Antenatal and Postnatal Mental Health NICE Clinical Guideline 45: 2007 DTV VTS Sept 2016 Dr Rachel Lunney (& thanks to Dr Dinah Roy)

Objectives Consider cases of mental health problems in pregnancy and the postnatal period Revise NICE guidance on peri- & postnatal health problems Consider how to identify postnatal depression in primary care Discuss how to manage the spectrum of perinatal mental health disorders Consider the diagnosis and management of Bipolar Affective Disorder in Primary Care (Part 2 after tea)

Session Plan Discuss experiences of patients with mental disorders during pregnancy & postnatal period Presentation NICE CG45 2014 Inc Case examples: discussion Tea Presentation: NICE Bipolar Disorder

Experiences of dealing with Mental Disorder during pregnancy and postnatal period Can you recall any memorable patients? Roles in Primary Care teams GP, Midwife, Health Visitor? Perspectives from secondary care attachments Paediatrics Psychiatry Obstetrics Questions and learning needs? Core roles Visiting schedules Virtual teams – different parts of Tees Valley and Co Durham / Darlington

Self test quiz 1: True or False? Baby Blues occurs in the first 7 days after delivery Baby Blues affects >30% of women Postnatal Depression affects 10% of women Postpartum psychosis affects women in 1 in 1000 deliveries Women with Bipolar Disorder have a 1 in 4 risk of Postpartum psychosis Suicide is the commonest cause of maternal death in the 1 year postpartum

Self test quiz 1: True or False? Baby Blues occurs in the first 7 days after delivery T Baby Blues affects >30% of women T Postnatal Depression affects 10% of women T Postpartum psychosis affects women in 1 in 1000 deliveries T Women with Bipolar Disorder have a 1 in 4 risk of Postpartum psychosis F – worse: 1 in 2 & 40-70% relapse risk postnatally Suicide is the commonest cause of maternal death in the 1 year postpartum T

Self test quiz 2: True or False? Risk factors for maternal mental health disorders can be identified and acted on to affect outcomes Psychological treatment of mild depression in pregnancy reduces progression to more severe illness Tricyclic antidepressants are the safest drug choice in pregnancy SSRIs are safe throughout pregnancy Sertraline is the best choice for breast feeding mums Midwives are the best people to identify MH problems

Self test quiz 2: True or False? Risk factors for maternal mental health disorders can be identified and acted on to affect outcomes T Psychological treatment of mild depression in pregnancy reduces progression to more severe illness T Tricyclic antidepressants are the safest drug choice in pregnancy F – Safer, tho overdose risk high SSRIs are safe throughout pregnancy F: Less safe >20wks Sertraline is best choice for breast feeding mums T Midwives are the best people to identify MH problems F – Family, GP if contact, MH team

NICE CG 192: 2014 Antenatal and postnatal mental health: clinical management and service guidance Predict those at risk Detect those affected Treat those who need it

Case 1 Liz 26 yrs, 2 weeks post-partum full term normal delivery Breast feeding her son Jack Supportive partner 5 year old daughter to previous partner PMH moderate depression aged 20. Treated w antidepressants, discontinued when pregnant Tearful, tired, poor appetite and sleep Biospsyhosocial (BPS) Assessment? Issues? Predict? Detect? Treat?

Case 2 Kelly 27 yrs, 5 weeks postpartum full term normal delivery PMH mod postnatal depression after first son 3y ago Weepy, tired, angry and low Tearful, agitated; no thought disorder, not suicidal Lack of support, husband works away, no family locally. Breast feeding BPS Assessment? Issues? Predict? Detect? Treat?

Case 3 Gillian 19 yrs, 7 months postpartum after NVD girl, Skye Dad’s mother concerned– couldn’t see her grandchild. PMH psychosis aged 17yrs, MH section Met Skye’s Dad in psychiatric inpatient unit Hallucinations, paranoia Gillian’s mother obstructive? Mental health issues BPS Assessment? Issues? Predict? Detect? Treat?

