1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

Terms used in this guideline

Anxiety disorders These include generalised anxiety disorder, panic disorder, obsessive‑compulsive disorder, phobias, post‑traumatic stress disorder and social anxiety disorder.

Baby refers to an infant aged between 0 and 12 months.

High‑intensity intervention A formal psychological intervention usually delivered face to face (either in a group or individually) by a qualified therapist who has specific training in the delivery of the intervention.

Low‑intensity intervention A psychological or psychosocial intervention delivered by a trained coach or facilitator (rather than a therapist) to enable use of self‑help materials.

Postnatal period This is defined in this guideline as up to 1 year after childbirth.

Postpartum psychosis Psychosis often with mania and/or depressive symptoms in the immediate postnatal period, which can become very severe extremely quickly.

Psychotropic medication This is defined in this guideline as all medication used to treat mental health problems.

Severe mental illness This is defined in this guideline as severe and incapacitating depression, psychosis, schizophrenia, bipolar disorder, schizoaffective disorder and postpartum psychosis.

Traumatic birth includes births, whether preterm or full term, which are physically traumatic (for example, instrumental or assisted deliveries or emergency caesarean sections, severe perineal tears, postpartum haemorrhage) and births that are experienced as traumatic, even when the delivery is obstetrically straightforward.

Valproate Refers to 3 formulations of valproate available in the UK: sodium valproate and valproic acid (licensed for the treatment of epilepsy) and semi‑sodium valproate (licensed for the treatment of acute mania and continuation treatment in people whose mania responds to treatment). Both semi‑sodium and sodium valproate are metabolised to valproic acid (also known as valproate), which is the pharmacologically active component.

Woman/women refer(s) to female(s) of childbearing potential, including girls and young women under 18 years.

1.1 Using this guideline in conjunction with other NICE guidelines

Improving the experience of care

1.1.1 Use this guideline in conjunction with the guidance on service user experience in adult mental health (NICE guideline CG136) and patient experience in adult NHS services (NICE guideline CG138) to improve the experience of care for women with a mental health problem in pregnancy or the postnatal period. [new 2014]

Assessment and treatment in pregnancy and the postnatal period

1.1.2 Use this guideline in conjunction with the NICE guideline for a specific mental health problem (see our web pages on pregnancy and mental health and wellbeing) to inform assessment and treatment decisions in pregnancy and the postnatal period, and take into account:

  • any variations in the nature and presentation of the mental health problem in pregnancy or the postnatal period

  • the setting for assessment and treatment (for example, primary or secondary care services or in the community, the home or remotely by phone or computer)

  • recommendations 1.6.1 to 1.6.6 in this guideline on assessment in pregnancy and the postnatal period

  • recommendations 1.4.10 to 1.4.37 in this guideline on starting, using and stopping treatment in pregnancy and the postnatal period

  • recommendations 1.8.1 to 1.8.23 in this guideline on treating specific mental health problems in pregnancy and the postnatal period. [new 2014]

1.2 Considerations for women of childbearing potential

1.2.1 Discuss with all women of childbearing potential who have a new, existing or past mental health problem:

  • the use of contraception and any plans for a pregnancy

  • how pregnancy and childbirth might affect a mental health problem, including the risk of relapse

  • how a mental health problem and its treatment might affect the woman, the fetus and baby

  • how a mental health problem and its treatment might affect parenting. [new 2014]

1.2.2 When prescribing psychotropic medication for women of childbearing potential, take account of the latest data on the risks to the fetus and baby. [new 2014]

1.2.3 Do not offer valproate for acute or long‑term treatment of a mental health problem in women of childbearing potential. [new 2014]

1.3 Principles of care in pregnancy and the postnatal period

Supporting women and their partners, families and carers

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

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

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

  • be familiar with local and national guidelines on confidentiality and the rights of the child

  • be aware of the recommendations in section 1.4 of the guideline on pregnancy and complex social factors (NICE guideline CG110)

