Dr Moira Kennedy reviews the principles of prescribing medication for mental illness during the perinatal period, as recommended in the SIGN guideline
|SIGN Guideline 127 on Management of perinatal mood disorders has been awarded the NHS Evidence Accreditation Mark.
This Mark identifies the most robustly produced guidance available. See evidence.nhs.uk/accreditation for further details.
By definition, perinatal mood disorders occur from conception until the end of the first postnatal year, and encompass antenatal and postnatal depression, anxiety, and postpartum psychosis.1 Perinatal depression occurs at a critical time in the lives of the woman, the baby, and the family—without prompt treatment, it can affect the baby’s psychological, social, and educational development. 2
Generally, diagnosis of depression is often delayed because of the stigma and shame felt by patients.1 During the perinatal period, strong feelings of guilt may cause the woman to fear that her child might be taken from her care.1 Although depression cannot be prevented, identification of women at high risk and initiation of effective treatment at an earlier stage can help to reduce the adverse effects on the baby as well as the mother.
The SIGN guideline on Management of perinatal mood disorders (SIGN 127; www.sign.ac.uk/pdf/sign127.pdf) updates SIGN 60 on postnatal depression and puerperal psychosis. It provides recommendations based on current evidence for best practice in the management of antenatal and postnatal mood and anxiety disorders.1
Approximately 10%–15% of women who have recently had a baby have postnatal depression.3 Untreated postnatal depression is associated with detrimental effects on infant development.2 Mental illness is a significant factor in maternal mortality.4
Postpartum psychosis is a severe affective psychosis of sudden onset, which occurs early in the postnatal period—usually during the first month.1 Women are at higher risk of a postpartum psychotic episode if they:1,5–7
- have had a previous episode of:
- postpartum psychosis
- bipolar disorder
- have family history of affective psychosis.
A woman who has discontinued her mood stabiliser prophylaxis is at increased risk of relapse shortly after giving birth.1,7 Primiparity and delivery complications (e.g. breech, foetal distress, cord prolapse) have also been associated independently with an episode of postpartum psychosis.1,8
To identify women at risk of postpartum psychosis, all pregnant women should be asked if there is: a personal history of bipolar disorder, postpartum psychosis, or severe depressive disorder; or a family history of bipolar disorder or postpartum psychosis. Women regarded as being at high risk of postpartum psychosis should have a detailed plan in place by 32-weeks’ gestation. This plan should be agreed with the woman and her carers and be shared with all relevant healthcare professionals and should include:1
- psychiatric management for late pregnancy and the early postnatal period
- early warning signs
- who to contact if problems arise (including out of hours)
- decisions on medication management in late pregnancy, the immediate postnatal period, and during breastfeeding.
Women who have been treated with effective prophylaxis for psychotic disorder in the past, should have treatment reinstated after birth.1
Any significant change in a woman’s mental state during late pregnancy or the early postnatal period should prompt further urgent assessment by mental health services. Admission to a mother and baby unit is recommended if inpatient care is needed.1
Antenatal and postnatal depression
Currently, there is no way to prevent antenatal depression. Risk factors for this illness include maternal anxiety, life stress, previous depression, lack of social support, domestic violence, and relationship factors.1,9
The risk factors for postnatal depression are shown in Table 1 (see below).1,10–18 There is insufficient evidence to support the use of psychological or psychosocial interventions, antidepressants, or hormones in the prevention of postnatal depression.19–21 The Edinburgh Postnatal Depression Scale (EPDS) and Whooley questions are useful aids to facilitate discussion of emotional issues, but are less useful for screening of mental health issues.22,23
At a minimum, women should be asked about depressive symptoms at their first antenatal appointment, and at 4–6 weeks and 3–4 months postnatally. It is important to remember that emotional changes are normal at this time and these need to be differentiated from depression.1
|Table 1: Risk factors for postnatal depression1,10–18|
|With a strong association||With a weaker association|
When managing perinatal mental illness, healthcare professionals should remember to assess any risks to the well-being of the baby and any other children. Although suicide and infanticide are rare, they do occur on occasion and local child protection policies should be followed if the potential for harm to mother and/or baby exists.1
It is important to share information and work together with other healthcare professionals who care for the woman (e.g. health visitor, midwife, community mental health nurse).1
Cognitive behavioural therapy and listening visits from trained health visitors should be considered for mild to moderate postnatal depression.24,25 Unfortunately, many areas have a long waiting list for psychological therapies. In some areas, health visitor numbers are decreasing with attendant increase in workload, which compromises the availability of listening visits.
