Antenatal Mental Health Problems

Mental health problems seen in the antenatal period include anxiety disorders, depression, bipolar disorder and schizophrenia.¹

Treating mental health conditions in pregnancy can be challenging as the risks and benefits of various treatment options need to be considered in terms of the welfare of the mother and the unborn child, and any individual needs and preferences.

Communication with the patient, their families and if relevant carers is vital and information should be given in a format that can be understood, taking into account any barriers such as language, culture or disability.

Due regard should be given to the prevailing legislation and guidelines² on consent, including the Mental Health Act and the Mental Capacity Act.³
Treating adolescent patients can raise additional issues such as Gillick competence, child protection concerns, and the Children Act

At a woman's first contact with services in both the antenatal and the postnatal periods, healthcare professionals should ask about:

• Past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in the postnatal period and severe depression
• Previous treatment by a psychiatrist/specialist mental health team including inpatient care
• A family history of perinatal mental illness

If a serious mental health illness is suspected or diagnosed:

• Consult with/refer to specialist mental health colleagues.
• Ask about mental health at all subsequent consultations.
• Develop a written care plan in collaboration with the patient, her family, carers and specialist mental health services which should deal with the management of the condition in pregnancy, delivery and the postnatal period. This should be recorded in all copies of the patient's notes (i.e. those held in primary and secondary care, and by the woman herself).

Depression

Despite the focus on postnatal depression, antenatal depression is still of considerable importance. A study of depression in the perinatal period estimated the point prevalence of major depression (i.e. the rate at a particular point in time) as 3.8% at the end of the first trimester, 4.9% at the end of the second and 3.1% at the end of the third trimester.⁴ Severe depression is associated with an increased rate of obstetric complications, still birth, suicide attempts, postnatal specialist care for the infant and low-birthweight infants.⁵The following interventions should be considered:

Mild Depression

• In patients planning a pregnancy and who are on antidepressants, withdraw the drug and observe over time ('watchful waiting').
• If interventions are required consider guided self-help, self-directed cognitive behaviour therapy(CBT)⁶ with or without computer assistance (C-CBT), or exercise.⁷ If this fails, consider brief psychological treatments such as counselling, CBT or interpersonal psychotherapy (IPT). The same considerations would apply to a patient presenting with an unplanned pregnancy.
• For patients with a history of severe depression who present with a new episode of mild depression, consider antidepressants if the patient declines psychological treatment or such treatment fails.

Moderate and severe depression

• In patients planning a pregnancy whose last episode of depression was moderate, consider switching any antidepressant she may be taking to CBT/IPT or substitute the antidepressant for one with lower risk (see below). If the patient's last episode was severe, consider combining CBT/IPT with a low risk antidepressant. Apply the same principles to patients with an unplanned pregnancy.
• Treat a patient with a new episode of moderate depression as you would a patient with first presenting mild depression.
• For patients with a history of depression presenting with a moderate recurrence or for those with a new severe episode, consider CBT/IPT, an antidepressant, or both depending on the woman's wishes and response to treatment.
• For treatment-resistant depression, follow the NICE clinical guidance.⁸ Consider a different antidepressant, or ECT (electro-convulsive therapy)⁹ before a combination of drugs is used. Lithium should be avoided.

Generalised anxiety disorder (GAD) and panic disorder

• For patients planning a pregnancy or presenting with an unplanned pregnancy, consider withdrawing existing medication and referring for CBT. Use a low risk drug if medication is required.
• Patients with a first attack of GAD during pregnancy should be offered CBT.
• Patients with a first attack of panic disorder in pregnancy should be offered CBT, self-help or C-CBT prior to considering drug treatment. If a drug has to be used, consider a safer alternative than the normal first line treatment, paroxetine.

Obsessive-compulsive disorder (OCD)

For patients who are planning a pregnancy or already pregnant, consider withdrawing medication and starting psychological therapy. For patients who are not already on medication, psychotherapy should be considered first line. If medication is required, avoid paroxetine.

