Antenatal and Postnatal Mental Health NICE Clinical Guideline

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Antenatal and Postnatal Mental Health NICE Clinical Guideline 45: 2007 DTV VTS Sept 2016

Antenatal and Postnatal Mental Health NICE Clinical Guideline 45: 2007 DTV VTS Sept 2016 Dr Rachel Lunney (& thanks to Dr Dinah Roy)

Objectives Consider cases of mental health problems in pregnancy and the postnatal period Revise

Objectives Consider cases of mental health problems in pregnancy and the postnatal period Revise NICE guidance on peri- & postnatal health problems Consider how to identify postnatal depression in primary care Discuss how to manage the spectrum of perinatal mental health disorders Consider the diagnosis and management of Bipolar Affective Disorder in Primary Care (Part 2 after tea)

Session Plan Discuss experiences of patients with mental disorders during pregnancy & postnatal period

Session Plan Discuss experiences of patients with mental disorders during pregnancy & postnatal period Presentation NICE CG 45 2014 Inc Case examples: discussion Tea Presentation: NICE Bipolar Disorder

Experiences of dealing with Mental Disorder during pregnancy and postnatal period Can you recall

Experiences of dealing with Mental Disorder during pregnancy and postnatal period Can you recall any memorable patients? Roles in Primary Care teams GP, Midwife, Health Visitor? Perspectives from secondary care attachments Paediatrics Psychiatry Obstetrics Questions and learning needs?

Self test quiz 1: True or False? Baby Blues occurs in the first 7

Self test quiz 1: True or False? Baby Blues occurs in the first 7 days after delivery Baby Blues affects >30% of women Postnatal Depression affects 10% of women Postpartum psychosis affects women in 1000 deliveries Women with Bipolar Disorder have a 1 in 4 risk of Postpartum psychosis Suicide is the commonest cause of maternal death in the 1 year postpartum

Self test quiz 1: True or False? Baby Blues occurs in the first 7

Self test quiz 1: True or False? Baby Blues occurs in the first 7 days after delivery T Baby Blues affects >30% of women T Postnatal Depression affects 10% of women T Postpartum psychosis affects women in 1000 deliveries T Women with Bipolar Disorder have a 1 in 4 risk of Postpartum psychosis F – worse: 1 in 2 & 40 -70% relapse risk postnatally Suicide is the commonest cause of maternal death in the 1 year postpartum T

Self test quiz 2: True or False? Risk factors for maternal mental health disorders

Self test quiz 2: True or False? Risk factors for maternal mental health disorders can be identified and acted on to affect outcomes Psychological treatment of mild depression in pregnancy reduces progression to more severe illness Tricyclic antidepressants are the safest drug choice in pregnancy SSRIs are safe throughout pregnancy Sertraline is the best choice for breast feeding mums Midwives are the best people to identify MH problems

Self test quiz 2: True or False? Risk factors for maternal mental health disorders

Self test quiz 2: True or False? Risk factors for maternal mental health disorders can be identified and acted on to affect outcomes T Psychological treatment of mild depression in pregnancy reduces progression to more severe illness T Tricyclic antidepressants are the safest drug choice in pregnancy F – Safer, tho overdose risk high SSRIs are safe throughout pregnancy F: Less safe >20 wks Sertraline is best choice for breast feeding mums T Midwives are the best people to identify MH problems F – Family, GP if contact, MH team

NICE CG 192: 2014 Antenatal and postnatal mental health: clinical management and service guidance

NICE CG 192: 2014 Antenatal and postnatal mental health: clinical management and service guidance Predict those at risk Detect those affected Treat those who need it

Case 1 Liz 26 yrs, 2 weeks post-partum full term normal delivery Breast feeding

Case 1 Liz 26 yrs, 2 weeks post-partum full term normal delivery Breast feeding her son Jack Supportive partner 5 year old daughter to previous partner PMH moderate depression aged 20. Treated w antidepressants, discontinued when pregnant Tearful, tired, poor appetite and sleep Biospsyhosocial (BPS) Assessment? Issues? Predict? Detect? Treat?

