Nice Guidelines of Management of Perinatal Mental Health

Antenatal and postnatal
mental health: clinical

management and service
guidance
Clinical guideline
Published: 17 December 2014
www.nice.org.uk/guidance/cg192
© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-

rights). Last updated 11 February 2020
Antenatal and postnatal mental health: clinical management and service guidance (CG192)
Your responsibility
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual needs,
preferences and values of their patients or the people using their service. It is not mandatory to
apply the recommendations, and the guideline does not override the responsibility to make
decisions appropriate to the circumstances of the individual, in consultation with them and their
families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be
applied when individual professionals and people using services wish to use it. They should do so in
the context of local and national priorities for funding and developing services, and in light of their
duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a
way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of implementing
NICE recommendations wherever possible.
© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- Page 2
conditions#notice-of-rights). Last updated 11 February 2020 of 53
Contents
Overview ................................................................................................................................................................................ 5
Who is it for? ...................................................................................................................................................................................... 5
Introduction .......................................................................................................................................................................... 6
Medicines ............................................................................................................................................................................................ 7
Key priorities for implementation ................................................................................................................................ 8
Considerations for women of childbearing potential ........................................................................................................ 8
Principles of care in pregnancy and the postnatal period ................................................................................................ 9
Treatment decisions, advice and monitoring for women who are planning a pregnancy, pregnant or in
the postnatal period ........................................................................................................................................................................ 10
Recognising mental health problems in pregnancy and the postnatal period and referral ............................... 12
Providing interventions in pregnancy and the postnatal period................................................................................... 12
Considerations for women and their babies in the postnatal period .......................................................................... 13
The organisation of services ........................................................................................................................................................ 13
1 Recommendations ..........................................................................................................................................................15
Terms used in this guideline ......................................................................................................................................................... 15
1.1 Using this guideline in conjunction with other NICE guidelines ............................................................................ 16
1.2 Considerations for women of childbearing potential ................................................................................................ 17
1.3 Principles of care in pregnancy and the postnatal period ........................................................................................ 18
1.4 Treatment decisions, advice and monitoring for women who are planning a pregnancy, pregnant or
in the postnatal period ................................................................................................................................................................... 19
1.5 Recognising mental health problems in pregnancy and the postnatal period and referral ........................ 28
1.6 Assessment and care planning in pregnancy and the postnatal period .............................................................. 31
1.7 Providing interventions in pregnancy and the postnatal period ........................................................................... 33
1.8 Treating specific mental health problems in pregnancy and the postnatal period ......................................... 34
1.9 Considerations for women and their babies in the postnatal period................................................................... 40
1.10 The organisation of services .............................................................................................................................................. 43
2 Research recommendations .......................................................................................................................................46
2.1 Preventing postpartum psychosis...................................................................................................................................... 46
2.2 The safety of drugs for bipolar disorder in pregnancy and the postnatal period ............................................ 46
2.3 Psychological interventions focused on the mother-baby relationship ............................................................. 47
2.4 Structured clinical management for moderate to severe personality disorders in pregnancy and the
postnatal period................................................................................................................................................................................ 48
2.5 Psychological interventions for moderate to severe anxiety disorders in pregnancy .................................. 49
More information ............................................................................................................................................................................. 50
Update information ............................................................................................................................................................51
Strength of recommendations .................................................................................................................................................... 52
This guideline replaces CG45.
This guideline partially replaces CG62.
This guideline is the basis of QS115 and QS37.
Overview
This guideline covers recognising, assessing and treating mental health problems in women who are
planning to have a baby, are pregnant, or have had a baby or been pregnant in the past year. It
covers depression, anxiety disorders, eating disorders, drug- and alcohol-use disorders and severe
mental illness (such as psychosis, bipolar disorder and schizophrenia). It promotes early detection
and good management of mental health problems to improve women's quality of life during
pregnancy and in the year after giving birth.
MHRA advice on valproate:

valproate:In February 2020, we amended recommendations on anticonvulsants
for mental health problems in line with the MHRA guidance on valproate use by women and girls.
The MHRA states that valproate must not be used in women and girls of childbearing potential
(including young girls who are likely to need treatment into their childbearing years), unless other
options are unsuitable and the pregnancy prevention programme is in place. This is because of the
risk of malformations and developmental abnormalities in the baby. See update information for
details.
Who is it for?
• Healthcare professionals
• Commissioners
• Social services
• Voluntary and private sectors
• Women who have, or are at risk of, mental health disorders during pregnancy and the
postnatal period and their partners, families and carers
Introduction
This guideline updates and replaces NICE clinical guideline 45. See update information for
details.
In pregnancy and the postnatal period, many mental health problems have a similar nature, course
and potential for relapse as at other times. However, there can be differences; for example, bipolar
disorder shows an increased rate of relapse and first presentation in the postnatal period. Some
changes in mental health state and functioning (such as appetite) may represent normal pregnancy
changes, but they may be a symptom of a mental health problem.
The management of mental health problems during pregnancy and the postnatal period differs
from at other times because of the nature of this life stage and the potential impact of any
difficulties and treatments on the woman and the baby. There are risks associated with taking
psychotropic medication in pregnancy and during breastfeeding and risks of stopping medication
taken for an existing mental health problem. There is also an increased risk of postpartum
psychosis.
Depression and anxiety are the most common mental health problems during pregnancy, with
around 12% of women experiencing depression and 13% experiencing anxiety at some point; many
women will experience both. Depression and anxiety also affect 15-20% of women in the first year
after childbirth. During pregnancy and the postnatal period, anxiety disorders, including panic
disorder, generalised anxiety disorder (GAD), obsessive-compulsive disorder (OCD),
post-traumatic stress disorder (PTSD) and tokophobia (an extreme fear of childbirth), can occur on
their own or can coexist with depression. Psychosis can re-emerge or be exacerbated during
pregnancy and the postnatal period. Postpartum psychosis affects between 1 and 2 in 1000 women
who have given birth. Women with bipolar I disorder are at particular risk, but postpartum
psychosis can occur in women with no previous psychiatric history.
Changes to body shape, including weight gain, in pregnancy and after childbirth may be a concern
for women with an eating disorder. Although the prevalence of anorexia nervosa and bulimia
nervosa is lower in pregnant women, the prevalence of binge eating disorder is higher. Smoking and
the use of illicit drugs and alcohol in pregnancy are common, and prematurity, intrauterine growth
restriction and fetal compromise are more common in women who use these substances,
particularly women who smoke.
Between 2006 and 2008 there were 1.27 maternal deaths per 100,000 maternal deliveries in the
UK as a result of mental health problems. Although response to treatment for mental health
problems is good, these problems frequently go unrecognised and untreated in pregnancy and the
postnatal period. If untreated, women can continue to have symptoms, sometimes for many years,
and these can also affect their babies and other family members.
This guideline makes recommendations for the recognition, assessment, care and treatment of
mental health problems in women during pregnancy and the postnatal period (up to 1 year after
childbirth) and in women who are planning a pregnancy. The guideline covers depression, anxiety
disorders, eating disorders, drug and alcohol-use disorders and severe mental illness (such as
psychosis, bipolar disorder, schizophrenia and severe depression). It covers subthreshold
symptoms as well as mild, moderate and severe mental health problems. However, the guideline
focuses on aspects of expression, risks and management that are of special relevance in pregnancy
and the postnatal period.
The recommendations are relevant to all healthcare professionals who recognise, assess and refer
for or provide interventions for mental health problems in pregnancy and the postnatal period. It
will also be relevant to non-NHS services, such as social services and the voluntary and private
sectors, but does not make specific recommendations for these. The guideline also makes
recommendations about the primary and secondary care services needed to support the effective
identification and treatment of most mental health problems in pregnancy and the postnatal
period. This guideline should be read in conjunction with other NICE guidelines on the treatment
and management of specific mental health problems. The guideline indicates where modifications
to treatment and management are needed in pregnancy and the postnatal period.
The guideline draws on the best available evidence. However, there are significant limitations to
the evidence base, including limited data on the risks of psychotropic medication in pregnancy and
during breastfeeding.
Medicines
No psychotropic medication has a UK marketing authorisation specifically for women who are
pregnant or breastfeeding. The prescriber should follow relevant professional guidance, taking full
responsibility for the decision. The woman (or those with authority to give consent on her behalf)
should provide informed consent, which should be documented. See the General Medical Council's
Good practice in prescribing and managing medicines and devices for further information. Where
recommendations have been made for the use of medicines outside their licensed indications
('off-label use'), these medicines are marked with a footnote in the recommendations.
Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list
of recommendations is in section 1.
Considerations for women of childbearing potential

