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National Collaborating Centre for Mental Health (UK). Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance: Updated edition. Leicester (UK): British Psychological Society; 2014 Dec. (NICE Clinical Guidelines, No. 192.)

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  • April 2018: Footnotes and cautions have been added and amended by NICE to link to the MHRA's latest advice and resources on sodium valproate. Sodium valproate must not be used in pregnancy, and only used in girls and women when there is no alternative and a pregnancy prevention plan is in place. This is because of the risk of malformations and developmental abnormalities in the baby.

April 2018: Footnotes and cautions have been added and amended by NICE to link to the MHRA's latest advice and resources on sodium valproate. Sodium valproate must not be used in pregnancy, and only used in girls and women when there is no alternative and a pregnancy prevention plan is in place. This is because of the risk of malformations and developmental abnormalities in the baby.

Cover of Antenatal and Postnatal Mental Health

Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance: Updated edition.

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APPENDIX 1SCOPE FOR THE DEVELOPMENT OF THE CLINICAL GUIDELINE

1. GUIDELINE TITLE

Antenatal and postnatal mental health: clinical management and service guidance

1.1. Short title

Antenatal and postnatal mental health (update)

2. THE REMIT

This is a partial update of Antenatal and Postnatal Mental Health (NICE clinical guideline 45). We will also carry out an editorial review of all recommendations to ensure that they comply with NICE's duties under equalities legislation.

This update is being undertaken as part of the guideline review cycle.

