1. Antenatal and postnatal mental health
PRESENTER NOTES
You can add your own organisation’s logo alongside the NICE logo.
The clinical guideline implementation tools symbol found in the bottom right-hand corner of slides throughout this presentation is used to clearly differentiate between the implementation advice and the key priority recommendations from the guideline. Slides with the tools symbol highlight suggested actions that may be useful when implementing recommendations.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
February 2007
NICE clinical guideline 45

2. What this presentation covers
Context
The guideline recommendations
Key areas for implementation
Costs and savings
Further information and support
PRESENTER NOTES
This presentation covers the background to the NICE guideline on antenatal and postnatal mental health, the key recommendations and suggested actions to support their implementation.
There is information about the costs and savings that are likely to be incurred in implementing the guideline and about practical support tools that are available from NICE to support implementation.

3. Changing clinical practice
NICE guidelines are based on the best available evidence
The Department of Health asks NHS organisations to work towards implementing guidelines
Compliance with developmental standards will be monitored by the Healthcare Commission
PRESENTER NOTES
NICE clinical guidelines aim to ensure that the promotion of good health and patient care in the NHS are in line with the best available evidence of clinical effectiveness and cost effectiveness. Guidelines help healthcare professionals in their work, but they do not replace their knowledge and skills.
The Healthcare Commission assesses the performance of NHS organisations in meeting core and developmental standards set by the Department of Health in ‘Standards for better health’, published in July 2004 (updated in April 2006). The implementation of NICE clinical guidelines forms part of the developmental standard D2. Core standard C5 states that national agreed guidance should be taken into account when NHS organisations are planning and delivering care.

4. Need for this guideline
Risk of women with an existing disorder stopping medication abruptly
Increased risk of relapse and first presentation of bipolar disorder
More urgent intervention may be required
More rapid onset of postnatal psychotic disorders
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.

5. Need for this guideline
Psychological health is as important as physical health
Effects on the extended family
Appropriate use of psychotropic drugs in this context
Need for prompt and effective psychological interventions
PRESENTER NOTES
Psychological health is as important as physical health. Mental disorders in women will inevitably affect the health and functioning of fathers, partners, carers and children. They will also potentially affect their social economic situation.
During pregnancy the shifting risk/benefit ratio in the use of psychotropic drugs and the need for prioritising prompt and effective psychological interventions is important.

6. What the guideline covers
Prediction and detection
Management:
psychological treatments
psychotropic medication
risk discussion
Organisation of care and service delivery
PRESENTER NOTES
The guideline focuses on the mental healthcare of women with mental disorders who are pregnant or in their first postnatal year. The guideline also covers women with existing mental disorders who are planning a pregnancy.
Recommendations focus on prediction and detection, as well as treatment and management, and the configuration of services for this group.
The risks of psychotropic medication, including the teratogenic risks and the risks during breastfeeding, are also covered

7. Mental disorders during 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.
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 -

8. Prediction
At first contact with maternity services, ask specific questions about:
Past or present severe mental illness
Previous treatment by psychiatrist/specialist mental health team
Family history of perinatal mental illness
PRESENTER NOTES
NICE recommendation
At a woman’s initial contact with services in both the antenatal and postnatal periods, healthcare professionals (including midwives, obstetricians, health visitors and general practitioners) should ask specific 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
Healthcare professionals should note that other specific predictors, such as poor relationships with her partner, should not be used for the routine prediction of future illness.

9. Detection Identify possible depression
Use the ‘Whooley’ questions at first contact with primary care, at the booking visit, and postnatally
Other self-report measures can be used as part of subsequent assessment
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.

10. 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
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?

11. Psychosocial treatments
provide treatment within 1 month of initial assessment
Subthreshold symptoms
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 such as regular informal individual or group-based support
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
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
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

12. Management of depression
Mild or moderate depression
Self-help strategies
Counselling (listening visits)
Brief cognitive behavioural therapy
Interpersonal psychotherapy
PRESENTER NOTES
NICE recommendation
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
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.

13. Explaining risks Absolute and relative risk 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
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
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).

