9.1.1. Improving the experience of care

9.1.1.1.

Use this guideline in conjunction with the guidance on service user experience in adult mental health (NICE clinical guideline 136) and patient experience in adult NHS services (NICE clinical guideline 138) to improve the experience of care for women with a mental health problem in pregnancy or the postnatal period. [new 2014]

9.1.2. Assessment and treatment in pregnancy and the postnatal period

9.1.2.1.

Use this guideline in conjunction with the NICE guideline for a specific mental health problem (see the related NICE guidance in section 3.2 [in the NICE guideline]) to inform assessment and treatment decisions in pregnancy and the postnatal period, and take into account:

• any variations in the nature and presentation of the mental health problem in pregnancy or the postnatal period
• the setting for assessment and treatment (for example, primary or secondary care services or in the community, the home or remotely by phone or computer)
• recommendations 9.6.1.1 to 9.6.1.6 in this guideline on assessment in pregnancy and the postnatal period
• recommendations 9.4.2.1 to 9.4.2.28 in this guideline on starting, using and stopping treatment in pregnancy and the postnatal period
• recommendations 7.7.1.6 to 9.8.8.1 in this guideline on treating specific mental health problems in pregnancy and the postnatal period. [new 2014]

9.3.1. Supporting women and their partners, families and carers

9.3.1.1.

Acknowledge the woman's role in caring for her baby and support her to do this in a non-judgmental and compassionate way. [new 2014]

9.3.1.2.

Involve the woman and, if she agrees, her partner, family or carer, in all decisions about her care and the care of her baby. [new 2014]

9.3.1.3.

When working with girls and young women with a mental health problem in pregnancy or the postnatal period:

• be familiar with local and national guidelines on confidentiality and the rights of the child
• be aware of the recommendations in section 1.4 of the guideline on pregnancy and complex social factors (NICE clinical guideline 110)
• ensure continuity of care for the mental health problem if care is transferred from adolescent to adult services. [new 2014]

9.3.1.4.

Take into account and, if appropriate, assess and address the needs of partners, families and carers that might affect a woman with a mental health problem in pregnancy and the postnatal period. These include:

• the welfare of the baby and other dependent children and adults
• the role of the partner, family or carer in providing support
• the potential effect of any mental health problem on the woman's relationship with her partner, family or carer. [new 2014]

9.3.2. Coordinated care

9.3.2.1.

Develop an integrated care plan for a woman with a mental health problem in pregnancy and the postnatal period that sets out:

• the care and treatment for the mental health problem
• the roles of all healthcare professionals, including who is responsible for:

  -

  coordinating the integrated care plan

  -

  the schedule of monitoring

  -

  providing the interventions and agreeing the outcomes with thewoman. [new 2014]

9.3.2.2.

The healthcare professional responsible for coordinating the integrated care plan should ensure that:

• everyone involved in a woman's care is aware of their responsibilities
• there is effective sharing of information with all services involved and with the woman herself
• mental health (including mental wellbeing) is taken into account as part of all care plans
• all interventions for mental health problems are delivered in a timely manner, taking into account the stage of the pregnancy or age of the baby. [new 2014]

9.4.1. Information and advice

9.4.1.1.

Provide culturally relevant information on mental health problems in pregnancy and the postnatal period to the woman and, if she agrees, her partner, family or carer. Ensure that the woman understands that mental health problems are not uncommon during these periods and instil hope about treatment. [new 2014]

9.4.1.2.

Consider referring a woman to a secondary mental health service (preferably a specialist perinatal mental health service) for preconception counselling if she has a current or past severe mental health problem and is planning a pregnancy. [new 2014]

9.4.1.3.

Discuss treatment and prevention options and any particular concerns the woman has about the pregnancy or the fetus or baby. Provide information to the woman and, if she agrees, her partner, family or carer, about:

• the potential benefits of psychological interventions and psychotropic medication
• the possible consequences of no treatment
• the possible harms associated with treatment
• what might happen if treatment is changed or stopped, particularly if psychotropic medication is stopped abruptly. [new 2014]

9.4.1.4.

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. [new 2014]

9.4.1.5.

If needed, seek more detailed advice about the possible risks of mental health problems or the benefits and harms of treatment in pregnancy and the postnatal period from a secondary mental health service (preferably a specialist perinatal mental health service). This might include advice on the risks and possible harms of taking psychotropic medication while breastfeeding and how medication might affect a woman's ability to care for her baby (for example, sedation). [new 2014]

9.4.1.6.