• Discuss with all women of childbearing potential who have a new, existing or past mental
health problem:
－ the use of contraception and any plans for a pregnancy
－ how pregnancy and childbirth might affect a mental health problem, including the risk of
relapse
－ how a mental health problem and its treatment might affect the woman, the fetus and
baby
－ how a mental health problem and its treatment might affect parenting. [new 2014]
• Do not offer valproate for acute or long-term treatment of a mental health problem in women
or girls of childbearing potential (including young girls who are likely to need treatment into
their childbearing years). See the MHRA safety advice on valproate use by women and girls.
[amended 2020]
Principles of care in pregnancy and the postnatal period

Coordinated care
• 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. [new 2014]
Treatment decisions, advice and monitoring for women

who are planning a pregnancy, pregnant or in the
postnatal period
Information and advice
• 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. [new 2014]
Starting, using and stopping treatment

• Before starting any treatment in pregnancy and the postnatal period, discuss with the woman
the higher threshold for pharmacological interventions arising from the changing risk-benefit
ratio for psychotropic medication at this time and the likely benefits of a psychological
intervention. [new 2014]
• If a pregnant woman has taken psychotropic medication with known teratogenic risk at any
time in the first trimester:
－ confirm the pregnancy as soon as possible
－ explain that stopping or switching the medication after pregnancy is confirmed may not
remove the risk of fetal malformations
－ offer screening for fetal abnormalities and counselling about continuing the pregnancy
－ explain the need for additional monitoring and the risks to the fetus if she continues to
take the medication.
Seek advice from a specialist if there is uncertainty about the risks associated with specific
drugs. [new 2014]
TCAs, SSRIs, (S)NRIs

• When choosing a tricyclic antidepressant (TCA), selective serotonin reuptake inhibitor (SSRI)
or (serotonin-) noradrenaline reuptake inhibitor [(S)NRI][ ], take into account:
1
－ the woman's previous response to these drugs
－ the stage of pregnancy
－ what is known about the reproductive safety of these drugs (for example, the risk of fetal
cardiac abnormalities and persistent pulmonary hypertension in the newborn baby)
－ the uncertainty about whether any increased risk to the fetus and other problems for the
woman or baby can be attributed directly to these drugs or may be caused by other
factors
－ the risk of discontinuation symptoms in the woman and neonatal adaptation syndrome in
the baby with most TCAs, SSRIs and (S)NRIs, in particular paroxetine and venlafaxine.
[new 2014]
Recognising mental health problems in pregnancy and

the postnatal period and referral
• 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?[ ] 2
－ Over the last 2 weeks, how often have you been bothered by not being able to stop or
control worrying?[ ] [new 2014]
2
Providing interventions in pregnancy and the postnatal

period
• All healthcare professionals providing assessment and interventions for mental health
problems in pregnancy and the postnatal period should understand the variations in their
presentation and course at these times, how these variations affect treatment, and the context
in which they are assessed and treated (for example, maternity services, health visiting and
mental health services). [new 2014]
Considerations for women and their babies in the

postnatal period
Traumatic birth, stillbirth and miscarriage
• 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. [new 2014]
The organisation of services

• Clinical networks should be established for perinatal mental health services, managed by a
coordinating board of healthcare professionals, commissioners, managers, and service users
and carers. These networks should provide:
－ a specialist multidisciplinary perinatal service in each locality, which provides direct

services, consultation and advice to maternity services, other mental health services and
community services; in areas of high morbidity these services may be provided by
separate specialist perinatal teams
－ access to specialist expert advice on the risks and benefits of psychotropic medication
during pregnancy and breastfeeding
－ clear referral and management protocols for services across all levels of the existing
stepped-care frameworks for mental health problems, to ensure effective transfer of
information and continuity of care
－ pathways of care for service users, with defined roles and competencies for all
professional groups involved. [2007]
[1]
Although this use is common in UK clinical practice, at the time of publication (December 2014),
TCAs, SSRIs and (S)NRIs did not have a UK marketing authorisation for this indication. The
prescriber should follow relevant professional guidance, taking full responsibility for the decision.
Informed consent should be obtained and documented. See the General Medical Council's Good
practice in prescribing and managing medicines and devices for further information.
[2]
An answer of 'Not at all' scores 0; 'Several days' scores 1; 'More than half the days' scores 2;
'Nearly every day' scores 3.
1 Recommendations
The following guidance is based on the best available evidence. The full guideline gives details of
the methods and the evidence used to develop the guidance.
Terms used in this guideline

Anxiety disorders These include generalised anxiety disorder, panic disorder, obsessive-compulsive
disorder, phobias, post-traumatic stress disorder and social anxiety disorder.
Baby refers to an infant aged between 0 and 12 months.
High-intensity intervention A formal psychological intervention usually delivered face to face

