Dr Stephanie de Giorgio offers top tips for the detection, assessment, and management of perinatal mental health problems in primary care
Read this article to learn more about:
- identifying and counselling women with postnatal, perinatal, and current or previous mental health problems
- non-pharmacological and pharmacological treatment options
- when to refer to secondary care.
Mental health problems in the perinatal period, that is, during pregnancy and up to 1 year after birth, are very common. While approximately 20% of women are affected, only one half of them are ever identified, meaning that many women are unnecessarily experiencing symptoms detrimental to their overall health and wellbeing.1 The importance of diagnosing and offering effective treatment to these women cannot be overstated. It is vital to remember that suicide is one of the leading direct causes of death in the perinatal period2 and some of these deaths may be preventable.
It is hoped that the following practical tips, based on the relevant guidance, will enable clinicians to feel more confident in managing women with perinatal mental health disorders in primary care.
1. Recognise the most common perinatal mental health disorders
Women can present in many ways, for example, with symptoms of depression, anxiety (which is possibly more common than depression antenatally3), insomnia, and obsessive compulsive disorder. The timing, severity, and pervasiveness of these symptoms will help to distinguish what is related to normal pregnancy or postnatal worries, and what is pathological.
2. Know which women are most at risk
All women are at risk of perinatal mental illness, but some are at increased risk, including:4
- women with (or with a family history of) bipolar disorder or schizophrenia
- women with previous perinatal mental illness
- women experiencing domestic abuse, social isolation, or unplanned pregnancy.
Women with bipolar disorder and previous significant perinatal mental illness should be referred antenatally, even if well, to ensure a good plan can be put in place.2,4
Ideally, all women of reproductive age with mental health problems should be counselled on what to do if they become pregnant, and to seek advice pre-conceptually or early in pregnancy—in the same way as would be done for a woman with diabetes or epilepsy.
Although not in the remit of this article, remember that men can experience perinatal mental health problems and are at increased risk if their partner has been diagnosed with a perinatal mental illness.1,4
3. Be aware of societal expectations
Don’t presume that the patient and her partner are enjoying the experience of parenthood when you meet them, and avoid normalising problems a woman may be having through statements such as ‘all new mothers are tired.’
The difficulties and realities of parenthood are often not discussed openly and women may be reluctant to admit that they are finding things hard. This may be especially true of women from cultures where mental health problems are not discussed. Multigenerational living, migration status, and maternal isolation in the home may also increase the risk of perinatal mental health problems.5,6
4. Remember that appearances can be deceptive
Most mothers will attempt to hide their distress at postnatal appointments for fear of judgment or having their baby taken away.1 Make-up, a beautifully dressed baby, and a smiling mother do not mean that a woman is not experiencing significant mental health problems.
5. Ask the right questions
Use every contact with a woman during pregnancy and post-natally to find out how she is managing.1 Although screening and detection tools (such as the Edinburgh Postnatal Depression Scale, Whooley Questions, and the 7-item Generalized Anxiety Disorder scale) can be used as an aid to diagnosis,4,7 women report that the best way of finding out how they are doing is for GPs to ask the right questions, provide reassurance that they are being taken seriously, and really listen to the answers.1 Perhaps consider asking:
- ‘How are you finding being a mum (again)?’
- ‘Tell me about the birth.’
Asking both of these questions, focusing entirely on the mother and her verbal and non-verbal responses (such as pauses, looking away, and becoming tearful)8 encourages disclosure and facilitates the start of a therapeutic relationship.
While postnatal checks are still offered,1 invite the mother to come to an appointment by herself separate to the baby check, use the tools and questions above, and look to see whether she comes alone or with her partner. A partner attending can be a sign of a supportive relationship, but as the incidence of domestic abuse increases during pregnancy, it is important to be sure that their presence isn’t due to controlling behaviour.1,8
6. Always act on red flags
Bipolar disorder is a red flag.8
A woman disclosing that she thinks she has postnatal or antenatal mental health symptoms is a red flag and her concerns must be taken seriously.8
Likewise, a partner disclosing fears about his or her partner’s mental health in the antenatal or postnatal period must be acted upon.
7. Be alert to postpartum psychosis
Postpartum psychosis is a psychiatric emergency. It comes on rapidly in the first hours to 2 weeks post-partum, with psychotic features of delusions, hallucinations, and mania, often focused on the baby. Mothers presenting with these features need to be seen by secondary care mental health services (preferably a specialist perinatal mental health service) within 4 hours.7 Not all areas have specialist perinatal psychiatry services, so the on-call psychiatric team for the area or the emergency department may be necessary if specialist services are not available. Although postpartum psychosis is more common in women with a history of bipolar disorder, 50% of women who experience postpartum psychosis have no history that suggests they are at high risk of developing it.9
8. Consider non-pharmacological treatments first
For mild-to-moderate depression, NICE Clinical Guideline (CG) 192 recommends facilitated self-help;7 however, it may also be very appropriate to initiate talking therapies at this level of illness to facilitate recovery as self-help can be hard for the patient to do if they are feeling unwell. Specialist and timely talking therapies can be difficult to access, so if women are showing significant symptoms or worsening quickly, it may be necessary to consider pharmacological therapy sooner rather than later.
Making use of peer support groups, both face-to-face and online, voluntary sector groups, and the patient’s own network of social support should also be encouraged.10
9. Offer medication when necessary
Consider medication for those with moderate-to-severe depression or those presenting with mild depression or anxiety who have worsened significantly in previous pregnancies or at other times.7 Using medication in pregnancy and post-natally can feel daunting for a non-experienced prescriber but can be life-saving and life-changing.