14. Prescribing antidepressant medication
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 fewer known risks
during pregnancy than 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
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

15. Organisation of care 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
Provision of care in the most appropriate setting
Appropriate communication about care with other services as required, taking into account confidentiality
Choice
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.

16. Service delivery: perinatal mental health networks
Coordinating board
Specialist perinatal services in each locality providing direct services, consultation and advice
Access to specialist expert advice on psychotropic medication
Clear referral and management protocols
Clearly defined roles and competencies for all professional groups
Clearly defined pathways of care for service users
PRESENTER NOTES
NICE Recommendation
Clinical networks should be established for perinatal mental health services, managed by a coordinating board of healthcare professionals, commissioners, managers, and service users and carers. These networks should provide:
a specialist multidisciplinary perinatal service in each locality, which provides direct services, consultation and advice to maternity services, other mental health services and community services; in areas of high morbidity these services may be provided by separate specialist perinatal teams
access to specialist expert advice on the risks and benefits of psychotropic medication during pregnancy and breastfeeding
clear referral and management protocols for services across all levels of the existing stepped-care framework for mental disorders, to ensure effective transfer of information and continuity of care
pathways for service users, with defined roles and competencies for all professional groups involved.

17. Organisation of care: the stepped/tiered care model
Personnel
Service
Core functions
Psychiatrists, nurses,
nursery nurses,
psychologists
Specialist perinatal
mental health
services
Prevention, management
& treatment of moderate/severe
illness; specialist advice
and consultation to primary care
CMHT (psychiatrists,
psychologists, nurses
social workers)
Specialist mental
health services
Assessment; treatment;
referral to specialist services;
inpatient care
GPs, obstetricians,
psychological
therapists, PCMHWs
Primary care mental
health services
Assessment and
referral; treatment of
mild to moderate illness
PRESENTER NOTES
The full guideline describes the ‘stepped/tiered care’ approach which supports the function of the managed clinical network.
This slide demonstrates the kind of staff operating within each tier of the stepped care framework and the core functions that they should be responsible for.
Note: CMHT - Community Mental Health Trust
PCMHW – Primary care mental health worker
Throughout England and Wales, community mental health teams are being replaced by primary care liaison teams. Other teams such as crisis teams, and early intervention in psychosis teams may be relevant steps within such a model as well as Accident and Emergency departments and psychiatric out of hours teams. These will vary locally.
GPs, obstetricians,
midwives, health visitors,
practice nurses
General healthcare
services (maternity
and primary care)
Detection of history of
and current mental
illness; referral

18. Perinatal clinical network
Coordinating centre
Coordinate associated inpatient
units
Coordinating board
Network manager
Local specialist service provision
Protocol development and
monitoring
Specialist perinatal services
Local specialist provision
Managing admissions
Consultancy, training to 10 and 20 care
May be separate or part of specialist
mental health service
Specialist mental health services
Local service provision
Assessment and referral
Consultancy and advice
PRESENTER NOTES
This slide demonstrates the interactions across each of the services that may form part of a perinatal clinical network.
The costing template (see costing tools) has provided cost data for the establishment of a core team (coordinating centre) that consists of a clinical lead for eight sessions per month, a whole-time-equivalent manager and a whole-time-equivalent coordinator.
The cost of a session for a clinical lead in the core team of the perinatal network has been calculated using the mid point of the Consultant pay and allowances 2006 for consultants appointed on or after 31st October The cost of a session has been calculated as £246.50
Revenue investment will be needed to manage, administer and maintain the network. Examples of areas requiring investment include:
• board recruitment, membership and reimbursement of expenses
• general administration, including marketing of networks, venue hire for board meetings and day-to-day office expenses
• recruitment of the clinical lead, manager and coordinator; generally it is expected that a clinical lead will be required to work approximately 8 sessions per month leading the network.
Primary care services
Local service provision
Assessment and referral
Maternity services
Local service provision
Assessment and referral

