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“One in seven women will have some kind of psychological
problem during the antenatal and postnatal periods and it is
absolutely vital that healthcare professionals, including
midwives and health visitors, are able to identify those women
who are at risk of developing a mental health problem during
pregnancy and after giving birth. This guideline is an
indispensable tool to aid professionals in that endeavour."
Dr Gwyneth Lewis,
National Clinical Lead for Maternal Health and Maternity Services
and Director of the Maternal Deaths Enquiry for CEMACH
The guideline, commissioned by NICE and developed by the National Collaborating
Centre for Mental Health (NCCMH), covers the care and treatment of women with
mental health problems during pregnancy and the first postnatal year. This includes
depression, anxiety disorders, and severe mental illnesses such as bipolar disorder
and schizophrenia.
The impact of mental disorders on women, their infants and other members of their
family can be greater during pregnancy and the postnatal period than at any other
time. It is therefore of great importance that any problem is recognised and managed
quickly and safely. The guideline sets out clear recommendations, based on the best
available evidence, for healthcare staff on how to work with pregnant and
breastfeeding women to significantly improve their treatment and care.
This publication brings together all of the evidence that led to the recommendations
in the guideline. It provides an overview of how mental health problems manifest
during pregnancy and postnatally and covers prediction and detection, prevention,
and psychological and pharmacological interventions for specific disorders, including
balancing the risks and benefits of drug treatment during pregnancy and while
breastfeeding. The guideline also encompasses the organisation of perinatal mental
health services, making it the first of its kind to fully integrate the clinical and service
aspects of care into a single volume. The book is illustrated by women’s experiences
of mental health problems, treatment and services.
An accompanying CD contains further information about the evidence, including:
● included and excluded studies
● profile tables that summarise both the quality of the evidence and the results
of the evidence synthesis
● all meta-analytical data presented as forest plots
● detailed information about how to use and interpret forest plots.
antenatal and
postnatal
mental health
antenatal
and postnatal
mental health
THE NICE GUIDELINE ON CLINICAL MANAGEMENT
AND SERVICE GUIDANCE
APMHv6 11/9/07 14:05 Page 1
© The British Psychological Society
& The Royal College of Psychiatrists, 2007
The views presented in this book do not necessarily reflect those of the British
Psychological Society, and the publishers are not responsible for any error of
omission or fact. The British Psychological Society is a registered charity
(no. 229642).
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from
the publishers. Enquiries in this regard should be directed to the British
Psychological Society.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from
the British Library.
ISBN-: 978-1-85433-454-1
Printed in Great Britain by Alden Press.
developed by National Collaborating Centre for Mental Health
Royal College of Psychiatrists’ Research and Training Unit
4th Floor, Standon House
21 Mansell Street
London
E1 8AA
commissioned by National Institute for Health and Clinical Excellence
MidCity Place, 71 High Holborn
London
WCIV 6NA
www.nice.org.uk
published by The British Psychological Society
St Andrews House
48 Princess Road East
Leicester
LE1 7DR
www.bps.org.uk
and
The Royal College of Psychiatrists
17 Belgrave Square
London
SW1X 8PG
www.rcpsych.ac.uk
CONTENTS
GUIDELINE DEVELOPMENT GROUP MEMBERSHIP 6
1. EXECUTIVE SUMMARY 9
1.1 Principles of care for all women with mental disorders during
pregnancy and the postnatal period 11
1.2 Prediction, detection and initial management of mental disorders 12
1.3 Prevention of mental disorders 14
1.4 Care of women with a mental disorder during pregnancy and