(either in a group or individually) by a qualified therapist who has specific training in the delivery of
the intervention.
Low-intensity intervention A psychological or psychosocial intervention delivered by a trained

coach or facilitator (rather than a therapist) to enable use of self-help materials.
Postnatal period This is defined in this guideline as up to 1 year after childbirth.
Postpartum psychosis Psychosis often with mania and/or depressive symptoms in the immediate
postnatal period, which can become very severe extremely quickly.
Psychotropic medication This is defined in this guideline as all medication used to treat mental
health problems.
Severe mental illness This is defined in this guideline as severe and incapacitating depression,
psychosis, schizophrenia, bipolar disorder, schizoaffective disorder and postpartum psychosis.
Traumatic birth includes births, whether preterm or full term, which are physically traumatic (for
example, instrumental or assisted deliveries or emergency caesarean sections, severe perineal
tears, postpartum haemorrhage) and births that are experienced as traumatic, even when the
delivery is obstetrically straightforward.
Valproate Refers to 3 formulations of valproate available in the UK: sodium valproate and valproic
acid (licensed for the treatment of epilepsy) and semi-sodium valproate (licensed for the treatment
of acute mania and continuation treatment in people whose mania responds to treatment). Both
semi-sodium and sodium valproate are metabolised to valproic acid (also known as valproate),
which is the pharmacologically active component. Valproate must not be used in pregnancy, and
only used in girls and women when there is no alternative and a pregnancy prevention plan is in
place. This is because of the risk of malformations and developmental abnormalities in the baby.
See update information for important safety advice from the MHRA on the use of valproate.
Woman/women refer(s) to female(s) of childbearing potential, including girls and young women
under 18 years.
People have the right to be involved in discussions and make informed decisions about their
care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or
certainty) of our recommendations, and has information about prescribing medicines (including
off-label use), professional guidelines, standards and laws (including on consent and mental
capacity), and safeguarding.
1.1 Using this guideline in conjunction with other NICE

guidelines
Improving the experience of care
1.1.1 Use this guideline in conjunction with the guidance on service user experience
in adult mental health (NICE guideline CG136) and patient experience in adult
NHS services (NICE guideline CG138) to improve the experience of care for
women with a mental health problem in pregnancy or the postnatal period.
[new 2014]
Assessment and treatment in pregnancy and the postnatal period

1.1.2 Use this guideline in conjunction with the NICE guideline for a specific mental
health problem (see our web 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 1.6.1 to 1.6.6 in this guideline on assessment in pregnancy and the

postnatal period
• recommendations 1.4.10 to 1.4.37 in this guideline on starting, using and stopping

treatment in pregnancy and the postnatal period
• recommendations 1.8.1 to 1.8.23 in this guideline on treating specific mental health

problems in pregnancy and the postnatal period. [new 2014]
1.2 Considerations for women of childbearing potential

1.2.1 Discuss with all women of childbearing potential who have a new, existing or
past mental health problem:
• the use of contraception and any plans for a pregnancy
• how pregnancy and childbirth might affect a mental health problem, including the risk
of relapse
• how a mental health problem and its treatment might affect the woman, the fetus and
baby
• how a mental health problem and its treatment might affect parenting. [new 2014]
1.2.2 When prescribing psychotropic medication for women of childbearing potential,

take account of the latest data on the risks to the fetus and baby. [new 2014]
1.2.3 Do not offer valproate for acute or long-term treatment of a mental health
problem in women or girls of childbearing potential (including young girls who
are likely to need treatment into their childbearing years), unless other options
are ineffective or not tolerated and the pregnancy prevention programme is in
place. See the MHRA safety advice on valproate use by women and girls.
[amended 2020]
1.3 Principles of care in pregnancy and the postnatal

period
Supporting women and their partners, families and carers
1.3.1 Acknowledge the woman's role in caring for her baby and support her to do this
in a non-judgmental and compassionate way. [new 2014]
1.3.2 Involve the woman and, if she agrees, her partner, family or carer, in all decisions
about her care and the care of her baby. [new 2014]
1.3.3 When working with girls and young women with a mental health problem in
pregnancy or the postnatal period:
• be familiar with local and national guidelines on confidentiality and the rights of the
child
• be aware of the recommendations in section 1.4 of the guideline on pregnancy and

complex social factors (NICE guideline CG110)
• ensure continuity of care for the mental health problem if care is transferred from
adolescent to adult services. [new 2014]
1.3.4 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. [new 2014]
Coordinated care
1.3.5 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. [new 2014]
1.3.6 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. [new 2014]
1.4 Treatment decisions, advice and monitoring for

women who are planning a pregnancy, pregnant or in the
postnatal period
Information and advice
1.4.1 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. [new 2014]
1.4.2 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.
[new 2014]
1.4.3 Discuss treatment and prevention options and any particular concerns the
woman has about the pregnancy or the fetus or baby. Provide information to the
woman and, if she agrees, her partner, family or carer, about:
• the potential benefits of psychological interventions and psychotropic medication
• the possible consequences of no treatment
• the possible harms associated with treatment
• what might happen if treatment is changed or stopped, particularly if psychotropic

medication is stopped abruptly. [new 2014]
1.4.4 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.
[new 2014]
1.4.5 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).
[new 2014]
1.4.6 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. [new 2014]
1.4.7 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
• use absolute values based on a common denominator (that is, numbers out of
100 or 1000)
• acknowledge and describe, if possible, the uncertainty around any estimate of risk,
harm or benefit
• use high-quality decision aids in a variety of numerical and pictorial formats that focus
on a personalised view of the risks and benefits, in line with the guidance on patient
experience in adult NHS services (NICE guideline CG138)
• consider providing records of the consultation, in a variety of visual, verbal or audio

formats. [new 2014]
Monitoring and increased contact

1.4.8 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. [new 2014]
1.4.9 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]). [new 2014]
Starting, using and stopping treatment