Post-traumatic stress disorder

For patients planning a pregnancy or already pregnant, withdraw medication - usually an antidepressant, and offer trauma-focused CBT or Eye Movement Desensitisation and Reprocessing therapy (EMDR),¹⁰ Olanzipine is sometimes prescribed in cases resistant to a selective serotonin re-uptake inhibitor (SSRI) but should not be given in this circumstance.

Eating Disorders

• Anorexia Follow the NICE guidance on eating disorders.¹¹ This recommends assessment and psychological therapy in an outpatient setting wherever possible. In severe cases, inpatient treatment may be required for re-feeding. Medication used in anorexia may include antipsychotics, tricyclic antidepressants, macrolide antibiotics, and some antihistamines. In pregnancy, it is particularly important to balance risks against benefits, and if drugs cannot be avoided, to use the least harmful options (see below).
• Binge Eating Patients who are planning a pregnancy or already pregnant should be treated as per depression.
• Bulimia For patients planning a pregnancy or already pregnant, consider withdrawing medication gradually. If the problem persists, refer for specialist treatment.

Bipolar Disorder

• This is classified as a serious mental disorder and is now known to encompass a spectrum of conditions. Some patients have severe episodes of mania interspersed with severe bouts of depression (bipolar I) , some have less polarised forms of mental disturbance, and many seem to spend large amount of time in a depressive phase (bipolar II). Epidemiological studies consistently report a lifetime prevalence of 1% for bipolar I and 0.2-2% for bipolar II. The first episode usually occurs before the age of 30.¹²
• Patients planning a pregnancy should remain on a typical or atypical anti-psychotic if treatment is required to control mania, but a low dose should be chosen.If depression returns after stopping prophylactic medication, CBT should be offered.
• An SSRI is the first-line drug treatment for a depressive episode, but paroxetine should be avoided.
• If a pregnant patient is stable but likely to relapse if an antipsychotic is withdrawn, it should be continued.
• If a patient with an unplanned pregnancy is taking lithium, an antipsychotic should be substituted. If a patient develops an acute episode of mania during pregnancy, check compliance with prophylactic medication and institute or increase the dose as appropriate, In the event of treatment failure and severe mania, consider ECT, lithium or rarely valproate. If valproate has to be prescribed, consider augmenting with other antimanic medication (except carbamazepine).
• Mild depressive symptoms may be managed with self-help approaches (guided self-help, C-CBT), or brief psychological treatments. Moderate depression may also respond to CBT. Moderate or severe depression may need medication combined with CBT. Quetiapine alone, or any SSRI except paroxetine, may be considered, as well as a prophylactic antipsychotic. The patient should be monitored closely for signs of mania or hypomania, and the SSRI stopped if this develops.

Schizophrenia

This is a major psychiatric disorder which affects about 1 in 100 people, and is usually first presents in the 20-30 age group. It should be treated as per the NICE guidance on schizophrenia¹³ except that patients on an atypical antipsychotic should be switched to haloperidol, chlorpromazine or trifluoperazine.

Sleep Problems

• Women with mental health problems who have sleep disorders should be advised about sleep hygiene measures (e.g. bedtime routines, avoiding caffeine, reduced activity before sleep).¹⁴
• Low dose amitriptyline or chlorpromazine can be given if the problem is serious and chronic and does not respond to sleep hygiene measures.

ECT

This may be considered for pregnant women who have :

• Severe depression
• Severe mixed affective states or mania in the context of bipolar disorder
• Catatonia

and whose physical health or that of the fetus is at serious risk.

Rapid Tranquilisation

There may be occasions when a woman with disturbed/violent behaviour needs to be restrained and rapidly tranquilized (e.g. bipolar disorder, schizophrenia). The appropriate NICE guidance for the patient group needs to be followed but in addition:

• A restrained patient should not be secluded.
• Any restraint should be so adjusted as to not harm the fetus.
• An antipsychotic or benzodiazepine with a short half-life should be considered.
• Care should be planned with the involvement of an anaesthetist and paediatrician.