3. CLINICAL NEED FOR THE GUIDELINE

3.1. Epidemiology

  1. Women in the antenatal and postnatal period are vulnerable to the same mental health disorders as other adults. Pregnancy is not protective and affects the probability of relapse, particularly if women discontinue medication. There is a high risk of puerperal psychosis postpartum in women with bipolar disorder and women with a history of puerperal psychosis.
  2. The management of mental health disorders in the antenatal and postnatal periods can differ from management of mental health disorders in adults at other times. This is because of:
    • the impact of abruptly stopping medication
    • the increased risk of developing an episode of a psychotic disorder in the postpartum period
    • the rapid onset and severity of puerperal psychosis
    • the risk–benefit ratio of psychotropic drugs during pregnancy and breastfeeding
    • the impact of illness on the developing fetus and baby.1
  3. There is concern that misuse of the term ‘postnatal depression’ to describe any mental health disorder occurring in the postnatal period has led to a failure to identify other mental health disorders that occur at this time. In addition to depression and psychosis, anxiety disorders, substance misuse and eating disorders can also occur in the postnatal and antenatal periods.
  4. At least half of women who have a baby experience low mood, either at some point in their pregnancy, or in the initial days or weeks following the birth. Symptoms include feeling tearful, overwhelmed and irritable, but these usually pass with rest, support and reassurance.
  5. If low mood persists during pregnancy, a diagnosis of antenatal depression may be appropriate. Antenatal depression is thought to affect around 12% of pregnant women, which is similar to the prevalence of postnatal depression. However, despite high prevalence rates, antenatal depression and anxiety disorders are often a neglected aspect of pregnancy. Early detection, assessment and management could prevent the development of postnatal problems and improve the mother's quality of life during pregnancy.
  6. If, during the postnatal period, low mood persists or occurs for the first time (de novo cases), the mother may be diagnosed with postnatal depression. Diagnostic features include:
    • irritability
    • difficulty sleeping even when the baby is sleeping
    • lack of appetite
    • anxiety
    • poor mother–infant interaction (for example, lack of interest in the child or lack of sensitivity to the infant's needs)
    • anxieties about the child
    • thoughts of harming the child
    • lack of motivation or enjoyment
    • panic attacks
    • feelings of isolation
    • a sense of being overwhelmed
    • physical signs of tension such as headaches or gastrointestinal symptoms.
    Thoughts of self-harm and suicide can also be present, and these may or may not lead to self-harming behaviour.
  7. Anxiety disorders, characterised by abnormal or inappropriate anxiety, occur on their own but can also occur with depressive disorders. Anxiety disorders can include panic disorder, generalised anxiety disorder, obsessive-compulsive disorder, tokophobia (fear of childbirth or pregnancy) and post-traumatic stress disorder. Prevalence rates vary according to the type of anxiety disorder.
  8. A personality disorder causes persistent difficulties in the way a person manages their day-to-day life and interacts with others. Approximately 3% of women in the UK are thought to have a personality disorder: the most prevalent are schizoid personality disorder, avoidant personality disorder, obsessive-compulsive personality disorder and borderline personality disorder. Pregnancy and childbirth in women with personality disorders (particularly borderline personality disorder) can evoke many issues relating to trauma in their past, which in turn can affect their ability to cope with being a mother and caring for their baby.
  9. A more severe illness, with acute onset, is puerperal psychosis, a relatively rare disorder characterised by psychotic depression, mania or atypical psychosis. It affects between 1 and 2 in every 1000 women who give birth. Characteristic features in those with mania include excitability, disinhibition and intense over-activity. Pregnancy, childbirth and the postnatal period can be associated with the re-emergence or exacerbation of a previous psychotic illness, such as schizophrenia, schizoaffective disorder or bipolar disorder. For some women, there can be an increased risk of danger to themselves or others, including the baby.
  10. Changes to body shape, including weight gain, during pregnancy and the postnatal period can be of particular concern to women with an eating disorder. Eating disorders are characterised by significant disturbances in normal eating patterns, body image and normal weight gain. They include anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified, including binge eating disorder. The prevalence of eating disorders in the general population is approximately 4%. The prevalence of anorexia nervosa and bulimia nervosa during pregnancy is lower than at other times, but pregnant women with a history of an eating disorder can have some subthreshold eating disorder symptoms.
  11. The misuse of drugs, alcohol and nicotine during pregnancy is thought to be common: 15% of pregnant women in inner cities screen positive for drug use, most of which is cannabis; 10% of pregnant women binge drink; and 13% of pregnant women smoke throughout pregnancy (self-reported data collected at delivery). The misuse of drugs and alcohol during pregnancy is known to have significant harmful effects on pregnancy and infant outcomes.. Complications during pregnancy, for example prematurity, intrauterine growth retardation and fetal distress, are more common in women who misuse drugs than those who do not. Drug misuse in pregnancy can also result in neonatal abstinence syndrome and negative effects on the growth and development of the infant.
  12. Mental health disorders during pregnancy and the postnatal period can be associated with, or aggravated by, a number of factors, including:
    • psychosocial factors, such as the demands and expectations of being a mother in addition to the psychological effects of a traumatic delivery
    • social factors, including social isolation, economic status, ethnicity, cultural issues and housing
    • family factors, including the relationship with the baby's father and the support received from family and friends
    • biological factors, including genetic factors and the hormonal changes that occur during pregnancy, childbirth and following childbirth
    • personal history (including lifestyle factors, domestic violence, childhood sexual and physical abuse, past psychiatric history and previous maternal history) and family history
    • stillbirth
    • the infant's general health
    • admission of the infant to neonatal care.
  13. The UK Confidential Enquiry into Maternal Deaths (CMACE) reports that between 2006 and 2008 there were 1.27 deaths per 100,000 maternal deliveries in the UK as a result of psychiatric disorders. Although response to treatment is good, mental health disorders can go unrecognised and untreated in pregnancy and postpartum. If untreated, women can continue to have symptoms, sometimes for many years, with the negative impact affecting not only the mother, but also other family members.
  14. All mental health disorders in the antenatal and postnatal period can have a significant effect on the mother–infant relationship, and as a result, there may be longer-term consequences for all areas of the infant's development.

3.2. Current practice

  1. Women with antenatal and postnatal mental health disorders are treated in a variety of NHS settings, including primary care services, obstetric and gynaecological services, general mental health services and specialist secondary care mental health services. Most mental health disorders that arise during pregnancy and the postnatal period will be mild to moderate, and treated and managed in primary care.
  2. The provision and uptake of services varies across England and Wales. In part this reflects variation in the recognition of disorders, but also the presence or absence of specialist multidisciplinary and multi-agency services, particularly for women with more severe illness.