  • ensure continuity of care for the mental health problem if care is transferred from adolescent to adult services. [new 2014]

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

  • the welfare of the baby and other dependent children and adults

  • the role of the partner, family or carer in providing support

  • the potential effect of any mental health problem on the woman's relationship with her partner, family or carer. [new 2014]

Coordinated care

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

  • the care and treatment for the mental health problem

  • the roles of all healthcare professionals, including who is responsible for:

    • coordinating the integrated care plan

    • the schedule of monitoring

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

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

  • everyone involved in a woman's care is aware of their responsibilities

  • there is effective sharing of information with all services involved and with the woman herself

  • mental health (including mental wellbeing) is taken into account as part of all care plans

  • all interventions for mental health problems are delivered in a timely manner, taking into account the stage of the pregnancy or age of the baby. [new 2014]

1.4 Treatment decisions, advice and monitoring for women who are planning a pregnancy, pregnant or in the postnatal period

Information and advice

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

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

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

  • the potential benefits of psychological interventions and psychotropic medication

  • the possible consequences of no treatment

  • the possible harms associated with treatment

  • what might happen if treatment is changed or stopped, particularly if psychotropic medication is stopped abruptly. [new 2014]

1.4.4 Discuss breastfeeding with all women who may need to take psychotropic medication in pregnancy or in the postnatal period. Explain to them the benefits of breastfeeding, the potential risks associated with taking psychotropic medication when breastfeeding and with stopping some medications in order to breastfeed. Discuss treatment options that would enable a woman to breastfeed if she wishes and support women who choose not to breastfeed. [new 2014]

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

1.4.6 Mental health professionals providing detailed advice about the possible risks of mental health problems or the benefits and harms of treatment in pregnancy and the postnatal period should include discussion of the following, depending on individual circumstances:

  • the uncertainty about the benefits, risks and harms of treatments for mental health problems in pregnancy and the postnatal period

  • the likely benefits of each treatment, taking into account the severity of the mental health problem

  • the woman's response to any previous treatment

  • the background risk of harm to the woman and the fetus or baby associated with the mental health problem and the risk to mental health and parenting associated with no treatment

  • the possibility of the sudden onset of symptoms of mental health problems in pregnancy and the postnatal period, particularly in the first few weeks after childbirth (for example, in bipolar disorder)

  • the risks or harms to the woman and the fetus or baby associated with each treatment option

  • the need for prompt treatment because of the potential effect of an untreated mental health problem on the fetus or baby

  • the risk or harms to the woman and the fetus or baby associated with stopping or changing a treatment. [new 2014]

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

  • acknowledge the woman's central role in reaching a decision about her treatment and that the role of the professional is to inform that decision with balanced and up‑to‑date information and advice

  • use absolute values based on a common denominator (that is, numbers out of 100 or 1000)

  • acknowledge and describe, if possible, the uncertainty around any estimate of risk, harm or benefit

  • use high‑quality decision aids in a variety of numerical and pictorial formats that focus on a personalised view of the risks and benefits, in line with the guidance on patient experience in adult NHS services (NICE guideline CG138)

  • consider providing records of the consultation, in a variety of visual, verbal or audio formats. [new 2014]

Monitoring and increased contact

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

  • assess the level of contact and support needed by women with a mental health problem (current or past) and those at risk of developing one

  • agree the level of contact and support with each woman, including those who are not having treatment for a mental health problem

  • monitor regularly for symptoms throughout pregnancy and the postnatal period, particularly in the first few weeks after childbirth. [new 2014]

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

Starting, using and stopping treatment

General advice

1.4.10 Before starting any treatment in pregnancy and the postnatal period, discuss with the woman the higher threshold for pharmacological interventions arising from the changing risk‑benefit ratio for psychotropic medication at this time and the likely benefits of a psychological intervention. [new 2014]

1.4.11 If the optimal treatment for a woman with a mental health problem is psychotropic medication combined with a psychological intervention, but she declines or stops taking psychotropic medication in pregnancy or the postnatal period, ensure that:

