Antenatal and postnatal mental health: clinical management and service guidance

Use this guideline in conjunction with the NICE guideline for a specific mental health problem (see our topic pages on pregnancy and mental health and wellbeing) to inform assessment and treatment decisions in pregnancy and the postnatal period, and take into account:

• any variations in the nature and presentation of the mental health problem in pregnancy or the postnatal period

• the setting for assessment and treatment (for example, primary or secondary care services or in the community, the home or remotely by phone or computer)

• recommendations on assessment and care planning in pregnancy and the postnatal period

• recommendations 1.4.10 to 1.4.37 on starting, using and stopping treatment in pregnancy and the postnatal period

• recommendations 1.8.1 to 1.8.23 on treating specific mental health problems in pregnancy and the postnatal period. [2014]

Acknowledge the woman's role in caring for her baby and support her to do this in a non‑judgmental and compassionate way. [2014]

When working with girls and young women with a mental health problem in pregnancy or the postnatal period:

• be aware of the recommendations in section 1.4 of the NICE guideline on pregnancy and complex social factors

• ensure continuity of care for the mental health problem if care is transferred from adolescent to adult services. [2014]

Take into account and, if appropriate, assess and address the needs of partners, families and carers that might affect a woman with a mental health problem in pregnancy and the postnatal period. These include:

• the welfare of the baby and other dependent children and adults

• the role of the partner, family or carer in providing support

• the potential effect of any mental health problem on the woman's relationship with her partner, family or carer. [2014]

Develop an integrated care plan for a woman with a mental health problem in pregnancy and the postnatal period that sets out:

• the care and treatment for the mental health problem

• the roles of all healthcare professionals, including who is responsible for:

  • coordinating the integrated care plan

  • the schedule of monitoring

  • providing the interventions and agreeing the outcomes with the woman. [2014]

The healthcare professional responsible for coordinating the integrated care plan should ensure that:

• everyone involved in a woman's care is aware of their responsibilities

• there is effective sharing of information with all services involved and with the woman herself

• mental health (including mental wellbeing) is taken into account as part of all care plans

• all interventions for mental health problems are delivered in a timely manner, taking into account the stage of the pregnancy or age of the baby. [2014]

Provide culturally relevant information on mental health problems in pregnancy and the postnatal period to the woman and, if she agrees, her partner, family or carer. Ensure that the woman understands that mental health problems are not uncommon during these periods and instil hope about treatment. [2014]

Consider referring a woman to a secondary mental health service (preferably a specialist perinatal mental health service) for preconception counselling if she has a current or past severe mental health problem and is planning a pregnancy. [2014]

Discuss treatment and prevention options and any particular concerns the woman has about the pregnancy or the fetus or baby. [2014]

Discuss breastfeeding with all women who may need to take psychotropic medication in pregnancy or in the postnatal period. Explain to them the benefits of breastfeeding, the potential risks associated with taking psychotropic medication when breastfeeding and with stopping some medications in order to breastfeed. Discuss treatment options that would enable a woman to breastfeed if she wishes and support women who choose not to breastfeed. [2014]

If needed, seek more detailed advice about the possible risks of mental health problems or the benefits and harms of treatment in pregnancy and the postnatal period from a secondary mental health service (preferably a specialist perinatal mental health service). This might include advice on the risks and possible harms of taking psychotropic medication while breastfeeding and how medication might affect a woman's ability to care for her baby (for example, sedation). [2014]

Mental health professionals providing detailed advice about the possible risks of mental health problems or the benefits and harms of treatment in pregnancy and the postnatal period should include discussion of the following, depending on individual circumstances:

• 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

• the woman's response to any previous treatment

• the background risk of harm to the woman and the fetus or baby associated with the mental health problem and the risk to mental health and parenting associated with no treatment

• the possibility of the sudden onset of symptoms of mental health problems in pregnancy and the postnatal period, particularly in the first few weeks after childbirth (for example, in bipolar disorder)