General advice
1.4.10 Before starting any treatment in pregnancy and the postnatal period, discuss
with the woman the higher threshold for pharmacological interventions arising
from the changing risk-benefit ratio for psychotropic medication at this time
and the likely benefits of a psychological intervention. [new 2014]
1.4.11 If the optimal treatment for a woman with a mental health problem is
psychotropic medication combined with a psychological intervention, but she
declines or stops taking psychotropic medication in pregnancy or the postnatal
period, ensure that:
• she is adequately supported and
• has the opportunity to discuss the risk associated with stopping psychotropic
medication and
• is offered, or can continue with, a psychological intervention. [new 2014]
1.4.12 When psychotropic medication is started in pregnancy and the postnatal period,
consider seeking advice, preferably from a specialist in perinatal mental health,
and:
• choose the drug with the lowest risk profile for the woman, fetus and baby, taking into
account a woman's previous response to medication
• use the lowest effective dose (this is particularly important when the risks of adverse
effects to the woman, fetus and baby may be dose related), but note that
sub-therapeutic doses may also expose the fetus to risks and not treat the mental
health problem effectively
• use a single drug, if possible, in preference to 2 or more drugs
• take into account that dosages may need to be adjusted in pregnancy. [2014]
1.4.13 When a woman with severe mental illness decides to stop psychotropic
medication in pregnancy and the postnatal period, discuss with her:
• her reasons for doing so
• the possibility of:
－ restarting the medication
－ switching to other medication
－ having a psychological intervention
• increasing the level of monitoring and support.
Ensure she knows about any risks to herself, the fetus or baby when stopping
medication. [new 2014]
1.4.14 When a woman with depression or an anxiety disorder decides to stop taking
psychotropic medication in pregnancy and the postnatal period, discuss with
her:
• her reasons for doing so
• the possibility of:
－ having a psychological intervention
－ restarting the medication if the depression or anxiety disorder is or has been

severe and there has been a previous good response to treatment
－ switching to other medication
• increasing the level of monitoring and support while she is not taking any medication.
Ensure she knows about any risks to herself, the fetus or baby when stopping
medication. [new 2014]
1.4.15 If a pregnant woman has taken psychotropic medication with known

teratogenic risk at any time in the first trimester:
• confirm the pregnancy as soon as possible
• explain that stopping or switching the medication after pregnancy is confirmed may
not remove the risk of fetal malformations
• offer screening for fetal abnormalities and counselling about continuing the pregnancy
• explain the need for additional monitoring and the risks to the fetus if she continues to
take the medication.
Seek advice from a specialist if there is uncertainty about the risks associated with
specific drugs. [new 2014]
TCAs, SSRIs, (S)NRIs

1.4.16 When choosing a tricyclic antidepressant (TCA), selective serotonin reuptake
inhibitor (SSRI) or (serotonin-) noradrenaline reuptake inhibitor [(S)NRI][ ], take 3
into account:
• the woman's previous response to these drugs
• the stage of pregnancy
• what is known about the reproductive safety of these drugs (for example, the risk of
fetal cardiac abnormalities and persistent pulmonary hypertension in the newborn
baby)
• the uncertainty about whether any increased risk to the fetus and other problems for
the woman or baby can be attributed directly to these drugs or may be caused by other
factors
• the risk of discontinuation symptoms in the woman and neonatal adaptation syndrome
in the baby with most TCAs, SSRIs and (S)NRIs, in particular paroxetine and
venlafaxine. [new 2014]
1.4.17 When assessing the risks and benefits of TCAs, SSRIs or (S)NRIs[ ] for a woman3
who is considering breastfeeding, take into account:
• the benefits of breastfeeding for the woman and baby
• the uncertainty about the safety of these drugs for the breastfeeding baby
• the risks associated with switching from or stopping a previously effective medication.
Seek advice from a specialist (preferably from a specialist perinatal mental health
service) if there is uncertainty about specific drugs[ ]. [new 2014]
4
Benzodiazepines
1.4.18 Do not offer benzodiazepines to women in pregnancy and the postnatal period
except for the short-term treatment of severe anxiety and agitation. [2014]
1.4.19 Consider gradually stopping benzodiazepines in women who are planning a

pregnancy, pregnant or considering breastfeeding. [2014]
Antipsychotic medication
1.4.20 When assessing the risks and benefits of antipsychotic medication[ ] for a 5
pregnant woman, take into account risk factors for gestational diabetes and
excessive weight gain. [new 2014]
1.4.21 When choosing an antipsychotic, take into account that there are limited data
on the safety of these drugs in pregnancy and the postnatal period. [new 2014]
1.4.22 Measure prolactin levels in women who are taking prolactin-raising

antipsychotic medication and planning a pregnancy, because raised prolactin
levels reduce the chances of conception. If prolactin levels are raised, consider a
prolactin-sparing antipsychotic. [2014]
1.4.23 If a pregnant woman is stable on an antipsychotic and likely to relapse without

medication, advise her to continue the antipsychotic. [new 2014]
1.4.24 Advise pregnant women taking antipsychotic medication about diet and
monitor for excessive weight gain, in line with the guideline on weight
management before, during and after pregnancy (NICE guideline PH27).
[new 2014]
1.4.25 Monitor for gestational diabetes in pregnant women taking antipsychotic

medication in line with the NICE guideline on diabetes in pregnancy and offer an
oral glucose tolerance test. [new 2014]
1.4.26 Do not offer depot antipsychotics to a woman who is planning a pregnancy,

pregnant or considering breastfeeding, unless she is responding well to a depot
and has a previous history of non-adherence with oral medication. [new 2014]
Anticonvulsants for mental health problems (valproate, carbamazepine and

lamotrigine)
1.4.27 Do not offer valproate for acute or long-term treatment of a mental health
problem in women or girls who are planning a pregnancy, pregnant or
considering breastfeeding. Valproate must not be used in girls and women
unless alternative treatments are not suitable and the pregnancy prevention
programme is in place. See the MHRA safety advice on valproate use by women
and girls. [amended 2020]
1.4.28 If a woman or girl is already taking valproate and is planning a pregnancy, advise
her to gradually stop the drug because of the risk of fetal malformations and
adverse neurodevelopment outcomes after any exposure in pregnancy. See the
MHRA safety advice on valproate use by women and girls. [amended 2020]
1.4.29 If a woman or girl is already taking valproate and becomes pregnant, stop the
drug because of the risk of fetal malformations and adverse
neurodevelopmental outcomes. See the MHRA safety advice on valproate use
by women and girls. [amended 2020]
1.4.30 Do not offer carbamazepine to treat a mental health problem in women who are
planning a pregnancy, pregnant or considering breastfeeding. [new 2014]
1.4.31 If a woman is already taking carbamazepine and is planning a pregnancy or

becomes pregnant, discuss with the woman the possibility of stopping the drug
(because of the risk of adverse drug interactions and fetal malformations).
[new 2014]
1.4.32 If a woman is taking lamotrigine[ ] during pregnancy, check lamotrigine levels