  • she is adequately supported and

  • has the opportunity to discuss the risk associated with stopping psychotropic medication and

  • is offered, or can continue with, a psychological intervention. [new 2014]

1.4.12 When psychotropic medication is started in pregnancy and the postnatal period, consider seeking advice, preferably from a specialist in perinatal mental health, and:

  • choose the drug with the lowest risk profile for the woman, fetus and baby, taking into account a woman's previous response to medication

  • use the lowest effective dose (this is particularly important when the risks of adverse effects to the woman, fetus and baby may be dose related), but note that sub‑therapeutic doses may also expose the fetus to risks and not treat the mental health problem effectively

  • use a single drug, if possible, in preference to 2 or more drugs

  • take into account that dosages may need to be adjusted in pregnancy. [2014]

1.4.13 When a woman with severe mental illness decides to stop psychotropic medication in pregnancy and the postnatal period, discuss with her:

  • her reasons for doing so

  • the possibility of:

    • restarting the medication

    • switching to other medication

    • having a psychological intervention

  • increasing the level of monitoring and support.

    Ensure she knows about any risks to herself, the fetus or baby when stopping medication. [new 2014]

1.4.14 When a woman with depression or an anxiety disorder decides to stop taking psychotropic medication in pregnancy and the postnatal period, discuss with her:

  • her reasons for doing so

  • the possibility of:

    • having a psychological intervention

    • restarting the medication if the depression or anxiety disorder is or has been severe and there has been a previous good response to treatment

    • switching to other medication

  • increasing the level of monitoring and support while she is not taking any medication.

    Ensure she knows about any risks to herself, the fetus or baby when stopping medication. [new 2014]

1.4.15 If a pregnant woman has taken psychotropic medication with known teratogenic risk at any time in the first trimester:

  • confirm the pregnancy as soon as possible

  • explain that stopping or switching the medication after pregnancy is confirmed may not remove the risk of fetal malformations

  • offer screening for fetal abnormalities and counselling about continuing the pregnancy

  • explain the need for additional monitoring and the risks to the fetus if she continues to take the medication.

    Seek advice from a specialist if there is uncertainty about the risks associated with specific drugs. [new 2014]

TCAs, SSRIs, (S)NRIs

1.4.16 When choosing a tricyclic antidepressant (TCA), selective serotonin reuptake inhibitor (SSRI) or (serotonin‑) noradrenaline reuptake inhibitor [(S)NRI][3], take into account:

  • the woman's previous response to these drugs

  • the stage of pregnancy

  • what is known about the reproductive safety of these drugs (for example, the risk of fetal cardiac abnormalities and persistent pulmonary hypertension in the newborn baby)

  • the uncertainty about whether any increased risk to the fetus and other problems for the woman or baby can be attributed directly to these drugs or may be caused by other factors

  • the risk of discontinuation symptoms in the woman and neonatal adaptation syndrome in the baby with most TCAs, SSRIs and (S)NRIs, in particular paroxetine and venlafaxine. [new 2014]

1.4.17 When assessing the risks and benefits of TCAs, SSRIs or (S)NRIs[3] for a woman who is considering breastfeeding, take into account:

  • the benefits of breastfeeding for the woman and baby

  • the uncertainty about the safety of these drugs for the breastfeeding baby

  • the risks associated with switching from or stopping a previously effective medication.

    Seek advice from a specialist (preferably from a specialist perinatal mental health service) if there is uncertainty about specific drugs. [new 2014]

Benzodiazepines

1.4.18 Do not offer benzodiazepines to women in pregnancy and the postnatal period except for the short‑term treatment of severe anxiety and agitation. [2014]

1.4.19 Consider gradually stopping benzodiazepines in women who are planning a pregnancy, pregnant or considering breastfeeding. [2014]

Antipsychotic medication

1.4.20 When assessing the risks and benefits of antipsychotic medication[4] for a pregnant woman, take into account risk factors for gestational diabetes and excessive weight gain. [new 2014]