• the risks or harms to the woman and the fetus 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 fetus or baby

• the risk or harms to the woman and the fetus or baby associated with stopping or changing a treatment. [2014]

When discussing likely benefits and risks of treatment with the woman (and, if she agrees, her partner, family or carer), acknowledge the woman's central role in reaching a decision about her treatment and that the role of the professional is to inform that decision with balanced and up‑to‑date information and advice. [2014]

Healthcare professionals working in universal services and those caring for women in mental health services should:

• assess the level of contact and support needed by women with a mental health problem (current or past) and those at risk of developing one

• agree the level of contact and support with each woman, including those who are not having treatment for a mental health problem

• monitor regularly for symptoms throughout pregnancy and the postnatal period, particularly in the first few weeks after childbirth. [2014]

Discuss and plan how symptoms will be monitored (for example, by using validated self‑report questionnaires, such as the Edinburgh Postnatal Depression Scale [EPDS], Patient Health Questionnaire [PHQ‑9] or the 7‑item Generalized Anxiety Disorder scale [GAD‑7]). [2014]

Recognise that the range and prevalence of anxiety disorders (including generalised anxiety disorder, obsessive‑compulsive disorder, panic disorder, phobias, post‑traumatic stress disorder and social anxiety disorder) and depression are under‑recognised throughout pregnancy and the postnatal period. [2014]

At a woman's first contact with primary care or her booking visit, and during the early postnatal period, consider asking the following depression identification questions as part of a general discussion about a woman's mental health and wellbeing:

• 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?
  
  Also consider asking about anxiety using the 2‑item Generalized Anxiety Disorder scale (GAD‑2):

• Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?

• Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?
  
  For questions about anxiety: an answer of 'not at all' scores 0; 'several days' scores 1; 'more than half the days' scores 2; 'nearly every day' scores 3. [2014, amended 2015]

If a woman responds positively to either of the depression identification questions in recommendation 1.5.4, is at risk of developing a mental health problem, or there is clinical concern, consider:

• using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ‑9) as part of a full assessment or

• referring the woman to her GP or, if a severe mental health problem is suspected, to a mental health professional. [2014]

If a woman scores 3 or more on the GAD‑2 scale, consider:

• using the GAD‑7 scale for further assessment or

• referring the woman to her GP or, if a severe mental health problem is suspected, to a mental health professional. [2014]

If a woman scores less than 3 on the GAD‑2 scale, but you are still concerned she may have an anxiety disorder, ask the following question:

• Do you find yourself avoiding places or activities and does this cause you problems?
  
  If she responds positively, consider:

• using the GAD‑7 scale for further assessment or

• referring the woman to her GP or, if a severe mental health problem is suspected, to a mental health professional. [2014]

At all contacts after the first contact with primary care or the booking visit, the health visitor, and other healthcare professionals who have regular contact with a woman in pregnancy and the postnatal period (first year after birth), should consider:

• asking the 2 depression identification questions and the GAD‑2 (see recommendation 1.5.4) as part of a general discussion about her mental health and wellbeing and

• using the EPDS or the PHQ‑9 as part of monitoring. [2014]

At a woman's first contact with services in pregnancy and the postnatal period, ask about:

• any past or present severe mental illness

• past or present treatment by a specialist mental health service, including inpatient care

• any severe perinatal mental illness in a first‑degree relative (mother, sister or daughter). [2014]

Refer to a secondary mental health service (preferably a specialist perinatal mental health service) for assessment and treatment, all women who:

• have or are suspected to have severe mental illness

• have any history of severe mental illness (during pregnancy or the postnatal period or at any other time).
  