the postnatal period 15
1.5 The organisation of services 26
1.6 Research recommendations 27
2. INTRODUCTION 30
2.1 National guidelines 30
2.2 The national antenatal and postnatal mental health guideline 32
2.3 The structure of this guideline 34
3. METHODS USED TO DEVELOP THIS GUIDELINE 35
3.1 Overview 35
3.2 The scope 35
3.3 The Guideline Development Group 36
3.4 Clinical questions 38
3.5 Systematic clinical literature review 39
3.6 Health economics review strategies 49
3.7 Stakeholder contributions 52
3.8 Testimonies from women with mental disorders in the
antenatal and postnatal period 52
3.9 Validation of this guideline 53
4. ANTENATAL AND POSTNATAL MENTAL
HEALTH: POPULATION, DISORDERS AND SERVICES 54
4.1 Scope of the guideline 54
4.2 Mental disorders during pregnancy and the postnatal period 55
4.3 Incidence and prevalence of perinatal disorders 57
4.4 Aetiology of antenatal and postnatal mental disorders 68
4.5 Consequences of mental disorder during pregnancy and the
postnatal period 69
4.6 Treatment in the NHS 74
Contents
3
4.7 The economic burden of mental disorders in the antenatal
and postnatal period 77
4.8 Explaining risk to women: helping patients to make decisions
about treatment 78
5. THE PREDICTION AND DETECTION OF MENTAL
ILLNESS DURING PREGNANCY AND THE
POSTNATAL PERIOD 85
5.1 Introduction 85
5.2 Prediction – risk factors for the onset of mental disorder
during pregnancy and the postnatal period 89
5.3 Methods for predicting mental disorder during pregnancy
and the postnatal period 108
5.4 Methods for detecting mental disorder during pregnancy
and the postnatal period 111
5.5 Referral pathways 118
6. PSYCHOLOGICAL AND PSYCHOSOCIAL INTERVENTIONS 121
6.1 Introduction 121
6.2 Issues in research into psychological treatments 121
6.3 Definitions of psychological and psychosocial interventions 125
6.4 Overview of clinical review 129
6.5 Review of treatments aimed at preventing the development
of mental disorders during the antenatal and postnatal
periods for women with existing risk factors 131
6.6 Health economics evidence on psychological and
psychosocial interventions aimed at preventing the development
of depression during the antenatal and postnatal periods
in women with identified psychosocial risk factors and/or
subthreshold depressive symptoms 144
6.7 Clinical practice and research recommendations 155
6.8 Review of treatments aimed at preventing the development
of mental disorders during the antenatal and postnatal periods
for women with no identified risk factors 156
6.9 Review of non-pharmacological treatments for depression
in the postnatal period 161
6.10 Health economics evidence on psychosocial interventions
for treatment of depression in the postnatal period 174
6.11 Focusing on the infant: intervening in the mother-infant
interaction or measuring child-related outcomes 185
6.12 Broader psychosocial interventions and other treatments 192
6.13 Treatments for women with disorders other than depression 200
Contents
4
7. THE PHARMACOLOGICAL TREATMENT OF MENTAL
DISORDERS IN PREGNANT AND BREASTFEEDING
WOMEN 201
7.1 Introduction 201
7.2 Risk associated with specific drugs in pregnancy
and the postnatal period 203
7.3 The pharmacological treatment of mental disorder
during pregnancy and the postnatal period – review
of available studies 215
7.4 Prescribing psychotropic medication to pregnant
and breastfeeding women 232
7.5 The pharmacological treatment of specific mental disorders
during pregnancy and the postnatal period – adaptation
of existing guidelines 235
8. THE ORGANISATION OF PERINATAL MENTAL
HEALTH SERVICES 242
8.1 Introduction 242
8.2 The current structure of services 242
8.3 Estimating the need for services 245
8.4 The functions of services for women, their partners and
carers in the antenatal and postnatal period 248
8.5 The structure of perinatal mental health services 257
8.6 Implementing the managed network model:
service recommendations 264
8.7 Research recommendation 265
9. Appendices 266
10. References 345
11. Abbreviations 367
Contents
5
GUIDELINE DEVELOPMENT GROUP MEMBERSHIP
Dr Dave Tomson
Guideline Development Group Chair