1.4.21 When choosing an antipsychotic, take into account that there are limited data on the safety of these drugs in pregnancy and the postnatal period. [new 2014]

1.4.22 Measure prolactin levels in women who are taking prolactin‑raising antipsychotic medication and planning a pregnancy, because raised prolactin levels reduce the chances of conception. If prolactin levels are raised, consider a prolactin‑sparing antipsychotic. [2014]

1.4.23 If a pregnant woman is stable on an antipsychotic and likely to relapse without medication, advise her to continue the antipsychotic. [new 2014]

1.4.24 Advise pregnant women taking antipsychotic medication about diet and monitor for excessive weight gain, in line with the guideline on weight management before, during and after pregnancy (NICE guideline PH27). [new 2014]

1.4.25 Monitor for gestational diabetes in pregnant women taking antipsychotic medication in line with the NICE guideline on diabetes in pregnancy and offer an oral glucose tolerance test. [new 2014]

1.4.26 Do not offer depot antipsychotics to a woman who is planning a pregnancy, pregnant or considering breastfeeding, unless she is responding well to a depot and has a previous history of non‑adherence with oral medication. [new 2014]

Anticonvulsants for mental health problems (valproate, carbamazepine and lamotrigine)

1.4.27 Do not offer valproate for acute or long‑term treatment of a mental health problem in women who are planning a pregnancy, pregnant or considering breastfeeding. [new 2014]

1.4.28 If a woman is already taking valproate and is planning a pregnancy, advise her to gradually stop the drug because of the risk of fetal malformations and adverse neurodevelopment outcomes after any exposure in pregnancy. [2014]

1.4.29 If a woman is already taking valproate and becomes pregnant, stop the drug because of the risk of fetal malformations and adverse neurodevelopmental outcomes. [2014]

1.4.30 Do not offer carbamazepine to treat a mental health problem in women who are planning a pregnancy, pregnant or considering breastfeeding. [new 2014]

1.4.31 If a woman is already taking carbamazepine and is planning a pregnancy or becomes pregnant, discuss with the woman the possibility of stopping the drug (because of the risk of adverse drug interactions and fetal malformations). [new 2014]

1.4.32 If a woman is taking lamotrigine[5] during pregnancy, check lamotrigine levels frequently during pregnancy and into the postnatal period because they vary substantially at these times. [new 2014]

Lithium

1.4.33 Do not offer lithium[6] to women who are planning a pregnancy or pregnant, unless antipsychotic medication has not been effective. [new 2014]

1.4.34 If antipsychotic medication has not been effective and lithium is offered to a woman who is planning a pregnancy or pregnant, ensure:

  • the woman knows that there is a risk of fetal heart malformations when lithium is taken in the first trimester, but the size of the risk is uncertain

  • the woman knows that lithium levels may be high in breast milk with a risk of toxicity for the baby

  • lithium levels are monitored more frequently throughout pregnancy and the postnatal period. [new 2014]

1.4.35 If a woman taking lithium becomes pregnant, consider stopping the drug gradually over 4 weeks if she is well. Explain to her that:

  • stopping medication may not remove the risk of fetal heart malformations

  • there is a risk of relapse, particularly in the postnatal period, if she has bipolar disorder. [2014]

1.4.36 If a woman taking lithium becomes pregnant and is not well or is at high risk of relapse, consider:

  • switching gradually to an antipsychotic or

  • stopping lithium and restarting it in the second trimester (if the woman is not planning to breastfeed and her symptoms have responded better to lithium than to other drugs in the past) or

  • continuing with lithium if she is at high risk of relapse and an antipsychotic is unlikely to be effective. [new 2014]

1.4.37 If a woman continues taking lithium during pregnancy:

  • check plasma lithium levels every 4 weeks, then weekly from the 36th week

  • adjust the dose to keep plasma lithium levels in the woman's therapeutic range

  • ensure the woman maintains an adequate fluid balance

  • ensure the woman gives birth in hospital

  • ensure monitoring by the obstetric team when labour starts, including checking plasma lithium levels and fluid balance because of the risk of dehydration and lithium toxicity