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 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
• the woman's response to any previous treatment
• the background risk of harm to the woman and the fetus or baby associated with the mental health problem and the risk to mental health and parenting associated with no treatment
• the possibility of the sudden onset of symptoms of mental health problems in pregnancy and the postnatal period, particularly in the first few weeks after childbirth (for example, in bipolar disorder)
• 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. [new 2014]

9.4.1.7.

When discussing likely benefits and risks of treatment with the woman and, if she agrees, her partner, family or carer:

• acknowledge the woman's central role in reaching a decision about her treatment and that the role of the professional is to inform that decision with balanced and up-to-date information and advice
• use absolute values based on a common denominator (that is, numbers out of 100 or 1000)
• acknowledge and describe, if possible, the uncertainty around any estimate of risk, harm or benefit
• use high-quality decision aids in a variety of numerical and pictorial formats that focus on a personalised view of the risks and benefits, in line with the guidance on patient experience in adult NHS services (NICE clinical guideline 138)
• consider providing records of the consultation, in a variety of visual, verbal or audio formats. [new 2014]

9.4.1.8.

Healthcare professionals working in universal services and those caring for women in mental health services should:

• assess the level of contact and support needed by women with a mental health problem (current or past) and those at risk of developing one
• agree the level of contact and support with each woman, including those who are not having treatment for a mental health problem
• monitor regularly for symptoms throughout pregnancy and the postnatal period, particularly in the first few weeks after childbirth. [new 2014]

9.4.1.9.

Discuss and plan how symptoms will be monitored (for example, by using validated self-report questionnaires, such as the Edinburgh Postnatal Depression Scale [EPDS], Patient Health Questionnaire [PHQ-9] or the 7-item Generalized Anxiety Disorder scale [GAD-7]). [new 2014]

9.4.2. Starting, using and stopping treatment

9.5.2. Depression and anxiety disorders

9.5.2.1.

Recognise that the range and prevalence of anxiety disorders (including generalised anxiety disorder, obsessive-compulsive disorder, panic disorder, phobias, post-traumatic stress disorder and social anxiety disorder) and depression are under-recognised throughout pregnancy and the postnatal period. [new 2014]

9.5.2.2.

At a woman's first contact with primary care or her booking visit, and during the early postnatal period, consider asking the following depression identification questions as part of a general discussion about a woman's mental health and wellbeing:

• 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?

Also consider asking about anxiety using the 2-item Generalized Anxiety Disorder scale (GAD-2):

• Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?³¹
• Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?³² [new 2014]

9.5.2.3.

If a woman responds positively to either of the depression identification questions in recommendation 9.5.2.2, is at risk of developing a mental health problem, or there is clinical concern, consider:

• using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9) as part of a full assessment or
• referring the woman to her GP or, if a severe mental health problem is suspected, to a mental health professional. [new 2014]

9.5.2.4.

If a woman scores 3 or more on the GAD-2 scale, consider:

• using the GAD-7 scale for further assessment or
• referring the woman to her GP or, if a severe mental health problem is suspected, to a mental health professional. [new 2014]

9.5.2.5.

If a woman scores less than 3 on the GAD-2 scale, but you are still concerned she may have an anxiety disorder, ask the following question:

• Do you find yourself avoiding places or activities and does this cause you problems?

If she responds positively, consider:

• using the GAD-7 scale for further assessment or
• referring the woman to her GP or, if a severe mental health problem is suspected, to a mental health professional. [new 2014]

9.5.2.6.

At all contacts after the first contact with primary care or the booking visit, the health visitor, and other healthcare professionals who have regular contact with a woman in pregnancy and the postnatal period (first year after birth), should consider:

• asking the 2 depression identification questions and the GAD-2 (see recommendation 9.5.2.2) as part of a general discussion about her mental health and wellbeing and
• using the EPDS or the PHQ-9 as part of monitoring. [new 2014]

9.5.3. Severe mental illness

9.5.3.1.

At a woman's first contact with services in pregnancy and the postnatal period, ask about:

• any past or present severe mental illness
• past or present treatment by a specialist mental health service, including inpatient care
• any severe perinatal mental illness in a first-degree relative (mother, sister or daughter). [2014]

9.5.3.2.

Refer to a secondary mental health service (preferably a specialist perinatal mental health service) for assessment and treatment, all women who:

• have or are suspected to have severe mental illness
• have any history of severe mental illness (during pregnancy or the postnatal period or at any other time).

Ensure that the woman's GP knows about the referral. [new 2014]

9.5.3.3.

