Pregnancy, childbirth and the puerperal period (up to the end of the first postnatal year) are important milestones in a woman’s life. They bring physical and psychological changes that necessitate adjustment to new roles and responsibilities, and increased contact with medical and obstetric services for routine health checks.

Pregnancy itself does not appear to be associated with an increased risk of new psychiatric diagnosis in general, risk of disorder recurrence, or deterioration.^1,2

In contrast, the postnatal period appears to be associated with higher rates of adjustment disorder, generalised anxiety disorder, and depression.^3-6 Women who have a history of serious mental illness are at higher risk of developing a postpartum relapse, even if they have been well during pregnancy.^7,8

Mortality

Psychiatric causes of maternal death (i.e. during or up to six weeks after the end of pregnancy) are more common than some direct causes of death;⁹ UK rates increased from 13/100,000 in 2006-2008 to 16/100,000 in 2010-2012, higher than, for example, mortality caused by haemorrhage or anaesthetic complications of childbirth.⁹ In the period between 2006 and 2008, 67 women died from psychiatric causes. The main cause of death was suicide (29 women), followed by accidental overdose from drug misuse (10 women).¹⁰

Mood disorders

A range of healthcare professionals, for example, the GP, midwife or psychiatrist may first identify early warning signs indicating a possible mood disorder. It is important that information is shared between healthcare professionals, as classic signs of depression (low mood, poor sleep, poor appetite) may be difficult to spot in the postnatal period. For example, a mother suffering from depression may be withdrawn, miss appointments, and perhaps will initially not bond well with her baby, leading to signs of distress in the baby, which may then further demoralise the mother. As the postnatal period is typically seen as being a happy period, it may be even more difficult and less acceptable for a mother with depression to report low mood and other associated symptoms.

Baby blues occurs in 30-80% of women in the first weeks postpartum. Women complain of fatigue, tearfulness, and difficulty concentrating. It is transient, starting in the first few days after delivery and resolving by day seven to ten.¹¹ If it continues, the mother may be suffering from postnatal depression.

Postnatal depression is more severe, follows a chronic course and may relapse outside the perinatal period.^12,13 Although 13% of patients (combined point prevalence) already have depression in pregnancy, the majority tend to be diagnosed after delivery: up to 19% from childbirth to three months postpartum.¹⁴ Prevalence of depression in the postnatal period is increased,^3,6 but it is possible that some such cases had already begun in pregnancy and represent late diagnoses.¹⁵

Bipolar affective disorder

The limited evidence available suggests that the incidence and relapse rates for bipolar disorder and schizophrenia are probably no higher in pregnant women than in women who are not pregnant.^15-17

Bipolar disorder may relapse in pregnancy, because women decide to stop their medication, worried about its teratogenic potential.¹⁸ It may also present as a first depressive episode in pregnancy or the postnatal period.

It is estimated that approximately 13% of women with bipolar II disorder are depressed in pregnancy and 22% in the postnatal period.^15,16 Women with bipolar ll disorder may present with a first depressive episode in the perinatal period, and may be diagnosed with unipolar depression, if hypomanic features are not identified in the history. This would lead to inappropriate treatment with antidepressants, possibly inducing rapid cycling or a hypomanic or manic episode.

In the postpartum period, women have a high risk of experiencing a severe relapse.^3,5,19,20

Postpartum psychosis

Postpartum psychosis has a sudden and dramatic presentation with delusions, mania, severe depression, or mixed episodes, with wide fluctuations of symptoms and severe mood swings. It can present within the first 90 days after childbirth, but usually starts in the first postnatal days, or even in the first hours after giving birth, and leads to high psychiatric admission rates.^3,17,21,22

The incidence is between 0.5 and 1 per 1,000 deliveries.^23,24 Risk factors include a previous episode of postpartum psychosis, a family history of postpartum psychosis, and a personal or family history of bipolar disorder.^8,25 Delusions and hallucinations may relate to the baby, are usually abrupt in onset and often fluctuate widely.¹⁷ Bewilderment may be a prominent feature.²¹

Anxiety disorders

It is difficult to make a clear assessment of anxiety disorders in pregnancy and postpartum, as they are comorbid with depressive disorders^15,16 and much research uses self-report questionnaires instead of psychiatric diagnosis. Some studies show that the prevalence of anxiety disorders among pregnant and postpartum women is comparable with women who are not pregnant,² while others find higher rates of anxiety. These include panic disorder, generalised anxiety disorder,4 and obsessive compulsive disorder.²⁶