4. THE GUIDELINE

The guideline development process is described in detail on the NICE website (see section 6, ‘Further information’).

This scope defines what the guideline will (and will not) examine, and what the guideline developers will consider. The scope is based on the referral from the Department of Health.

The areas that will be addressed by the guideline are described in the following sections.

4.1. Population

4.1.1. Groups that will be covered

  1. Women who have, or are at risk of, mental health disorders during pregnancy and the postnatal period (from delivery to the end of the first year). This will include women with subthreshold symptoms and women with mild, moderate and severe disorders.
  2. Specific consideration will be given to the needs of black and minority ethnic groups, socioeconomic groups, asylum seekers, women who are victims of trafficking, and women with learning and physical disabilities.

4.2. Healthcare setting

  1. Care and shared care provided in primary, secondary and tertiary healthcare services in the NHS and NHS provided and funded services, including care provided by healthcare professionals and others working in healthcare settings, who have contact with, and make decisions concerning, the mental healthcare of women in pregnancy and the postnatal period. This update covers the same healthcare settings as the original NICE guideline (CG45).

4.3. Clinical management

4.3.1. Key clinical issues that will be covered

  1. The prevention of mental health disorders in pregnancy and the postnatal period.
  2. Case identification, diagnosis and assessment of mental health disorders in women during pregnancy and the postnatal period.
  3. Psychosocial interventions (including type, form and duration) and the balance of risk and benefit for the mother, fetus and baby.
  4. Pharmacological interventions (including type, dose and duration) and the balance of risk and benefit for the mother, fetus and baby.
    Note that guideline recommendations will normally fall within licensed indications; exceptionally, and only if clearly supported by evidence, use outside a licensed indication may be recommended. The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.
  5. Appropriate use of combined pharmacological and psychosocial treatments.
  6. Electroconvulsive therapy.
  7. The role of the family, carers and peers in the treatment and support of women with mental health disorders in pregnancy and the postnatal period.
  8. Identification and management of risk to self, baby and others, including physical, sexual and emotional abuse such as neglect
  9. The impact of the mother's mental health on the quality of the mother–baby interaction.

4.3.2. Clinical issues that will not be covered

Areas not covered by the original guideline or the update:

  1. The needs of infants, other children and partners of women who have developed mental health disorders in pregnancy and the postnatal period.
  2. Consideration of the need for specialist inpatient services (for example, mother and baby units).

Areas from the original guideline that will not be updated:

  1. Configuration of services for the provision of effective care for women and their children.

4.4. Main outcomes

  1. Diagnosis of a mental disorder
  2. Symptomatology
  3. Quality of life
  4. Relapse
  5. Hospitalisation
  6. Drop-out (including all cause and drop-out because of side effects)
  7. Side effects
  8. Quality of mother–infant interaction and infant care
  9. Fetal and infant development, including congenital malformations.

4.5. Review questions

Review questions guide a systematic review of the literature. They address only the key clinical issues covered in the scope, and usually relate to interventions, diagnosis, prognosis, service delivery or patient experience.