  • stop lithium during labour and check plasma lithium levels 12 hours after her last dose. [2014]

1.5 Recognising mental health problems in pregnancy and the postnatal period and referral

1.5.1 Recognise that women who have a mental health problem (or are worried that they might have) may be:

  • unwilling to disclose or discuss their problem because of fear of stigma, negative perceptions of them as a mother or fear that their baby might be taken into care

  • reluctant to engage, or have difficulty in engaging, in treatment because of avoidance associated with their mental health problem or dependence on alcohol or drugs. [new 2014]

1.5.2 All healthcare professionals referring a woman to a maternity service should ensure that communications with that service (including those relating to initial referral) share information on any past and present mental health problem. [2014]

Depression and anxiety disorders

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

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

  • During the past month, have you often been bothered by feeling down, depressed or hopeless?

  • During the past month, have you often been bothered by having little interest or pleasure in doing things?

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

  • Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?[7]

  • Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?[7][new 2014]

1.5.5 If a woman responds positively to either of the depression identification questions in recommendation 1.5.4, is at risk of developing a mental health problem, or there is clinical concern, consider:

  • using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ‑9) as part of a full assessment or

  • referring the woman to her GP or, if a severe mental health problem is suspected, to a mental health professional. [new 2014]

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

  • using the GAD‑7 scale for further assessment or

  • referring the woman to her GP or, if a severe mental health problem is suspected, to a mental health professional. [new 2014]

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

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

    If she responds positively, consider:

  • using the GAD‑7 scale for further assessment or

  • referring the woman to her GP or, if a severe mental health problem is suspected, to a mental health professional. [new 2014]

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

  • asking the 2 depression identification questions and the GAD‑2 (see recommendation 1.5.4) as part of a general discussion about her mental health and wellbeing and

  • using the EPDS or the PHQ‑9 as part of monitoring. [new 2014]

Severe mental illness

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

  • any past or present severe mental illness

  • past or present treatment by a specialist mental health service, including inpatient care

  • any severe perinatal mental illness in a first‑degree relative (mother, sister or daughter). [2014]

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

  • have or are suspected to have severe mental illness

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

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

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

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

Alcohol and drug misuse

1.5.13 If alcohol misuse is suspected, use the Alcohol Use Disorders Identification Test (AUDIT) as an identification tool in line with recommendation 1.2.1.4 of the guideline on alcohol-use disorders (NICE guideline CG115). [new 2014]

1.5.14 If drug misuse is suspected, follow the recommendations on identification and assessment in section 1.2 of the guideline on drug misuse – psychosocial interventions (NICE guideline CG51). [new 2014]

1.6 Assessment and care planning in pregnancy and the postnatal period

1.6.1 Assessment and diagnosis of a suspected mental health problem in pregnancy and the postnatal period should include:

  • history of any mental health problem, including in pregnancy or the postnatal period

  • physical wellbeing (including weight, smoking, nutrition and activity level) and history of any physical health problem

  • alcohol and drug misuse

  • the woman's attitude towards the pregnancy, including denial of pregnancy

  • the woman's experience of pregnancy and any problems experienced by her, the fetus or the baby

  • the mother–baby relationship

  • any past or present treatment for a mental health problem, and response to any treatment

  • social networks and quality of interpersonal relationships

  • living conditions and social isolation

  • family history (first‑degree relative) of mental health problems

  • domestic violence and abuse, sexual abuse, trauma or childhood maltreatment

  • housing, employment, economic and immigration status

  • responsibilities as a carer for other children and young people or other adults. [new 2014]

1.6.2 When assessing or treating a mental health problem in pregnancy or the postnatal period, take account of any learning disabilities or acquired cognitive impairments, and assess the need to consult with a specialist when developing care plans. [new 2014]

