How we made the decision
We check our guidelines regularly to ensure they remain up to date. We based the decision on surveillance 3 years after the publication of NICE's guideline on antenatal and postnatal mental health (NICE guideline CG192) in 2014.
For details of the process and update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.
We found 23 relevant studies in a search for randomised controlled trials and systematic reviews published between 1 April 2014 and 16 January 2017. We also included 6 relevant studies from a total of 37 identified by members of the guideline committee who originally worked on this guideline.
From all sources, we considered 29 studies to be relevant to the guideline.
We also checked for relevant ongoing research, which will be evaluated again at the next surveillance review of the guideline.
See appendix A: summary of evidence from surveillance for details of all evidence considered, and references.
We considered the views of topic experts, including those who helped to develop the guideline and other correspondence we have received since the publication of the guideline.
Stakeholders commented on the decision not to update the guideline. See appendix B for stakeholders' comments and our responses.
Twelve stakeholders responded to the consultation not to update the guideline with 11 stakeholders providing comments. Of the stakeholders who commented on the proposal not to update the guideline: 5 agreed with the decision, 5 disagreed with the decision and 1 provided no answer. Stakeholders who disagreed suggested that carbamazepine, lithium and valproate can be used with caution during breastfeeding that could impact on recommendation 1.9.8, which states: 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).
The comments were considered in detail. In terms of mental health conditions, valproate is only licensed for treating manic episodes in bipolar disorder when lithium is contraindicated or not tolerated. In developing the guideline, the committee was of the view that the evidence of significant harms (both congenital and neurodevelopmental) to the fetus associated with valproate was such that it should not be used in the acute or long-term treatment of a mental health problem in women of childbearing potential. This would also cover women that are breastfeeding.
During guideline development, evidence was also identified showing carbamazepine was associated with an increased rate of congenital harms, albeit not at the same level as valproate and not at a level that would preclude the use of carbamazepine in women of childbearing potential. However, the risk for harm associated with carbamazepine was greater than that observed for lamotrigine, and the committee recommended that carbamazepine is not offered for treating a mental health problem to women who are planning a pregnancy, pregnant or considering breastfeeding. No new evidence on valproate or carbamazepine use in women of childbearing potential or breastfeeding was identified through the surveillance review to change current guidance.
In terms of lithium, the British National Formulary states that lithium salts should be avoided when breastfeeding because of risk of toxicity in the infant. This information supports current recommendations.
A comment received through consultation suggested that NICE guideline CG192 should include recommendations on preventing postnatal post-traumatic stress disorder (PTSD), particularly through including information on what staff can do during labour to reduce the trauma to the woman. This is outside the scope of NICE guideline CG192, but is addressed by NICE's guideline on intrapartum care. An additional comment received through consultation asked NICE to consider postnatal PTSD separately from other kinds of PTSD. Neither NICE guideline CG192 nor the current surveillance review found evidence to support recommending postnatal-specific interventions for PTSD. Instead, NICE guideline CG192 recommends that women with PTSD that has resulted from a traumatic birth, miscarriage, stillbirth or neonatal death should be treated in line with NICE's guideline on PTSD. This area will be considered again at the next surveillance review of NICE guideline CG192.
See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.
Philip Alderson (until February 2017)
Consultant Clinical Adviser
Martin Allaby (from March 2017)
Consultant Clinical Adviser
The NICE project team would like to thank the topic experts who participated in the surveillance process.
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