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NICE guidance on antenatal and postnatal mental health

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VOL: 103, ISSUE: 13, PAGE NO: 25

The NICE clinical management and service guidance on antenatal and postnatal mental health, published recently, is ...

The NICE clinical management and service guidance on antenatal and postnatal mental health, published recently, is relevant to healthcare professionals who care for women who are planning a pregnancy, are pregnant or during the postnatal period (the first year after giving birth) (NICE, 2007). According to NICE, it is estimated that as many as one in seven women experience a mental health disorder in the antenatal or postnatal period. The guidance is the first of its kind to make specific recommendations on identification, treatment and management of all mental health disorders, including anxiety, depression, eating disorders, bipolar disorder, schizophrenia and obsessive-compulsive disorder. It should be read in conjunction with existing NICE guidance on mental disorders (NICE, 2004a; 2004b).

Principles of care

The guidance states that clients with a mental health disorder should be given culturally sensitive information at each stage of assessment, diagnosis, course and treatment about the impact of the disorder. This information should cover appropriate use and likely side-effects of medication. This recommendation applies to women with an existing mental health disorder who are pregnant or planning a pregnancy, and those who develop a mental health disorder during pregnancy or the postnatal period.

Healthcare professionals should work to develop a trusting relationship with the woman, and her partner, family members and carers where appropriate and acceptable to the woman. In particular, they should be sensitive to the issues of stigma and shame in relation to mental illness.

The needs of the woman's partner, family members and carers should be assessed and, where appropriate, addressed. This assessment should include the welfare of her infant and other dependent children and adults, and the impact of any mental health disorder on relationships with her partner and family members.

Detection and management

Routine contact with nurses and healthcare professionals during pregnancy and the postnatal period provides an opportunity to identify women who have, or are at risk of developing, a mental health disorder. At a woman's first contact with services in both antenatal and postnatal periods, nurses and healthcare professionals should ask about:

- Past or present severe mental illness, including schizophrenia, bipolar disorder, psychosis in the postnatal period and severe depression;

- Previous treatment by a psychiatrist or specialist mental health team, including inpatient care;

- A family history of perinatal mental illness.

However, the guidance stresses that other specific predictors, such as poor relationships with her partner, should not be used for the routine prediction of the development of a mental health disorder.

Two questions should be asked to identify possible depression at a woman's first contact with primary care, at her booking appointment and postnatal visit:

- 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?

If the woman answers 'yes' to both of these questions, a third question should then be considered:

- Is this something you feel you need or want help with?

The use of self-report measures such as the Edinburgh Postnatal Depression Scale (EPDS), Hospital Anxiety and Depression Scale (HADS) or Patient Health Questionnaire-9 (PHQ-9) may be considered as part of a subsequent assessment or for the routine monitoring of outcomes.

Referral and initial care

If a possible mental health disorder is identified during pregnancy or the postnatal period, consider further assessment.

- If the healthcare professional or client has significant concerns, the woman should be referred to her GP for further assessment.

- If the woman has or is suspected of having a severe mental illness (for example bipolar disorder or schizophrenia), she should be referred to a specialist mental health service, including, if appropriate, a specialist perinatal mental health service.

- The woman's GP should be informed in all cases in which a possible current mental health disorder or a history of significant mental health disorder is detected, even if no further assessment or referral is made.

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. This should be developed in collaboration with the woman and her partner, family and carers, and include increased contact with specialist mental health services. It should also be recorded in all versions of the client's notes (her own records and maternity, primary care and mental health notes), and communicated to the woman and all relevant healthcare professionals.

The guidance recommends there should be clearly specified care pathways so that all relevant primary and secondary healthcare professionals know how to access assessment and treatment.

Preventative measures

NICE states that there is evidence to support the use of targeted psychosocial interventions for women who have symptoms of depression and/or anxiety that do not meet the threshold for a formal diagnosis. The guidance explains that certain treatment or support for pregnant women should be considered when symptoms do not meet diagnostic criteria but 'significantly interfere with personal and social functioning'.

For this group of women the following should be considered:

- Offering individual, brief psychological treatment (four to six sessions), such as interpersonal psychotherapy or cognitive behavioural therapy for clients who have had a previous episode of depression or anxiety;

- Offering social support during pregnancy and the postnatal period (such as regular informal individual or group-based support) for women who have not had a previous episode of depression or anxiety.

However, it adds that psychosocial interventions designed specifically to reduce the likelihood of developing a mental health disorder should not be part of routine antenatal and postnatal care.

Care and management

The guidance stresses that the care of women with a mental health disorder during this period should be the same as for any client with such a disorder. But it adds that treatment decisions are complicated by the presence of the developing foetus, breastfeeding and the timescales imposed by pregnancy and birth.

It explains that drugs should be prescribed cautiously for women who are planning a pregnancy, pregnant or breastfeeding. As a result, it argues that the thresholds for non-drug treatments, particularly psychological treatments, 'are likely to be lower than those set in NICE clinical guidelines'.

It emphasises that women who need psychological therapies should be seen for treatment normally within one month of initial assessment and no longer than three months afterwards.

For recommendations on what should be covered in discussions about treatment options, see box below.

Conclusion

This guidance outlines the role nurses can play in detecting, preventing and caring for women with a mental health disorder when planning pregnancy, during pregnancy and the postnatal period.

DISCUSSIONS ABOUT TREATMENT

Discussions with a woman with a mental health disorder who is planning a pregnancy, is pregnant or breastfeeding should cover the following (NICE, 2007):

- The risk of relapse or deterioration in symptoms and the client's ability to cope with untreated or subthreshold symptoms;

- Severity of previous episodes, response to treatment and the woman's preference;

- The possibility that stopping a drug with known teratogenic risk after pregnancy is confirmed may not remove the risk of malformations;

- The risks from stopping medication abruptly;

- The need for prompt treatment due to the potential impact of an untreated disorder on the foetus or infant;

- The increased risk of harm associated with drug treatments during pregnancy and the postnatal period, including the overdose risk;

- Treatment options that would enable the woman to breastfeed if desired, rather than recommending that she does not.

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