Scottish Intercollegiate Guidelines Network

Postnatal Depression
60 and Puerperal Psychosis
A national clinical guideline

1 Introduction 1
2 Diagnosis, screening and prevention 3
3 Management 7
4 Prescribing issues in pregnancy and 11
lactation
5 Implementation and audit 16
6 Information for patients and carers 20
7 Development of the guideline 23
References 26

June 2002
KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS

LEVELS OF EVIDENCE

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk
of bias
1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++
High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias
and a high probability that the relationship is causal
2+ Well-conducted case control or cohort studies with a low risk of confounding or bias
and a moderate probability that the relationship is causal
2- Case control or cohort studies with a high risk of confounding or bias and a significant
risk that the relationship is not causal
3 Non-analytic studies, e.g. case reports, case series
4 Expert opinion

GRADES OF RECOMMENDATION

Note: The grade of recommendation relates to the strength of the evidence on which the
recommendation is based. It does not reflect the clinical importance of the recommendation.

A At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++

and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to
the target population, and demonstrating overall consistency of results

B A body of evidence including studies rated as 2++, directly applicable to the target
population, and demonstrating overall consistency of results;
or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target
population and demonstrating overall consistency of results;
or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+

GOOD PRACTICE POINTS

þ Recommended best practice based on the clinical experience of the guideline

development group

© Scottish Intercollegiate Guidelines Network

ISBN 1 899893 18 0
First published 2002
SIGN consents to the photocopying of this guideline for the purpose of implementation in NHS Scotland

SIGN Executive
Royal College of Physicians
9 Queen Street
Edinburgh EH2 1JQ
www.sign.ac.uk
 1 INTRODUCTION

1 Introduction
1.1 THE NEED FOR A GUIDELINE

1.1.1 PREVALENCE
The World Health Organisation (WHO) predicts that depression will be the second greatest cause
of premature death and disability worldwide by the year 2020.1 The suffering caused by depression
is profound yet often underestimated. It can affect every aspect of a person’s being: their feelings,
thoughts and functioning. Postnatal depression is particularly important because it is so common
and because it occurs at such a critical time in the lives of the mother, her baby and her family.
For every 1,000 live births, 100-150 women will suffer a depressive illness and one or two women
will develop a puerperal psychosis.2,3 Failure to treat either disorder may result in a prolonged,
deleterious effect on the relationship between the mother and baby and on the child’s psychological,
social and educational development.4 The relationship between the mother and her partner may
also deteriorate.

1.1.2 MORBIDITY AND MORTALITY

The morbidity of clinical depression is often prolonged by a delay in diagnosis or an inadequate
course of treatment. The stigma and shame felt by the sufferers who may be reluctant to ‘confess’
their feelings are frequently important factors in delayed diagnosis. Such reticence is particularly
common in postnatal depression, when feelings of guilt and failure may be intense. A mother
may even fear that she will be thought unfit to care for her child.
Mental illness is also a significant factor in maternal mortality. The UK Confidential Enquiry into
Maternal Deaths (CEMD)5 reports that psychiatric disorders contributed to 12% of all maternal
deaths. Suicide is the second leading cause of maternal death in the UK after cardiovascular disease.
The report comments on the inaccurately low measurement of deaths from mental illness and
demonstrates that record linkage reveals approximately as many deaths again by suicide or violent
means. If included, these make deaths from mental illness the leading cause of maternal mortality.
A small body of evidence points to an association between a mother’s depression and the subsequent
report of depression in her partner.6 Fathers are significantly more likely to suffer from depression
and general health problems if their partners are diagnosed with postnatal depression.6 This is
significant in the context of the detrimental effects which depressed partners may have on each
other and the consequences for the infant being cared for by depressed parents. However, research
evidence of satisfactory quality indicating possible interventions for members of the family other
than the mother is very limited.
Untreated postnatal depression is associated with detrimental effects on infant development. The
cognitive, emotional, social and behavioural development of the infant all may be affected both
in the long and short term.4,7,8 Depressed mothers give more negative and fewer positive responses
in their interactions with their infants.8 Longer term negative influences of mothers’ postnatal
depression in the first year of life on infants’ language skills, social and emotional development
and (particularly in boys) intelligence quotients, have been demonstrated.9-12 Cognitive development
in the children of postnatally depressed women is not universally impaired. The effect appears
limited to those children whose mothers find it difficult to maintain sensitive and active engagement
with the infant.13

1.1.3 MULTIDISCIPLINARY TREATMENT

Delay in delivering adequate treatment for postnatal depression or puerperal psychosis is particularly
unfortunate since the response to treatment is good.14 Effective detection and adequate management
of these disorders requires co-ordination of a wide variety of primary and secondary care services,
including midwives, health visitors, clinical psychologists, community psychiatric services, general
practitioners, pharmacists, obstetricians and psychiatrists, with other community agencies, such
as voluntary organisations and social services, providing further support.

1
POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

1.1.4 VARIATION IN PRACTICE

The guideline development group obtained information from Primary Care Trusts and Health
Boards in Scotland on current and planned developments in their local postnatal mental illness
management strategies. Considerable geographical variation in the management of postnatal
depression in Scotland was identified (see section 5.2.1). Variation was also found in co-ordination
between primary care teams, health visitors and midwives with community psychiatric team
members; in the degree of specialisation of these services; and in access to suitable facilities to
admit mother and baby together, if necessary.

1.2 REMIT OF THE GUIDELINE

This guideline provides recommendations based on current evidence for best practice in the
management of postnatal depression and puerperal psychosis. The guideline includes screening,
diagnosis, prevention and management involving both primary and secondary care, leading to an
integrated and effective multidisciplinary approach. This document is likely to assist in the
development of local evidence-based integrated care pathways. The guideline is likely to be of
interest to midwives, health visitors, general practitioners, pharmacists, psychiatric nurses,
psychiatrists, obstetricians, clinical psychologists, social workers, public health physicians, users
of services, and all other professions caring for women and their families.

1.3 DEFINITIONS

1.3.1 POSTNATAL DEPRESSION

Postnatal depression is regarded as any non-psychotic depressive illness of mild to moderate
severity occurring during the first postnatal year. However, for a significant proportion of women,
the illness may have its onset in the antenatal period.15 It is important to distinguish postnatal
depression from “baby blues”, the brief episode of misery and tearfulness that affects at least half
of all women following delivery, especially those having their first baby. It is also important that
the term postnatal depression should not be used as a generic term for all mental illness following
delivery.

1.3.2 PUERPERAL PSYCHOSIS

Puerperal psychosis, in almost all cases, is a mood disorder accompanied by features such as loss
of contact with reality, hallucinations, severe thought disturbance, and abnormal behaviour.

1.4 REVIEW AND UPDATING

This guideline will be issued in June 2002 and will be kept under review as new evidence becomes
available. Any updates to the guideline will be noted on the SIGN website: www.sign.ac.uk.