  Ensure that the woman's GP knows about the referral. [2014]

If a woman has any past or present severe mental illness or there is a family history of severe perinatal mental illness in a first‑degree relative, be alert for possible symptoms of postpartum psychosis in the first 2 weeks after childbirth. [2014]

If a woman has sudden onset of symptoms suggesting postpartum psychosis, refer her to a secondary mental health service (preferably a specialist perinatal mental health service) for immediate assessment (within 4 hours of referral). [2014]

If alcohol misuse is suspected, use the Alcohol Use Disorders Identification Test (AUDIT) as an identification tool in line with recommendation 1.2.1.4 of the NICE guideline on alcohol-use disorders. [2014]

If drug misuse is suspected, follow the recommendations on identification and assessment in the NICE guideline on drug misuse in over 16s: psychosocial interventions. [2014]

For a woman with persistent subthreshold depressive symptoms, or mild to moderate depression, in pregnancy or the postnatal period, consider facilitated self‑help (delivered as described in NICE's guideline on depression in adults). [2014]

For a woman with a history of severe depression who initially presents with mild depression in pregnancy or the postnatal period, consider a TCA, SSRI or (S)NRI. [2014]

For a woman with moderate or severe depression in pregnancy or the postnatal period, consider the following options:

• a high-intensity psychological intervention (for example, CBT)

• a TCA, SSRI or (S)NRI if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and:

  • she has expressed a preference for medication or

  • she declines psychological interventions or

  • her symptoms have not responded to psychological interventions

• a high‑intensity psychological intervention in combination with medication if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and there is no response, or a limited response, to a high‑intensity psychological intervention or medication alone. [2014]

If a woman who is taking a TCA, SSRI or (S)NRI for mild to moderate depression becomes pregnant, discuss stopping the medication gradually and consider facilitated self‑help (delivered as described in NICE's guideline on depression in adults). [2014]

If a pregnant woman is taking a TCA, SSRI or (S)NRI for moderate depression and wants to stop her medication, take into account previous response to treatment, stage of pregnancy, risk of relapse, risk associated with medication and her preference, and discuss with her the following options:

• switching to a high‑intensity psychological intervention (for example, CBT)

• changing medication if there is a drug that is effective for her with a lower risk of adverse effects. [2014]

If a pregnant woman is taking a TCA, SSRI or (S)NRI for severe depression, take into account previous response to treatment, stage of pregnancy, risk of relapse, risk associated with medication and her preference, and discuss with her the following options:

• continuing with the current medication

• changing medication if there is a drug that is effective for her with a lower risk of adverse effects

• combining medication with a high‑intensity psychological intervention (for example, CBT)

• switching to a high‑intensity psychological intervention (for example, CBT) if she decides to stop taking medication. [2014]

For a woman with tokophobia (an extreme fear of childbirth), offer an opportunity to discuss her fears with a healthcare professional with expertise in providing perinatal mental health support in line with the NICE guideline on caesarean birth. [2014]

For a woman with persistent subthreshold symptoms of anxiety in pregnancy or the postnatal period, consider facilitated self‑help. This should consist of use of CBT‑based self‑help materials over 2 to 3 months with support (either face to face or by telephone) for a total of 2 to 3 hours over 6 sessions. [2014]

For a woman with an anxiety disorder in pregnancy or the postnatal period, offer a low-intensity psychological intervention (for example, facilitated self‑help) or a high‑intensity psychological intervention (for example, CBT) as initial treatment in line with the recommendations set out in the NICE guideline for the specific mental health problem and be aware that:

• only high‑intensity psychological interventions are recommended for post‑traumatic stress disorder

• high‑intensity psychological interventions are recommended for the initial treatment of social anxiety disorder

• progress should be closely monitored and a high‑intensity psychological intervention offered within 2 weeks if symptoms have not improved. [2014]

If a woman who is taking a TCA, SSRI or (S)NRI for an anxiety disorder becomes pregnant, discuss with her the following options:

• stopping the medication gradually and switching to a high‑intensity psychological intervention (for example, CBT)

• continuing with medication if she understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and:

  • has expressed a preference for medication or

  • declines psychological interventions or

  • her symptoms have not responded to psychological interventions

• changing medication if there is a drug that is effective for her with a lower risk of adverse effects

• combining medication with a high‑intensity psychological intervention (for example, CBT) if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and there is no response, or a limited response, to a high‑intensity psychological intervention alone. [2014]

For a woman with an eating disorder in pregnancy or the postnatal period:

• offer a psychological intervention in line with the NICE guideline on eating disorders

• monitor the woman's condition carefully throughout pregnancy and the postnatal period

• assess the need for fetal growth scans

• discuss the importance of healthy eating during pregnancy and the postnatal period in line with the NICE guideline on maternal and child nutrition

• advise her about feeding the baby in line with the NICE guideline on maternal and child nutrition and support her with this. [2014]

If hazardous drug or alcohol misuse is identified in pregnancy or the postnatal period, refer or offer brief interventions in line with section 1.3.1 of the NICE guideline on drug misuse in over 16s: psychosocial interventions or the NICE guideline on alcohol-use disorders: prevention. [2014]

If harmful or dependent drug or alcohol misuse is identified in pregnancy or the postnatal period, refer the woman to a specialist substance misuse service for advice and treatment. [2014]

Offer assisted alcohol withdrawal in collaboration with specialist mental health and alcohol services (preferably in an inpatient setting) to pregnant women who are dependent on alcohol. Work with a woman who does not want assisted alcohol withdrawal to help her reduce her alcohol intake. [2014]

Offer detoxification in collaboration with specialist mental health and substance misuse services to pregnant women who are dependent on opioids. Monitor closely after completion of detoxification. Work with a woman who does not want detoxification to help her reduce her opioid intake. Recognise the risk of accidental overdose in women who stop or reduce drug misuse in pregnancy but start misusing again after childbirth. [2014]

Consider psychological interventions for women with bipolar disorder. This includes:

• CBT, IPT and behavioural couples therapy for bipolar depression

• structured individual, group and family interventions designed for bipolar disorder to reduce the risk of relapse, particularly when medication is changed or stopped. [2014]

If a pregnant woman develops mania or psychosis and is not taking psychotropic medication, offer an antipsychotic. [2014]

Consider psychological interventions (CBT or family intervention) delivered as described in the section on how to deliver psychological interventions in the NICE guideline on psychosis and schizophrenia in adults, for a woman with psychosis or schizophrenia who becomes pregnant and is at risk of relapse arising from:

• stress associated with pregnancy or the postnatal period

• a change in medication, including stopping antipsychotic medication. [2014]

Offer an antipsychotic in line with recommendations 1.5.3 and 1.5.4 of the NICE guideline on bipolar disorder as prophylactic medication if a woman with bipolar disorder:

• becomes pregnant and is stopping lithium, or

• plans to breastfeed. [2014]

If a pregnant woman with bipolar disorder develops mania while taking prophylactic medication:

• check the dose of the prophylactic medication and adherence

• increase the dose if the prophylactic medication is an antipsychotic

• suggest changing to an antipsychotic if she is taking another type of prophylactic medication

• consider lithium if there is no response to an increase in dose or change of drug and the woman has severe mania

• consider electroconvulsive therapy (ECT) if there has been no response to lithium. [2014]

Advise pregnant women who have a sleep problem about sleep hygiene (including having a healthy bedtime routine, avoiding caffeine and reducing activity before sleep). For women with a severe or chronic sleep problem, consider promethazine.

