“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