Dr Emma Fisher advises how GPs can support perinatal women with mental health issues
Mental illness affects 10-20% of women in the perinatal period1 and community perinatal mental health teams have expanded in the past decade. While there are slight variations in referral criteria for different teams, in general they will assess and manage women from preconception to between one and two years postnatally, through a multidisciplinary approach. They see women with moderate to severe pre-existing mental illness and also those with new presentations in the perinatal period. This includes depression (pre and postnatal), bipolar affective disorder, schizophrenia, schizoaffective disorder, PTSD and anxiety disorders. They may also offer support to women who have experienced a trauma or loss relating to the maternity experience and those with tokophobia (fear of childbirth).
Most services will have a trust website showing the referral pathway, and many teams offer a telephone or email advice service to professionals.
Preconception counselling
Women of childbearing age who have a serious mental illness (SMI) – schizophrenia, schizoaffective disorder, bipolar affective disorder or major depressive disorder – should be counselled about the risks of any medications they are on and about future pregnancy. Contraception should be discussed as part of medication reviews, which should take place at least annually, either in primary or secondary care.
Perinatal teams offer preconception counselling for women with SMI (or those with previous severe perinatal mental illness such as postpartum psychosis) who may be thinking about a pregnancy in the coming years.
Most community perinatal teams will accept referrals from primary or secondary care. These are normally one-off appointments and the management plan may include advice to continue current medications while trying to conceive and once pregnant, or changes to medication, as well as a plan for re-referral once a viable pregnancy is confirmed at 12 weeks.
Referring to perinatal services
Most community perinatal teams accept referrals of women from 12 weeks of confirmed viable pregnancy, up to around one year postnatally (see box). Many teams are now expanding this referral window to two years postnatally, so check local criteria.
Usual criteria for referring to perinatal services
- Pre-existing serious mental illness (SMI), either in remission or during relapse, including bipolar affective disorder, schizophrenia or severe depression
- Previous perinatal mental illness if the woman is pregnant again, including severe depression, severe anxiety disorders or postpartum psychosis
- Where there have been previous admissions to psychiatric inpatient settings postpartum or significant risks such as suicide attempts during the perinatal period
- Tokophobia, previous birth trauma or other trauma related to the birth experience – often these conditions are managed in maternal mental health teams
- Traumas that may affect the birth experience such as sexual abuse – these conditions are also often managed in maternal mental health teams• Severe personality disorder, such as emotionally unstable personality disorder, but usually only if there has been significant deterioration or change in functioning because of the perinatal period• ADHD where medication advice is needed
- Some preconception counselling services
Exclusion criteria usually include:
- Primary drug or alcohol addiction – local drug and alcohol services often run services specifically for pregnant women.
- Personality disorder, unless there are significant changes in symptoms and functioning.
- Bereavement, unless it might be complicated or accompanied by moderate to severe mental illness.
- Mild mental health difficulties.
Who should always be referred
Anyone who becomes pregnant and has a pre-existing psychotic illness, such as bipolar, schizophrenia or psychotic depression (or previous postpartum psychosis) should be referred to the local community perinatal team, even if they have been well for many years. Rates of relapse of a psychotic illness in the postpartum period are as high as 66%2, and consequently women with a history of SMI are at significantly increased risk of suicide in the perinatal period.
Women who have had severe anxiety or previous depressive illnesses involving serious risk such as suicide attempts should always be referred.
Those with current moderate to severe mental illness who are not receiving treatment or who are not responding adequately to treatment started in other services are likely to benefit from a referral to the local perinatal team.
How GPs can manage mild illness
Offering prebooked follow-up can help women feel they are being taken seriously, especially during a period of watchful waiting. Often women don’t book follow-up appointments by themselves.
For women with mild illness, signposting or a referral to the local IAPT service for psychological therapy is often beneficial. There will also probably be a number of third-sector services that offer potentially beneficial services, such as peer support, stay-and-play groups, psychoeducation or other social interventions such as mum-and-baby exercise classes.