However, there are also specific anxiety disorders related to pregnancy and parturition, such as tokophobia (phobia of childbirth)²⁷ and post traumatic stress disorder, following a traumatic childbirth, stillbirth or premature delivery.^28,29

Having a personal or family history of mental illness may already put some patients in contact with mental health services.^30,31

Being single or dealing with the break up of a relationship, having a violent and abusive partner, pregnancy complications, such as traumatic birth, caesarean section, perinatal death, and adverse life events with socioeconomic impact, such as loss of income and job, or being currently unemployed increases risk. There is no conclusive evidence about the effect of the mother’s age or educational status.^{2,6,15,16,22,32}

Screening tools

Depression and anxiety disorders

NICE recommends using the Two Question Depression Screen and the Generalized Anxiety Disorder³³ scale from the booking visit through to one year postpartum, see box 1.

A positive response to depression or anxiety questions warrants a full assessment using either PHQ-9 or the well validated Edinburgh Postnatal Depression Scale (EPDS) for depression, see box 2 above,^34-36 or the Generalized Anxiety Disorder-7 for anxiety. A score above 14 (out of 30) in pregnancy, or 10 postpartum on the EPDS, is widely used to indicate probable depressive disorder and should warrant a full assessment.³⁶

A recent systematic review of 37 studies concluded that, as a screening tool, EPDS was free, easy to administer, appeared useful across cultures and was generally acceptable to women.³⁶ Sensitivities and specificities for detecting major depression are variable, but many studies have found it to be a helpful adjunct to clinical assessment.³²

The EPDS is non-specific in that it detects a range of different diagnoses including adjustment disorder, post traumatic stress disorder and borderline personality disorder.³⁷

Drug and alcohol abuse

Clinicians should be vigilant for drug and alcohol misuse during the perinatal period. The Alcohol Use Disorders Identification Test (AUDIT; www.talkingalcohol.com/files/pdfs/WHO_audit.pdf)³⁸ is recommended in these women as part of a general discussion about mental health and wellbeing.

Psychosocial assessment

A thorough psychosocial assessment involving the mother as well as a third party, partner or close relative is required. This includes a full medical, psychiatric history and family history, covering perinatal or antenatal problems, a mental state examination and a risk assessment.

Monitoring in the antenatal and perinatal period should focus on common disorders, such as depression and anxiety.³⁹ Changes in appetite may be normal during pregnancy, but marked diet changes can be the result of mental illness. Body shape in pregnancy and after birth can be of particular concern for women with eating disorders.

Feeling excited, elated or high, needing less sleep or not being able to sleep, feeling energetic and being overtalkative may be early postpartum symptoms in women, who later develop puerperal psychosis.⁴⁰

The clinical picture usually overlaps with severe mood symptoms and can manifest as a mixture of depression, mania, mixed affective state, hallucinations, delusions and thought disorder. Sometimes it can resemble delirium, with altered level of consciousness, inability to concentrate, rapid onset and fluctuation of symptoms.⁴¹

A detailed risk assessment should involve self-neglect, self-harm, suicide, as well as risk to others, especially the baby, violence, abuse and child maltreatment.

Delusional homicidal ideas towards the baby can occur in puerperal psychosis, and patients should not be left alone with their infants until fully recovered.⁴¹

Perinatal disorders can be difficult to distinguish from severe chronic conditions, such as personality disorders. Repeat assessments help to separate women with transient stress symptoms from those with more enduring problems.⁴²

A team member with relevant experience should examine social needs. This may include living conditions, attitudes towards pregnancy, mother-baby relationship, quality of interpersonal relationships, and history of social isolation, domestic violence, abuse or trauma. Financial problems, employment, carer responsibilities and learning disability may be considered. Of high importance is agreement on the level of contact and support needed by a woman during pregnancy and the weeks after birth.

Examination and investigations

Physical examination is essential to exclude any coexisting medical conditions. Staff should monitor women taking psychiatric medication that may lead to discontinuation symptoms in mother and baby and to neonatal adaption syndromes. This includes weight gain and gestational diabetes during pregnancy.³⁹ Blood tests include routine haematology and biochemistry, thyroid function tests, and prolactin.

