following:

• seeing a photograph of the baby
• having mementos of the baby
• seeing the baby
• holding the baby.

This should be facilitated by an experienced practitioner and the woman and her partner and family should be offered a follow up appointment in primary or secondary care. If it is known that the baby has died in utero, this discussion should take place before the delivery, and continue after delivery if needed.

Commenting on the guideline, Rachael Dobson, Co-Founder and CEO PANDAS(Pre and Postnatal Depression Advice and Support), said: “Being pregnant and becoming a parent often brings great expectations of what motherhood will be like and unfortunately for many, the reality does not match these expectations. Suffering mental illness during pregnancy and post natal is very common. These new guidelines highlight how important the quality of care, treating each women as an individual and working with them to determine the right treatment and support for them is. I welcome these new guidelines as an aid to assisting doctors, midwives, health visitors and nurses identify mental health illnesses in pregnant women and mothers, which will allow the illnesses to be treated and supported earlier thus helping to lower the impact both on women and the wider family unit.”

Neal Long, Chief Executive of Sands said: “We welcome the inclusion in the guidance of women who experience a stillbirth, or whose baby dies shortly after birth, and their partners and families.  We have found that offering women and their families the opportunity to create memories if they wish can positively impact the grieving process. We know that many thousands of parents have cherished the opportunity to see and hold their baby, take photos, and create other mementoes such as hand and footprints. This is a very individual decision, and the role of staff should be to always offer parents the option, and offer sensitive support and help for parents as they make their own choices about whether to see and hold their baby.”

For more information call the NICE press office on 0845 003 7782 or out of hours on 07775 583 813.

Notes to Editors

References

1. Louise M Howard, Emma Molyneaux, Cindy-Lee Dennis, Tamsen Rochat, Alan Stein, Jeannette Milgrom. Perinatal Mental Health 1: Non-psychotic mental disorders in the perinatal period. The Lancet 2014 384: 1775–88.
2. Ian Jones, Prabha Chandra, Paola Dazzan, Louise M Howard. Perinatal Mental Health 2: Psychotic Mental Disorders in the Perinatal Period. The Lancet 2014; 384: 1789–99.

About the guidance

3. The guideline is now available at /Guidance/CG192.
4. Depression and anxiety are the most common mental health problems during pregnancy, with around 12% of women experiencing depression and 13% experiencing anxiety at some point; many women will experience both. Depression and anxiety also affect 15–20% of women in the first year after childbirth. During pregnancy and the postnatal period, anxiety disorders, including panic disorder, generalised anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and tokophobia (an extreme fear of childbirth), can occur on their own or can coexist with depression. Psychosis can re-emerge or be exacerbated during pregnancy and the postnatal period. Postpartum psychosis affects between 1 and 2 in 1000 women who have given birth. Women with bipolar I disorder are at particular risk, but postpartum psychosis can occur in women with no previous psychiatric history.
5. Drugs have an important role in treating antenatal and postnatal mental health disorders, however they may not always be suitable. What is important is that women and their healthcare professionals reach an informed decision about what treatment they should follow. Many patients do not require drug treatments as there are some very effective psychological therapies that may be used. The guideline highlights the importance of understanding the risks and benefits of any potential treatments before deciding the best course of action for an individual person. Through making an informed decision, women can decide whether or not to take medication, whether and when to stop it or to change onto another drug. The guideline stresses the importance of careful monitoring and follow-up in women taking drugs for a mental health disorder.
6. Information and advice regarding breast feeding: Discuss breastfeeding with all women who may need to take psychotropic medication in pregnancy or in the postnatal period. Explain to them the benefits of breastfeeding, the potential risks associated with taking psychotropic medication when breastfeeding and with stopping some medications in order to breastfeed. Discuss treatment options that would enable a woman to breastfeed if she wishes and support women who choose not to breastfeed.

About NICE

The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.

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