If a woman has any past or present severe mental illness or there is a family history of severe perinatal mental illness in a first-degree relative, be alert for possible symptoms of postpartum psychosis in the first 2 weeks after childbirth. [new 2014]

9.5.3.4.

If a woman has sudden onset of symptoms suggesting postpartum psychosis, refer her to a secondary mental health service (preferably a specialist perinatal mental health service) for immediate assessment (within 4 hours of referral). [new 2014]

9.5.4. Alcohol and drug misuse

9.5.4.1.

If alcohol misuse is suspected, use the Alcohol Use Disorders Identification Test (AUDIT) as an identification tool in line with recommendation 1.2.1.4 of the guideline on alcohol-use disorders (NICE clinical guideline 115). [new 2014]

9.5.4.2.

If drug misuse is suspected, follow the recommendations on identification and assessment in section 1.2 of the guideline on drug misuse – psychosocial interventions (NICE clinical guideline 51). [new 2014]

9.8.1. Interventions for depression

9.8.1.1.

For a woman with persistent subthreshold depressive symptoms, or mild to moderate depression, in pregnancy or the postnatal period, consider facilitated self-help (delivered as described in recommendation 1.4.2.2 of the guideline on depression in adults [NICE clinical guideline 90]). [new 2014]

9.8.1.2.

For a woman with a history of severe depression who initially presents with mild depression in pregnancy or the postnatal period, consider a TCA, SSRI or (S)NRI. [new 2014]

9.8.1.3.

For a woman with moderate or severe depression in pregnancy or the postnatal period, consider the following options:

• a high-intensity psychological intervention (for example, CBT)
• a TCA, SSRI or (S)NRI if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and:

  -

  she has expressed a preference for medication or

  -

  she declines psychological interventions or

  -

  her symptoms have not responded to psychological interventions

• a high-intensity psychological intervention in combination with medication if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and there is no response, or a limited response, to a high-intensity psychological intervention or medication alone. [new 2014]

9.8.1.4.

If a woman who is taking a TCA, SSRI or (S)NRI for mild to moderate depression becomes pregnant, discuss stopping the medication gradually and consider facilitated self-help (delivered as described in recommendation 1.4.2.2 of the guideline on depression in adults [NICE clinical guideline 90]). [new 2014]

9.8.1.5.

If a pregnant woman is taking a TCA, SSRI or (S)NRI for moderate depression and wants to stop her medication, take into account previous response to treatment, stage of pregnancy, risk of relapse, risk associated with medication and her preference, and discuss with her the following options:

• switching to a high-intensity psychological intervention (for example, CBT)
• changing medication if there is a drug that is effective for her with a lower risk of adverse effects. [new 2014]

9.8.1.6.

If a pregnant woman is taking a TCA, SSRI or (S)NRI for severe depression, take into account previous response to treatment, stage of pregnancy, risk of relapse, risk associated with medication and her preference, and discuss with her the following options:

• continuing with the current medication
• changing medication if there is a drug that is effective for her with a lower risk of adverse effects
• combining medication with a high-intensity psychological intervention (for example, CBT)
• switching to a high-intensity psychological intervention (for example, CBT) if she decides to stop taking medication. [new 2014]

9.8.2. Interventions for anxiety disorders

9.8.2.1.

For a woman with tokophobia (an extreme fear of childbirth), offer an opportunity to discuss her fears with a healthcare professional with expertise in providing perinatal mental health support in line with section 1.2.9 of the guideline on caesarean section (NICE clinical guideline 132). [new 2014]

9.8.2.2.

For a woman with persistent subthreshold symptoms of anxiety in pregnancy or the postnatal period, consider facilitated self-help. This should consist of use of CBT-based self-help materials over 2–3 months with support (either face to face or by telephone) for a total of 2–3 hours over 6 sessions. [new 2014]

9.8.2.3.

For a woman with an anxiety disorder in pregnancy or the postnatal period, offer a low-intensity psychological intervention (for example, facilitated self-help) or a high-intensity psychological intervention (for example, CBT) as initial treatment in line with the recommendations set out in the NICE guideline for the specific mental health problem and be aware that:

• only high-intensity psychological interventions are recommended for post-traumatic stress disorder
• high-intensity psychological interventions are recommended for the initial treatment of social anxiety disorder
• progress should be closely monitored and a high-intensity psychological intervention offered within 2 weeks if symptoms have not improved. [new 2014]

9.8.2.4.