NICE CG192 recommends that the woman and her family are given information about pharmacological treatment that considers:7
- 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.
The following NICE CG192 framework is recommended when using psychotropic medication in pregnancy:7
- choose the drug with the lowest risk profile for the woman, foetus, 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, foetus, and baby may be dose-related), but note that sub-therapeutic doses may also expose the foetus to risks and not treat the mental health problem effectively
- use a single drug, if possible, in preference to two or more drugs.
The antidepressants most commonly prescribed by GPs are selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors, and tricyclics. All are unlicensed for use in pregnancy so it can be difficult to recommend which ones to use. For the unlicensed use of a medicine, 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.11
Box 1 outlines a few key points relating to psychotropic medication in the perinatal period. Fluoxetine, sertraline, and citalopram are all commonly prescribed—further information can be found by following the links provided in Box 2. Taking into account any response a woman has had previously to any treatment is important.
Box 1: Key points about psychotropic medication in the perinatal period
- Abrupt withdrawal causes problems. If a woman presents when newly pregnant on medication, do not stop the medication until specialist advice has been sought. It may be better not to stop it, as seven out of 10 women will relapse if medication is stopped12
- The potential risks to the foetus, such as congenital abnormalities and autism, are far from clear and must be balanced against the risk of not treating13
- Intention to breastfeed or current breastfeeding should be discussed. Breastfeeding is not a barrier to treatment but may influence the choice of medication used.
Box 2: Resources relating to treatment in pregnancy and breastfeeding
The UK Teratology Information Service (UKTIS) provides a national service on all aspects of the toxicity of drugs and chemicals in pregnancy.
Provides information for patients about drug use in the perinatal time.
US-based website about medication in breastfeeding.
Provides evidence-based information on the use of drugs during the breastfeeding period.
An independent source of support and information for breastfeeding women and others.
Research regarding the relationship between breastfeeding and postnatal depression has failed to come to any definite conclusions.14 Successful breastfeeding may be protective against developing postnatal depression, but failing to establish effective breastfeeding when a woman has intended to breastfeed may increase the risk of developing postnatal depression. It is important to keep this in mind when advising women on breast and formula feeding as it is a highly emotive topic and women need support with their choice of feeding method.
Mood stabilisers and antipsychotic medication are the realm of secondary and tertiary care prescribing for the perinatal period.15
10. Consider the psychological effects of pregnancy loss
Miscarriage and stillbirth are particular risk factors for perinatal mental health problems. Ensure that women who have been through pregnancy loss are sensitively asked about their mental health in a timely fashion. It is also important to consider their mental health if they go on to have a subsequent pregnancy.
- Khan L. Falling through the gaps: perinatal mental health and general practice. Centre for Mental Health, 2015. Available at: www.centreformentalhealth.org.uk/falling-through-the-gaps
- Knight M, Nair M, Tuffnel D et al (editors) on behalf of Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries. Saving lives, improving mothers’ care—surveillance of maternal deaths in the UK 2012–2014 and lessons learned to inform maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2009–14. National Perinatal Epidemiology Unit, 2016. Available at: www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202016%20-%20website.pdf
- Lee A, Lam S, Sze Mun Lau S et al. Prevalence, course, and risk factors for antenatal anxiety and depression. Obstet Gynecol 2007; 110 (5): 1102–1112.
- Scottish Intercollegiate Guidelines Network. Management of perinatal mood disorders. SIGN 127. SIGN, 2012. Available at: www.sign.ac.uk/assets/sign127.pdf
- Fellmeth G, Fazel M, Plugge E. Migration and perinatal mental health in women from low- and middle-income countries: a systematic review and meta-analysis. BJOG 2017; 124 (5): 742–752.
- Fisher J, de Mello M, Patel V et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ 2012; 90 (2): 139–149H.
- NICE. Antenatal and postnatal mental health: clinical management and service guidance. Clinical Guideline 192. NICE, 2014 (updated 2017). Available at: nice.org.uk/cg192
- Shakespeare J. Practical implications for primary care of the NICE guideline CG192 antenatal and postnatal mental health. Royal College of General Practitioners, 2015. Available at: gpifn.files.wordpress.com/2016/08/rcgp-ten-top-tips-nice-guidance-june-2015.pdf
- Jones I, Chandra P, Dazzan P, Howard L. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet 2014; 384 (9956): 1789–1799
- Royal College of General Practitioners. Perinatal mental health toolkit. www.rcgp.org.uk/clinical-and-research/toolkits/perinatal-mental-health-toolkit.aspx (accessed 8 November 2017).
- General Medical Council. Good practice in prescribing and managing medicines and devices. Prescribing guidance: Prescribing unlicensed medicines. London: GMC, 2013. Available at: www.gmc-uk.org/guidance/ethical_guidance/14327.asp (accessed 8 November 2017).
- Royal College of Psychiatrists. Postnatal depression. www.rcpsych.ac.uk/healthadvice/problemsdisorders/postnataldepression.aspx (accessed 8 November 2017).
- Chisolm M, Payne J. Management of psychotropic drugs during pregnancy. BMJ 2016; 352: h5918.
- Pope C, Mazmanian D. Breastfeeding and postpartum depression: an overview and methodological recommendations for future research. Hindawi 2016; 2016: 4765310.
- Ladd C. Top tips using psychotropic medication in the perinatal time. Royal College of General Practitioners, 2016. Available at: www.rcgp.org.uk/clinical-and-research/toolkits/~/media/D017392BD963481E905BB24A9651E37C.ashx