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

2. 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)

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

11. 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?

12. 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?

13. 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?

14. Talking about depression in the postnatal period
- A Perinatal Psychiatrist & several women share perspectives

15. 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

16. 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

18. 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 -

19. 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

20. 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’

21. 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

22. 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

24. 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

25. 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
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).

26. 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

27. 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 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

28. 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.

29. 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.

30. 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?

31. 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
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

32. 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
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.

33. 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
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

34. 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

35. Talking about postnatal mental health problems: MIND
MIND – 3 women share their experiences (6 mins)

36. 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:

37. 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

38. 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:

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

40. 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.

41. 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

42. 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

43. Revisiting the case examples Applying NICE CG45

44. 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?

45. 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?

46. 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?

47. 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?

48. 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?

49. 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

50. Resources www.patient.co.uk www.nice.org.uk
SIGN 127, March 2012 ‘Management of perinatal mood disorders’
- Patient booklet: Mood disorders during pregnancy and after the birth of your baby
Association for Post Natal Illness