19. Specialist perinatal inpatient services
Typically provide for a population of between 25,000 and 50,000 live births with 6–12 beds
Designed specifically for mothers and infants
Staffing appropriate to care for infants
Effective liaison with general medical and mental health services
Full range of therapeutic services
Closely integrated with community mental health services
PRESENTER NOTES
This slide demonstrates the core components of specialist perinatal inpatient services
The quality provision of specialist perinatal inpatient services may feature as part of the commissioning arrangements of the managed clinical network. They are presented here for information.
NICE recommendation Each managed perinatal mental health network should have designated specialist inpatient services and cover a population where there are between 25,000 and 50,000 live births a year, depending on the local psychiatric morbidity rates.
NICE recommendation : Specialist perinatal inpatient services should:
provide facilities designed specifically for mothers and infants (typically with 6–12 beds)
be staffed by specialist perinatal mental health staff
be staffed to provide appropriate care for infants
have effective liaison with general medical and mental health services
have available the full range of therapeutic services
be closely integrated with community-based mental health services to ensure continuity of care and minimum length of stay.
The structure of services in different parts of the country should be based on local factors, including the organisation of existing services, local demographics and geographical/access issues.
However, services need to be seen in terms of the core components, which can be adopted by any service and adapted to meet local needs in order to deliver integrated care.
NICE recommendation Women who needs inpatient care for a mental disorder within 12 months of childbirth should be admitted to a specialist mother and baby unit unless there are specific reasons for not doing so.
Consideration of the needs of the extended family in discussing risk and management will be important, for example when considering admission to an inpatient bed.
Following discussions with experts it is estimated that across England there is currently a shortage of between 60 and 80 inpatient beds suitable for mothers and baby. NICE have calculated the cost based on 70 additional beds, which are occupied for a full year.
The costing tool details the revenue cost for a specialist inpatient bed. Locally organisations will need to review the availability of services and an assessment as to whether capital investment will be required to meet the requirements of the recommendation and the guideline
The estimated cost of this recommendation nationally is £6.9 million. Please see the costing tool for more information about how this figure has been reached

20. Key areas for implementation
Coordination of service delivery
The competencies of the multidisciplinary team
• Promoting prediction and detection
• Effective communication
• Appropriate use of medication
PRESENTER NOTES
Five key focus areas have been identified based on the key priorities for implementation. Action in these areas will support the full implementation of the guideline over time.
It may be helpful to follow the steps contained within the document ‘How to implement NICE guidance’ when developing an action plan.
The next few slides discuss each focus area in turn, and highlight some generic actions which might be undertaken locally. The presenter notes for each slide area also suggest some specific actions for local discussion based on the individual recommendations.

21. Coordination of service delivery
Engage with local commissioning partners to commission and develop a managed clinical network for perinatal mental health provision
Develop clear pathways and protocols for referral and management to ensure effective care for women who need to access this service
Develop clearly defined roles and competencies for all professional groups involved in the care pathway
Review local provision of psychological therapies
PRESENTER NOTES
Suggested actions are:
undertake a baseline assessment which identifies existing service provision, skills and capacity, as well as data on the utilisation of inpatient services and specialist perinatal expertise locally
identify key partners with whom to develop and commission a network
work with partners to develop:
– clearly defined pathways of care for service users
– clearly defined roles and competencies for all professional groups involved in the care pathway
– clear referral and management protocols
review local provision and access to social support for women with no previous depression or anxiety
review provision of psychological therapies locally
build into review of psychological therapies a review of self-help strategies and listening visits available to women
review access to and provision of computerised cognitive behavioural therapy
review access to and referral for exercise

22. Competencies of the multidisciplinary team
Ensure effective risk discussion and use of screening questions by providing appropriate training
Ensure thorough knowledge of perinatal mental health issues and develop competencies
Invest in training to ensure sufficient local provision of CBT and IPT
PRESENTER NOTES
Suggested actions are:
review skills required for risk discussion, and where appropriate provide formal training
review provision of information which can support risk discussion. Ensure that this is in a format which can be personalised
Review training provision for all staff groups and ensure that all relevant staff have access to perinatal mental health education
Work with the multidisciplinary team to develop competencies
Review access to and provision of computerised cognitive behavioural therapy (CBT)
Review access to and provision of CBT and interpersonal psychotherapy (IPT) locally.