If a woman who is taking a TCA, SSRI or (S)NRI for an anxiety disorder becomes pregnant, discuss with her the following options:

• stopping the medication gradually and switching to a high-intensity psychological intervention (for example, CBT)
• continuing with medication if she understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and:

  -

  has expressed a preference for medication or

  -

  declines psychological interventions or

  -

  her symptoms have not responded to psychological interventions

• changing medication if there is a drug that is effective for her with a lower risk of adverse effects
• combining medication with a high-intensity psychological intervention (for example, CBT) if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and there is no response, or a limited response, to a high-intensity psychological intervention alone. [new 2014]

9.8.3. Psychological interventions for eating disorders

9.8.3.1.

For a woman with an eating disorder in pregnancy or the postnatal period:

• offer a psychological intervention in line with the guideline on eating disorders (NICE clinical guideline 9)
• monitor the woman's condition carefully throughout pregnancy and the postnatal period
• assess the need for fetal growth scans
• discuss the importance of healthy eating during pregnancy and the postnatal period in line with the guideline on maternal and child nutrition (NICE public health guidance 11)
• advise her about feeding the baby in line with the guideline on maternal and child nutrition (NICE public health guidance 11) and support her with this. [new 2014]

9.8.4. Interventions for alcohol and drug misuse

9.8.4.1.

If hazardous drug or alcohol misuse is identified in pregnancy or the postnatal period, refer or offer brief interventions in line with section 1.3.1 of the guideline on drug misuse – psychosocial interventions (NICE clinical guideline 51) or the guideline on alcohol-use disorders: preventing harmful drinking (NICE public health guidance 24). [new 2014]

9.8.4.2.

If harmful or dependent drug or alcohol misuse is identified in pregnancy or the postnatal period, refer the woman to a specialist substance misuse service for advice and treatment. [new 2014]

9.8.4.3.

Offer assisted alcohol withdrawal in collaboration with specialist mental health and alcohol services (preferably in an inpatient setting) to pregnant women who are dependent on alcohol. Work with a woman who does not want assisted alcohol withdrawal to help her reduce her alcohol intake. [new 2014]

9.8.4.4.

Offer detoxification in collaboration with specialist mental health and substance misuse services to pregnant women who are dependent on opioids. Monitor closely after completion of detoxification. Work with a woman who does not want detoxification to help her reduce her opioid intake. Recognise the risk of accidental overdose in women who stop or reduce drug misuse in pregnancy but start misusing again after childbirth. [new 2014]

9.8.5. Interventions for severe mental illness

9.8.5.1.

Consider psychological interventions for women with bipolar disorder. This includes:

• CBT, IPT and behavioural couples therapy for bipolar depression
• structured individual, group and family interventions designed for bipolar disorder to reduce the risk of relapse, particularly when medication is changed or stopped. [new 2014]

9.8.5.2.

If a pregnant woman develops mania or psychosis and is not taking psychotropic medication, offer an antipsychotic. [new 2014]

9.8.5.3.

Consider psychological interventions (CBT or family intervention) delivered as described in section 1.3.7 of the guideline on psychosis and schizophrenia in adults (NICE clinical guideline 178) for a woman with psychosis or schizophrenia who becomes pregnant and is at risk of relapse arising from:

• stress associated with pregnancy or the postnatal period
• a change in medication, including stopping antipsychotic medication. [new 2014]

9.8.5.4.

Offer an antipsychotic in line with recommendations 1.5.3 and 1.5.4 of the guideline on bipolar disorder (NICE clinical guideline 185) as prophylactic medication if a woman with bipolar disorder:

• becomes pregnant and is stopping lithium, or
• plans to breastfeed. [new 2014]

9.8.5.5.

If a pregnant woman with bipolar disorder develops mania while taking prophylactic medication:

• check the dose of the prophylactic medication and adherence
• increase the dose if the prophylactic medication is an antipsychotic
• suggest changing to an antipsychotic if she is taking another type of prophylactic medication
• consider lithium if there is no response to an increase in dose or change of drug and the woman has severe mania
• consider electroconvulsive therapy (ECT) if there has been no response to lithium. [new 2014]

9.8.6. Interventions for sleep problems

9.8.6.1.

Advise pregnant women who have a sleep problem about sleep hygiene (including having a healthy bedtime routine, avoiding caffeine and reducing activity before sleep). For women with a severe or chronic sleep problem, consider promethazine³⁴. [new 2014]

9.8.7. Electroconvulsive therapy

9.8.7.1.