2
 2 DIAGNOSIS, SCREENING AND PREVENTION

2 Diagnosis, screening and prevention

2.1 DIAGNOSIS
Depression is a common condition, affecting a large proportion of women of childbearing age.
Studies are evenly divided in reporting postnatal depression as either more or less severe than
depression at other times16-19 and there is little evidence that the nature of symptoms differs between
2+
postnatal and non-postnatal depression.20,21 In diagnosing depression in the postnatal period, there
is a risk that normal emotional changes may be mistaken for depression or may mask depressive
symptoms.7
A large number of studies have assessed the prevalence of postnatal depression.6,19,23-35 In those
where robust methodology was used, prevalence (whether point or period) ranges from 4.5% to
28% of women in the postnatal period. The majority cluster around 10% to 15% with one meta-
analysis giving a prevalence of 13%.2 Variance between studies can be accounted for in part by the
2++
period under evaluation and the method of assessment used. There is some evidence that, while
the overall prevalence of postnatal depression is not significantly different from that of depression
at other times, there is an increased risk of depression occurring in the early postnatal period
(threefold in the first five postnatal weeks).35,36
Although research exists on the prevalence of postnatal depression in other cultures, little work
has been published on ethnic minority groups within Scotland. It is important to remember that
there are widely varying cultural traditions and rituals surrounding pregnancy and childbirth and a
lack of cross-cultural equivalence in concepts of depression. Effective detection and management
requires an understanding of these differences.
Puerperal psychosis is a much less common condition, affecting one to two per thousand women.3,37
Most studies agree that this rate represents a significantly increased risk for psychotic illness when
compared with other times in a woman’s life. Puerperal psychosis is largely affective in nature,
although several studies comment on atypical features in the presentation such as mixed affective
state, confusion and disturbed behaviour.38 It typically presents in the early postpartum period,
usually within the first month.

þ When assessing women in the postnatal period it is important to remember that normal
emotional changes may mask depressive symptoms or be misinterpreted as depression.

þ Primary care teams should be aware that with decreasing duration of stay in postnatal
wards, puerperal psychosis is more likely to present following a mother’s discharge home.

2.2 RISK FACTORS

2.2.1 RISK FACTORS FOR POSTNATAL DEPRESSION

If risk factors predicting postnatal depression can be identified by screening this would allow
optimum targeting of effective interventions.
The evidence suggests that risk factors for postnatal depression are no different to the risk factors
for non-postnatal depression. Three systematic reviews identified the following risk factors as
having moderate to strong associations with postnatal depression:2, 39,40
n past history of psychopathology and psychological disturbance during pregnancy
n low social support 1+
n poor marital relationship
n recent life events
n “baby blues”.
Weak associations have been found with obstetric complications, a history of abuse, low family
income and lower occupational status.2,39-41 An American review found no evidence regarding the 3
effect of early postpartum discharge.42

3
POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

In addition to the above factors, cohort and case control studies have identified the following as
risk factors:19,43-50
n parents’ perceptions of their own upbringing
n unplanned pregnancy
n unemployment
n not breastfeeding
n antenatal parental stress
n antenatal thyroid dysfunction 2+
n coping style
n longer time to conception
n depression in fathers
n emotional lability in maternity blues
n low quality social support
n having two or more children.
There is no conclusive evidence on hormonal changes as a risk factor for postnatal depression. In
a small experimental study, simulating hormone changes after delivery led to a significant change
1-
in mood in five of eight women with a previous history of postnatal depression compared with
none of eight comparison women, suggesting differential sensitivity to hormone change.51
Mothers’ mental health may also be affected by the health of the baby. In cohort studies depression
has been associated with neonatal risk,52 stillbirth, neonatal death or Sudden Infant Death Syndrome 2+
(SIDS),53 and very low birth weight (less than 1500 g).54,55

2.2.2 RISK FACTORS FOR PUERPERAL PSYCHOSIS

Factors that increase the risk of puerperal psychosis include a past history of puerperal psychosis,
pre-existing psychotic illness (especially affective psychosis) of severity requiring admission to
hospital, and family history of affective psychosis in first or second degree relatives.56-59 Women
who have had a previous puerperal psychosis are at significant risk of future puerperal and non- 2+
puerperal episodes.56,57,60-63 The risk of a future puerperal episode lies between 25% and 57% and
the risk of non-puerperal relapse is even higher.

A Procedures should be in place to ensure that all women are routinely assessed during the
antenatal period for a history of depression.

þ Psychosocial and biological risk factors for postnatal depression and puerperal psychosis
should be recorded in the antenatal period in a routine and systematic fashion.

þ Pregnant women and their partners should be given information during the antenatal period
on the nature of postnatal mood disorders and puerperal psychosis.

2.3 SCREENING
Screening for postnatal depression has gained in popularity since the original studies on the
effectiveness of screening by health visitors in primary care were published.64 Screening can have
negative consequences however, particularly so in the field of mental health. It is therefore important
that the health professionals administering any aspect of a screening programme are adequately
trained to do so.
Many areas throughout Scotland have already instituted screening programmes, often in the context
of integrated care pathways for the detection and management of postnatal depression. 65 To be
effective, screening programmes should meet certain criteria, the most important of which include:
n adequate understanding of the condition 4
n a simple, safe, validated screening test with appropriate cut-off levels
n effective treatment for those screened as positive
n adequate resources to ensure any programme is implemented in an acceptable, expert manner.66

4
 2 DIAGNOSIS, SCREENING AND PREVENTION

The issue of screening for postnatal depression is currently being assessed by the Department of
Health National Screening Committee. In practice, screening is already taking place, albeit in
varying styles and with varying levels of resources. While evidence may not yet be available to
meet the strictest criteria for recommending screening programmes, if programmes are instigated
they should conform to best available research evidence on effectiveness, be adequately resourced,
and include ongoing evaluation as an integral part of the programme. The SIGN guideline
development group’s recommendations are based on these premises.

2.3.1 ANTENATAL SCREENING – POSTNATAL DEPRESSION

Screening tools have been devised to predict postnatal depression in the antenatal period. These
have been based around known risk factors for postnatal depression (see section 2.2.1), but many
have not been properly evaluated to determine sensitivity, specificity and predictive value. The
2+
Edinburgh Postnatal Depression Scale (EPDS) has also been examined as an antenatal screening
tool.67 As yet, no antenatal tool has been devised which will accurately predict those who go on
to develop postnatal depression.
There is no evidence to support routine screening in the antenatal period to predict the development
of postnatal depression.

2.3.2 ANTENATAL SCREENING – PUERPERAL PSYCHOSIS

While no specific screening tools have been devised to identify women at high risk of puerperal
psychosis, there is ample evidence that risk factors can be easily identified and are highly predictive 4
(see section 2.2.2). Based on this evidence, enquiry about such risk factors has been recommended
by several expert reports.5,68

D All women should be screened during pregnancy for previous puerperal psychosis, history
of other psychopathology (especially affective psychosis) and family history of affective
psychosis.

þ Women with positive risk factors for puerperal psychosis should receive specialist psychiatric
assessment antenatally.

