Dr Henk Parmentier discusses NICE recommendations on treatment of depression and mental disorders during and after pregnancy

Postnatal mental health disorders are common, with depression affecting 8–15% of newly delivered mothers, and approximately one-third of these cases become chronic or recurrent.1,2 Children from affected mothers have poorer infant development, poorer interpersonal functioning, insecure attachment, raised rates of emotional and behavioural problems, and difficulties in adjusting to school.3

Need for the guideline

Although the evidence on the benefits of early detection and treatment of antenatal and postnatal mental disorders is clear, current data show that less than 50% of cases of postnatal depression are detected in the primary care setting.4 Reductions in midwife and health visitor contacts by many community trusts will lead to even lower rates of early detection. Uncertainty on the part of GPs about how to treat these disorders has also contributed to less than effective treatment.

What the guideline covers

The recently published revised NICE guideline for antenatal and postnatal mental health not only covers postnatal depression, but has a much wider remit.5,6 It covers the whole spectrum of mental illness:

  • the affective disorders — like depression, bipolar disease, and anxiety disorders
  • the psychotic illnesses in the postnatal period (up to 1 year after delivery of the baby)
  • the care of women with an existing mental disorder who are planning a pregnancy. The guideline also provides advice on the use of psychotropic medication during pregnancy and breastfeeding.5

Screening methods

For early detection of depression, the guideline recommends using the same principles as those followed by the depression screening method for diabetes and cardiovascular disease.7 When a pregnant woman attends the clinic at her first booking appointment and then postnatally, the following questions should be asked by the healthcare worker to try and identify early signs of depression:

  • '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?’
  • If the answer to either of the above questions is ‘Yes’, then a third question can be asked: ‘Is this something you feel you need or want help with?’

There is overlap with other NICE guidance, such as the stepped-care model in the depression guideline,8 which makes the approach to mental health care universal and, therefore, easily implemented in primary care. Although, one should always take into consideration that not every form of therapy is suitable for pregnant/breastfeeding women or women with newborn babies. In addition to side-effects of medication, there are practical problems for these women in undertaking exercise as recommended in the guideline and, for example, in attending counselling sessions where there might be lengthy waits, which can cause difficulties with feeding newborn babies.

Labelling mental disorders

The guideline recommends following diagnostic criteria of labelling mental disorders, such as those in the American Psychiatric Association Diagnostic and statistical manual of mental disorders9 or the World Health Organization ICD-10 classification of mental and behavioural disorders.10 In primary care, however, more and more GPs are following a dimensional rather than a categorical approach to depression.11 This implies that:

  • functioning is more important than labelling
  • prevention is better than treatment
  • promoting well being is better than prescribing antidepressant medication.

Co-morbidity between physical, mental, and social aspects of pregnancy will influence the success of treatment strategies and this could have been further explored in the guideline. This includes issues such as those arising around domestic violence, housing, benefits, cultural differences, asylum seekers, and physical illness.

Treatment recommendations

The NICE guideline on antenatal and postnatal mental health further influences our decisions on making a balanced choice of which treatment to recommend, and what medication to prescribe. The evidence and statistics provided will allow doctors to discuss the therapeutic range with the patient. This will allow for an informed choice by both the patient and the physician. One example of this involves the prescribing of lithium. Clear guidance is given on:

  • what the contraindications are
  • risks for fetal development
  • how to stop
  • what can be used as an alternative
  • if lithium is not stopped, how to monitor toxicity.

Implementation requires funding

Guidelines are not valuable unless a funding stream is provided to allow for implementation of the recommendations, and to fund research for evaluation and further development. For example, the recommendation that a patient should be seen for psychological treatment within 1 month of initial assessment will stretch the capacities of many PCTs and mental health trusts. I hope that there will be substantial financial backup for the recommendations made in this guideline.

Conclusion

Overall, the NICE guideline for antenatal and postnatal mental health disorders is a helpful tool to improve the antenatal and postnatal care of women with mental health problems.

 

  1. Kumar R, Robson K. A prospective study of emotional disorders in childbearing women. Br J Psychiatry 1984; 144: 35–47.
  2. O’Keane V, Marsh M. Depression during pregnancy. Br Med J 2007; 334 (7601): 1003–1005.
  3. Murray L. The impact of postnatal depression on infant development. J Child Psychol Psychiatry 1992; 33 (3): 543–561.
  4. Hearn G, Iliff A, Jones I et al. Postnatal depression in the community. Br J Gen Pract 1998; 48 (428): 1064–1066.
  5. National Institute for Health and Care Excellence. Antenatal and postnatal mental health: Clinical management and service guidance. Clinical guideline 45. London: NICE, reissued 2007.
  6. National Collaborating Centre for Mental Health. Antenatal and postnatal mental health: clinical management and service guidance. London: NICE, 2006.
  7. British Medical Association. Revisions to the GMS Contract, 2006/2007. Delivering Investment in General Practice. London: BMA, 2006.
  8. National Institute for Clinical Excellence. Depression: management of depression in primary and secondary care. Clinical guideline 23. London: NICE, 2004.
  9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV), fourth edition. Washington, DC: American Psychiatric Association, 1994.
  10. World Health Organization. The ICD-10 classification of mental and behavioural disorders. Geneva: World Health Organization, 1992.
  11. Gunn J. Towards a practical solution for depression in general practice. NZFP 2006; 33 (4): 239–242.G