Where the mother–infant relationship is impaired, interventions aimed at improving that relationship should be offered (e.g. toddler–parent psychotherapy, infant massage).26,27
Structured exercise may be offered as a treatment option for postnatal depression;28,29 however, this intervention is difficult for new mothers to access unless there are childcare facilities on site.
The points in Box 1 (see below) are worth considering when investigating ways to improve access to interventions for women with perinatal mood disorders.
|Box 1: Points to consider when developing services for pregnant and postnatal women with mental illness|
The principles of prescribing medication during pregnancy and breast feeding are shown in Table 2 (see below).1 The healthcare professional should remember that not treating mental illness during pregnancy or postpartum may, in itself, be associated with adverse outcomes for the woman, her pregnancy, and her baby.1
All women of childbearing potential who take psychotropic medication should be made aware of the potential effects of medication in pregnancy. The use of reliable contraception should be discussed. If a woman is planning a pregnancy, the healthcare professional should consider discontinuing treatment if she is well and at low risk of relapse.1
Hormonal therapy and St John's Wort are not recommended during pregnancy and the early postnatal period because of safety issues.1,30
Due to confounding and poor study design, there is conflicting evidence on the effects that antidepressants have on the risks of spontaneous abortion, congenital malformation, neonatal adaptation, persistent pulmonary hypertension of the newborn, and neurodevelopmental outcomes.31–35 General practitioners should review antidepressant use as early as possible in pregnancy to discuss whether therapy should be continued or if a non-pharmacological treatment should be initiated.1
Choice of antidepressants in pregnancy should take into account implications for breast feeding (i.e. to avoid changing treatment after birth). Doxepin should be avoided during breast feeding. If a selective serotonin reuptake inhibitor is initiated when the woman is breast feeding, fluoxetine, citalopram, and escitalopram should be avoided.1 Paroxetine should not be initiated as first-line therapy during pregnancy.1,36
The prescribing of medication during the perinatal period is a rapidly developing area—clinicians should update their knowledge frequently or contact their regional perinatal mental health service for specific advice.
Lithium has been associated with Ebstein's anomaly and neurological effects in the neonate.35,36 Monitoring of mood stabilisers is recommended because of pregnancy related changes in drug metabolism. Women taking lithium during pregnancy should have an individualised psychiatric care plan and be offered detailed ultrasound scanning for foetal abnormalities. There should be liaison between mental health and maternity services on the recognition of lithium toxicity, lithium-drug interactions, and pregnancy related events that may contribute to toxicity.1
Women who stop taking lithium during pregnancy are at high risk of recurrence of mental illness after delivery of the baby,37 and may need to resume prophylaxis shortly after birth. Mothers who are receiving lithium should be advised to avoid breast feeding. If a mother decides to breast feed while taking this drug, the baby should be monitored closely (e.g. serum lithium and thyroid and renal monitoring).1
Valproate should not be used as a mood stabiliser in women of childbearing potential because of the risk of early teratogenicity and longer-term neurobehavioural toxicity.1,38 If there is no alternative treatment option, long-acting contraception should be recommended.1
Women taking antiepileptic drugs as a mood stabiliser should be prescribed folic acid 5 mg daily from preconception until the end of the first trimester (12 weeks' gestation), and should have detailed ultrasound scanning for foetal abnormalities.1
|Table 2: General principles for prescribing medication during the perinatal period1|
When prescribing psychotropic medication for women who are pregnant or breast feeding, the following principles should be applied:
Perinatal mood disorders affect a large number of women and their families. Although postpartum psychosis is rare, it is a serious illness that can sometimes be anticipated and planned for in advance. Postnatal depression is less severe, and may not be recognised as readily—however, it still has serious consequences for the baby as well as the mother.
The SIGN guideline contains an extensive list of resources that patients and their families will find useful. A patient leaflet is also available from the SIGN website (www.sign.ac.uk/guidelines/fulltext/127/index.html), which provides information on perinatal mental illness and its management.