23. Promoting prediction and detection
Review use of tools used to detect depression
Review use of the Edinburgh Postnatal Depression Scale with practitioners
Incorporate key predictor questions (‘Whooley questions’) into clinical practice
PRESENTER NOTES
Suggested actions are:
Review maternity documentation questions regarding mental health
Incorporate prediction questions into initial booking documentation
Raise awareness of the ‘Whooley’ questions within primary care, maternity and health visiting services, and incorporate into relevant documentation
Develop and agree a referral pathway in line with responses to ‘Whooley’ questions
Ensure that other specific predictors, such as poor relationships with partner, are not used for the routine prediction of future illness
Review the use of self-report measures such as the Edinburgh Postnatal Depression Scale, HADS or PHQ-9 within the community. Use only as part of subsequent assessment of mental health status
Ensure mechanisms are in place to determine if a woman is experiencing interference with personal and social functioning
Review local provision of and access to social support for women with no previous history of depression or anxiety

24. Effective communication
Review communication processes across settings as part of developing perinatal network activity
Develop and agree communication pathways between service providers in line with developing perinatal network activity
Review competence in issues of consent and capacity in relation to adolescents
PRESENTER NOTES
Suggested actions are:
Ensure that the views of service users and their carers are represented in the developing network
Review communication mechanisms between professionals, the woman and her family to ensure that the negative impact of any mental disorder on the family is minimised
In relation to discussing risk and seeking consent to treatment for adolescents experiencing mental disorder, those professionals assessing children or adolescents for possible inpatient admission (tier4 CAMHS staff) should be specifically trained in issues of consent and capacity

25. Appropriate use of medication
Review local formularies in line with guideline recommendations related to antidepressant medication
Review local formularies in line with guideline recommendations related to other psychotropic medication
Work with local prescribers to raise awareness and promote effective prescribing practices
PRESENTER NOTES
Suggested actions are:
Review current prescribing policies and formularies
Consider prescribing mechanisms for all women of childbearing potential
Ensure that the risks associated with TCAs and SSRIs are highlighted appropriately to prescribers and patients
Consider using local reporting mechanisms, for example the ‘yellow card’ system for reporting suspected fetal anomaly where a woman has taken psychotropic medication during pregnancy
Consider developing a local reporting mechanism to collate information on adverse effects for woman and fetus/neonate where psychotropic medication has been taken by a woman during pregnancy

26. Costs and savings
Use NICE costing tools to identify recommendations with the greatest impact on resources:
interpersonal psychotherapy
cognitive behavioural therapy
managed clinical networks for the delivery of perinatal mental health services
PRESENTER NOTES
NICE have developed a costing template to identify local costs which focuses on the costs to providers related to the provision of IPT and CBT and the development of managed clinical networks for the delivery of perinatal mental health services.
For further information, please refer to the costing template for this guideline, which can be found at

27. Available from: www.nice.org.uk/CG045
Access tools online
Costing tools
costing report
costing template
Audit criteria
Implementation advice
Available from:
PRESENTER NOTES
NICE has developed tools to help organisations implement this guidance, which can be found on the NICE website.
Costing tools
− a costing report to estimate the national savings and costs associated with implementation
– a costing template to estimate the local costs and savings involved.
Implementation advice on how to put the guidance into practice and national initiatives which support this locally.
Audit criteria to monitor local practice.

28. Access the guideline online
Quick reference guide – a summary
NICE guideline – all of the recommendations
Full guideline – all of the evidence and rationale
‘Understanding NICE guidance’ – a plain English version
PRESENTER NOTES
The guideline is available in a number of formats. You can download them from the NICE website or order hard copies of the quick reference guide or ‘Understanding NICE guidance’ by calling the NHS Response Line on Quote reference numbers N1201 for the quick reference guide and N1202 for ‘Understanding NICE guidance’.
Please refer to the accompanying implementation advice for the policy context and useful links