2.3.3 POSTNATAL DEPRESSION SCREENING

The most commonly used screening tool in the postnatal period is the EPDS. There is good
evidence for its effectiveness, although its sensitivity, specificity and predictive value are dependent
on the cut-off scores chosen. A cut-off of greater than 9 has been suggested for ‘possible depression’
and greater than 12 for ‘probable depression’.67,69,70 The lower cut-off will ensure that very few
women are missed, but at the expense of a high false positive rate. Taking this into account, the
positive predictive value of the EPDS varies from 44% to 73%. 71-73
Concerns have been expressed that the EPDS may perform less well in cases where there are 2+
psychomotor symptoms (often suggestive of severe depression).74 More work is required on the
timing and number of administrations, and on appropriate cut-offs to use.
There is some evidence that, in research settings, combining two screening tools (the EPDS and
the General Health Questionnaire, GHQ) may be more effective than either tool alone.75
4
C The EPDS should be offered to women in the postnatal period as part of a screening
programme for postnatal depression.
2+
C The EPDS is not a diagnostic tool. Diagnosis of postnatal depression requires clinical
evaluation.

þ A cut-off on the EPDS of 10 or above is suggested for whole population screening.

þ The EPDS should be used at approximately six weeks and three months following delivery
and should be administered by trained health visitors or other health professionals.

5
POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

2.4 PREVENTION

2.4.1 PREVENTION OF POSTNATAL DEPRESSION

An effective intervention to prevent postnatal depression in high risk groups would benefit women
in reducing depression and its impact on the child and marital relationships. However, the evidence
for the effectiveness of interventions to prevent postnatal depression is conflicting. Few good
quality randomised controlled trials have been published and those that have give inconclusive
findings.
The provision of home support workers,76 midwife managed care,77 and postnatal check up at six
weeks78 have all been found in randomised controlled trials to have no significant effect in women
with no complications in pregnancy or delivery. No long term effect of a doula (female birthing
companion) was found in a study of pre-term babies in South Africa, although the follow-up rate in
this study was low (50%).79 An antenatal preparation for parenthood intervention (six one-hour
antenatal classes) was found to have no effect on depression or psychosocial risk factors at three
months, although only 45% of women attended more than two sessions.80 A small study found that
individualised, family-based interventions resulted in improved maternal psychological well-being.81
Weekly visits by a child health nurse significantly reduced the scores on the EPDS at six weeks in 1+
a group of mothers screened for high risk factors, although only 53% returned questionnaires.82
Reduced anxiety and depression has also been found after debriefing by midwives, although the
morbidity in the control group in this study was high (55% above threshold for depression on the
Hospital Anxiety and Depression (HAD) scale). A large Australian study found no effect of debriefing
in women following operative childbirth.83,84 In another small study, women with at least one
predictor of postnatal depression who were given interpersonal therapy had reduced Beck depression
scores compared with the control group, but 33% of the control group had major postnatal
depression.85
A cohort study in mothers identified antenatally as vulnerable to depression found that first time
mothers who had taken part in a parenthood educational programme had significantly lower EPDS
scores compared with routine care.86
A placebo controlled randomised clinical trial examined the use of nortriptyline to prevent recurrence
of depression in 51 postnatal women who had a previous history of postpartum depression. No 2+
difference in the rate of recurrence was found between the two groups.87
In a small study of eleven women with a history of puerperal psychosis or puerperal major depression
but no history of non-puerperal depression, prophylactic oestrogen prevented relapse in all but
one.88
The current research base for preventive interventions in low risk women is extremely limited.

þ In high risk women it may be effective to have postnatal visits, interpersonal therapy and/
or antenatal preparation.

2.4.2 PREVENTION OF PUERPERAL PSYCHOSIS

Two cohort studies have examined the use of prophylactic lithium given either in late pregnancy
or immediately after delivery for the purpose of preventing the development of puerperal psychosis
in high risk women. The first found that fewer than 10% of treated patients developed illness,
substantially lower than their estimate of 20%.89 The second study examined 27 women with
2-
bipolar mood disorder.90 Only one of 14 who received mood stabilisers developed puerperal
psychosis compared with eight of 13 untreated women.90 Both these studies were limited by their
open design, but their findings are reinforced by one study showing a high risk of puerperal relapse
in bipolar women who discontinue lithium during pregnancy.127
The evidence suggests that lithium is an effective treatment when used to prevent puerperal
psychosis in high risk groups but it is not of sufficient quality to support a recommendation.

þ Women identified at high risk of puerperal psychosis should receive specialist psychiatric
review.

6
 3 MANAGEMENT

3 Management
Untreated postnatal depression may be prolonged and may have a deleterious effect on the
2+
relationship between mother and baby and on the child’s cognitive and emotional development.4,91
1+
However, the response to both pharmacological and psychosocial interventions is good.14

B Postnatal depression and puerperal psychosis should be treated.

Many women are reluctant to consider the use of psychotropic medicine during pregnancy and the
postnatal period. The choice of treatment for postnatal depression should be governed by efficacy,
incidence of side effects, likely compliance, patient preference and, in the case of pharmacological
therapies, safety of use when pregnant or breast feeding (see section 4).
There are instances where the mother and infant may be at risk because of the mother’s mental
illness. Although rare, infanticide and suicide do occur. Multidisciplinary risk assessment and risk
management protocols and, if necessary, local child protection procedures should always be followed
when there is the potential for serious harm to the mother and/or baby.92 These should provide a
protective framework by ensuring good communication between the family and professionals.

3.1 PHARMACOLOGICAL AND PHYSICAL MANAGEMENT

3.1.1 POSTNATAL DEPRESSION

n Hormonal therapies
Hormonal therapies have been the subject of considerable debate, however little reliable evidence
is available. No evidence could be identified for the effectiveness of natural progesterone or
synthetic progestogens in the treatment of postnatal depression.93
One double blind randomised controlled trial indicates that transdermal oestrogen (with cyclical
progestogen) is more effective than placebo in moderate to severe postnatal depression.93,94 However, 1-
concern about side effects, particularly endometrial hyperplasia and thrombosis, may limit its use.

n Antidepressants
A randomised controlled trial of the use of antidepressant therapy in postnatal depression carried
out in a community setting in Manchester demonstrated a beneficial effect from fluoxetine combined 1+
with at least one session of modified cognitive behavioural therapy (CBT) in women with mild
postnatal depression.14
Evidence from a case control study carried out in the United States suggests that both SSRIs and
tricyclic antidepressants (TCAs) are effective in postnatal depression.95 A small case series suggests 2-
3
that SSRIs are no less effective in patients with postnatal depression than in other patient groups.96

n Physical therapies
No evidence was identified relating to the use of electroconvulsive (ECT) therapy in postnatal
depression.

n St John’s Wort (hypericum perforatum)

No evidence was identified relating specifically to the treatment of postnatal depression by St
John’s Wort or other alternative medicines. The potential for interactions with other prescription
medicines and the lack of pharmacoregulation of these products means that caution should always
be exercised before recommending their use in pregnancy and lactation.97

n Physical exercise
There is good evidence to support the role of exercise in reducing levels of depression in the
general population98 but little research has been conducted into its role in postnatal depression.99

7
POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

D Postnatal depression should be managed in the same way as depression at any other time,
but with the additional considerations regarding the use of antidepressants when breast
feeding and in pregnancy (see section 4).