The local perinatal mental health team should be able to advise, as may the health visiting service. Most perinatal teams are happy to run sessions for GP surgeries, not only to advise what they can offer, but also tell you what other support is available locally for women in the perinatal period.
Prescribing in primary care
It is important to monitor women presenting with mild mental illness in primary care. If depression or anxiety worsens or presents initially as more severe, antidepressants can be used and are generally considered safe in pregnancy and breastfeeding. The BUMPs and Choice and Medication websites offer details of specific risks.
If there is an indication for medication such as antidepressants or antipsychotics, it is usually best to prescribe one to which the woman has previously responded well. However, if she is new to psychotropics, sertraline is usually considered the first-line antidepressant because of its low passage via the placenta and breastmilk. The full dose range should be used as necessary – suboptimal treatment exposes the foetus to the effects of untreated mental illness as well as the medication.
For pregnant women who are already on an antidepressant, the following factors should be considered. If she is currently unwell, stopping the antidepressant is likely to worsen symptoms. Also, consider how severe her illness has been in the past – has she been in remission? If she has for at least six months following a first episode, or two years if recurrent, cautious gradual tapering may be reasonable. Antidepressants should never be stopped suddenly since doing so increases the risk of an acute relapse.
The risks of untreated mental illness should be discussed with women when deciding whether to continue medication (including increased risk of negative pregnancy outcomes, bonding difficulties, and short- and longer-term emotional and physical health difficulties in offspring). While decreasing the dose may slightly decrease the amount of drug the foetus is exposed to, it may increase the risk of a relapse. As stated earlier, there is little point in giving a subtherapeutic dose. Women who choose to stop antidepressants in pregnancy should do so gradually and consider talking therapy as an alternative if needed.
Most antidepressants cross into the breastmilk in very small amounts, which is not felt to be harmful to the infant. The LactMed website offers a database on the safety of medications while breastfeeding. Advise women to monitor their infants and to consult with their prescriber if the infant appears excessively drowsy, irritable or has feeding difficulties, although these effects are rare.
Antipsychotics in pregnancy should never be stopped suddenly. Doing so – or reducing the dose – presents a significant risk of relapse. If used to treat SMI, the benefits of antipsychotics will usually outweigh the risks of continuing.
Sodium valproate
Sodium valproate should not be used in women of childbearing age because of the very high risk of teratogenicity. If a woman who is taking it becomes pregnant, an urgent appointment should be requested via the duty line of the community perinatal team.
Dr Emma Fisher is a consultant perinatal psychiatrist at Northamptonshire Healthcare NHS Foundation Trust
References
- Sambrook Smith M, Lawrence V, Sadler E et al. Barriers to accessing mental health services for women with perinatal mental illness : systematic review and meta-synthesis of qualitative studies in the UK. BMJ Open 2019;9:e024803. Link
- Wesseloo R, Kamperman A, Munk-Olsen T et al. Risk of postpartum relapse in bipolar disorder and postpartum psychosis: a systematic review and meta-analysis. Am J Psychiatry 2016;173:2. Link
Resources
- UK Teratology Information Service. Medicines in pregnancy. Link
- Best Use of Medicines in Pregnancy (BUMPs). Link
- Choice and Medication. Link
- LactMed (database from the US National Library of Medicine). Link
- British Association of Psychopharmacology Perinatal Guidelines 2017. Link
- NHS England. List of community perinatal team contact details. Link
READERS' COMMENTS [1]
Please note, only GPs are permitted to add comments to articles
Is this perinatal service going to be provided within and as part of the Obstetric and Midwifery Services Directorates, to whom all pregnant women are referred anyway ?
Or not provided within the Community Mental Health Team, to which a large proportion of women of childbearing age with mental health issues are already known, but GPs are more likely to refer them to Obs and Gynae ?