It should not be assumed that all prescribing in pregnancy should be avoided, as there is evidence that untreated mental health problems can lead to more harm than the drugs themselves. It is however known that many psychoactive drugs can cause fetal toxicity, and whenever medication is prescribed de novo in pregnancy the risks and benefits should be assessed. Women with chronic mental health problems should similarly be reviewed, and switched to a less harmful option if available.

Antidepressants

• Tricyclics As a class carry the lowest known risk to the fetus, although they are more toxic in overdose than most other antidepressants (except lofepramine). There are some risks associated with individual members of the group (e.g. positive evidence of fetal risk with imipramine, increased risk of spontaneous abortion with trazodone).
• SSRIs These do not appear riskier than other antidepressants as a class, although again there are individual problems. A warning was issued in 2005 advising that paroxetine should be avoided in the first trimester, as there were reports of congenital malformations, especially cardiac malformations, such as atrial and ventricular septal defects. Fluoxetine is considered the safest of the group.
• MAOIs There is limited evidence of an increased risk of congenital malformation.
• Novel drugs Some drugs such as mirtazipine are too new to have extensive data about safety. Venlafaxine is not recommended by the manufacturers in pregnancy.
• Neonatal complications Pulmonary hypertension, jitteriness, crying and hypotonia have been reported in women taking antidepressants. Most were taking SSRIs but a few were taking tricyclics.

Anxiolytics and Hypnotics

Benzodiazepines There is suggestion that exposure to benzodiazepines in the first trimester may be linked to congenital malformations (e.g. cleft palate). Exposure in later pregnancy can result in 'floppy baby syndrome' and withdrawal symptoms in the neonate. This class of drug should only be given for chronic severe symptoms, and prescribing limited to no longer than four weeks.
'Z' hypnotics (zopiclone, zolpidem and zaleplon) This is very little data on the fetotoxicity of these drugs, although studies on zopiclone have not shown any association with major malformations compared to controls. There have been reports of hypothermia and respiratory depression when taken in the third trimester. In view of the lack of data, the British National Formulary recommends avoiding this class of drugs in pregnancy.

Antipsychotics

The general consensus is that most antipsychotics are not associated with malformations.

• Clozapine This should not be routinely used in pregnancy because of the theoretical risk of agranulocytosis in the fetus, and the woman should be switched to another drug.
• Olanzipine This can cause weight gain and gestational diabetes, so risk factors such as existing weight, ethnicity and family history need to be taken into account.
• Depot antipsychotics These should be avoided as there is insufficient safety data, and there have been reports of extrapyramidal effects in babies several months after maternal administration.
• Anticholinergic Drugs Although frequently used as an adjunct to stave off extrapyramidal side effects, they should be avoided in pregnancy It is safer to alter the dosage and timings of the antipsychotic.

Valproate

This has a high teratogenic potential in the first 28 days of pregnancy. Women planning a pregnancy and requiring treatment for bipolar disorder should be switched to another antipsychotic. Women with an unplanned pregnancy should be switched as soon as possible. If there is no alternative to valproate, doses should be limited to a maximum of 1 gram per day, administered in divided doses and in the slow release form, with 5 mg/day folic acid.

Lithium

Lithium can cause cardiac defects in the fetus, particularly if taken in the first trimester. For a woman planning a pregnancy, lithium should be tailed off over four weeks (although this does not entirely remove the risk). If the patient required further treatment, another antipsychotic should be introduced. If lithium the only medication that controls symptoms and the patient is not going to breastfeed, it can be re-introduced in the second trimester.

Carbamazepine and lamotrigine

These should be avoided in pregnancy because of the risk of neural tube defects and other malformations. A safer antipsychotic should be substituted.