Case 2 Kelly 27 yrs, 5 weeks postpartum full term normal delivery PMH mod

Case 2 Kelly 27 yrs, 5 weeks postpartum full term normal delivery PMH mod postnatal depression after first son 3 y ago Weepy, tired, angry and low Tearful, agitated; no thought disorder, not suicidal Lack of support, husband works away, no family locally. Breast feeding BPS Assessment? Issues? Predict? Detect? Treat?

Case 3 Gillian 19 yrs, 7 months postpartum after NVD girl, Skye Dad’s mother

Case 3 Gillian 19 yrs, 7 months postpartum after NVD girl, Skye Dad’s mother concerned– couldn’t see her grandchild. PMH psychosis aged 17 yrs, MH section Met Skye’s Dad in psychiatric inpatient unit Hallucinations, paranoia Gillian’s mother obstructive? Mental health issues BPS Assessment? Issues? Predict? Detect? Treat?

Talking about depression in the postnatal period http: //www. nhs. uk/conditions/postnataldepression/p ages/introduction. aspx -

Talking about depression in the postnatal period http: //www. nhs. uk/conditions/postnataldepression/p ages/introduction. aspx - A Perinatal Psychiatrist & several women share perspectives

NICE CG 45: General principles of care Be culturally sensitive Build trust Elicit ideas,

NICE CG 45: General principles of care Be culturally sensitive Build trust Elicit ideas, concerns and expectations Be aware of stigma re mental disorders (MD) BJGP 2019: 60; 829 – Postnatal depression: women feel shame, & fear of appearing “not to cope” Ensure continuity of care Consider the impact on partner and children

Impact on partner and children JAMA 19 May 2010 Postnatal depression is common: 10

Impact on partner and children JAMA 19 May 2010 Postnatal depression is common: 10 -13% of women BUT 10% fathers suffer depression 1 st trimester - 1 st yr of life Most are affected between 3 -6 months post-partum Other family members – children? Wider family? Be alert to symptoms in women, partners and others

Which mental disorders may affect pregnancy and the postnatal period? Severe mental illness Anxiety

Which mental disorders may affect pregnancy and the postnatal period? Severe mental illness Anxiety disorders Schizophrenia Panic disorder Bipolar disorder Generalised anxiety disorder Depression Mild, moderate or severe Obsessive–compulsive disorder (OCD) Post-traumatic stress disorder (PTSD) Eating disorders

How do MH problems present? A range: adjustment reaction. . . mild. . .

How do MH problems present? A range: adjustment reaction. . . mild. . . mod. . . severe Severe mental illness: may be rapid & an emergency Women with all mental disorders have babies! Pregnancy, birth, childcare may precipitate problems Women may seek help then for ongoing problems Mental disorders increase the risks of pregnancy Mental disorders affect maternal, foetal & infant health & well being

NB Mental disorders/labels ‘Postnatal depression’ is not used in NICE 45: Why? Misused, to

NB Mental disorders/labels ‘Postnatal depression’ is not used in NICE 45: Why? Misused, to cover all mental disorders Specific guidance in NICE CG 45 for most MDs NICE guidance for each condition also exists ICD 10 and DSM- IV inform the guideline NB SIGN guidance uses ‘Postnatal depression’ SIGN 127, March 2012 ‘Management of perinatal mood disorders’ http: //sign. ac. uk/pdf/PAT 127. pdf

Why the need for this guideline: 1? Psychological health as important as physical health

Why the need for this guideline: 1? Psychological health as important as physical health Some MDs are unaffected by maternal period (see on*) Risk if meds stopped abruptly in mental disorders (MD) vs Medication risks to foetus and newborn baby vs Risks to mother & baby if MD undetected or untreated: Bonding, infant cognitive & emotional development Maternal suicide risk and rarely infanticide

Why the need for this guideline 2? Increased risk of relapse / first presentation