Talking about depression in the postnatal period http://www.nhs.uk/conditions/postnataldepression/pages/introduction.aspx - A Perinatal Psychiatrist & several women share perspectives

NICE CG45: General principles of care Be culturally sensitive Build trust Elicit ideas, concerns and expectations Be aware of stigma re mental disorders (MD) BJGP2019:60; 829 – Postnatal depression: women feel shame, & fear of appearing “not to cope” Ensure continuity of care Consider the impact on partner and children

Impact on partner and children JAMA 19 May 2010 Postnatal depression is common: 10-13% of women BUT 10% fathers suffer depression 1st trimester - 1st yr of life Most are affected between 3-6 months post-partum Other family members – children? Wider family? Be alert to symptoms in women, partners and others

Which mental disorders may affect pregnancy and the postnatal period? Severe mental illness Schizophrenia Bipolar disorder Depression Mild, moderate or severe Anxiety disorders Panic disorder Generalised anxiety disorder Obsessive–compulsive disorder (OCD) Post-traumatic stress disorder (PTSD) Eating disorders PRESENTER NOTES This slide is an overview of mental disorders that can affect this group. DEPRESSION 13%; 1-2/1000 Psychological difficulties during pregnancy and in the postnatal period range from minor transient disturbance with rapid unaided adjustment through common mental disorders to severe psychiatric disturbance. Women with the whole range of mental disorders become pregnant and have children. Pregnancy, childbirth and the demands of a child may precipitate problems, or lead a woman to seek help for her longstanding difficulties at this time. All pregnancies carry risk but these risks increase where the woman has a mental disorder, and there is evidence that mental disorder can have a significant detrimental impact on the well-being of the woman, the fetus and the infant. There is also emerging evidence that untreated mental disorder in pregnancy may be associated with poorer long-term outcomes for children beyond the immediate postnatal period. Mental disorders in their more severe forms are associated with significant impairment in social and personal functioning The term ‘postnatal depression’ is not used in the guideline because it is often used inappropriately as a general term for any perinatal mental disorder. Use of the ICD10 and DSM- IV with careful consideration of the context will ensure that policy and service development is focused on the full range of mental disorders that can occur antenatally and postnatally. NICE has also issued guidance documents on the management of these specific mental disorders. These are listed in the ‘Related NICE guidance’ section of the quick reference guide, and more details are available on the website - www.nice.org.uk

How do MH problems present? A range: adjustment reaction...mild...mod...severe Severe mental illness: may be rapid & an emergency Women with all mental disorders have babies! Pregnancy, birth, childcare may precipitate problems Women may seek help then for ongoing problems Mental disorders increase the risks of pregnancy Mental disorders affect maternal, foetal & infant health & well being

NB Mental disorders/labels ‘Postnatal depression’ is not used in NICE 45: Why? Misused, to cover all mental disorders Specific guidance in NICE CG45 for most MDs NICE guidance for each condition also exists ICD10 and DSM- IV inform the guideline NB SIGN guidance uses ‘Postnatal depression’ SIGN 127, March 2012 ‘Management of perinatal mood disorders’ http://sign.ac.uk/pdf/PAT127.pdf

Why the need for this guideline: 1? Psychological health as important as physical health Some MDs are unaffected by maternal period (see on*) Risk if meds stopped abruptly in mental disorders (MD) vs Medication risks to foetus and newborn baby vs Risks to mother & baby if MD undetected or untreated: Bonding, infant cognitive & emotional development Maternal suicide risk and rarely infanticide PRESENTER NOTES Women with an existing mental disorder often stop taking their medication when they become pregnant, without the benefit of an informed discussion. Stopping medication in this way can precipitate or worsen an episode. There is little evidence that the underlying course of most pre-existing mental disorders is significantly altered during pregnancy and the postnatal period, with the exception of bipolar disorder, which shows an increased rate of relapse and first presentation. However, during this time: More urgent intervention is often required, because of the potential impact of any disorder on the fetus or infant, as well as on the woman's physical health and care, and her ability to function and care for her family. As well as being more rapid in onset, psychotic episodes during this time have more severe symptoms than psychoses occurring at other times. There are potential serious consequences for mother and baby if mental health problems are not identified and treated. Suicide – main cause of maternal death in 1st yr post-partum Reduced likelihood of maternal / baby attachment, increased likelihood impaired cognitive and emotional development of the child Rarely, women with severe depression / post-partum psychosis may harm the child / infant Some cases last less than 3/12 or longer than 6/12 Postnatal – post-TOP

Why the need for this guideline 2? Increased risk of relapse / first presentation of bipolar disorder* More rapid onset of postnatal psychotic disorders* Urgent intervention may be required (Psyc Emerg’y) Need for careful use of psychotropic drugs Need for prompt and effective psychological interventions Effects on the extended family

Care starts Pre Conception “Discuss contraception and the risks of pregnancy (including relapse, risks associated with stopping or changing medication, and risk to the foetus) with all women of child-bearing potential who have a mental disorder and/or who are taking psychotropic medication. Encourage them to discuss pregnancy plans.” Also applies to breast feeding