1.6.3 Carry out a risk assessment in conjunction with the woman and, if she agrees, her partner, family or carer. Focus on areas that are likely to present possible risk such as self‑neglect, self‑harm, suicidal thoughts and intent, risks to others (including the baby), smoking, drug or alcohol misuse and domestic violence and abuse. [new 2014]

1.6.4 If there is a risk of, or there are concerns about, suspected child maltreatment, follow local safeguarding protocols. [new 2014]

1.6.5 If there is a risk of self‑harm or suicide:

  • assess whether the woman has adequate social support and is aware of sources of help

  • arrange help appropriate to the level of risk

  • inform all relevant healthcare professionals (including the GP and those identified in the care plan [see recommendation 1.6.6])

  • advise the woman, and her partner, family or carer, to seek further help if the situation deteriorates. [new 2014]

1.6.6 Professionals in secondary mental health services, including specialist perinatal mental health services, should develop a written care plan in collaboration with a woman who has or has had a severe mental illness. If she agrees, her partner, family or carer should also be involved. The plan should cover pregnancy, childbirth and the postnatal period (including the potential impact of the illness on the baby) and should include:

  • a clear statement of jointly agreed treatment goals and how outcomes will be routinely monitored

  • increased contact with and referral to specialist perinatal mental health services

  • the names and contact details of key professionals.

    The care plan should be recorded in all versions of the woman's notes (her own records and maternity, primary care and mental health notes) and a copy given to the woman and all involved professionals. [new 2014]

1.7 Providing interventions in pregnancy and the postnatal period

1.7.1 All healthcare professionals providing assessment and interventions for mental health problems in pregnancy and the postnatal period should understand the variations in their presentation and course at these times, how these variations affect treatment, and the context in which they are assessed and treated (for example, maternity services, health visiting and mental health services). [new 2014]

1.7.2 All interventions for mental health problems in pregnancy and the postnatal period should be delivered by competent practitioners. Psychological and psychosocial interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions practitioners should:

  • receive regular high‑quality supervision

  • use routine outcome measures and ensure that the woman is involved in reviewing the efficacy of the treatment

  • engage in monitoring and evaluation of treatment adherence and practitioner competence – for example, by using video and audio tapes, and external audit and scrutiny where appropriate. [new 2014][8]

1.7.3 When a woman with a known or suspected mental health problem is referred in pregnancy or the postnatal period, assess for treatment within 2 weeks of referral and provide psychological interventions within 1 month of initial assessment. [new 2014]

1.7.4 When offering psychotropic medication during pregnancy and the postnatal period, follow the principles in recommendations 1.4.10 to 1.4.37. [new 2014]

1.7.5 Provide interventions for mental health problems in pregnancy and the postnatal period within a stepped‑care model of service delivery in line with recommendation 1.5.1.3 of the guideline on common mental health disorders (NICE guideline CG123). [new 2014]

1.8 Treating specific mental health problems in pregnancy and the postnatal period

Interventions for depression

1.8.1 For a woman with persistent subthreshold depressive symptoms, or mild to moderate depression, in pregnancy or the postnatal period, consider facilitated self‑help (delivered as described in recommendation 1.4.2.2 of the guideline on depression in adults [NICE guideline CG90]). [new 2014]

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

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

  • a high‑intensity psychological intervention (for example, CBT)

  • a TCA, SSRI or (S)NRI if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and:

    • she has expressed a preference for medication or

    • she declines psychological interventions or

    • her symptoms have not responded to psychological interventions

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

1.8.4 If a woman who is taking a TCA, SSRI or (S)NRI for mild to moderate depression becomes pregnant, discuss stopping the medication gradually and consider facilitated self‑help (delivered as described in recommendation 1.4.2.2 of the guideline on depression in adults [NICE guideline CG90]). [new 2014]

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

  • switching to a high‑intensity psychological intervention (for example, CBT)

  • changing medication if there is a drug that is effective for her with a lower risk of adverse effects. [new 2014]

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

  • continuing with the current medication

  • changing medication if there is a drug that is effective for her with a lower risk of adverse effects