Consider electroconvulsive therapy (ECT) for pregnant women with severe depression, severe mixed affective states or mania, or catatonia, whose physical health or that of the fetus is at serious risk. [2014]

9.8.8. Rapid tranquillisation

9.8.8.1.

A pregnant woman requiring rapid tranquillisation should be treated according to the NICE clinical guidelines on the short-term management of disturbed/violent behaviour, schizophrenia and bipolar disorder (see the related NICE guidance in section 3.2 for details [in the NICE guideline]), except that:

• she should not be secluded after rapid tranquillisation
• restraint procedures should be adapted to avoid possible harm to the fetus
• when choosing an agent for rapid tranquillisation in a pregnant woman, an antipsychotic or a benzodiazepine with a short half-life should be considered; if an antipsychotic is used, it should be at the minimum effective dose because of neonatal extrapyramidal symptoms; if a benzodiazepine is used, the risks of floppy baby syndrome should be taken into account
• during the perinatal period, the woman's care should be managed in close collaboration with a paediatrician and an anaesthetist. [2007]

9.9.1. Reviewing treatment for women with severe mental illness

9.9.1.1.

After childbirth, review and assess the need for starting, restarting or adjusting psychotropic medication as soon as a woman with a past or present severe mental illness is medically stable. [new 2014]

9.9.2. Monitoring babies for effects of psychotropic medication taken in pregnancy

9.9.2.1.

If a woman has taken psychotropic medication during pregnancy, carry out a full neonatal assessment of the newborn baby, bearing in mind:

• the variation in the onset of adverse effects of psychotropic medication
• the need for further monitoring
• the need to inform relevant healthcare professionals and the woman and her partner, family or carer of any further monitoring, particularly if the woman has been discharged early. [new 2014]

9.9.3. Care of women and their babies if there has been alcohol or drug misuse in pregnancy

9.9.3.1.

If there has been alcohol or drug misuse in pregnancy, offer treatment and support after childbirth to both the woman and the baby, including:

• a full neonatal assessment for any congenital abnormalities or neonatal adaptation syndrome
• continuing psychological treatment and support for the woman
• monitoring of the baby. [new 2014]

9.9.4. Traumatic birth, stillbirth and miscarriage

9.9.4.1.

Offer advice and support to women who have had a traumatic birth or miscarriage and wish to talk about their experience. Take into account the effect of the birth or miscarriage on the partner and encourage them to accept support from family and friends. [new 2014]

9.9.4.2.

Offer women who have post-traumatic stress disorder, which has resulted from a traumatic birth, miscarriage, stillbirth or neonatal death, a high-intensity psychological intervention (trauma-focused CBT or eye movement desensitisation and reprocessing [EMDR]) in line with the guideline on post-traumatic stress disorder (PTSD) (NICE clinical guideline 26). [new 2014]

9.9.4.3.

Do not offer single-session high-intensity psychological interventions with an explicit focus on ‘re-living’ the trauma to women who have a traumatic birth. [new 2014]

9.9.4.4.

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. [new 2014]

9.9.5. Psychotropic medication and breastfeeding

9.9.5.1.

Encourage women with a mental health problem to breastfeed, unless they are taking carbamazepine, clozapine or lithium (valproate is not recommended to treat a mental health problem in women of childbearing potential). However, support each woman in the choice of feeding method that best suits her and her family. [new 2014]

9.9.5.2.

When assessing the risks and benefits of TCAs, SSRIs or (S)NRIs for women who are breastfeeding, take into account:

• the limited data about the safety of these drugs and
• the risks associated with switching from a previously effective medication.

Seek advice from a specialist (preferably from a specialist perinatal mental health service) if needed for specific drugs. [new 2014]

9.9.5.3.

When assessing the risks and benefits of antipsychotic medication for women who are breastfeeding, take into account:

• the limited data on the safety of these drugs and
• the level of antipsychotic medication in breast milk depends on the drug. [new 2014]

9.9.5.4.

If a woman is taking psychotropic medication while breastfeeding, monitor the baby for adverse effects. [2014]

9.9.6. The mother–baby relationship

9.9.6.1.

Recognise that some women with a mental health problem may experience difficulties with the mother–baby relationship. Assess the nature of this relationship, including verbal interaction, emotional sensitivity and physical care, at all postnatal contacts. Discuss any concerns that the woman has about her relationship with her baby and provide information and treatment for the mental health problem. [new 2014]

9.9.6.2.

Consider further intervention to improve the mother–baby relationship if any problems in the relationship have not resolved. [new 2014]