Why the need for this guideline 2? Increased risk of relapse / first presentation of bipolar disorder* More rapid onset of postnatal psychotic disorders* Urgent intervention may be required (Psyc Emerg’y) Need for careful use of psychotropic drugs Need for prompt and effective psychological interventions Effects on the extended family

Care starts Pre Conception “Discuss contraception and the risks of pregnancy (including relapse, risks

Care starts Pre Conception “Discuss contraception and the risks of pregnancy (including relapse, risks associated with stopping or changing medication, and risk to the foetus) with all women of child-bearing potential who have a mental disorder and/or who are taking psychotropic medication. Encourage them to discuss pregnancy plans. ” Also applies to breast feeding

Discussing risks with pts with Mental Disorders (MD) – Secondary Care Absolute and relative

Discussing risks with pts with Mental Disorders (MD) – Secondary Care Absolute and relative risk of treating MD vs not treating Foetal risks to those with no MD vs those with one on Rx Decision aids Personalised view of risk Written material Needs of adolescents

Risks of specific drugs Antipsychotics Raised prolactin levels: some Gestational diabetes and weight gain:

Risks of specific drugs Antipsychotics Raised prolactin levels: some Gestational diabetes and weight gain: olanzapine Agranulocytosis: clozapine Specific guidance in NICE 45 Lithium Foetal heart defects (up from 8 in 1000 to 60 in 1000) Ebstein’s anomaly (up from 1 in 20, 000 to 10 in 20, 000) High levels in breast milk Specific guidance in NICE 45

Risks of specific drugs Benzodiazepines Cleft palate and other foetal malformations Floppy baby syndrome

Risks of specific drugs Benzodiazepines Cleft palate and other foetal malformations Floppy baby syndrome Avoid routine use except in extreme agitation Withdraw slowly Carbamazepine, Lamotrigine, Valproate Carb: Neural tube defects (up from 6 in 10, 000 to 20 -50 in 10, 000). Other major foetal malformations including GI tract and cardiac abnormalities Lamot: oral cleft (risk approx 9 in 1000), Stevens–Johnson syndrome in breastfed babies Valp: Neural tube defects up from 6 in 10, 000 to 100– 200 in 10, 000 Specific guidance in NICE 45

Primary care - Predict: Prediction of Mental Disorders At first contact with services in

Primary care - Predict: Prediction of Mental Disorders At first contact with services in the antenatal and postnatal period, predict those at increased risk. Ask about : Past or present severe mental illness (Schiz’a, Bipolar, Postnatal Psychosis, Severe Depression) Previous treatment by psychiatrist/specialist mental health team Family history of perinatal mental illness Audit of records at booking appointment w GP/MW SIGN: PH Postpartum psychosis or Bipolar: Refer.

Detect: Detection of Depression Identify possible depression Use the ‘Whooley’ questions at first contact

Detect: Detection of Depression Identify possible depression Use the ‘Whooley’ questions at first contact with primary care, at the booking visit, and postnatally (4 -6 wk & 3 -4 mths) Positive screening? At risk? Concern? Used Edinburgh Postnatal Depression scale (Consider GAD-7 for Anxiety) Other conditions? Psychosis?

The ‘Whooley’ questions During the past month, have you often been bothered by feeling

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?

Subthreshold or Mild Symptoms Depression and/or anxiety that do not meet diagnostic criteria but

Subthreshold or Mild Symptoms Depression and/or anxiety that do not meet diagnostic criteria but significantly affect personal and social functioning: Previous depression or anxiety? 4– 6 sessions of brief psychological treatment such as interpersonal therapy (IPT) or cognitive behavioural therapy (CBT) No previous depression or anxiety ? Social support e. g. regular informal individual or group-based support Psychological treatments Provide treatment within 1 month of initial assessment, where appropriate – risks/benefits of meds change so start earlier

Treat: Management of Mild to Moderate Depression Pregnancy & Postnatal, consider: Self-help strategies Counselling