- Perinatal mood disorders are often predictable based on previous history, so primary care practitioners should be encouraged to discuss the possible effects of pregnancy with women who have a history of pre-existing depressive illness or bipolar disorder before conception
- CCGs should ensure that a specialist service is commissioned to treat and advise on mental health problems in pregnancy
- This should include CBT interventions as well as specialised psychiatric advice and inpatient mother and baby facilities
- Local safeguarding training and procedures should cover the risks to newborn and yet-to-be born infants in women with perinatal mood disorders
- Local care pathways would be useful to define the roles of the many disciplines involved (GPs, midwives, health visitors, obstetricians, and psychiatrists)
- Local formularies should identify which drugs to use (and when) for mood disorders and signpost prescribers to specialist advice where needed as decisions are often a balance of risks and benefits.
- Scottish Intercollegiate Guidelines Network. Management of perinatal mood disorders. SIGN 127. Edinburgh; SIGN, 2012. Available at: www.sign.ac.uk/pdf/sign127.pdf
- Murray L, Cooper P. Effects of postnatal depression on infant development. Arch Dis Child 1997; 77 (2): 99–101.
- Lee D, Yip A, Leung T, Chung T. Ethnoepidemiology of postnatal depression: Prospective multivariate study of sociocultural risk factors in a Chinese population in Hong Kong. BJP 2004; 184: 34–40.
- Cantwell R, Clutton-Brock T, Cooper G et al. Saving mothers' lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The eighth report of the confidential enquiries into maternal deaths in the United Kingdom. BJOG 2011; 118 (Suppl 1): 1–203.
- Harlow B, Vitonis A, Sparen P et al. Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and
without prior prepregnancy or prenatal psychiatric hospitalizations. Arch Gen Psychiatr 2007; 64 (1): 42–48.
- Jones I, Craddock N. Familiality of the puerperal trigger in bipolar disorder: results of a family study. Am J Psychiatry 2001; 158 (6): 913–917.
- Viguera A, Nonacs R, Cohen L et al. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance. Am J Psychiatry 2000; 157 (2): 179–184.
- Blackmore E, Jones I, Doshi M et al. Obstetric variables associated with bipolar affective puerperal psychosis. Br J Psychiatry 2006; 188: 32–36.
- Lancaster C, Gold K, Flynn H et al. Risk factors for depressive symptoms during pregnancy: a systematic review. Am J Obstet Gynecol 2010; 202 (1): 5–14.
- O'Hara M, Swain A. Rates and risk of postpartum depression—a meta-analysis. Int Rev Psychiatry 1996; 8 (1): 37–54.
- Beck C. A meta-analysis of predictors of postpartum depression. Nurs Res 1996; 45 (5): 297–303.
- Wilson L, Reid A, Midmer D et al. Antenatal psychosocial risk factors associated with adverse postpartum family outcomes. CMAJ 1996; 154 (6): 785–799.
- Gotlib I, Whiffen V, Wallace P, Mount J. Prospective investigation of postpartum depression: factors involved in onset and recovery. J Abnorm Psychol 1991; 100 (2): 122–132.
- Warner R, Appleby L, Whitton A, Faragher B. Demographic and obstetric risk factors for postnatal psychiatric morbidity. Br J Psychiatry 1996; 168 (5): 607–611.
- Grazioli R, Terry D. The role of cognitive vulnerability and stress in the prediction of postpartum depressive symptomology. Br J Clin Psychol 2000; 39 (Pt 4): 329–347.
- Pedersen C. Postpartum mood and anxiety disorders: a guide for the nonpsychiatric clinician with an aside on thyroid associations with postpartum mood. Thyroid 1999; 9 (7): 691–697.
- Demyttenaere K, Lenaerts H, Nijs P, Van Assche F. Individual coping style and psychological attitudes during pregnancy predict depression levels during pregnancy and during postpartum. Acta Psychiatr Scand 1995; 91 (2): 95–102.
- Areias M, Kumar R, Barros H, Figueiredo E. Correlates of postnatal depression in mothers and fathers. Br J Psychiatry 1996; 169 (1): 36–41.