4.5.1. Prediction, identification and assessment of mental health disorders during pregnancy and the postnatal period

  1. What instruments and psychosocial factors reliably predict the development or recurrence of mental health disorders in women during pregnancy and the postnatal period2?
    Subsidiary questions, repeat for:
    • depression
    • puerperal psychosis (including schizophrenia, schizoaffective disorder and bipolar disorder)
    • anxiety disorders (including panic disorder, generalised anxiety disorder, obsessive-compulsive disorder, tokophobia, post-traumatic stress disorder)
    • personality disorders (including schizoid, avoidant, obsessive-compulsive, borderline)
    • substance misuse (including drugs, alcohol and nicotine)
    • eating disorders (including anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified).
  2. Does the benefit of using these instruments and/or considering these psychological factors outweigh the harm?
  3. What instruments have been developed that reliably detect the presence of mental health disorders in women during pregnancy and the postnatal period?
    Subsidiary questions, repeat for:
    • Depression
    • puerperal psychosis (including schizophrenia, schizoaffective disorder and bipolar disorder)
    • anxiety disorders (including panic disorder, generalised anxiety disorder, obsessive-compulsive disorder, tokophobia, post-traumatic stress disorder)
    • personality disorders (including schizoid, avoidant, obsessive-compulsive, borderline)
    • substance misuse (including drugs, alcohol and nicotine)
    • eating disorders (including anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified).
  4. Does the benefit of using these instruments and/or considering these psychosocial factors outweigh the harm?
  5. What instruments and/or methods have been developed that reliably assess mental health disorders in women during the antenatal and postnatal period?
    Subsidiary questions, repeat for:
    • depression
    • puerperal psychosis (including schizophrenia, schizoaffective disorder and bipolar disorder)
    • anxiety disorders (including panic disorder, generalised anxiety disorder, obsessive-compulsive disorder, tokophobia, post-traumatic stress disorder)
    • personality disorders (including schizoid, avoidant, obsessive-compulsive, borderline)
    • substance misuse (including drugs, alcohol and nicotine)
    • eating disorders (including anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified).
  6. Does the benefit of using these instruments and/or considering these psychosocial factors outweigh the harm?

4.5.2. Prevention

  1. For women identified as being at risk of developing a mental health disorder during pregnancy and in the postnatal period, what interventions are most effective in reducing that risk?
    Subsidiary questions, repeat for:
    • depression
    • puerperal psychosis (including schizophrenia, schizoaffective disorder and bipolar disorder)
    • anxiety disorders (including panic disorder, generalised anxiety disorder, obsessive-compulsive disorder, tokophobia, post-traumatic stress disorder)
    • personality disorders (including schizoid, avoidant, obsessive-compulsive, borderline)
    • substance misuse (including drugs, alcohol and nicotine)
    • eating disorders (including anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified).
    Subsidiary questions, repeat for:
    • psychosocial interventions
    • pharmacological interventions
    • ECT
    • combined interventions.

4.5.3. Treatment

  1. For women with mental health disorders during pregnancy and the postnatal period, what interventions are associated with a reduction in symptomatology, improved quality of life and increased remission rates?
    Subsidiary questions, repeat for:
    • depression
    • puerperal psychosis (including schizophrenia, schizoaffective disorder and bipolar disorder)
    • anxiety disorders (including panic disorder, generalised anxiety disorder, obsessive-compulsive disorder, tokophobia, post-traumatic stress disorder)
    • personality disorders (including schizoid, avoidant, obsessive-compulsive, borderline)
    • substance misuse (including drugs, alcohol and nicotine)
    • eating disorders (including anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified).
    Subsidiary questions, repeat for:
    • psychosocial interventions
    • pharmacological interventions
    • ECT
    • combined interventions.
  2. For women with mental health disorders during pregnancy and the postnatal period, what interventions are associated with an increase in harm to the mother, fetus or baby (measures might include relapse, hospitalisation, increased attrition or side effects)?
    Subsidiary questions, repeat for:
    • depression
    • puerperal psychosis (including schizophrenia, schizoaffective disorder and bipolar disorder)
    • anxiety disorders (including panic disorder, generalised anxiety disorder, obsessive-compulsive disorder, tokophobia, post-traumatic stress disorder)
    • personality disorders (including schizoid, avoidant, obsessive-compulsive, borderline)
    • substance misuse (including drugs, alcohol and nicotine)
    • eating disorders (including anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified).
    Subsidiary questions, repeat for:
    • psychosocial interventions
    • pharmacological interventions
    • ECT
    • combined interventions.
  3. For women with mental health disorders during pregnancy and the postnatal period, what interventions (beyond those targeting the mental health disorder) help to improve the quality of the mother–infant interaction?