Treat: Management of Mild to Moderate Depression Pregnancy & Postnatal, consider: Self-help strategies Counselling (listening visits) Brief Cognitive Behavioural Therapy Interpersonal psychotherapy Moderate to severe? Balance risks & benefits of meds

Treat: Prescribing antidepressants: Moderate-Severe Depression Tricyclics (TCAs) have lower known risks during pregnancy than

Treat: Prescribing antidepressants: Moderate-Severe Depression Tricyclics (TCAs) have lower known risks during pregnancy than other antidepressants. May be more dangerous if taken in overdose Fluoxetine has lowest known risks during pregnancy vs other SSRIs Paroxetine taken in the first trimester may be associated with fetal heart defects Most antidepressants pass into the breast milk. 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 All antidepressants carry the risk of withdrawal or toxicity symptoms in neonates

Treat: Severe: Referral and initial care Severe mental illness suspected? (Schizophrenia or bipolar ).

Treat: Severe: Referral and initial care Severe mental illness suspected? (Schizophrenia or bipolar ). Refer to specialist mental health service If appropriate refer to a perinatal mental health service Ask about mental health at all subsequent contacts Current or past history of severe mental illness? Develop a written care plan: pregnancy, delivery and postnatal. Share the information Increase contact with mental health services Inpatient care for a mental disorder within 12 months of childbirth? Use a specialist mother and baby unit

Talking about postnatal mental health problems: MIND https: //www. youtube. com/watch? v=w 0 aa.

Talking about postnatal mental health problems: MIND https: //www. youtube. com/watch? v=w 0 aa. M 9 Xzw. TA MIND – 3 women share their experiences (6 mins)

Treat: Mother and Baby Unit, Morpeth Purpose-built 6 bed unit; en-suite double bedrooms For

Treat: Mother and Baby Unit, Morpeth Purpose-built 6 bed unit; en-suite double bedrooms For women experiencing mental health problems at 34+ weeks pregnant or with babies </=12 months old Takes referrals via Psychiatry from northern region & beyond Homely atmosphere fosters bonding between mother & child Access to range of psychiatric treatments and services Partner & family encouraged to help care for mother & baby Address: Beadnell Ward, St George's Park, Morpeth, NE 61 2 NU. Telephone number: 01670 501869.

Severe Depression. . . can lead to tragedy Sept 2013, Swindon – The Daily

Severe Depression. . . can lead to tragedy Sept 2013, Swindon – The Daily Mail Wife of Army major threw herself to death in front of 100 mph train 'while suffering severe post-natal depression‘ Emma Cadywould, 32 y, University researcher, found it 'hard to cope' with six-month-old son Inquest heard she was supported by husband, Major Steve Cadywould Baby Harrison would wake 20 times a night Family say Emma had expressed

Severe Depression ‘Since we lost Emma we have become aware of some astonishing and

Severe Depression ‘Since we lost Emma we have become aware of some astonishing and desperately sad statistics. In the UK, one mother a week will be totally overwhelmed by post natal depression and will tragically be lost to a loving family. Post-natal depression is a silent killer. ’ Emma Cadywould’s sister NICE aims to predict, detect & treat mental illness in women like Emma Read more: http: //www. dailymail. co. uk/news/article-2424496/Post-natal-depression-Wife-Army-majorthrew-train. html#ixzz 3 lr 5 P 4 OO 5

Postpartum Psychosis https: //www. youtube. com/watch? v=Bcaub. Xp. Qi. FI BBC Newsnight special report:

Postpartum Psychosis https: //www. youtube. com/watch? v=Bcaub. Xp. Qi. FI BBC Newsnight special report: 25 mins, for those who want to learn more

Organisation of care Effective detection Effective assessment and referral to appropriate services Timely, appropriate

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 NB Midwife shortages nationally; little GP input into maternity care – a challenge!