þ St John’s Wort and other alternative medicines should not be used during pregnancy and
lactation until further evidence as to their safety in these situations is available.

þ The use of hormonal therapies in the routine management of patients with PND is not advised.

3.1.2 PUERPERAL PSYCHOSIS

There is limited evidence for the effectiveness of treatment specifically for puerperal psychosis. As the
nature of puerperal psychosis is essentially affective, treatments used for affective psychoses in general
are also appropriate for puerperal psychosis. Such treatments would typically involve one or more
drugs from the antidepressant, mood stabilising or neuroleptic groups and /or occasionally ECT.

D Puerperal psychosis should be managed in the same way as psychotic disorders at any
other time, but with the additional considerations regarding the use of drug treatments
when breast feeding and in pregnancy (see section 4).

3.2 PSYCHOSOCIAL MANAGEMENT

The evidence relating to the role of psychosocial interventions in the treatment of postnatal depression
focuses mainly on the “talking” therapies, including counselling, psychotherapy, and approaches based
upon these techniques. A number of studies have investigated the role of complementary therapies,
including massage, infant massage and relaxation therapies in postnatal depression; and a few studies
have reviewed the interaction between the depressed mother and her infant. The majority of published
studies are descriptive and observational in nature. Methodological weaknesses and small sample sizes
limit the conclusions that can be drawn from the few randomised controlled trials identified.

3.2.1 COUNSELLING AND PSYCHOTHERAPY

A number of studies indicate that this type of intervention, when provided by trained practitioners,
can significantly reduce depressive symptoms in women diagnosed with postnatal depression.

n Counselling
Counselling is a systematic process which gives individuals an opportunity to explore, discover
and clarify ways of living more resourcefully and with a greater sense of wellbeing. It may be
concerned with addressing and resolving specific problems, making decisions, coping with crises,
working through conflict, or improving relationships with others.100
Evidence consistently demonstrates that a systematic intervention based on non-directive counselling
(supportive listening without giving opinions or advice) of around six to eight sessions, delivered
by trained primary health care workers (e.g. health visitors), is effective in reducing mothers’
1+
depression in the postnatal period compared with routine care.7,101,102 Although there are some
difficulties in defining “routine care” and one of the studies is now over 15 years old, the size of
the effects described outweighs the problems of completely controlling confounding variables.

n Cognitive behavioural approaches

Cognitive behaviour therapy (CBT) is a structured therapy combining concepts and techniques
from cognitive and behaviour therapies. It seeks to solve problems and reduce symptoms by
changing unhelpful thoughts, beliefs and behaviours.100
Brief interventions using cognitive behavioural and problem-solving approaches are effective in
reducing depressive symptoms in women during the postnatal period.7,14 Such interventions, which
are based around a minimum number of sessions, can be as effective as antidepressants in alleviating 1+
the symptoms of mild to moderate depression in new mothers.14 The use of these techniques can
be transferred to telephone counselling with good effect.103

8
 3 MANAGEMENT

n Interpersonal therapy
The interpersonal therapy approach focuses on the mother’s past and present relationships, including
the relationship with her own mother, and helps her to relate problematical aspects of these
relationships to her current depression.
Interpersonal therapy has been shown to significantly reduce depressive symptoms in postnatally 1+
depressed women.104

3.2.2 SOCIAL SUPPORT

The relationship between postnatal depression and adverse social circumstances is similar to that
for depression generally. Both cultural and environmental factors are important when considering
social support and little work has been done specifically in Scotland.
There are various local initiatives and responsive services in Scotland offering support to the
mother, the baby and family. Many of these have been established by practitioners with an
interest in the field of postnatal depression and, like much of current practice, have not been
subjected to rigorous evaluation.
Systematic review of a small body of evidence indicates that social support may be helpful in
reducing depressive symptoms in the mother.105 Help must be carefully matched to the mother and 1+
family’s particular needs to avoid undermining the mother’s confidence and place in the family.106,107
It is clear from a number of studies that a mother’s perception of lack of support can be a risk
factor in predisposing her to depression. A mother’s ability to use social support (e.g. home help 2+
and childcare) may be affected by her depression. A confiding relationship and secure adult
attachment are protective factors.108

3.2.3 FAMILY FOCUSED INTERVENTIONS

Several studies focusing on interventions involving the mother and partner and mother with baby
have described various benefits.109-112

n Couple interventions
One study suggests that couples involved in an individual or group intervention focused on parenting
and their reactions to it experience a reduction in their depressive symptoms and a benefit to their 1+
general health.109

n Interaction focused interventions

The quality of relationship between a mother and her child may be adversely affected by the
mother’s depressive condition. Several early intervention studies suggest that working with depressed
4
mothers in order to teach different response patterns to their children can positively affect the
mother-infant bond. 110,111

n Infant massage
A small randomised controlled study demonstrated that attending infant massage classes had a significant
and positive effect on both mother-infant interaction and depressive symptoms in the mother. 112,113 1-

B Psychosocial interventions should be considered when deciding on treatment options for

a mother diagnosed as suffering from postnatal depression.

C Interventions that work with more than one family member at a time should be considered
when assessing the treatment options available.

þ The effects of a mother’s postnatal depression on other family members and their subsequent
needs should be considered and support offered as appropriate.

þ The psychosocial treatment option chosen should reflect both clinical judgement and the
mother’s and family’s preferences where possible.

9
POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

3.3 MOTHER AND BABY UNITS

In severe cases of postnatal depression and puerperal psychosis, there is frequently a difficult
question: whether admission to hospital would hasten the recovery of the mother. If the answer is
yes, there is an important follow-up question: whether to admit the baby as well. This applies
equally to mothers with severe postnatal depression or puerperal psychosis and to mothers with a
schizophrenic illness exacerbated by the impact of a new baby.
Several studies have examined whether mother and baby admissions are an effective approach.
The papers are descriptive, largely written by the clinicians running the units. The authors have
generally found advantages in avoiding separation of mother and infant: establishing positive
2+
attachment, enhancing the mother’s confidence in her maternal role, and providing support to the
husband and family.114-116 A study of a specialist day hospital has also shown benefits for mother
and baby.68
There are concerns, however, that admission of mothers with their babies to general psychiatric
wards may not adequately ensure the safety and security of the baby. Guidelines published by the
Royal College of Psychiatrists discourage such ad hoc arrangements and recommend the provision 4
of mother and baby units.68 In England, the Mental Health Act Code of Practice and other national
guidance states that infants should not be admitted to general psychiatric wards.117,118 The SIGN
guideline development group endorses these recommendations.

D The option to admit mother and baby together to a specialist unit should be available.
Mothers and babies should not routinely be admitted to general psychiatric wards.

þ A multiprofessional assessment, including social work, and involving family members,

should take place to review the decision to admit mother and baby to a specialist unit
either before or shortly after admission.

þ Clinical responsibility for the baby whilst the mother is an inpatient needs to be clearly
determined.

