2 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline.

2.1 Preventing postpartum psychosis

What methods can improve the identification of women at high risk of postpartum psychosis and reduce this risk?

Why this is important

Postpartum psychosis is a severe mental illness with a rapid onset and a major impact on the woman and her ability to care for her baby. It is associated with an increased risk of mortality in both the woman and her baby. Prophylactic treatment can be effective for women who are known to be at high risk, but for some women postpartum psychosis may be their first episode of severe mental illness. Better identification of women at high risk and a greater understanding of prophylactic and acute treatment would have a significant impact on maternal and child welfare, and on service costs.

The question should be addressed by a programme of research into the prevention, treatment and management of postpartum psychosis comprising:

  • The development of a tool for routine clinical use to improve the identification of women at high risk of developing postpartum psychosis. This should be tested in a prospective cohort study.

  • The development of a set of interventions intended to prevent the onset of postpartum psychosis and a method for their effective and efficient delivery.

  • The testing of the clinical and cost effectiveness of the interventions in a large scale randomised controlled trial.

  • The development and testing of a programme for the implementation of an effective strategy for preventing and identifying postpartum psychosis.

2.2 The safety of drugs for bipolar disorder in pregnancy and the postnatal period

How safe are drugs used to treat bipolar disorder in pregnancy and the postnatal period?

Why this is important

Drugs are effective for the acute treatment of bipolar disorder and for preventing relapse. All drugs used to treat mental health problems may carry some risk for the woman, fetus and baby. For some drugs such as sodium valproate these risks are well described, but the data are drawn from epilepsy case registers. For others such as lithium, the data are very limited. In addition, the prevalence of adverse outcomes for the woman, fetus or baby in untreated bipolar disorder is not well described.

The question should be addressed by establishing a long‑term register of women with bipolar disorder to provide data on:

  • the drugs used for treating bipolar disorder in pregnancy

  • the following outcomes (by drug type and for women who had no treatment for bipolar disorder in pregnancy):

    • maternal outcomes (for example, episodes of mood disorder in pregnancy and the postnatal period, miscarriage, preterm delivery)

    • congenital malformations (for example, spinal cord and cardiac malformation)

    • baby outcomes (for example, mortality, birthweight)

    • childhood outcomes (for example, cognitive development).

2.3 Psychological interventions focused on the mother‑baby relationship

Are interventions designed to improve the quality of the mother–baby relationship in the first year after childbirth effective in women with a diagnosed mental health problem?

Why this is important

Problems in the mother–baby relationship in the first year after childbirth may increase maternal mental health problems and are associated with a range of problems for the baby, including delayed cognitive and emotional development. A number of interventions are effective in improving the interaction between women and their babies, but it is not known if these are effective in women with a diagnosed mental health problem.

The question should be addressed in a randomised controlled trial comparing an intervention (proven to be effective in improving the quality of mother–baby interactions in women without a diagnosed mental health problem) against standard care. The trial should report the following outcomes, with a follow‑up period of at least 2 years:

  • the mental health of the woman

  • the emotional and cognitive development of the baby

  • the quality of the interaction.

    The trial should also examine the cost effectiveness of the intervention.

2.4 Structured clinical management for moderate to severe personality disorders in pregnancy and the postnatal period

Is structured clinical management for moderate to severe personality disorders in pregnancy and the postnatal period effective at improving outcomes for women and their babies?

Why this is important

Personality disorders are associated with poor engagement with maternity services and perinatal mental health services and this leads to poor mental and physical health outcomes for the woman, fetus and baby. The complex psychological interventions that are effective for treating personality disorder may present problems for engagement even in those motivated to seek treatment. Structured clinical management is a psychologically informed model of case management, which is effective for treating personality disorder and may have greater flexibility and capacity to engage women with personality disorder in pregnancy and the postnatal period.

The question should be addressed in a randomised controlled trial comparing structured clinical management of personality disorder in pregnancy and the postnatal period against standard care. The trial should report the following outcomes, with a follow‑up period of at least 2 years:

  • the mental and physical health of the woman

  • the physical health of the fetus

  • the mental and physical health of the baby

  • the quality of the mother–baby relationship.

The trial should also examine the cost effectiveness of the intervention.

2.5 Psychological interventions for moderate to severe anxiety disorders in pregnancy

Are psychological interventions effective for treating moderate to severe anxiety disorders (including obsessive‑compulsive disorder, panic disorder, post‑traumatic stress disorder and social anxiety disorder) in pregnancy?

Why this is important

Anxiety disorders are often not identified or treated in pregnancy. In addition, many women who are taking medication for such problems stop taking it when they are pregnant. The development of effective psychological interventions is therefore important. Although there are effective psychological interventions for anxiety disorders, there is limited evidence about their effectiveness in pregnancy and how these interventions might be adapted for use in pregnant women.

The question should be addressed by a programme of research evaluating psychological interventions (including individual and group approaches) for moderate to severe anxiety disorders in pregnancy, comprising:

  • a development programme to establish the adaptations to effective interventions (for example, mode of delivery, duration, content, and intensity of treatment) that are needed for use in pregnancy

  • the testing of the adapted interventions in a series of pilot studies

  • the testing of the clinical and cost effectiveness of the adapted interventions in large‑scale randomised controlled trials

  • the development and testing of a programme for the implementation of psychological interventions for moderate to severe anxiety disorders.

More information

You can also see this guideline in the NICE pathway on antenatal and postnatal mental health.

To find out what NICE has said on topics related to this guideline, see our web pages on pregnancy and mental health and wellbeing.

See also the guideline committee's discussion and the evidence reviews (in the full guideline), and information about how the guideline was developed, including details of the committee.

  • National Institute for Health and Care Excellence (NICE)