6
frequently during pregnancy and into the postnatal period because they vary
substantially at these times. [new 2014]
Lithium
1.4.33 Do not offer lithium[ ] to women who are planning a pregnancy or pregnant,
7
unless antipsychotic medication has not been effective. [new 2014]
1.4.34 If antipsychotic medication has not been effective and lithium is offered to a
woman who is planning a pregnancy or pregnant, ensure:
• the woman knows that there is a risk of fetal heart malformations when lithium is
taken in the first trimester, but the size of the risk is uncertain
• the woman knows that lithium levels may be high in breast milk with a risk of toxicity
for the baby
• lithium levels are monitored more frequently throughout pregnancy and the postnatal
period. [new 2014]
1.4.35 If a woman taking lithium becomes pregnant, consider stopping the drug
gradually over 4 weeks if she is well. Explain to her that:
• stopping medication may not remove the risk of fetal heart malformations
• there is a risk of relapse, particularly in the postnatal period, if she has bipolar disorder.
[2014]
1.4.36 If a woman taking lithium becomes pregnant and is not well or is at high risk of
relapse, consider:
• switching gradually to an antipsychotic or
• stopping lithium and restarting it in the second trimester (if the woman is not planning
to breastfeed and her symptoms have responded better to lithium than to other drugs
in the past) or
• continuing with lithium if she is at high risk of relapse and an antipsychotic is unlikely
to be effective. [new 2014]
1.4.37 If a woman continues taking lithium during pregnancy:
• check plasma lithium levels every 4 weeks, then weekly from the 36th week
• adjust the dose to keep plasma lithium levels in the woman's therapeutic range
• ensure the woman maintains an adequate fluid balance
• ensure the woman gives birth in hospital
• ensure monitoring by the obstetric team when labour starts, including checking plasma
lithium levels and fluid balance because of the risk of dehydration and lithium toxicity
• stop lithium during labour and check plasma lithium levels 12 hours after her last dose.
[2014]
1.5 Recognising mental health problems in pregnancy

and the postnatal period and referral
1.5.1 Recognise that women who have a mental health problem (or are worried that
they might have) may be:
• unwilling to disclose or discuss their problem because of fear of stigma, negative

perceptions of them as a mother or fear that their baby might be taken into care
• reluctant to engage, or have difficulty in engaging, in treatment because of avoidance

associated with their mental health problem or dependence on alcohol or drugs.
[new 2014]
1.5.2 All healthcare professionals referring a woman to a maternity service should

ensure that communications with that service (including those relating to initial
referral) share information on any past and present mental health problem.
[2014]
Depression and anxiety disorders

1.5.3 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. [new 2014]
1.5.4 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?[ ] 8
• Over the last 2 weeks, how often have you been bothered by not being able to stop or
control worrying?[ ] [new 2014]
8
1.5.5 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. [new 2014]
1.5.6 If a woman scores 3 or more on the GAD-2 scale, consider:
• using the GAD-7 scale for further assessment or
1.5.7 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
1.5.8 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. [new 2014]
Severe mental illness

1.5.9 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]
1.5.10 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. [new 2014]
1.5.11 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.
[new 2014]
1.5.12 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).
[new 2014]
Alcohol and drug misuse

1.5.13 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
guideline on alcohol-use disorders (NICE guideline CG115). [new 2014]
1.5.14 If drug misuse is suspected, follow the recommendations on identification and

assessment in section 1.2 of the guideline on drug misuse – psychosocial
interventions (NICE guideline CG51). [new 2014]
1.6 Assessment and care planning in pregnancy and the

postnatal period
1.6.1 Assessment and diagnosis of a suspected mental health problem in pregnancy
and the postnatal period should include:
• history of any mental health problem, including in pregnancy or the postnatal period
• physical wellbeing (including weight, smoking, nutrition and activity level) and history
of any physical health problem
• alcohol and drug misuse
• the woman's attitude towards the pregnancy, including denial of pregnancy
• the woman's experience of pregnancy and any problems experienced by her, the fetus
or the baby
• the mother–baby relationship
• any past or present treatment for a mental health problem, and response to any
treatment
• social networks and quality of interpersonal relationships
• living conditions and social isolation
• family history (first-degree relative) of mental health problems
• domestic violence and abuse, sexual abuse, trauma or childhood maltreatment
• housing, employment, economic and immigration status
• responsibilities as a carer for other children and young people or other adults.
[new 2014]
1.6.2 When assessing or treating a mental health problem in pregnancy or the

postnatal period, take account of any learning disabilities or acquired cognitive
impairments, and assess the need to consult with a specialist when developing
care plans. [new 2014]
1.6.3 Carry out a risk assessment in conjunction with the woman and, if she agrees,
her partner, family or carer. Focus on areas that are likely to present possible
risk such as self-neglect, self-harm, suicidal thoughts and intent, risks to others
(including the baby), smoking, drug or alcohol misuse and domestic violence and
abuse. [new 2014]
1.6.4 If there is a risk of, or there are concerns about, suspected child maltreatment,
follow local safeguarding protocols. [new 2014]
1.6.5 If there is a risk of self-harm or suicide:
• assess whether the woman has adequate social support and is aware of sources of help
• arrange help appropriate to the level of risk
• inform all relevant healthcare professionals (including the GP and those identified in
the care plan [see recommendation 1.6.6])
• advise the woman, and her partner, family or carer, to seek further help if the situation
deteriorates. [new 2014]
1.6.6 Professionals in secondary mental health services, including specialist perinatal

mental health services, should develop a written care plan in collaboration with
a woman who has or has had a severe mental illness. If she agrees, her partner,
family or carer should also be involved. The plan should cover pregnancy,
childbirth and the postnatal period (including the potential impact of the illness
on the baby) and should include:
• a clear statement of jointly agreed treatment goals and how outcomes will be routinely
monitored
• increased contact with and referral to specialist perinatal mental health services
• the names and contact details of key professionals.
The care plan should be recorded in all versions of the woman's notes (her own records
and maternity, primary care and mental health notes) and a copy given to the woman
and all involved professionals. [new 2014]
1.7 Providing interventions in pregnancy and the

postnatal period
1.7.1 All healthcare professionals providing assessment and interventions for mental
health problems in pregnancy and the postnatal period should understand the
variations in their presentation and course at these times, how these variations
affect treatment, and the context in which they are assessed and treated (for
example, maternity services, health visiting and mental health services).
[new 2014]
1.7.2 All interventions for mental health problems in pregnancy and the postnatal
period should be delivered by competent practitioners. Psychological and
psychosocial interventions should be based on the relevant treatment
manual(s), which should guide the structure and duration of the intervention.
Practitioners should consider using competence frameworks developed from
the relevant treatment manual(s) and for all interventions practitioners should:
• receive regular high-quality supervision
• use routine outcome measures and ensure that the woman is involved in reviewing the
efficacy of the treatment
• engage in monitoring and evaluation of treatment adherence and practitioner

competence – for example, by using video and audio tapes, and external audit and
scrutiny where appropriate. [new 2014][ ] 9
1.7.3 When a woman with a known or suspected mental health problem is referred in
pregnancy or the postnatal period, assess for treatment within 2 weeks of
referral and provide psychological interventions within 1 month of initial
assessment. [new 2014]
1.7.4 When offering psychotropic medication during pregnancy and the postnatal
period, follow the principles in recommendations 1.4.10 to 1.4.37. [new 2014]
1.7.5 Provide interventions for mental health problems in pregnancy and the
postnatal period within a stepped-care model of service delivery in line with
recommendation 1.5.1.3 of the guideline on common mental health disorders
(NICE guideline CG123). [new 2014]
1.8 Treating specific mental health problems in

pregnancy and the postnatal period
Interventions for depression
1.8.1 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 recommendation 1.4.2.2 of the guideline on
depression in adults [NICE guideline CG90]). [new 2014]
1.8.2 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.
[new 2014]
1.8.3 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.
[new 2014]
1.8.4 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 recommendation 1.4.2.2 of the
guideline on depression in adults [NICE guideline CG90]). [new 2014]
1.8.5 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. [new 2014]
1.8.6 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
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. [new 2014]
Interventions for anxiety disorders