GP and Consultant in patient-centred primary care, North Shields
Mr Stephen Pilling
Facilitator, Guideline Development Group
Joint Director, National Collaborating Centre for Mental Health
Director, Centre for Outcomes, Research and Effectiveness, University
College London
Consultant Clinical Psychologist, Camden and Islington Mental Health
and Social Care Trust
Dr Fiona Blake
Consultant Psychiatrist, Cambridge University Hospitals, NHS Foundation Trust
Ms Rachel Burbeck
Systematic Reviewer (from July 2005), National Collaborating Centre for
Mental Heath
Dr Sandra Elliott
Consultant Clinical Psychologist, South London and Maudsley NHS Trust
Dr Pauline Evans
Service user representative, Guideline Development Group
Senior Lecturer in Health and Social Care, University of Gloucestershire
Ms Josephine Foggo
Project Manager (until August 2005), National Collaborating Centre for
Mental Health
Dr Alain Gregoire
Consultant Perinatal Psychiatrist, Hampshire Partnership, NHS Trust and University
of Southampton
Dr Jane Hamilton
Consultant Psychiatrist in Maternal Health, Sheffield Care Trust
Mrs Claire Hesketh
Primary Care Mental Health Services Manager, Northumberland, Tyne and Wear
NHS Trust
Ms Rebecca King
Project Manager (August 2005 to August 2006), National Collaborating Centre
for Mental Health
Guideline development group membership
6
Dr Elizabeth McDonald
Consultant Perinatal Psychiatrist, East London and the City Mental Health
NHS Trust
Ms Rosa Matthews
Systematic Reviewer (until July 2005), National Collaborating Centre for
Mental Health
Dr Ifigeneia Mavranezouli
Health Economist, National Collaborating Centre for Mental Health
Mr Patrick O’Brien
Obstetrician, University College London Hospitals NHS Foundation Trust
Dr Donald Peebles
Obstetrician, University College London Hospitals NHS Foundation Trust
Dr Catherine Pettinari
Project Manager (August 2006–present), National Collaborating Centre
for Mental Health
Mrs Sue Power
Team Manager for Community Mental Health Team, Vale of Glamorgan
County Council
Mrs Yana Richens
Consultant Midwife, University College London Hospitals NHS Foundation Trust
Mrs Ruth Rothman
Specialist Health Visitor for Postnatal Depression and Clinical Lead for Mental
Health, Southend Primary Care Trust
Ms Fiona Shaw
Service user representative, Guideline Development Group and author
Ms Sarah Stockton
Information Scientist, National Collaborating Centre for Mental Health
Dr Clare Taylor
Editor, National Collaborating Centre for Mental Health
Ms Lois Thomas
Research Assistant (until September 2005), National Collaborating Centre for
Mental Health
Dr Clare Thormod
GP, London
Ms Jenny Turner
Research Assistant (from November 2005), National Collaborating Centre for
Mental Health
Guideline development group membership
7
ACKNOWLEDGEMENTS
The antenatal and postnatal mental health Guideline Development Group and review
team at the National Collaborating Centre for Mental Health would like to thank the
following people:
Those women who have experienced mental health problems in the antenatal or
postnatal period who contributed testimonies that have been included in this
guideline
Those who acted as advisers on specialist topics or have contributed to the
process by reviewing drafts of the guideline:
Mr Stephen Bazire
Dr Roch Cantwell
Dr Margaret Oates
Speakers at an infant mental health day:
Dr Eia Asen
Mr Robin Balbernie
Professor Vivette Glover
Dr Sebastian Kraemer
Dr Tessa Leverton
Dr Veronica O’Keane
Dr Susan Pawlby
Speakers in a consensus conference on the pharmacological management
of mental disorders in pregnancy and lactating women:
Professor David Chadwick
Professor Nicol Ferrier
Dr Peter Haddad
Dr Elizabeth McDonald
Dr Patricia McElhatton
Mr Patrick O’Brien
Development of the specialist perinatal services survey:
Dr Sonia Johnson
Dr Alain Gregoire
Development of the primary care trust survey:
Ms Susannah Pick
Responders to the primary care trust and specialist perinatal services surveys
Editorial assistance
Ms Emma Brown
Acknowledgements
8
1. EXECUTIVE SUMMARY
KEY PRIORITIES FOR IMPLEMENTATION
The following recommendations have been identified as recommendations for
implementation.
