Antenatal and postnatal mental health: clinical management ... how a mental health problem and its treatment

  • View
    0

  • Download
    0

Embed Size (px)

Text of Antenatal and postnatal mental health: clinical management ... how a mental health problem and its...

  • Antenatal and postnatal mental health: clinical management and service guidance

    Issued: December 2014

    NICE clinical guideline 192 guidance.nice.org.uk/cg192

    NICE has accredited the process used by the Centre for Clinical Practice at NICE to produce guidelines. Accreditation is valid for 5 years from September 2009 and applies to guidelines produced since April 2007 using the processes described in NICE's 'The guidelines manual' (2007, updated 2009). More information on accreditation can be viewed at www.nice.org.uk/accreditation

    © NICE 2014

  • Contents Introduction .................................................................................................................................. 4

    Medicines ................................................................................................................................................ 5

    Patient-centred care ..................................................................................................................... 7

    Key priorities for implementation .................................................................................................. 8

    Considerations for women of childbearing potential ............................................................................... 8

    Principles of care in pregnancy and the postnatal period ....................................................................... 8

    Treatment decisions, advice and monitoring for women who are planning a pregnancy, pregnant or in the postnatal period................................................................................................................................. 9

    Recognising mental health problems in pregnancy and the postnatal period and referral ..................... 11

    Providing interventions in pregnancy and the postnatal period............................................................... 11

    Considerations for women and their babies in the postnatal period ....................................................... 11

    The organisation of services ................................................................................................................... 12

    1 Recommendations .................................................................................................................... 14

    Terms used in this guideline .................................................................................................................... 14

    1.1 Using this guideline in conjunction with other NICE guidelines......................................................... 15

    1.2 Considerations for women of childbearing potential ......................................................................... 16

    1.3 Principles of care in pregnancy and the postnatal period ................................................................. 16

    1.4 Treatment decisions, advice and monitoring for women who are planning a pregnancy, pregnant or in the postnatal period......................................................................................................................... 18

    1.5 Recognising mental health problems in pregnancy and the postnatal period and referral ............... 27

    1.6 Assessment and care planning in pregnancy and the postnatal period ............................................ 31

    1.7 Providing interventions in pregnancy and the postnatal period......................................................... 33

    1.8 Treating specific mental health problems in pregnancy and the postnatal period............................. 34

    1.9 Considerations for women and their babies in the postnatal period ................................................. 40

    1.10 The organisation of services ........................................................................................................... 43

    2 Research recommendations ..................................................................................................... 47

    2.1 Preventing postpartum psychosis ..................................................................................................... 47

    Antenatal and postnatal mental health: clinical management and service guidance

    NICE clinical guideline 192

    © NICE 2014. All rights reserved. Last modified December 2014 Page 2 of 62

  • 2.2 The safety of drugs for bipolar disorder in pregnancy and the postnatal period ............................... 48

    2.3 Psychological interventions focused on the mother-baby relationship.............................................. 48

    2.4 Structured clinical management for moderate to severe personality disorders in pregnancy and the postnatal period................................................................................................................................. 49

    2.5 Psychological interventions for moderate to severe anxiety disorders in pregnancy ........................ 50

    3 Other information....................................................................................................................... 52

    3.1 Scope and how this guideline was developed .................................................................................. 52

    3.2 Related NICE guidance..................................................................................................................... 52

    4 The Guideline Development Group, National Collaborating Centre and NICE project team .... 55

    4.1 Guideline Development Group.......................................................................................................... 55

    4.2 National Collaborating Centre for Mental Health............................................................................... 56

    4.3 NICE project team............................................................................................................................. 57

    About this guideline ...................................................................................................................... 59

    Update information.................................................................................................................................. 59

    Strength of recommendations ................................................................................................................. 60

    Other versions of this guideline ............................................................................................................... 61

    Implementation........................................................................................................................................ 61

    Your responsibility ................................................................................................................................... 61

    Copyright ................................................................................................................................................. 62

    Antenatal and postnatal mental health: clinical management and service guidance

    NICE clinical guideline 192

    © NICE 2014. All rights reserved. Last modified December 2014 Page 3 of 62

  • Introduction

    This guideline updates and replaces NICE clinical guideline 45. See about this guideline for details.

    In pregnancy and the postnatal period, many mental health problems have a similar nature, course and potential for relapse as at other times. However, there can be differences; for example, bipolar disorder shows an increased rate of relapse and first presentation in the postnatal period. Some changes in mental health state and functioning (such as appetite) may represent normal pregnancy changes, but they may be a symptom of a mental health problem.

    The management of mental health problems during pregnancy and the postnatal period differs from at other times because of the nature of this life stage and the potential impact of any difficulties and treatments on the woman and the baby. There are risks associated with taking psychotropic medication in pregnancy and during breastfeeding and risks of stopping medication taken for an existing mental health problem. There is also an increased risk of postpartum psychosis.

    Depression and anxiety are the most common mental health problems during pregnancy, with around 12% of women experiencing depression and 13% experiencing anxiety at some point; many women will experience both. Depression and anxiety also affect 15-20% of women in the first year after childbirth. During pregnancy and the postnatal period, anxiety disorders, including panic disorder, generalised anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and tokophobia (an extreme fear of childbirth), can occur on their own or can coexist with depression. Psychosis can re-emerge or be exacerbated during pregnancy and the postnatal period. Postpartum psychosis affects between 1 and 2 in 1000 women who have given birth. Women with bipolar I disorder are at particular risk, but postpartum psychosis can occur in women with no previous psychiatric history.

    Changes to body shape, including weight gain, in pregnancy and after childbirth may be a concern for women with an eating disorder. Although the prevalence of anorexia nervosa and bulimia nervosa is lower in pregnant women, the prevalence of binge eating disorder is higher. Smoking and the use of illicit drugs and alcohol in pregnancy are common, and prematurity, intrauterine growth restriction and fetal compromise are more common in women who use t