1.8.7 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 section 1.2.9 of the
guideline on caesarean section (NICE guideline CG132). [new 2014]
1.8.8 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 2-3 months with support (either face to face
or by telephone) for a total of 2-3 hours over 6 sessions. [new 2014]
1.8.9 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. [new 2014]
1.8.10 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
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. [new 2014]
Psychological interventions for eating disorders

1.8.11 For a woman with an eating disorder in pregnancy or the postnatal period:
• offer a psychological intervention in line with the guideline on eating disorders (NICE
guideline NG69)
• 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 guideline on maternal and child nutrition (NICE guideline PH11)
• advise her about feeding the baby in line with the guideline on maternal and child
nutrition (NICE guideline PH11) and support her with this. [new 2014]
Interventions for alcohol and drug misuse

1.8.12 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
guideline on drug misuse - psychosocial interventions (NICE guideline CG51) or
the guideline on alcohol-use disorders: preventing harmful drinking (NICE
guideline PH24). [new 2014]
1.8.13 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. [new 2014]
1.8.14 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. [new 2014]
1.8.15 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. [new 2014]
Interventions for severe mental illness

1.8.16 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.
[new 2014]
1.8.17 If a pregnant woman develops mania or psychosis and is not taking psychotropic
medication, offer an antipsychotic. [new 2014]
1.8.18 Consider psychological interventions (CBT or family intervention) delivered as

described in section 1.3.7 of the guideline on psychosis and schizophrenia in
adults (NICE guideline CG178) 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. [new 2014]
1.8.19 Offer an antipsychotic in line with recommendations 1.5.3 and 1.5.4 of the
guideline on bipolar disorder (NICE guideline CG185) as prophylactic

medication if a woman with bipolar disorder:
• becomes pregnant and is stopping lithium, or
• plans to breastfeed. [new 2014]
1.8.20 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.

[new 2014]
Interventions for sleep problems

1.8.21 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[ ]. [new 2014]
10
Electroconvulsive therapy
1.8.22 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]
Rapid tranquillisation
1.8.23 A pregnant woman requiring rapid tranquillisation should be treated according
to the NICE clinical guidelines on the short-term management of violence and
aggression, schizophrenia and bipolar disorder (see our web pages 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]
1.9 Considerations for women and their babies in the

postnatal period
Reviewing treatment for women with severe mental illness
1.9.1 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. [new 2014]
Monitoring babies for effects of psychotropic medication taken in

pregnancy
1.9.2 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. [new 2014]
Care of women and their babies if there has been alcohol or drug
misuse in pregnancy
1.9.3 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. [new 2014]
Traumatic birth, stillbirth and miscarriage

1.9.4 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. [new 2014]
1.9.5 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 guideline on post-
traumatic stress disorder (PTSD) (NICE guideline CG26). [new 2014]
1.9.6 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.
[new 2014]
1.9.7 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. [new 2014]
Psychotropic medication and breastfeeding

1.9.8 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. [amended 2020]
1.9.9 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[ ]. [new 2014]
4
1.9.10 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. [new 2014]
1.9.11 If a woman is taking psychotropic medication while breastfeeding, monitor the

baby for adverse effects. [2014]
The mother–baby relationship

1.9.12 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. [new 2014]
1.9.13 Consider further intervention to improve the mother–baby relationship if any

problems in the relationship have not resolved. [new 2014]
1.10 The organisation of services

1.10.1 Women who need inpatient care for a mental health problem within 12 months
of childbirth should normally be admitted to a specialist mother and baby unit,
unless there are specific reasons for not doing so. [2007]
1.10.2 Managers and senior healthcare professionals responsible for perinatal mental
health services (including those working in maternity and primary care services)
should ensure that:
• there are clearly specified care pathways so that all primary and secondary healthcare
professionals involved in the care of women during pregnancy and the postnatal
period know how to access assessment and treatment
• staff have supervision and training, covering mental health problems, assessment
methods and referral routes, to allow them to follow the care pathways. [2007]
1.10.3 Clinical networks should be established for perinatal mental health services,
managed by a coordinating board of healthcare professionals, commissioners,
managers, and service users and carers. These networks should provide:
• a specialist multidisciplinary perinatal service in each locality, which provides direct

services, consultation and advice to maternity services, other mental health services
and community services; in areas of high morbidity these services may be provided by
separate specialist perinatal teams
• access to specialist expert advice on the risks and benefits of psychotropic medication
during pregnancy and breastfeeding
• clear referral and management protocols for services across all levels of the existing
stepped-care frameworks for mental health problems, to ensure effective transfer of
information and continuity of care
• pathways of care for service users, with defined roles and competencies for all
professional groups involved. [2007]
1.10.4 Each managed perinatal mental health network should have designated
specialist inpatient services and cover a population where there are between
25,000 and 50,000 live births a year, depending on the local psychiatric
morbidity rates. [2007]
1.10.5 Specialist perinatal inpatient services should:
• provide facilities designed specifically for mothers and babies (typically with
6-12 beds)
• be staffed by specialist perinatal mental health staff
• be staffed to provide appropriate care for babies
• have effective liaison with general medical and mental health services
• have available the full range of therapeutic services
• be closely integrated with community-based mental health services to ensure

continuity of care and minimum length of stay. [2007]
[3]
TCAs, SSRIs and (S)NRIs did not have a UK marketing authorisation for this indication. The
[4]
See also the UK Drugs in Lactation Advisory Service for information on the use of specific drugs.
[5]
antipsychotic medication did not have a UK marketing authorisation for this indication. The
[6]
At the time of publication (December 2014), lamotrigine did not have a UK marketing
authorisation for this indication. The prescriber should follow relevant professional guidance,
taking full responsibility for the decision. Informed consent should be obtained and documented.
See the General Medical Council's Good practice in prescribing and managing medicines and
devices for further information.
[7]
lithium did not have a UK marketing authorisation for this indication. The prescriber should follow
relevant professional guidance, taking full responsibility for the decision. Informed consent should
be obtained and documented. See the General Medical Council's Good practice in prescribing and
managing medicines and devices for further information.
[8]
An answer of 'Not at all' scores 0; 'Several days' scores 1; 'More than half the days' scores 2;
'Nearly every day' scores 3.
[9]
Adapted from the guideline on depression in adults (NICE guideline CG90).
[10]
At the time of publication (December 2014), promethazine did not have a UK marketing
authorisation for this indication. The prescriber should follow relevant professional guidance,
taking full responsibility for the decision. Informed consent should be obtained and documented.
See the General Medical Council's Good practice in prescribing and managing medicines and
devices for further information.
2 Research recommendations
The Guideline Development Group has made the following recommendations for research, based
on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline
Development Group's full set of research recommendations is detailed in the full guideline.
2.1 Preventing postpartum psychosis

