Antenatal and postnatal mental health

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Antenatal and postnatal mental health
February 2007
NICE clinical guideline 45
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What this presentation covers

• Context
• The guideline recommendations
• Key areas for implementation
• Costs and savings
• Further information and support

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Changing clinical practice

• NICE guidelines are based on the best available
  evidence
• The Department of Health asks NHS organisations
  to work towards implementing guidelines
• Compliance with developmental standards will be
  monitored by the Healthcare Commission

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Need for this guideline

• Risk of women with an existing disorder
  stopping medication abruptly
• Increased risk of relapse and first
  presentation of bipolar disorder
• More urgent intervention may be required
• More rapid onset of postnatal psychotic
  disorders

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Need for this guideline

• Psychological health is as important as physical
  health
• Effects on the extended family
• Appropriate use of psychotropic drugs in this
  context
• Need for prompt and effective psychological
  interventions

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What the guideline covers

• Prediction and detection
• Management
• psychological treatments
• psychotropic medication
• risk discussion
• Organisation of care and service delivery

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Mental disorders during pregnancy and the
postnatal period

• Severe mental illness
• Schizophrenia
• Bipolar disorder
• Depression
• Mild, moderate or severe

• Anxiety disorders
• Panic disorder
• Generalised anxiety disorder
• Obsessivecompulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Eating disorders

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Prediction

• At first contact with maternity services, ask
  specific questions about

• Past or present severe mental illness
• Previous treatment by psychiatrist/specialist
  mental health team
• Family history of perinatal mental illness

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Detection

• Use the Whooley questions at first contact with
  primary care, at the booking visit, and
  postnatally
• Other self-report measures can be used as part of
  subsequent assessment

• Identify possible depression

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The Whooley questions

• 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?
• Consider a third question
• Is this something you feel you need or want help
  with?

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Psychosocial treatments

• provide treatment within 1 month of initial
  assessment
• Subthreshold symptoms
• Previous depression or anxiety
• 46 sessions of brief psychological treatment
  such as interpersonal therapy (IPT) or cognitive
  behavioural therapy (CBT)
• No previous depression or anxiety
• Social support such as regular informal
  individual or group-based support

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Management of depression

• Mild or moderate depression
• Self-help strategies
• Counselling (listening visits)
• Brief cognitive behavioural therapy
• Interpersonal psychotherapy

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Explaining risks

• Absolute and relative risk
• Decision aids
• Personalised view of risk
• Written material
• Needs of adolescents

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Prescribing antidepressant medication
Tricyclics (TCAs) have lower known risks during
pregnancy than other antidepressants. May be
more dangerous if taken in overdose
SSRIs taken after 20 weeks gestation may be
associated with an increased risk of persistent
pulmonary hypertension in the neonate
Venlafaxine may be associated with increased risk
of high blood pressure at high doses, toxicity
in overdose compared with other drugs and
increased difficulty in withdrawal
Fluoxetine has fewer known risks during
pregnancy than other SSRIs Paroxetine taken in
the first trimester may be associated with fetal
heart defects
All antidepressants carry the risk of withdrawal
or toxicity symptoms in neonates
Most antidepressants pass into the breast milk.
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Organisation of care

• Effective detection
• Effective assessment and referral to appropriate
  services
• Timely, appropriate management and treatment
• Accurate information about the disorder and the
  benefits and risks associated with interventions

• Provision of care in the most appropriate setting
• Appropriate communication about care with other
  services as required, taking into account
  confidentiality
• Choice

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Service deliveryperinatal mental health networks

• Coordinating board
• Specialist perinatal services in each locality
  providing direct services, consultation and
  advice
• Access to specialist expert advice on
  psychotropic medication
• Clear referral and management protocols

• Clearly defined roles and competencies for all
  professional groups
• Clearly defined pathways of care for service
  users

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Organisation of carethe stepped/tiered care
model
Personnel
Service
Core functions
Specialist perinatal mental health services
Psychiatrists, nurses, nursery nurses,
psychologists
Prevention, management treatment of
moderate/severe illness specialist advice and
consultation to primary care
CMHT (psychiatrists, psychologists, nurses
social workers)
Specialist mental health services
Assessment treatment referral to specialist
services inpatient care
GPs, obstetricians, psychological therapists,
PCMHWs
Primary care mental health services
Assessment and referral treatment of mild to
moderate illness
GPs, obstetricians, midwives, health visitors,
practice nurses
General healthcare services (maternity and
primary care)
Detection of history of and current mental
illness referral
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Perinatal clinical network

• Coordinating centre
• Coordinate associated inpatient
• units
• Coordinating board
• Network manager
• Local specialist service provision
• Protocol development and
• monitoring

• Specialist perinatal services
• Local specialist provision
• Managing admissions
• Consultancy, training to 10 and 20 care
• May be separate or part of specialist
• mental health service

• Specialist mental health services
• Local service provision
• Assessment and referral
• Consultancy and advice

• Primary care services
• Local service provision
• Assessment and referral

• Maternity services
• Local service provision
• Assessment and referral

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Specialist perinatal inpatient services

• Typically provide for a population of between
  25,000 and 50,000 live births with 612 beds
• Designed specifically for mothers and infants
• Staffing appropriate to care for infants
• Effective liaison with general medical and mental
  health services
• Full range of therapeutic services
• Closely integrated with community mental health
  services

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Key areas for implementation

• Coordination of service delivery
• The competencies of the multidisciplinary team
• Promoting prediction and detection
• Effective communication
• Appropriate use of medication

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Coordination of service delivery

• Engage with local commissioning partners to
  commission and develop a managed clinical network
  for perinatal mental health provision
• Develop clear pathways and protocols for referral
  and management to ensure effective care for women
  who need to access this service
• Develop clearly defined roles and competencies
  for all professional groups involved in the care
  pathway
• Review local provision of psychological therapies

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Competencies of the multidisciplinary team

• Ensure effective risk discussion and use of
  screening questions by providing appropriate
  training
• Ensure thorough knowledge of perinatal mental
  health issues and develop competencies
• Invest in training to ensure sufficient local
  provision of CBT and IPT

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Promoting prediction and detection

• Review use of tools used to detect depression
• Review use of the Edinburgh Postnatal Depression
  Scale with practitioners
• Incorporate key predictor questions (Whooley
  questions) into clinical practice

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Effective communication

• Review communication processes across settings as
  part of developing perinatal network activity
• Develop and agree communication pathways between
  service providers in line with developing
  perinatal network activity
• Review competence in issues of consent and
  capacity in relation to adolescents

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Appropriate use of medication

• Review local formularies in line with guideline
  recommendations related to antidepressant
  medication
• Review local formularies in line with guideline
  recommendations related to other psychotropic
  medication
• Work with local prescribers to raise awareness
  and promote effective prescribing practices

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Costs and savings

• Use NICE costing tools to identify
  recommendations with the greatest impact on
  resources
• interpersonal psychotherapy
• cognitive behavioural therapy
• managed clinical networks for the delivery of
  perinatal mental health services

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Access tools online

• Costing tools
• costing report
• costing template
• Audit criteria
• Implementation advice
• Available from www.nice.org.uk/CG045

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Access the guideline online

• Quick reference guide a summary
  www.nice.org.uk/CG045quickrefguide
• NICE guideline all of the recommendations
  www.nice.org.uk/CG045niceguideline
• Full guideline all of the evidence and
  rationale www.nice.org.uk/CG045fullguideline
• Understanding NICE guidance a plain English
  version www.nice.org.uk/CG045publicinfo