- Petrou S, Cooper P, Murray L, Davidson L. Cost-effectiveness of a preventive counselling and support package for postnatal depression. Int J Technol Assess Health Care 2006; 22 (4): 443–453.
- Howard L, Hoffbrand S, Henshaw C et al. Antidepressant prevention postnatal depression. Cochrane Database of Systematic Reviews 2005 (2): CD004363.
- Dennis C, Ross L, Herxheimer A. Oestrogens and progestins for preventing and treating postpartum depression. Cochrane Database of Systematic Reviews 2008 (4): CD001690.
- Hewitt C, Gilbody S, Brealey S et al. Methods to identify postnatal depression in primary care: an integrated evidence synthesis and value of information analysis. Health Technol Assess 2009; 13 (36).
- National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance. Clinical Guideline 45. London: NICE, 2007. Available at: www.nice.org.uk/CG45
- Bledsoe S, Grote N. Treating depression during pregnancy and the postpartum: a preliminary meta-analysis. Res Soc Work Pract 2006; 16 (2): 109–120.
- Shaw E, Levitt C, Wong S, Kaczorowski J, Group. The Master University Postpartum Research Group. Systematic review of the literature on postpartum care: effectiveness of postpartum support to improve maternal parenting, mental health, quality of life, and physical health. Birth 2006; 33 (3): 210–220.
- Toth S, Rogosch F, Manly J, Cicchetti D. The efficacy of toddler-parent psychotherapy to reorganize attachment in the young offspring of mothers with major depressive disorder: a randomized preventive trial. J Consult Clin Psychol 2006; 74 (6): 1006–1016.
- O'Higgins M, St. James Roberts I, Glover V. Postnatal depression and mother and infant outcomes after infant massage. J Affect Disord 2008; 109 (1–2): 189–192.
- Mead G, Morley W, Campbell P et al. Exercise for depression. Cochrane Database of Systematic Reviews 2009; (3): CD004366.
- Da Costa D, Lowensteyn I, Abrahamowicz M et al. A randomized clinical trial of exercise to alleviate postpartum depressed mood. J Psychosom Obstet Gynaecol 2009; 30 (3): 191–200.
- Scottish Intercollegiate Guidelines Network Non-pharmaceutical management of depression in adults. SIGN 114. Edinburgh: SIGN, 2010. Available at: www.sign.ac.uk/guidelines/fulltext/114/index.html
- Hemels M, Einarson A, Koren G et al. Antidepressant use during pregnancy and the rates of spontaneous abortions: a meta-analysis. Ann Pharmacother 2005; 39 (5): 803–809.
- Rahimi R, Nikfar S, Abdollahi M. Pregnancy outcomes following exposure to serotonin reuptake inhibitors: a meta-analysis of clinical trials. Reprod Toxicol 2006; 22 (4): 571–575.
- Udechuku A, Nguyen T, Hill R, Szego K. Antidepressants in pregnancy: a systematic review. Aust N Z J Psychiatry 2010; 44 (11): 978–996.
- Jones D. Use of selective serotonin reuptake inhibitors in pregnancy. UK Teratology Information Service, 2011. Available at: www.nelm.nhs.uk/en/NeLM-Area/Evidence/Drugs-in-Pregnancy/Use-of-selective-serotonin-reuptake-inhibitors-SSRIs-in-pregnancy/ (accessed 3 July 2012).
- Wilson K, Zelig C, Harvey J et al. Persistent pulmonary hypertension of the newborn is associated with mode of delivery and not with maternal use of selective serotonin reuptake inhibitors. Am J Perinatol 2011; 28 (1): 19–24.
- Galbally M, Roberts M, Buist A. Mood stabilizers in pregnancy: a systematic review. Aust N Z J Psychiatry 2010; 44 (11): 967–977.
- Newport D, Viguera A, Beach A et al. Lithium placental passage and obstetrical outcome: implications for clinical management during late pregnancy. Am J Psychiatry 2005; 162 (11): 2162–2170.
- Royal College of Obstetricians and Gynaecologists. Management of women with mental health issues during pregnancy in the postnatal period. Good practice No 14. London: RCOG, 2011. Available at: www.rcog.org.uk/management-women-mental-health-issues-during-pregnancy-and-postnatal-period%20 G