What methods can improve the identification of women at high risk of postpartum psychosis and
reduce this risk?
Why this is important

Postpartum psychosis is a severe mental illness with a rapid onset and a major impact on the
woman and her ability to care for her baby. It is associated with an increased risk of mortality in
both the woman and her baby. Prophylactic treatment can be effective for women who are known
to be at high risk, but for some women postpartum psychosis may be their first episode of severe
mental illness. Better identification of women at high risk and a greater understanding of
prophylactic and acute treatment would have a significant impact on maternal and child welfare,
and on service costs.
The question should be addressed by a programme of research into the prevention, treatment and
management of postpartum psychosis comprising:
• The development of a tool for routine clinical use to improve the identification of women at
high risk of developing postpartum psychosis. This should be tested in a prospective cohort
study.
• The development of a set of interventions intended to prevent the onset of postpartum

psychosis and a method for their effective and efficient delivery.
• The testing of the clinical and cost effectiveness of the interventions in a large scale
randomised controlled trial.
• The development and testing of a programme for the implementation of an effective strategy
for preventing and identifying postpartum psychosis.
2.2 The safety of drugs for bipolar disorder in
pregnancy and the postnatal period

How safe are drugs used to treat bipolar disorder in pregnancy and the postnatal period?

Drugs are effective for the acute treatment of bipolar disorder and for preventing relapse. All drugs
used to treat mental health problems may carry some risk for the woman, fetus and baby. For some
drugs such as sodium valproate these risks are well described, but the data are drawn from epilepsy
case registers. For others such as lithium, the data are very limited. In addition, the prevalence of
adverse outcomes for the woman, fetus or baby in untreated bipolar disorder is not well described.
The question should be addressed by establishing a long-term register of women with bipolar
disorder to provide data on:
• the drugs used for treating bipolar disorder in pregnancy
• the following outcomes (by drug type and for women who had no treatment for bipolar
disorder in pregnancy):
－ maternal outcomes (for example, episodes of mood disorder in pregnancy and the
postnatal period, miscarriage, preterm delivery)
－ congenital malformations (for example, spinal cord and cardiac malformation)
－ baby outcomes (for example, mortality, birthweight)
－ childhood outcomes (for example, cognitive development).
2.3 Psychological interventions focused on the

mother-baby relationship
Are interventions designed to improve the quality of the mother–baby relationship in the first year
after childbirth effective in women with a diagnosed mental health problem?

Problems in the mother–baby relationship in the first year after childbirth may increase maternal
mental health problems and are associated with a range of problems for the baby, including delayed
cognitive and emotional development. A number of interventions are effective in improving the
interaction between women and their babies, but it is not known if these are effective in women
with a diagnosed mental health problem.
The question should be addressed in a randomised controlled trial comparing an intervention

(proven to be effective in improving the quality of mother–baby interactions in women without a
diagnosed mental health problem) against standard care. The trial should report the following
outcomes, with a follow-up period of at least 2 years:
• the mental health of the woman
• the emotional and cognitive development of the baby
• the quality of the interaction.
The trial should also examine the cost effectiveness of the intervention.
2.4 Structured clinical management for moderate to

severe personality disorders in pregnancy and the
postnatal period
Is structured clinical management for moderate to severe personality disorders in pregnancy and
the postnatal period effective at improving outcomes for women and their babies?

Personality disorders are associated with poor engagement with maternity services and perinatal
mental health services and this leads to poor mental and physical health outcomes for the woman,
fetus and baby. The complex psychological interventions that are effective for treating personality
disorder may present problems for engagement even in those motivated to seek treatment.
Structured clinical management is a psychologically informed model of case management, which is
effective for treating personality disorder and may have greater flexibility and capacity to engage
women with personality disorder in pregnancy and the postnatal period.
The question should be addressed in a randomised controlled trial comparing structured clinical
management of personality disorder in pregnancy and the postnatal period against standard care.
The trial should report the following outcomes, with a follow-up period of at least 2 years:
• the mental and physical health of the woman
• the physical health of the fetus
• the mental and physical health of the baby
• the quality of the mother–baby relationship.
The trial should also examine the cost effectiveness of the intervention.
2.5 Psychological interventions for moderate to severe

anxiety disorders in pregnancy
Are psychological interventions effective for treating moderate to severe anxiety disorders
(including obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder and social
anxiety disorder) in pregnancy?

Anxiety disorders are often not identified or treated in pregnancy. In addition, many women who
are taking medication for such problems stop taking it when they are pregnant. The development of
effective psychological interventions is therefore important. Although there are effective
psychological interventions for anxiety disorders, there is limited evidence about their
effectiveness in pregnancy and how these interventions might be adapted for use in pregnant
women.
The question should be addressed by a programme of research evaluating psychological

interventions (including individual and group approaches) for moderate to severe anxiety disorders
in pregnancy, comprising:
• a development programme to establish the adaptations to effective interventions (for

example, mode of delivery, duration, content, and intensity of treatment) that are needed for
use in pregnancy
• the testing of the adapted interventions in a series of pilot studies
• the testing of the clinical and cost effectiveness of the adapted interventions in large-scale
randomised controlled trials
• the development and testing of a programme for the implementation of psychological

interventions for moderate to severe anxiety disorders.
More information
You can also see this guideline in the NICE Pathway on antenatal and postnatal mental health.
To find out what NICE has said on topics related to this guideline, see our web pages on
pregnancy and mental health and wellbeing.
See also the guideline committee's discussion and the evidence reviews (in the full guideline),
and information about how the guideline was developed, including details of the committee.
Update information
Recommendations are marked as [amended 2020]
2020], [new 2014]
2014], [2014] or [2007]
[2007]:
• [amended 2020] indicates a recommendation has been amended in line with the MHRA
guidance that valproate must not be used in women and girls of childbearing potential
(including young girls who are likely to need treatment into their childbearing years), unless
other options are unsuitable and the pregnancy prevention programme is in place
• [new 2014] indicates that the evidence has been reviewed and the recommendation has
been added or updated
• [2014] indicates that the evidence has been reviewed but no change has been made to the
recommended action
• [2007] indicates that the evidence has not been reviewed since 2007.
February 2020: We amended recommendations on anticonvulsants for mental health problems in