4.6. Economic aspects

Developers will take into account both clinical and cost effectiveness when making recommendations involving a choice between alternative interventions. A review of the economic evidence will be conducted and analyses will be carried out as appropriate. The preferred unit of effectiveness is the quality-adjusted life year (QALY), and the costs considered will usually be only from an NHS and personal social services (PSS) perspective. Further detail on the methods can be found in ‘The guidelines manual’ (see ‘Further information’).

4.7. Status

4.7.1. Scope

This is the final scope.

4.7.2. Timing

The development of the guideline recommendations will begin in March 2013.

5. RELATED NICE GUIDANCE

5.1. Published guidance

5.1.1. NICE guidance to be updated

This guideline will partially update and will replace the following NICE guidance: Antenatal and postnatal mental health. NICE clinical guideline 45 (2007).

5.1.2. Other related NICE guidance

  • Patient experience in adult NHS services. NICE clinical guidance 138 (2012)
  • Antenatal care. NICE clinical guideline. Publication expected September 2012.
  • Antenatal care. NICE quality standard 22 (2012).
  • Service user experience in adult mental health. NICE clinical guidance 136 (2011)
  • Caesarean section. NICE clinical guideline 132 (2011)
  • Multiple pregnancy. NICE clinical guideline 129 (2011)
  • Common mental health disorders. NICE clinical guideline 123 (2011)
  • Alcohol dependence and harmful alcohol use. NICE clinical guideline 115 (2011)
  • Alcohol dependence and harmful alcohol use. NICE quality standard 11 (2011)
  • Anxiety. NICE clinical guideline 113 (2011)
  • Aripiprazole for the treatment of schizophrenia in people aged 15 to 17 years. NICE technology appraisal guidance 213 (2011)
  • Pregnancy and complex social factors. NICE clinical guideline 110 (2010)
  • Hypertension in pregnancy. NICE clinical guideline 107 (2011)
  • Weight management before, during and after pregnancy. NICE public health guidance 27 (2010)
  • Quitting smoking in pregnancy and following childbirth. NICE public health guidance 26 (2010)
  • Alcohol-use disorders: physical complications. NICE clinical guideline 100 (2010)
  • Depression in adults. NICE clinical guideline 90 (2009)
  • When to suspect child maltreatment. NICE clinical guideline 89 (2009)
  • Schizophrenia. NICE clinical guideline 82 (2009)
  • Borderline personality disorder. NICE clinical guideline 78 (2009)
  • Antisocial personality disorder. NICE clinical guideline 77 (2009)
  • Diabetes in pregnancy. NICE clinical guideline 63 (2008)
  • Antenatal care. NICE clinical guideline 62 (2008).
  • Maternal and child nutrition. NICE public health guidance 11 (2008)
  • Intrapartum care. NICE clinical guideline 55 (2007)
  • Drug misuse: psychosocial interventions. NICE clinical guideline 51 (2007)
  • Computerised cognitive behaviour therapy for depression and anxiety. NICE technology appraisal guidance 97 (2006)
  • Bipolar disorder. NICE clinical guideline 38 (2006)
  • Postnatal care. NICE guideline 37 (2006).
  • Eating disorders. NICE clinical guideline 9 (2004)
  • Guidance on the use of electroconvulsive therapy. NICE technology appraisal guidance 59 (2003)

5.1.3. Guidelines under development

NICE is currently developing the following related guidance (details available from the NICE website):

  • Diabetes in pregnancy (update). NICE clinical guideline. Publication expected June 2014.
  • Psychosis and schizophrenia (update). NICE clinical guideline. Publication expected February 2014.
  • Bipolar disorder (update). NICE clinical guideline. Publication expected June 2014.
  • Offenders: prevention and early treatment of mental health problems. NICE public health guidance. Publication date to be confirmed.

6. FURTHER INFORMATION

Information on the guideline development process is provided in:

  • How NICE clinical guidelines are developed: an overview for stakeholders the public and the NHS
  • The guidelines manual
  • Developing NICE quality standards: interim process guide.

Information on the progress of the guideline and quality standards is also available from the (NICE website).

Footnotes

1

In this document ‘baby’ refers to single and multiple births.

2

Postnatal period defined as from delivery to the end of the first year.

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