10
 4 PRESCRIBING ISSUES IN PREGNANCY AND LACTATION

4 Prescribing issues in pregnancy and lactation

4.1 INTRODUCTION
Clinicians are cautious about prescribing drugs during pregnancy or when a mother is breast
feeding due to the possible risks to the fetus and infant. In early pregnancy the risk of teratogenesis
is the main concern. The main risks associated with psychotropic drugs in later pregnancy are
neonatal toxicity or withdrawal syndrome following delivery and the possibility of a long term
impact on the infant’s neurodevelopment.119 During breast feeding many drugs taken by the mother
are excreted in the milk and ingested by the infant, with consequent concerns about their impact
on the infant with regard to both short term toxicity and longer term neurodevelopment.120 The
level of concern about prescribing during pregnancy and lactation is reflected in the Terms of
Marketing Authorisation, with most psychotropic drugs not being licensed for use in pregnancy
and lactation. This underlines the need to give very careful consideration to the risks and benefits
of prescribing psychotropic medication at this time.
Decisions may have to be made about commencing psychotropic drugs during pregnancy if a
woman becomes ill or, more commonly, stopping medication if a woman finds that she is
pregnant. As many pregnancies are unplanned, some are exposed inadvertently to psychotropic
medication. Advice may then be sought on the need for further investigation and possible therapeutic
termination of pregnancy. Studies based on systematic case registers such as the Swedish Medical
Birth Registry121 are contributing to more substantial evidence for such decisions, particularly in
relation to teratogenicity.

þ Scottish case registers to record outcomes for children exposed to psychotropic medication
in utero or through breast feeding are required.

Much of the evidence base for risk associated with drug treatments is based on case reports and
case series. As new antidepressants are introduced there will continue to be a time-lag in evidence
becoming available on which decisions can be made. Evidence is scant for newer agents and for
long term developmental risk. It is reasonable to assume that the fetus and newborn are as, if not
more, susceptible to the same side effects as adults. The evidence identified demonstrates a
relatively low risk with most psychotropic agents, however no treatment is risk-free. Pregnant
women and their families have the right to expect that treatments prescribed are clearly indicated
and are associated with lowest known risk.

The following general principles governing prescription of new medication or the continuation
of established therapy during pregnancy and in breast feeding apply to all recommendations in
this guideline:
n establish a clear indication for drug treatment
(i.e. the presence of significant illness in the absence of acceptable or effective alternatives)
n use treatments in the lowest effective dose for the shortest period necessary
n drugs with a better evidence base (generally more established drugs) are preferable
n assess the benefit/risk ratio of the illness and treatment for both mother and baby/fetus.

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POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

4.2 DRUG TREATMENT IN THE FIRST TRIMESTER

4.2.1 ANTIDEPRESSANTS
Evidence indicates no increased risk of major malformation in the newborn or spontaneous abortion
following exposure to antidepressants in early pregnancy.119,121-126 This evidence applies to a variety
2++
of tricyclic antidepressants (TCAs) and selective serotonin re-uptake inhibitors (SSRIs); 119,121,123,124
and more specifically, fluoxetine,122,125 citalopram,121 fluvoxamine,126 paroxetine,126 and sertraline.126

B The risks of stopping tricyclic or SSRI antidepressant medication should be carefully assessed
in relation to the mother’s mental state and previous history. There is no indication to
stop tricyclic or SSRI antidepressant medication as a matter of routine in early pregnancy.

þ If a pregnant woman becomes depressed, antidepressant medication should be prescribed

with caution and specialist psychiatric advice sought.

Adequate evidence is not available to make recommendations on the use of other antidepressant
medications.

4.2.2 MOOD STABILISERS

n Lithium
Lithium is regularly used on a maintenance basis in the prevention of relapse of bipolar affective
disorder. Such a relapse is more likely to occur following childbirth and when lithium is withdrawn.127 2+

Current practice for women with bipolar disorder who plan to or become pregnant ranges from
the discontinuation of lithium treatment accompanied by close monitoring or prescription of
antipsychotic medication, through to maintenance of lithium throughout pregnancy in cases where
the risk of relapse is significant. Evidence is not available to allow comparison of these strategies,
but recent studies have allowed a review of the risks associated with lithium treatment.
Early studies of lithium in pregnancy suggested that the risk of major fetal malformations, in
particular Ebstein’s anomaly, was increased by exposure to lithium in early pregnancy.128 Recent
evidence, based on prospective studies, suggests that the risk to the fetus of lithium exposure may 2+
have been over-estimated and the risk to the mother and child of lithium withdrawal may have
been under-estimated.127

C Where women with severe bipolar disorder are maintained on lithium, consideration
should be given to continuing lithium during pregnancy if clinically indicated.

C When a woman is maintained on lithium therapy, serum levels should be carefully

monitored. Detailed fetal ultrasound scanning (level III) should be offered.

þ Women with bipolar disorder maintained on lithium should receive specialist supervision.

þ The risks of lithium to the fetus and the effects of lithium withdrawal on the mother should
be discussed before pregnancy.

n Other mood stabilisers

The antiepileptic drugs (AEDs) carbamazepine, valproate and, more recently, lamotrigine are also
used as mood stabilisers. The evidence from studies of women with epilepsy suggests that exposure
to AEDs in early pregnancy increases the risk of congenital malformations and this effect is related 2+
to the use of antiepileptic drugs, not the epilepsy.129 The relative risk is higher with valproate than
carbamazepine and, in particular, with doses of valproate over 1000 mg per day.

12
 4 PRESCRIBING ISSUES IN PREGNANCY AND LACTATION

Several AEDs, including carbamazepine, are folate antagonists. Folic acid supplements are
recommended for women on AEDs from preconception to the end of the first trimester.130 (See the 2+
SIGN guideline Epilepsy in Adults due for publication in late 2002).
There is as yet no evidence available on the risks of lamotrigine in early pregnancy.

C All women on antiepileptic drugs as mood stabilisers should be prescribed a daily dose of
5 mg folic acid from preconception until the end of the first trimester.

D Valproate should be avoided as a mood stabiliser in pregnancy.

þ The risks of antiepileptic drugs used as mood stabilisers should be discussed with the
mother before pregnancy.

4.2.3 OTHER PSYCHOTROPIC MEDICATION

Evidence suggests that exposure to benzodiazepines in early pregnancy increases the risk of major
malformations and oral cleft in the fetus.131 1+

B Benzodiazepines should be avoided in the first trimester of pregnancy.

þ Women inadvertently exposed to benzodiazepines in early pregnancy should be referred

for investigation of possible fetal malformation, in particular oral cleft.

þ Caution should be exercised in the use of any other forms of psychotropic medication in
the first trimester of pregnancy.

