Addressing gaps in mental health care for new mothers
Between 10 and 20% of women develop a mental illness during pregnancy or within the first year after having a baby. Around 12% of women experience depression and 13% experience anxiety at some point - many women will experience both. Depression and anxiety disorders also affect 1 in 5 women in the first year after childbirth.
Approximately 90% of women with less severe perinatal mental illness will be treated in primary or community care. We know that only about half of women with significant illness are detected in primary care and that only half of them receive adequate treatment at present, so there is substantial scope for improvement in care1. Women with severe mental health illness need treatment from specialist perinatal mental health services. However, in almost half od the UK, pregnant women and new mothers do not have access to specialist services, potentially leaving them and their babies at risk.
Research from the National Childbirth Trust (NCT) found that just 3% of Clinical Commissioning Groups (CCGs) in England have a strategy for commissioning perinatal mental health services and a large majority have no plans in developing one.
An independent report commissioned by the Maternal Mental Health Alliance highlighted that perinatal depression, anxiety and psychosis carry a total long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK. Three quarters of this cost relates to adverse impacts on the child rather than the mother.
To help address the gaps in care, this updated guideline makes recommendations for the recognition, assessment, care and treatment of mental health problems in women during pregnancy and up to one year after childbirth, and in women who are planning a pregnancy. The NICE pathway is a very useful summary of the detailed guidance for GPs.
The updated guidance recommends discussing with all women of childbearing potential who have a new, existing or past mental health problem, the use of contraception and any plans for a pregnancy. GPs should discuss how pregnancy and childbirth might affect a mental health problem, including the risk of relapse, as well as how a mental health problem and treatment might affect the woman, the foetus and baby, and parenting.
GPs are likely to see a woman early in pregnancy for confirmation of pregnancy and at the post natal examination 6-8 weeks after the birth of the child. On every occasion that a GP sees a woman, he/she should consider the woman's mental health as well as her physical health. This should be proactive as women may not feel able to raise the topic themselves because of stigma, failure to recognise the problem themselves or because of fears that their baby may be taken away from them.
Benefits and harms of treatment
Women with a history of mental health problems are at risk of relapse when they become pregnant, especially if they stop taking their medication. Drugs often have an important role in treating antenatal and postnatal mental health problems, but they are not always suitable. Since the original guideline was published in 2007, more information has emerged on using drugs to treat mental health problems during pregnancy and on stopping medication. The updated guidance offers advice on starting, using and stopping treatment, as well as the use of tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRI) or (serotonin) noradrenaline reuptake inhibitors [(S)NRI]. For more information on this, click here to visit the relevant pathway.
It is critically important that a woman is able to make an informed decision about treatment and she is helped to weigh up the risks and benefits of stopping, starting or changing any treatment she is offered or currently receiving.
Women with previous severe mental health problems should be referred to mental health services (preferably specialist perinatal services) early in pregnancy, even if they are well. GPs may feel able to advise women who are taking antidepressants, but if they have any concern about their ability to do this they should also consider referral.
These discussions should include issues around:
- the risks or harms to the woman and the foetus or baby associated with each treatment option;
- the need for prompt treatment because of the potential effect of an untreated mental health problem on the foetus or baby;
- the risk or harms to the woman and the foetus or baby associated with stopping or changing a treatment;
- the uncertainty about the benefits, risks and harms of treatments for mental health problems in pregnancy and the postnatal period;
- the likely benefits of each treatment, taking into account the severity of the mental health problem.
It also states that there needs to be discussion with a woman whose baby is stillborn or dies soon after birth, and her partner and family, about the option of seeing a photograph of the baby, having mementos of the baby, seeing or holding the baby. This should take place before delivery if it is known that the baby has died in utero and continue after delivery if needed.
 Gavin, Meltzer-Brody, Glover, and Gaynes in press 2014.
The RCGP has recognised the importance of perinatal mental health by selecting this area as a clinical priority from 2014-17. Dr Judy Shakespeare is the Clinical Champion. For more information please click here.