Discussing risks with pts with Mental Disorders (MD) – Secondary Care Absolute and relative risk of treating MD vs not treating Foetal risks to those with no MD vs those with one on Rx Decision aids Personalised view of risk Written material Needs of adolescents PRESENTER NOTES The processes and skills needed for communication and discussing risks and benefits of treatments to patients are not well developed. Professionals will need to understand and be able to present and discuss the absolute and relative risks of treatment versus non-treatment and the incidence of mental illness. Describing risk in natural frequencies rather than percentages with a focus on a personalised risk will maximise understanding. Decision aids in a variety of verbal and visual formats can enhance understanding and recall. Written information or taped records will allow women and their families to revisit their personal risk outside of the consultation NICE recommendation 1.4.2.1 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 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, and focus on a personalised view of the risks provide written material to explain the risks (preferably individualised) and, if possible, audio-taped records of the consultation. There should be special consideration of the needs of young pregnant women. For information purposes the following recommendation is provided to give context, but it is not a key priority for implementation: NICE recommendation 1.1.3.1 Healthcare professionals working with adolescents experiencing a a mental disorder during pregnancy or the postnatal period should: be familiar with local and national guidelines on confidentiality and the rights of the child obtain appropriate consent, bearing in mind the adolescent’s understanding (including Gillick competence), parental consent and responsibilities, child protection issues, and the use of the Mental Health Act and of the Children Act (1989).

Risks of specific drugs Antipsychotics Lithium Raised prolactin levels: some Gestational diabetes and weight gain: olanzapine Agranulocytosis: clozapine Specific guidance in NICE 45 Foetal heart defects (up from 8 in 1000 to 60 in 1000) Ebstein’s anomaly (up from 1 in 20,000 to 10 in 20,000) High levels in breast milk Specific guidance in NICE 45

Risks of specific drugs Benzodiazepines Carbamazepine, Lamotrigine, Valproate Cleft palate and other foetal malformations Floppy baby syndrome Avoid routine use except in extreme agitation Withdraw slowly Specific guidance in NICE 45 Carb: Neural tube defects (up from 6 in 10,000 to 20-50 in 10,000). Other major foetal malformations including GI tract and cardiac abnormalities Lamot: oral cleft (risk approx 9 in 1000), Stevens–Johnson syndrome in breastfed babies Valp: Neural tube defects up from 6 in 10,000 to 100–200 in 10,000 Specific guidance in NICE 45

Primary care - Predict: Prediction of Mental Disorders At first contact with services in the antenatal and postnatal period, predict those at increased risk. Ask about : Past or present severe mental illness (Schiz’a, Bipolar, Postnatal Psychosis, Severe Depression) Previous treatment by psychiatrist/specialist mental health team Family history of perinatal mental illness Audit of records at booking appointment w GP/MW SIGN: PH Postpartum psychosis or Bipolar: Refer.

Detect: Detection of Depression Use the ‘Whooley’ questions at first contact with primary care, at the booking visit, and postnatally (4-6wk & 3-4mths) Positive screening? At risk? Concern? Used Edinburgh Postnatal Depression scale (Consider GAD-7 for Anxiety) Other conditions? Psychosis? Identify possible depression PRESENTER NOTES A study by Whooley et al in 1997 indicated that two brief focused questions that address mood and interest are as likely to be as effective as more elaborate methods for identifying depression, and are more compatible with routine use in many primary and secondary care settings. The Whooley questions are given in the next slide. Self-report measures such as the Edinburgh Postnatal Depression Scale (EPDS), Hospital Anxiety and Depression Scale (HADS) or Public Health Questionnaire-9 (PHQ-9) may be used as part of the subsequent assessment of mental health status. The questions adopted will need to be considered in terms of the woman’s social and cultural context.

The ‘Whooley’ questions 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? Consider a third question: Is this something you feel you need or want help with? PRESENTER NOTES NICE recommendation 1.2.1.3 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 general practitioners) should ask two questions to identify possible depression (the Whooley questions): during the past month, have you often been bothered by feeling down, depressed or hopeless? during the last 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?