4.3 DRUG TREATMENT BEYOND THE FIRST TRIMESTER

The evidence base on the risks of perinatal problems and impaired infant development following
exposure to psychotropic medication in pregnancy is limited to single case reports covering a
wide variety of types of psychotropic medication, and a limited number of cohort and case-
control studies. Perinatal toxic syndromes and withdrawal syndromes following delivery by mothers
who received psychotropic medication during pregnancy have been identified, and there are
understandable concerns regarding the long term effects of such medication on the neurological
development of the infant.119 In particular, newborn infants of women treated with lithium in
later pregnancy face potential risks of neonatal toxicity, thyroid and renal dysfunction.132
One cohort study found no evidence of impairment of neurological development at two years
2+
after delivery following exposure to antidepressants.133
A case control study found poor neonatal function and withdrawal syndromes in a significant
2++
proportion of infants exposed to antipsychotic medication in the last three months of pregnancy.119, 134

C Neonates exposed to psychotropic medication during pregnancy should be monitored for

withdrawal syndromes following delivery.

þ Psychotropic medication, if considered necessary for the woman’s mental state, should be
maintained at the minimum effective dose during pregnancy.

þ Consideration should be given to dose reduction and/or discontinuation two to four weeks
before the expected date of delivery, with recommencement after delivery.

13
POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

4.4 DRUG TREATMENT AND LACTATION

Women who develop mental illness following childbirth and need psychotropic medication are
likely to be discouraged from breast feeding because of the risks to the infant. However, the risk of
breast feeding in this situation may be over-estimated and the advantages under-estimated. 135
The process of excretion of psychotropic medication is complex, with variation in milk/maternal
plasma ratios for different drugs and between foremilk and hindmilk. The level of metabolic
maturity of the infant will also influence any effect of drugs taken by the mother. The evidence
base is limited due to the small number of breast feeding women who have been exposed to any
specific drug and the lack of any systematic approach to monitoring and registering information
about the use of psychotropic medication in breast feeding women.136

þ Medications prescribed to breast feeding mothers are best taken as a single dose where
possible and should be administered before the baby’s longest sleep period.

þ Breast feeding is best done immediately before administering the dose and should be
avoided for one to two hours after any dose of medication (the time of highest plasma
concentrations).

4.4.1 TRICYCLIC ANTIDEPRESSANTS (TCAs)

The use of TCAs is diminishing with the introduction of the SSRIs and other novel antidepressants.
The evidence base consists mainly of case studies, which confirm that TCAs are excreted in breast
milk in higher concentrations in hindmilk than foremilk and the milk/maternal plasma ratio 2+
exceeds one. The limited evidence available suggests no short term toxic effects for the infant
except in the use of doxepin.120,134,135,137-141 No long term developmental effects for the infant have
been demonstrated.

C There is no clinical indication for women treated with TCAs (other than doxepin) to stop
breast feeding, provided the infant is healthy and its progress monitored.

4.4.2 SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS (SSRIs)

SSRIs are being used increasingly in clinical practice. The evidence identified on the use of SSRIs
in breast feeding is based on individual case reports and a small case series.
Cumulative evidence on the use of sertraline142-146 indicates no significant adverse effects on the
breast-fed infant. In one cohort study, 24% of serum samples from infants of nursing mothers
taking sertraline had detectable levels of sertraline, particularly where the mother’s daily dose was
100 mg or more.147 No adverse clinical effects have been reported in breast-fed infants of mothers
taking paroxetine.147-150 Infant serum levels were undetectable in all studies.147-150 No adverse 2+
neurodevelopmental effects were noted in a study of fluoxetine and breast feeding.151 However,
fluoxetine and its metabolite nor-fluoxetine have been detected in the serum of a proportion of
breast-fed infants whose mothers were taking fluoxetine 152 and nor-fluoxetine has a particularly
long metabolic half life.153 Paroxetine has the lowest milk/plasma ratio of these three drugs.146,148,149
There is very limited evidence on citalopram but the milk/maternal plasma ratio is relatively high,
as is the calculated infant dose.154-156 There is little evidence on fluvoxamine but it has a low 3
milk/maternal plasma ratio and the calculated dose to the infant is low.157, 158

C There is no clinical indication for women treated with paroxetine, sertraline or fluoxetine
to stop breast feeding, provided the infant is healthy and his or her progress is monitored.

þ Paroxetine may be the preferred drug because of the low milk/plasma ratio.

14
 4 PRESCRIBING ISSUES IN PREGNANCY AND LACTATION

4.4.3 MOOD STABILISERS

Evidence indicates that lithium is excreted in breast milk at a level of approximately 40% of
maternal serum level. Lithium toxicity has been described in a breast-fed infant and lithium is 3
known to impair thyroid and renal function in adults.159, 160

D In view of the significant risks to the infant of a breast feeding mother taking lithium,
mothers should be encouraged to avoid breast feeding. If a decision is made to proceed,
close monitoring of the infant, including serum lithium levels, should be provided.

Sodium valproate is excreted in breast milk in low levels and infant serum levels are between one
and two per cent of the maternal serum level. No adverse clinical effects have been noted in 2-
breast-fed children when mothers are taking sodium valproate.159, 161
The evidence on carbamazepine suggests that it is excreted into breast milk in significant quantities
3
and infant carbamazepine levels in serum range from 6% to 65% of maternal serum levels.

þ Specialist psychiatric supervision should be provided for women with bipolar affective
disorder on mood stabilisers who wish to breast feed.

4.4.4 OTHER PSYCHOTROPIC MEDICATION

Benzodiazepines are excreted in breast milk with a low milk/plasma ratio.120, 162 4

D New prescriptions for benzodiazepines should be avoided in mothers who are breast
feeding.

Note: this recommendation does not cover drug dependence, where breast feeding may be
beneficial if the infant has been exposed to benzodiazepines in utero.
All forms of antipsychotic medication are excreted in breast milk but as yet there is no evidence
to suggest that breast-fed infants are at risk of toxicity or impaired development.119,120,137,162,163
There is little evidence on the new atypical antipsychotic drugs.120, 164
The evidence on other antidepressant drugs including moclobemide,165,166 venlafaxine,167 and
3
nefazodone168 in breast feeding is very limited, but they are all excreted in breast milk.

þ If a breast feeding mother is taking psychotropic medication, infant development should

be monitored and a careful assessment of the risks and benefits of prescribing at this time
should be made.

15
POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

5 Implementation and audit

5.1 INTRODUCTION
Implementation of national clinical guidelines is the responsibility of each NHS Trust and is an
essential part of clinical governance. It is acknowledged that every Trust cannot implement every
guideline immediately on publication, but mechanisms should be in place to ensure that the care
provided is reviewed against the guideline recommendations and the reasons for any differences
assessed and, where appropriate, addressed. These discussions should involve both clinical staff
and management. Local arrangements may then be made to implement the national guideline in
individual hospitals, units and practices, and to monitor compliance. This may be done by a
variety of means including patient-specific reminders, continuing education and training, and
clinical audit.
Local implementation groups, consisting of representatives from the Health Board, acute and
Primary Care Trusts, professionals, partner agencies (e.g. social services), the voluntary sector, and
service users should be drawn together to consider the many strands which make up an effective,
implementable service.65,169,170