Prediction and detection
● At a woman’s first contact with services in both the antenatal and postnatal peri-
ods, 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 either 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.
Executive summary
9
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 decision 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, audio-taped 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 anti-
depressants, 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 and interpersonal psychotherapy.
Executive summary
10
[...]... pharmacological agents in the treatment and management of antenatal and postnatal mental health problems ● evaluate the role of specific psychological interventions in the treatment and management of antenatal and postnatal mental health problems ● evaluate the role of specific service-delivery systems and service-level interventions in the management of antenatal and postnatal mental health problems 33 Introduction... ● Professionals in other health and non -health sectors who may have direct contact with or are involved in the provision of health and other public services for those diagnosed with antenatal and postnatal mental health problems; these may include accident and emergency staff, paramedical staff, prison doctors, the police and professionals who work in the criminal justice and education sectors ● Those... evidence by a multidisciplinary team of healthcare professionals, women who have experienced mental health problems in the antenatal or postnatal period and guideline methodologists It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high-quality care for women with antenatal and postnatal mental health problems while also emphasising the... This guideline will be of relevance to all women who suffer from antenatal and postnatal mental health problems The guideline covers the care provided by primary, secondary, tertiary and other healthcare professionals who have direct contact with, and make decisions concerning, the care of women with mental disorder in the antenatal and postnatal period Although this guideline will briefly address the... traditionally have training in mental health The Whooley questions appear to offer a relatively quick and convenient way of case finding for healthcare professionals who are not specialists in mental health 29 Introduction 2 INTRODUCTION This guideline has been developed to advise on the clinical management of and service provision for antenatal and postnatal mental health The guideline recommendations... include increased contact with specialist mental health services (including, if appropriate, specialist perinatal mental health services) ● be recorded in all versions of the woman’s notes (her own records and maternity, primary care and mental health notes) and communicated to the woman and all relevant healthcare professionals Women who need inpatient care for a mental disorder within 12 months of childbirth... families and carers 1.1.2.1 Healthcare professionals should assess and, where appropriate address, the needs of the partner, family members and carers of a woman with a mental disorder during pregnancy and the postnatal period, including: ● the welfare of her infant, and other dependent children and adults ● the impact of any mental disorder on relationships with her partner, family members and carers... the Mental Health Act and of the Children Act (1989) 1.2 PREDICTION, DETECTION AND INITIAL MANAGEMENT OF MENTAL DISORDERS 1.2.1 Prediction and detection 1.2.1.1 In all communications (including initial referral) with maternity services, healthcare professionals should include information on any relevant history of mental disorder At a woman’s first contact with services in both the antenatal and postnatal. .. best-practice advice on the care of individuals with a diagnosis of antenatal or postnatal mental health problems through the different phases of illness, including the initiation of treatment, the treatment of acute episodes and the promotion of recovery ● consider economic aspects of various standard treatments for antenatal and postnatal mental health problems The guideline will not cover treatments that... severe mental illness, she should be asked about her mental health at all subsequent contacts A written care plan covering pregnancy, delivery and the postnatal period should be developed for pregnant women with a current or past history of severe mental illness, usually in the first trimester It should: ● be developed in collaboration with the woman and her partner, family and carers, and relevant healthcare . 53 4. ANTENATAL AND POSTNATAL MENTAL HEALTH: POPULATION, DISORDERS AND SERVICES 54 4.1 Scope of the guideline 54 4.2 Mental disorders during pregnancy and the postnatal period 55 4.3 Incidence and. Collaborating Centre for Mental Health Guideline development group membership 7 ACKNOWLEDGEMENTS The antenatal and postnatal mental health Guideline Development Group and review team at the National. pregnancy and postnatally and covers prediction and detection, prevention, and psychological and pharmacological interventions for specific disorders, including balancing the risks and benefits
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