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NICE updates guidance on mental health problems linked to pregnancy

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Women who have experienced, or are at risk of, mental health problems should get extra support before, during and after their pregnancy, according to updated guidance for the NHS.

The National Institute for Health and Care Excellence has today published a wide-ranging update of guidance on the recognition, care and treatment of antenatal and postnatal mental health.

It noted that mental health problems during and after pregnancy were very common, with around 12% of women experience depression and 13% experience anxiety at some point.

“More than one in 10 women will experience depression at some point during their pregnancy”

Mark Baker

The guideline update will help nurses, health visitors and midwives – as well as doctors – to identify mental health problems in mothers and pregnant women, said NICE. It also offers guidance on the most appropriate drugs or other treatments to offer safely to mother and child.

Professor Mark Baker, director of the NICE centre for clinical practice, said: “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 Stephen Pilling, a clinical psychologist at University College London and facilitator of the group that drew up the guidance, said: “This updated guideline is about spotting what is not normal for each woman and making sure she gets the right treatment.

The guideline also covers women with an existing mental health problem who are planning a pregnancy. For example, discussing with all women of childbearing potential who have a new, existing or past mental health problem about how it or its treatment might affect pregnancy.

“We have again emphasised the need for rapid access to effective psychological interventions”

Stephen Pilling

Professor Pilling said: “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,” he said.

Regarding treatment decisions, NICE said health professionals should provide “detailed advice” about the possible risks of mental health problems or the benefits and harms of treatment. Among other things, this discussion should cover the risks to the woman, fetus or baby from each treatment option and those associated with stopping or changing a treatment. 

Before starting any treatment in pregnancy and the postnatal period, a discussion should take place about the higher threshold for pharmacological interventions arising from the changing risk-benefit ratio for psychotropic medication.

When choosing a tricyclic antidepressant, selective serotonin reuptake inhibitor or serotonin- noradrenaline reuptake inhibitor, the health professional should take into account reproductive safety and any increased risk to the fetus and other problems for the woman or baby.

The guidance also covers traumatic birth, stillbirth and miscarriage. It said a woman whose baby is stillborn or dies soon after birth, should have the option of seeing a photograph of it, having mementos, seeing the baby and/or holding it.

“It is not enough for the government to offer midwives more training in perinatal mental health care”

Cathy Warwick

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, said NICE.

Neal Long, chief executive of the charity Sands, welcomed the guidance’s inclusion of women who experience a stillbirth, or whose baby dies shortly after birth. 

“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,” he said. “This is a very individual decision, and the role of staff should be to always offer parents the option.”

Cathy Warwick, chief executive of the Royal College of Midwives, called on NHS commissioners to develop more comprehensive and effective perinatal mental health services.

“It is not enough for the government to offer midwives more training in perinatal mental health care,” she said.

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