Summary NICE CG 45 Consider MH in all pregnant women or those planning a

Summary NICE CG 45 Consider MH in all pregnant women or those planning a pregnancy: ask if they are Destigmatise , build trust and continuity of care Consider impact on partner and family Balance and discuss risks of MD & meds to mum/baby Primary care has a “window of opportunity” to recognise, support and treat MH problems: Ask at booking app, postnatal 6 wk check, and 3 -4 months

Summary NICE CG 45 Predict those at risk: PMH (maternity), severe MD Detect those

Summary NICE CG 45 Predict those at risk: PMH (maternity), severe MD Detect those affected: screening questions, be aware Treat: Psychological Rx if mild/subthreshold symptoms Meds if severe and risks<benefits. SSRI usually Urgent referral for those with severe MD eg psychosis Specialist & Perinatal services: involve them early

Revisiting the case examples Applying NICE CG 45

Revisiting the case examples Applying NICE CG 45

Case 1 Liz 26 yrs, 2 weeks post-partum full term normal delivery Breast feeding

Case 1 Liz 26 yrs, 2 weeks post-partum full term normal delivery Breast feeding her son Jack Supportive partner 5 year old daughter to previous partner PMH moderate depression aged 20. Treated w antidepressants, discontinued when pregnant Tearful, tired, poor appetite and sleep BPS Assessment? Issues? Predict? Detect? Treat?

Case 1 Liz Learning points Baby Blues’ – timing of symptoms vs depression Prediction

Case 1 Liz Learning points Baby Blues’ – timing of symptoms vs depression Prediction of depression/ at risk: PMH is key Assessment and follow up Partner support, and impact on him ‘Listening visits’ from Health Visitor Antidepressants during pregnancy – when to stop?

Case 2 Kelly 27 yrs, 5 weeks postpartum full term normal delivery PMH mod

Case 2 Kelly 27 yrs, 5 weeks postpartum full term normal delivery PMH mod postnatal depression after first son 3 yr ago Weepy, tired, angry and low Tearful, agitated; no thought disorder, not suicidal Lack of support, husband works away, no family locally. Breast feeding BPS Assessment? Issues? Predict? Detect? Treat?

Case 2 Kelly Learning points Prediction of depression/ at risk mother? Detection of depression

Case 2 Kelly Learning points Prediction of depression/ at risk mother? Detection of depression in postnatal period Treatments – psychological / medical Antidepressants in breastfeeding women Team working – who else to involve?

Case 3 Gillian 19 yrs, 7 months postpartum after NVD girl, Skye Dad’s mother

Case 3 Gillian 19 yrs, 7 months postpartum after NVD girl, Skye Dad’s mother concerned– couldn’t see her grandchild. PMH psychosis aged 17 yrs, MH section Met Skye’s Dad in psychiatric inpatient unit Hallucinations, paranoia Gillian’s mother obstructive? Mental health issues BPS Assessment? Issues? Predict? Detect? Treat?

Case 3 Gillian Learning points Role of extended family and impact of relationships /

Case 3 Gillian Learning points Role of extended family and impact of relationships / FH mental illness Serious mental illness – prediction, vigilance, Referral to secondary care Mother and Baby (perinatal mental health) Unit Confidentiality vs best interests & capacity Child protection issues

Resources www. patient. co. uk www. nice. org. uk http: //www. nice. org. uk/nicemedia/live/11004/30432.

Resources www. patient. co. uk www. nice. org. uk http: //www. nice. org. uk/nicemedia/live/11004/30432. pdf SIGN 127, March 2012 ‘Management of perinatal mood disorders’ http: //sign. ac. uk/pdf/PAT 127. pdf http: //www. rcgp-curriculum. org. uk/PDF/curr_13_Mental_Health. pdf http: //www. rcpsych. ac. uk/quality, accreditationaudit/perinatalqual itynetwork. aspx http: //www. sign. ac. uk/pdf/PAT 127. pdf - Patient booklet: Mood disorders during pregnancy and after the birth of your baby http: //www. pandasfoundation. org. uk/help-and-information/supportservices/mother-and-baby-unit/beadnell-ward-morpeth. html http: //apni. org/ Association for Post Natal Illness