Subthreshold or Mild Symptoms Depression and/or anxiety that do not meet diagnostic criteria but significantly affect personal and social functioning: Previous depression or anxiety? 4–6 sessions of brief psychological treatment such as interpersonal therapy (IPT) or cognitive behavioural therapy (CBT) No previous depression or anxiety ? Social support e.g. regular informal individual or group-based support Psychological treatments Provide treatment within 1 month of initial assessment, where appropriate – risks/benefits of meds change so start earlier PRESENTER NOTES There is evidence to support the use of targeted psychosocial interventions for women who have symptoms of depression and/or anxiety which do not meet the threshold for a formal diagnosis. NICE Recommendation 1.4.1.1 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. NICE recommendation 1.3.1.1 For pregnant women who have symptoms of depression and/or anxiety which do not meet diagnostic criteria but which significantly interfere with personal and social functioning, healthcare professionals should consider the following: For those who have had a previous episode of depression or anxiety, the provision of individual brief psychological treatment (4-6 sessions), such as interpersonal psychotherapy (IPT) or cognitive behavioural therapy (CBT) For those who have not had a previous episode of depression or anxiety, offering social support during pregnancy and the postnatal period – this may consist of regular informal individual or group-based support

Treat: Management of Mild to Moderate Depression Pregnancy & Postnatal, consider: Self-help strategies Counselling (listening visits) Brief Cognitive Behavioural Therapy Interpersonal psychotherapy Moderate to severe? Balance risks & benefits of meds PRESENTER NOTES NICE recommendation 1.4.8.4 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 or interpersonal psychotherapy. The next recommendation is not a key priority for implementation, but suggests possible next steps in the pathway of care NICE recommendation 1.4.8.5 Antidepressant drugs should be considered for women with mild depression during pregnancy or the postnatal period if they have a history of severe depression and they decline, or their symptoms do not respond to, psychological treatments.

Treat: Prescribing antidepressants: Moderate-Severe Depression Tricyclics (TCAs) have lower known risks during pregnancy than other antidepressants. May be more dangerous if taken in overdose SSRIs taken after 20 weeks’ gestation may be associated with an increased risk of persistent pulmonary hypertension in the neonate Fluoxetine has lowest known risks during pregnancy vs other SSRIs 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, toxicity in overdose compared with other drugs and increased difficulty in withdrawal PRESENTER NOTES Care is need when prescribing psychotropic medication to any woman of childbearing potential even if they are not pregnant or planning a pregnancy. Women should understand the risks associated with becoming pregnant while taking psychotropic medication, together with the risks of having an untreated disorder and of stopping medication abruptly without discussion with their doctor. Prescribers should consider the issues raised in the slide when choosing an antidepressant for pregnant or breastfeeding women. The guideline also makes recommendations about the risks of other psychotropic drugs, namely benzodiazepines, antipsychotics, valproate, lithium, carbemazepine and lamotrigine. The key priority recommendation is as follows: NICE recommendation 1.4.3.2 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 amitryptilline, 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, nortryptiline 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 antidepressants, 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 1st Box left: TCAs include: amitriptyline imipramine and nortriptyline 2nd Box left: SSRI stands for selective serotonin reuptake inhibitor 3rd Box left: imipramine, nortriptyline and sertraline (an SSRI) have relatively low levels in breast milk.; fluoxetine and citalopram (both SSRIs) have relatively high levels 3rd Box right: withdrawal and toxicity are in most cases mild and self-limiting Most antidepressants pass into the breast milk. All antidepressants carry the risk of withdrawal or toxicity symptoms in neonates

Treat: Severe: Referral and initial care Severe mental illness suspected? (Schizophrenia or bipolar ). Refer to specialist mental health service If appropriate refer to a perinatal mental health service Ask about mental health at all subsequent contacts Current or past history of severe mental illness? Develop a written care plan: pregnancy, delivery and postnatal. Share the information Increase contact with mental health services Inpatient care for a mental disorder within 12 months of childbirth? Use a specialist mother and baby unit

Talking about postnatal mental health problems: MIND https://www.youtube.com/watch?v=w0aaM9XzwTA MIND – 3 women share their experiences (6 mins)

Treat: Mother and Baby Unit, Morpeth Purpose-built 6 bed unit; en-suite double bedrooms For women experiencing mental health problems at 34+ weeks pregnant or with babies </=12 months old Takes referrals via Psychiatry from northern region & beyond Homely atmosphere fosters bonding between mother & child Access to range of psychiatric treatments and services Partner & family encouraged to help care for mother & baby Address: Beadnell Ward, St George's Park, Morpeth, NE61 2NU. Telephone number: 01670 501869.