In December 2014, this was an off-label use of promethazine. See NICE's information on prescribing medicines. [2014]

Consider electroconvulsive therapy (ECT) for pregnant women with severe depression, severe mixed affective states or mania, or catatonia, whose physical health or that of the fetus is at serious risk. [2014]

A pregnant woman requiring rapid tranquillisation should be treated according to the NICE guidelines on the short-term management of violence and aggression, psychosis and schizophrenia and bipolar disorder (see our topic page on mental health and wellbeing for details), except that:

• she should not be secluded after rapid tranquillisation

• restraint procedures should be adapted to avoid possible harm to the fetus

• when choosing an agent for rapid tranquillisation in a pregnant woman, an antipsychotic or a benzodiazepine with a short half‑life should be considered; if an antipsychotic is used, it should be at the minimum effective dose because of neonatal extrapyramidal symptoms; if a benzodiazepine is used, the risks of floppy baby syndrome should be taken into account

• during the perinatal period, the woman's care should be managed in close collaboration with a paediatrician and an anaesthetist. [2007]

After childbirth, review and assess the need for starting, restarting or adjusting psychotropic medication as soon as a woman with a past or present severe mental illness is medically stable. [2014]

If a woman has taken psychotropic medication during pregnancy, carry out a full neonatal assessment of the newborn baby, bearing in mind:

• the variation in the onset of adverse effects of psychotropic medication

• the need for further monitoring

• the need to inform relevant healthcare professionals and the woman and her partner, family or carer of any further monitoring, particularly if the woman has been discharged early. [2014]

If there has been alcohol or drug misuse in pregnancy, offer treatment and support after childbirth to both the woman and the baby, including:

• a full neonatal assessment for any congenital abnormalities or neonatal adaptation syndrome

• continuing psychological treatment and support for the woman

• monitoring of the baby. [2014]

Offer advice and support to women who have had a traumatic birth or miscarriage and wish to talk about their experience. Take into account the effect of the birth or miscarriage on the partner and encourage them to accept support from family and friends. [2014]

Offer women who have post‑traumatic stress disorder, which has resulted from a traumatic birth, miscarriage, stillbirth or neonatal death, a high-intensity psychological intervention (trauma‑focused CBT or eye movement desensitisation and reprocessing [EMDR]) in line with the NICE guideline on post-traumatic stress disorder. [2014]

Do not offer single‑session high‑intensity psychological interventions with an explicit focus on 're‑living' the trauma to women who have a traumatic birth. [2014]

Discuss with a woman whose baby is stillborn or dies soon after birth, and her partner and family, the option of 1 or more of the following:

• seeing a photograph of the baby

• having mementos of the baby

• seeing the baby

• holding the baby.
  
  This should be facilitated by an experienced practitioner and the woman and her partner and family should be offered a follow‑up appointment in primary or secondary care. If it is known that the baby has died in utero, this discussion should take place before the delivery, and continue after delivery if needed. [2014]

Encourage women with a mental health problem to breastfeed, unless they are taking carbamazepine, clozapine or lithium (valproate is not recommended to treat a mental health problem in women or girls of childbearing potential – see the MHRA safety advice on valproate use by women and girls). However, support each woman in the choice of feeding method that best suits her and her family. [2014, amended 2020]

When assessing the risks and benefits of TCAs, SSRIs or (S)NRIs for women who are breastfeeding, take into account:

• the limited data about the safety of these drugs and

• the risks associated with switching from a previously effective medication.
  
  Seek advice from a specialist (preferably from a specialist perinatal mental health service) if needed for specific drugs. See also the UK Drugs in Lactation Advisory Service for information on the use of specific drugs. [2014, amended 2017]

When assessing the risks and benefits of antipsychotic medication for women who are breastfeeding, take into account:

• the limited data on the safety of these drugs and

• the level of antipsychotic medication in breast milk depends on the drug. [2014]

If a woman is taking psychotropic medication while breastfeeding, monitor the baby for adverse effects. [2014]

Recognise that some women with a mental health problem may experience difficulties with the mother–baby relationship. Assess the nature of this relationship, including verbal interaction, emotional sensitivity and physical care, at all postnatal contacts. Discuss any concerns that the woman has about her relationship with her baby and provide information and treatment for the mental health problem. [2014]

Consider further intervention to improve the mother–baby relationship if any problems in the relationship have not resolved. [2014]