line with the MHRA guidance on valproate use by women and girls. The MHRA states that
valproate must not be used in women and girls of childbearing potential (including young girls who
are likely to need treatment into their childbearing years), unless other options are unsuitable and
the pregnancy prevention programme is in place. We amended recommendations by moving
cautions and links to the MHRA's latest advice on valproate into the recommendations.
Medicines containing valproate taken in pregnancy can cause malformations in 11% of babies and
developmental disorders in 30–40% of children after birth. Valproate treatment must not be used
in girls and women including in young girls below the age of puberty, unless alternative treatments
are not suitable and unless the terms of the pregnancy prevention programme are met. This
programme includes: assessment of patients for the potential of becoming pregnant; pregnancy
tests; counselling patients about the risks of valproate treatment; explaining the need for effective
contraception throughout treatment; regular (at least annual) reviews of treatment by a specialist,
and completion of a risk acknowledgement form. In pregnancy, valproate is contraindicated and an
alternative treatment should be decided on, with appropriate specialist consultation. See the
MHRA toolkit to ensure female patients are better informed about the risks of taking valproate
during pregnancy.
August 2017: Links were added to recommendations 1.2.3, 1.4.27, 1.4.28 and 1.4.29 to the MHRA
toolkit on the risks of valproate medicines in female patients. A crosslink in recommendation 1.8.23
was updated to link to the NICE guideline on violence and aggression. Footnotes were added to
recommendations 1.4.17 and 1.9.9 advising people that the UK Drugs in Lactation Advisory Service
is available as an additional resource when seeking advice about specific drugs.
Minor changes since publication
September 2016: The link in recommendation 1.4.25 has been updated.
June 2015: Corrected timescales for GAD-2 in recommendation 1.5.4.
This guideline updates and replaces NICE guideline CG45 (published February 2007).
Strength of recommendations
Some recommendations can be made with more certainty than others. The Guideline Development
Group makes a recommendation based on the trade-off between the benefits and harms of an
intervention, taking into account the quality of the underpinning evidence. For some interventions,
the Guideline Development Group is confident that, given the information it has looked at, most
patients would choose the intervention. The wording used in the recommendations in this guideline
denotes the certainty with which the recommendation is made (the strength of the
recommendation).
For all recommendations, NICE expects that there is discussion with the patient about the risks and
benefits of the interventions, and their values and preferences. This discussion aims to help them to
reach a fully informed decision.
Interventions that must (or must not) be used

We usually use 'must' or 'must not' only if there is a legal duty to apply the recommendation.
Occasionally we use 'must' (or 'must not') if the consequences of not following the
recommendation could be extremely serious or potentially life threatening.
Interventions that should (or should not) be used – a 'strong'

recommendation
We use 'offer' (and similar words such as 'refer' or 'advise') when we are confident that, for the vast
majority of patients, an intervention will do more good than harm, and be cost effective. We use
similar forms of words (for example, 'Do not offer…') when we are confident that an intervention
will not be of benefit for most patients.
Interventions that could be used

We use 'consider' when we are confident that an intervention will do more good than harm for
most patients, and be cost effective, but other options may be similarly cost effective. The choice of
intervention, and whether or not to have the intervention at all, is more likely to depend on the
patient's values and preferences than for a strong recommendation, and so the healthcare
professional should spend more time considering and discussing the options with the patient.
Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations in guidelines that
started development after publication of the 2009 version of 'The guidelines manual' (January
2009). This does not apply to any recommendations ending [2007] (see 'Update information' above
for details about how recommendations are labelled). In particular, for recommendations labelled
[2007] the word 'consider' may not necessarily be used to denote the strength of the
recommendation.
ISBN: 978-1-4731-0875-2
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Antenatal and postnatal

mental health: clinical

© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-

Commissioners and providers have a responsibility to promote an environmentally sustainable

Who is it for? ...................................................................................................................................................................................... 5

Key priorities for implementation ................................................................................................................................ 8

Considerations for women of childbearing potential ........................................................................................................ 8

Principles of care in pregnancy and the postnatal period ................................................................................................ 9

Providing interventions in pregnancy and the postnatal period................................................................................... 12

The organisation of services ........................................................................................................................................................ 13

Terms used in this guideline ......................................................................................................................................................... 15

1.2 Considerations for women of childbearing potential ................................................................................................ 17

1.3 Principles of care in pregnancy and the postnatal period ........................................................................................ 18

1.7 Providing interventions in pregnancy and the postnatal period ........................................................................... 33

1.10 The organisation of services .............................................................................................................................................. 43

2 Research recommendations .......................................................................................................................................46

2.1 Preventing postpartum psychosis...................................................................................................................................... 46

2.3 Psychological interventions focused on the mother-baby relationship ............................................................. 47

More information ............................................................................................................................................................................. 50

Update information ............................................................................................................................................................51

Strength of recommendations .................................................................................................................................................... 52

This guideline replaces CG45.

This guideline partially replaces CG62.

This guideline is the basis of QS115 and QS37.

MHRA advice on valproate:

• Voluntary and private sectors

Key priorities for implementation

Considerations for women of childbearing potential

－ the use of contraception and any plans for a pregnancy

Principles of care in pregnancy and the postnatal period

－ 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

Treatment decisions, advice and monitoring for women

－ the woman's response to any previous treatment

Starting, using and stopping treatment

－ confirm the pregnancy as soon as possible

TCAs, SSRIs, (S)NRIs

－ the woman's previous response to these drugs

－ the stage of pregnancy

Recognising mental health problems in pregnancy and

Providing interventions in pregnancy and the postnatal

Considerations for women and their babies in the

－ seeing a photograph of the baby

－ having mementos of the baby

－ seeing the baby

－ holding the baby.

The organisation of services

－ a specialist multidisciplinary perinatal service in each locality, which provides direct

Terms used in this guideline

Baby refers to an infant aged between 0 and 12 months.

High-intensity intervention A formal psychological intervention usually delivered face to face

Low-intensity intervention A psychological or psychosocial intervention delivered by a trained

Postnatal period This is defined in this guideline as up to 1 year after childbirth.

1.1 Using this guideline in conjunction with other NICE

Assessment and treatment in pregnancy and the postnatal period

• recommendations 1.6.1 to 1.6.6 in this guideline on assessment in pregnancy and the

• recommendations 1.4.10 to 1.4.37 in this guideline on starting, using and stopping