5.2 INTEGRATED CARE PATHWAYS

Integrated care pathways (ICPs) are structured multidisciplinary care plans which detail essential
steps in the care of patients with a specific clinical problem.171 ICPs have been in use in NHSScotland
since the mid 1990s. Although initially used almost exclusively in hospital settings, they have
become increasingly popular across a range of care contexts and for many different conditions,
including rehabilitation medicine and mental health. ICPs are based on the premise that, while
respect for individuals must dominate the approach to care planning and delivery, there are
nonetheless a series of steps that must be followed in relation to every individual with a particular
illness or condition if the best possible outcome is to be secured. This includes actions and
timetables for assessment, diagnosis, referrals and treatment. Standards for detecting and acting
upon symptoms can and must be agreed and adhered to by all professionals involved. The pathway
will ideally be held by the patient. ICPs offer service users and the people who care for them a
clear idea of what to expect and from whom and they offer an opportunity for audit, in particular,
of omissions of care.
There is no evaluative evidence available for the effectiveness of ICPs for perinatal disorders at
present. However, ICPs have been demonstrated to increase patient satisfaction, and reduce
documentation and duration of care in other conditions.171 ICPs for perinatal disorders have been
developed in several Health Board areas throughout Scotland following a recent Health Department
letter.65

5.2.1 ICP DEVELOPMENTS IN SCOTLAND

The guideline development group contacted all Primary Care Trusts (PCTs) and Health Boards in
Scotland for details of current or planned integrated care pathways for postnatal disorders. A 93%
response rate was achieved, providing a ‘snap shot’ view of ICP development in NHSScotland in
Spring 2001. Five Health Board/PCT areas had an ICP either already in use or being piloted, two
of which were approaching the initial evaluation stage. Three areas were working towards an ICP.
Training programmes had been developed either in-house or through modular further education
provision (e.g. from Napier and Paisley Universities).
The ICPs currently in use in Scotland all have flowcharts as their core. These have a comprehensive
and easy-to-follow format that illustrates the care components, options, roles, lines of consultation
and referral for all health professionals involved. They also include specific documentation reflecting
the care pathway and, to a greater or lesser extent, have provision to detail variances from this and
make comments related to a particular case. The other features identified as common to the ICPs
in use in Scotland are outlined overleaf:

16
 5 IMPLEMENTATION AND AUDIT

Antenatal period
n explanation of the ICP to the expectant mother
n screening of risk factors with timing and methodology detailed
n available options dependent on presence of risk factors
n provision of information and education to expectant mothers (and fathers).

Postnatal period
n details of screening through use of EPDS
n available options related to clinical judgement and the EPDS results
n criteria for consultation within primary care
n criteria for consultation with and / or referral to secondary care and other support services
(statutory or voluntary).

Additional features present in some ICPs

n the optional use of the EPDS during the antenatal period
n use of locally developed evidence-based checklists for risk factor assessment
n midwifery interventions during early postnatal stage e.g. labour debriefing
n attempts to provide access to records for all professionals involved, e.g. the use of patient-held
records.

ICPs were commonly incorporated within broader information packs which included all or some
of the following:
n a list of predisposing factors for PND
n a copy of the EPDS and information on its appropriate use and interpretation
n notes for the prescribing of psychotropic medication to expectant and breast feeding mothers
n ethnic and cultural issues relating to pregnancy, baby care, family and mental health
n recommended references and sources of information for professionals and mothers
n useful contact addresses, statutory and voluntary, local and national
n provision of a locally developed information booklet.

þ The development of an integrated care pathway should involve representatives of all

health professions engaged in the provision of ante- and postnatal care and service user
representatives. The ICP should relate to local needs and circumstances.

The ICP should be presented in a user-friendly and succinct format.

The ICP should include specific documentation reflecting the pathway and facilitate
recording of any variance from this to aid evaluation and audit.

Mechanisms should be in place to ensure the orientation of all staff (current and newly
appointed) to the ICP. Adequate training and on-going supervision should be available
for staff with identified knowledge or skill deficits related to the ICP.

5.3 KEY CRITERIA FOR CLINICAL AUDIT

The following suggested audit criteria are based on consensus within the guideline development
group:
Information
n Preparation for parenthood programmes includes information on postnatal depression and
puerperal psychosis.
Screening
n EPDS offered as part of screening for women in the postnatal period.
n Intervals at which the EPDS is used and how often it is used should be recorded per patient.
n Results of clinical assessments.

17
POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

Risk and Prevention

n Mental health status assessed on a regular basis throughout pregnancy.
n Risk factors for postnatal depression and puerperal psychosis identified antenatally.
Management
n All women identified with postnatal depression and puerperal psychosis should be offered
treatment and follow-up by appropriate professionals in appropriate settings.
n Requirement for mother and baby co-admissions monitored.
Prescribing
n Appropriate professional staff involved in the prescribing and monitoring of psychotropic
medication in pregnant and lactating women.

5.4 RESOURCE IMPLICATIONS

5.4.1 ANTENATAL BOOKING

The inclusion of additional questions on history of psychopathology during the history taking at
antenatal booking is, in itself, unlikely to lead to significant resource implications. Education of
midwives, general practitioners and obstetric staff to routinely ask such questions may, however,
have implications for education and training. Services for closely monitoring women with such a
history would also need to be in place.

5.4.2 SCREENING
The guideline recommends the use of the EPDS as a screening tool in the postnatal period. A
survey of EPDS screening practice carried out by the guideline development group found that
screening is undertaken routinely in all but one Primary Care Trust area in Scotland, where its use
is variable. The EPDS is used, with one exception, more than once in all Health Board areas in
Scotland. The routine use of EPDS postnatally carries significant implications associated with
ongoing training, health visitor time for screening and intervention, and facilities in general practice
and secondary care for treatment.

5.4.3 PSYCHOLOGICAL MANAGEMENT

The guideline recommends that psychological interventions should be considered when deciding
on treatment options. It has not been possible to estimate the resource implications associated
with this recommendation. These are likely to vary between different areas of Scotland, which
have different numbers of healthcare professionals with appropriate training in techniques such as
counselling, cognitive behavioural therapy or interpersonal therapy. The resulting resource
implications will therefore vary according to the availability of staff and their associated training
needs.

5.4.4 MOTHER AND BABY UNITS

The guideline endorses the Royal College of Psychiatrists’ recommendation that dedicated mother
and baby units be provided and that the current ad hoc arrangements for admitting mothers with
their babies to general psychiatric wards should stop. The Royal College of Psychiatrists recommends
provision of six to nine beds per 1 to 1.5 million population.68
This recommendation has significant resource implications for Scotland, with additional resources
required across all unified Health Board areas. With the current population of 5.12 million, there
would be a requirement for 30 to 45 beds for mothers with their babies in appropriate specialist
units with a minimum of four beds per unit. Larger units, which span several Health Board areas
are recommended by the Royal College of Psychiatrists’ report, and may provide greater cost
effectiveness.68 Given the current ad hoc arrangements, there are unlikely to be cost savings associated
with rationalising existing service provision.