  • combining medication with a high‑intensity psychological intervention (for example, CBT)

  • switching to a high‑intensity psychological intervention (for example, CBT) if she decides to stop taking medication. [new 2014]

Interventions for anxiety disorders

1.8.7 For a woman with tokophobia (an extreme fear of childbirth), offer an opportunity to discuss her fears with a healthcare professional with expertise in providing perinatal mental health support in line with section 1.2.9 of the guideline on caesarean section (NICE guideline CG132). [new 2014]

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

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

  • only high‑intensity psychological interventions are recommended for post‑traumatic stress disorder

  • high‑intensity psychological interventions are recommended for the initial treatment of social anxiety disorder

  • progress should be closely monitored and a high‑intensity psychological intervention offered within 2 weeks if symptoms have not improved. [new 2014]

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

  • stopping the medication gradually and switching to a high‑intensity psychological intervention (for example, CBT)

  • continuing with medication if she understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and:

    • has expressed a preference for medication or

    • declines psychological interventions or

    • her symptoms have not responded to psychological interventions

  • changing medication if there is a drug that is effective for her with a lower risk of adverse effects

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

Psychological interventions for eating disorders

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

  • offer a psychological intervention in line with the guideline on eating disorders (NICE guideline CG9)

  • monitor the woman's condition carefully throughout pregnancy and the postnatal period

  • assess the need for fetal growth scans

  • discuss the importance of healthy eating during pregnancy and the postnatal period in line with the guideline on maternal and child nutrition (NICE guideline PH11)

  • advise her about feeding the baby in line with the guideline on maternal and child nutrition (NICE guideline PH11) and support her with this. [new 2014]

Interventions for alcohol and drug misuse

1.8.12 If hazardous drug or alcohol misuse is identified in pregnancy or the postnatal period, refer or offer brief interventions in line with section 1.3.1 of the guideline on drug misuse - psychosocial interventions (NICE guideline CG51) or the guideline on alcohol-use disorders: preventing harmful drinking (NICE guideline PH24). [new 2014]

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

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

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

Interventions for severe mental illness

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

  • CBT, IPT and behavioural couples therapy for bipolar depression

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

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

1.8.18 Consider psychological interventions (CBT or family intervention) delivered as described in section 1.3.7 of the guideline on psychosis and schizophrenia in adults (NICE guideline CG178) for a woman with psychosis or schizophrenia who becomes pregnant and is at risk of relapse arising from:

  • stress associated with pregnancy or the postnatal period

  • a change in medication, including stopping antipsychotic medication. [new 2014]

1.8.19 Offer an antipsychotic in line with recommendations 1.5.3 and 1.5.4 of the guideline on bipolar disorder (NICE guideline CG185) as prophylactic medication if a woman with bipolar disorder:

  • becomes pregnant and is stopping lithium, or

  • plans to breastfeed. [new 2014]

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

  • check the dose of the prophylactic medication and adherence

  • increase the dose if the prophylactic medication is an antipsychotic

  • suggest changing to an antipsychotic if she is taking another type of prophylactic medication

  • consider lithium if there is no response to an increase in dose or change of drug and the woman has severe mania

  • consider electroconvulsive therapy (ECT) if there has been no response to lithium. [new 2014]

Interventions for sleep problems

1.8.21 Advise pregnant women who have a sleep problem about sleep hygiene (including having a healthy bedtime routine, avoiding caffeine and reducing activity before sleep). For women with a severe or chronic sleep problem, consider promethazine[9]. [new 2014]

Electroconvulsive therapy

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

Rapid tranquillisation

1.8.23 A pregnant woman requiring rapid tranquillisation should be treated according to the NICE clinical guidelines on the short‑term management of disturbed/violent behaviour, schizophrenia and bipolar disorder (see our web pages on mental health and wellbeing for details), except that:

  • she should not be secluded after rapid tranquillisation

  • restraint procedures should be adapted to avoid possible harm to the fetus

  • when choosing an agent for rapid tranquillisation in a pregnant woman, an antipsychotic or a benzodiazepine with a short half‑life should be considered; if an antipsychotic is used, it should be at the minimum effective dose because of neonatal extrapyramidal symptoms; if a benzodiazepine is used, the risks of floppy baby syndrome should be taken into account

  • during the perinatal period, the woman's care should be managed in close collaboration with a paediatrician and an anaesthetist. [2007]

1.9 Considerations for women and their babies in the postnatal period

Reviewing treatment for women with severe mental illness

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

Monitoring babies for effects of psychotropic medication taken in pregnancy

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

  • the variation in the onset of adverse effects of psychotropic medication

  • the need for further monitoring

  • the need to inform relevant healthcare professionals and the woman and her partner, family or carer of any further monitoring, particularly if the woman has been discharged early. [new 2014]

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

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

  • a full neonatal assessment for any congenital abnormalities or neonatal adaptation syndrome

  • continuing psychological treatment and support for the woman

  • monitoring of the baby. [new 2014]

Traumatic birth, stillbirth and miscarriage

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

1.9.5 Offer women who have post‑traumatic stress disorder, which has resulted from a traumatic birth, miscarriage, stillbirth or neonatal death, a high‑intensity psychological intervention (trauma‑focused CBT or eye movement desensitisation and reprocessing [EMDR]) in line with the guideline on post-traumatic stress disorder (PTSD) (NICE guideline CG26). [new 2014]

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

1.9.7 Discuss with a woman whose baby is stillborn or dies soon after birth, and her partner and family, the option of 1 or more of the following:

  • seeing a photograph of the baby

  • having mementos of the baby

  • seeing the baby

  • holding the baby.

    This should be facilitated by an experienced practitioner and the woman and her partner and family should be offered a follow‑up appointment in primary or secondary care. If it is known that the baby has died in utero, this discussion should take place before the delivery, and continue after delivery if needed. [new 2014]

Psychotropic medication and breastfeeding

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

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

  • the limited data about the safety of these drugs and

  • the risks associated with switching from a previously effective medication.

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

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

  • the limited data on the safety of these drugs and

  • the level of antipsychotic medication in breast milk depends on the drug. [new 2014]

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

The mother–baby relationship

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

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

1.10 The organisation of services

1.10.1 Women who need inpatient care for a mental health problem within 12 months of childbirth should normally be admitted to a specialist mother and baby unit, unless there are specific reasons for not doing so. [2007]

1.10.2 Managers and senior healthcare professionals responsible for perinatal mental health services (including those working in maternity and primary care services) should ensure that:

  • there are clearly specified care pathways so that all primary and secondary healthcare professionals involved in the care of women during pregnancy and the postnatal period know how to access assessment and treatment

  • staff have supervision and training, covering mental health problems, assessment methods and referral routes, to allow them to follow the care pathways. [2007]

1.10.3 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 frameworks for mental health problems, to ensure effective transfer of information and continuity of care

  • pathways of care for service users, with defined roles and competencies for all professional groups involved. [2007]

1.10.4 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. [2007]

1.10.5 Specialist perinatal inpatient services should:

  • provide facilities designed specifically for mothers and babies (typically with 6‑12 beds)

  • be staffed by specialist perinatal mental health staff

  • be staffed to provide appropriate care for babies

  • 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. [2007]



[3] Although this use is common in UK clinical practice, at the time of publication (December 2014]), TCAs, SSRIs and (S)NRIs did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[4] Although this use is common in UK clinical practice, at the time of publication (December 2014]), antipsychotic medication did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[5] At the time of publication (December 2014), lamotrigine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[6] Although this use is common in UK clinical practice, at the time of publication (December 2014), lithium did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[7] An answer of 'Not at all' scores 0; 'Several days' scores 1; 'More than half the days' scores 2; 'Nearly every day' scores 3.

[8] Adapted from the guideline on depression in adults (NICE guideline CG90).

[9] At the time of publication (December 2014), promethazine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

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