Management

Ideally, management of perinatal mental health should begin before conception. Women should be aware of the effect of their mental health problem and its treatment on a potential pregnancy and subsequent parenting and the effect pregnancy might have on their mental health.³⁹ Mothers with mental illness may require more careful monitoring to meet their physical health needs.43 The perceived needs of the fetus should not eclipse the mother’s needs, as effective management of the mother also has benefits for the rest of the family, the child⁴⁴ and the partner’s mental health.⁴⁵

A stepped approach to management entails low-key interventions for less severe illnesses, building up to specialist treatments for more severe and risky conditions.

Psychological therapies may be preferred over pharmacotherapy in the perinatal period to avoid risks to the child. The woman and her family must be helped to weigh up the potential consequences of drug treatment or withdrawal against the consequences of no treatment or a change in treatment.³⁹

Risk-benefit analyses change throughout the pregnancy and into the postnatal period, depending on whether the woman breastfeeds.

The treatment plan may have to be complex and involve changes in medication, depending on pharmacokinetics or teratogenicity and side effects of drugs changing throughout the trimesters of pregnancy. Women should avoid breastfeeding on carbamazepine, clozapine, lithium or valproate.³⁹

Reassurance and psycho-education may be sufficient for baby blues or mild depression and anxiety. Third sector support is available from the National Childbirth Trust (www.nct.org.uk) or the Association for Post Natal Illness (www.apni.org). For moderate to severe depression or anxiety, professional psychotherapy (such as CBT) is recommended, if necessary combined with an antidepressant.³⁹

Benzodiazepines should be avoided in the perinatal period, except for short-term treatment of severe agitation.³⁹ Insomnia may be addressed most safely with sleep hygiene, but if this is insufficient, promethazine is recommended.³⁹

Depot antipsychotic medication is to be avoided in the perinatal period and women on newer antipsychotic drugs require monitoring and advice about the risks of gestational diabetes.

Semi-sodium valproate, which is  contraindicated in women of childbearing age, carbamazepine and lamotrigine should not be given in the perinatal period. Sensitive advice about the risk of potential adverse outcomes of the pregnancy and help to stop the medication should be given, if patients become pregnant.

Lithium is given for bipolar disorder in pregnancy, if antipsychotics have been ineffective in controlling mood.

It increases the risk of fetal heart malformations, and high levels in breast milk may be toxic to the infant. Plasma levels must be monitored throughout because of changes in circulating fluid volume, dehydration must be avoided, and lithium must be stopped in labour and restarted immediately postpartum.³⁹ Psychosis or mania should be recognised and treated early to prevent adverse outcomes for mother and child.⁴⁶

Occasionally electroconvulsive therapy is given in the perinatal period for severe mental illness, particularly when the physical health of the woman or fetus are at risk.

Pregnant women with drug and alcohol problems should be encouraged to detoxify supported by specialist mental health and alcohol services. Where this is not feasible or acceptable, reduction of her substance abuse should be the target. Support should be continued after childbirth, as a woman who has detoxified and then restarts opiates is at high risk of an accidental overdose.³¹

Referral

Maternity services and general practice will usually share the care of pregnant women. It is important that information about mental health, as for physical health, flows freely between these and any other agencies involved. There may be resistance to disclose a psychiatric history, because of stigma and concerns that the baby will be taken into care,⁴⁷ but professionals should enquire about any relevant symptoms to ensure adequate assessment and treatment.

It may also be advisable to refer some women planning a pregnancy to a (specialist perinatal) mental health service for preconception counselling.

More than 90% of mental health problems can be managed in primary care.³⁹ Should the illness be more severe, require medication, or if there are risks to the mother or fetus, referral to a mental health team is recommended. Guidelines recommend that women are assessed by psychological services within two weeks of referral and that treatment starts within a month.³⁹ This requires services to be more flexible in approach, with shorter appointments, telephone appointments, or home visits, in order to meet these expectations. 

Postnatal psychotic disorders have a rapid onset and necessitate an urgent response from specialist mental health services;⁴⁸ women presenting with symptoms should be seen within four hours of referral.³⁹ Suicide continues to be a significant cause of maternal death in the UK,³¹ with infanticide being a rarer complication of maternal mental illness,⁴⁹ so that admission to a Mother and Baby Unit may be desirable, although admission of the mother to a psychiatric inpatient unit may be the only choice available. 

Specialist advice may also be able to provide reassurance, as mothers with perinatal obsessive-compulsive disorder may report distressing fears that they will harm their child. In such cases, harm to the infant is unlikely.⁵⁰