Severe Depression... can lead to tragedy Sept 2013, Swindon – The Daily Mail Wife of Army major threw herself to death in front of 100mph train 'while suffering severe post-natal depression‘ Emma Cadywould, 32y, University researcher, found it 'hard to cope' with six-month-old son Inquest heard she was supported by husband, Major Steve Cadywould Baby Harrison would wake 20 times a night Family say Emma had expressed suicidal thoughts but talked of 'normal domestic' matters on day of her death

Severe Depression ‘Since we lost Emma we have become aware of some astonishing and desperately sad statistics. In the UK, one mother a week will be totally overwhelmed by post natal depression and will tragically be lost to a loving family. Post-natal depression is a silent killer.’ Emma Cadywould’s sister NICE aims to predict, detect & treat mental illness in women like Emma Read more: http://www.dailymail.co.uk/news/article-2424496/Post-natal-depression-Wife-Army-major-threw-train.html#ixzz3lr5P4OO5

Postpartum Psychosis https://www.youtube.com/watch?v=BcaubXpQiFI BBC Newsnight special report: 25mins, for those who want to learn more

Organisation of care Provision of care in the most appropriate setting Appropriate communication about care with other services as required, taking into account confidentiality Choice NB Midwife shortages nationally; little GP input into maternity care – a challenge! Effective detection Effective assessment and referral to appropriate services Timely, appropriate management and treatment Accurate information about the disorder and the benefits and risks associated with interventions PRESENTER NOTES Perinatal mental health services The key function of any healthcare system is to place the patient’s needs central to the service. Services in perinatal mental health must also take into account the needs of fathers, partners, carers and other children in the family. A key principle in meeting the health needs of women in the perinatal period should be the delivery of a service which provides the most effective and accessible interventions in the least intrusive and disruptive manner. The guideline makes a recommendation related to service delivery which can inform the structuring of services locally according to the principles highlighted in this slide - see next slide.

Summary NICE CG45 Consider MH in all pregnant women or those planning a pregnancy: ask if they are Destigmatise , build trust and continuity of care Consider impact on partner and family Balance and discuss risks of MD & meds to mum/baby Primary care has a “window of opportunity” to recognise, support and treat MH problems: Ask at booking app, postnatal 6 wk check, and 3-4 months

Summary NICE CG45 Predict those at risk: PMH (maternity), severe MD Detect those affected: screening questions, be aware Treat: Psychological Rx if mild/subthreshold symptoms Meds if severe and risks<benefits. SSRI usually Urgent referral for those with severe MD eg psychosis Specialist & Perinatal services: involve them early

Revisiting the case examples Applying NICE CG45

Case 1 Liz 26 yrs, 2 weeks post-partum full term normal delivery Breast feeding her son Jack Supportive partner 5 year old daughter to previous partner PMH moderate depression aged 20. Treated w antidepressants, discontinued when pregnant Tearful, tired, poor appetite and sleep BPS Assessment? Issues? Predict? Detect? Treat?

Case 1 Liz Learning points Baby Blues’ – timing of symptoms vs depression Prediction of depression/ at risk: PMH is key Assessment and follow up Partner support, and impact on him ‘Listening visits’ from Health Visitor Antidepressants during pregnancy – when to stop?

Case 2 Kelly 27 yrs, 5 weeks postpartum full term normal delivery PMH mod postnatal depression after first son 3yr ago Weepy, tired, angry and low Tearful, agitated; no thought disorder, not suicidal Lack of support, husband works away, no family locally. Breast feeding BPS Assessment? Issues? Predict? Detect? Treat?

Case 2 Kelly Learning points Prediction of depression/ at risk mother? Detection of depression in postnatal period Treatments – psychological / medical Antidepressants in breastfeeding women Team working – who else to involve?

Case 3 Gillian 19 yrs, 7 months postpartum after NVD girl, Skye Dad’s mother concerned– couldn’t see her grandchild. PMH psychosis aged 17yrs, MH section Met Skye’s Dad in psychiatric inpatient unit Hallucinations, paranoia Gillian’s mother obstructive? Mental health issues BPS Assessment? Issues? Predict? Detect? Treat?

Case 3 Gillian Learning points Role of extended family and impact of relationships / FH mental illness Serious mental illness – prediction, vigilance, Referral to secondary care Mother and Baby (perinatal mental health) Unit Confidentiality vs best interests & capacity Child protection issues

Resources www.patient.co.uk www.nice.org.uk http://www.nice.org.uk/nicemedia/live/11004/30432/30432.pdf SIGN 127, March 2012 ‘Management of perinatal mood disorders’ http://sign.ac.uk/pdf/PAT127.pdf http://www.rcgp-curriculum.org.uk/PDF/curr_13_Mental_Health.pdf http://www.rcpsych.ac.uk/quality/quality,accreditationaudit/perinatalqualitynetwork.aspx http://www.sign.ac.uk/pdf/PAT127.pdf - Patient booklet: Mood disorders during pregnancy and after the birth of your baby http://www.pandasfoundation.org.uk/help-and-information/support-services/mother-and-baby-unit/beadnell-ward-morpeth.html http://apni.org/ Association for Post Natal Illness