18
 5 IMPLEMENTATION AND AUDIT

5.5 RESEARCH QUESTIONS

n What is the role of antenatal education in the prevention of postnatal depression?
n What is the role of antenatal screening for postnatal depression and puerperal psychosis?
n Do clinicians treat postnatal depression any differently to the way they treat other forms of
depression?
n What are the most effective screening and assessment tools for postnatal depression and when
should they be administered?
n To what extent do general practitioners prescribe antidepressants in the postnatal period?
n What are the risks and benefits of antidepressants in the management of postnatal depression?
n What is the role of hormonal therapies in postnatal depression?
n What is the role of physical activity in preventing and treating postnatal depression?
n What are the effects of complementary therapies in postnatal depression?
n What are the benefits of psychosocial approaches in the management and prevention of postnatal
depression?
n What is the role of counselling in the management of postnatal depression within the primary
care team?
n What psychosocial skills are available in the NHS work force of relevance to the management
of postnatal depression?
n What are the current management approaches for postnatal depression and puerperal psychoses
in the UK?
n What is the impact of using the EPDS as part of a screening programme for postnatal depression
in the community?
n What interventions are effective in the management of puerperal psychosis?
n Which interventions for postnatal depression improve outcomes for children and when should
they be used?
n What are the specific benefits to the mother and family of Mother and Baby units?
n What are the specific benefits to the mother and family unit of integrated care pathways?
n What is the most effective way of screening for postnatal disorders in ethnic minority groups?
n What are the long term consequences of psychotropic drug therapy in pregnancy and lactation
on fetal and child development?
n What are the effects of postnatal mental illness on partners and existing children?

19
POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

6 Information for patients and carers

6.1 NOTES ON POSTNATAL DEPRESSION FOR DISCUSSION WITH PATIENTS
The following points were drawn up in consultation with patient representatives on the guideline
development group to reflect the issues likely to be of most concern to patients following diagnosis
of postnatal depression. These points may be of use to health professionals when discussing
postnatal depression with patients and in guiding the production of locally produced patient
information materials. The advice is divided into sections to highlight the issues that patients
might wish to discuss at each stage of their care.

DIAGNOSIS
“Asking for help was the hardest thing to do. Having to admit to not coping made me feel
even more inadequate.”
“Being told to pull yourself together is no help at all.”
“I was petrified they would take my baby away. Then everyone would blame me.”
n Is postnatal depression a common illness?
n Is postnatal depression different to other forms of depression?
n What are the causes and common symptoms of postnatal depression?
Key point: PND affects feelings, thoughts and ability to carry out the activities of daily life.

TREATMENT OPTIONS
n Is my illness treatable?
n What care should I expect?
Key point: a package of care should be negotiated with patients. This may involve the practical
and family support provided by family, friends, local and national agencies or groups, informal
and formal therapies and antidepressant medication.

DEMYSTIFYING ANTIDEPRESSANTS
n How do antidepressants work? Are they addictive? Will they make me sleepy?
n How long will I take antidepressants for?
n Can I use antidepressants if I am pregnant or breastfeeding?
n Will I experience side effects?
n How will my use of antidepressants be monitored?
Key point: patients should normally continue to take antidepressant medication for six months
after recovery.

FAMILY AND CARERS

“I knew I felt different and judged myself really harshly and felt so inadequate as a mother.”
n Is my postnatal depression likely to affect the other members of my family?
n Who can offer support to my family?
Key point: the overall package of care should encompass the needs of the family. Practical support
should be offered to enable the parents to meet the baby’s needs e.g. parenting skills, self-help groups.

RECOVERY
n Will I get better?
n Am I going mad?
n Do I need to see a psychiatrist?
n Which health professionals am I likely to see?
n Am I still able to care for my baby?
Key point: the outcome is very good for the majority of women suffering from postnatal depression
provided they are managed appropriately.

20
 6 INFORMATION FOR PATIENTS AND CARERS

6.2 SOURCES OF FURTHER INFORMATION FOR PATIENTS AND CARERS

The National Childbirth Trust
Provides information and support on all aspects of pregnancy, childbirth and early parenthood.
There is individual and group support offered, and local groups around Scotland.
UK contact: Alexandra House, Oldham Terrace, London W3 1BE.
Enquiry line: 0870 444 8707. Web site: www.nctpregnancyandbabycare.com
The Church of Scotland Postnatal Depression Project
Wallace House, 3 Boswall Road, Edinburgh, EH5 3RJ. Tel: 0131 552 8901.
Meet-A-Mum Association (MAMA)
Self help group for antenatal women and mothers with young children with local groups
around Scotland. National Helpline open 7pm to 10pm. Tel: 0208 768 0123.
The Association for Postnatal Illness
Can link mothers with others who have recovered from postnatal depression.
145 Dawes Road, Fulham, London SW6 7EB, Tel: 0207 386 0868.
Action on Puerperal Psychosis
A research oriented project aimed at building up a pool of women who have experienced
puerperal psychosis and are interested in helping with research.
Contact: Jackie Benjamin, University of Birmingham, Queen Elizabeth Psychiatric Hospital,
Mindelsohn Way, Birmingham B15 2QZ. Tel: 0121 678 2361; www.bham.ac.uk/app
Depression Alliance Scotland
3 Grosvenor Gardens, Edinburgh, EH12 5JU. Tel: 0131 467 3050.
The Scottish Association for Mental Health
Cumbrae House, 15 Carlton Court, Glasgow, G5 9JP. Tel: 0141 568 7000
Email: [email protected]; Web site: www.samh.org.uk
Manic Depression Fellowship Scotland
Mile End Mill, Studio 1019, Abbey Mill Business Centre, Seedhill Road, Paisley, PA1 1TJ.
Tel: 0141 560 2050.
The Samaritans
Offers support to those in distress / despair / suicidal who need someone to talk to.
24 hour service. National Helpline Tel: 08457 909090.
Homestart
Offers support and friendship in the family home to families with at least one pre-school child.
Local groups in Scotland. Contacts: 1 Watergate, Perth, PH1 5TF Tel: 01738 444020
and Eldon Business Centre, 74 Townhead, Kirkintilloch, G66 1NZ Tel: 0141 776 3042.
Health Education Board for Scotland
Talking about Postnatal Depression patient information leaflet available. Woodburn House,
Canaan Lane, Edinburgh EH10 4SG. Tel: 0131 536 5500. www.hebs.scot.nhs.uk
The Royal College of Psychiatrists
Produce a leaflet Postnatal depression - Help is at hand. Downloadable from web site.
17 Belgrave Square, London SW1X 8PG. Tel: 020 7235 2351 http://www.rcpsych.ac.uk/
CRY-SIS
Offers support for carers of a crying baby. Tel: 020 7404 5011.
NHS Direct (in England and Wales): www.nhsdirect.nhs.uk
NHS24 (in Scotland): www.nhs24.com
NHS Helpline: 0800 22 44 88
Suggested Reading:
n Marshall F. Coping with postnatal depression. London: Sheldon; 1993.
n Nicolson P. Postnatal depression: facing the paradox of loss, happiness and motherhood.
Chichester: Wiley; 2001.
n Littlewood J, McHugh N. Maternal distress and postnatal depression: the myth of Madonna.
Basingstoke: Macmillan; 1997.

21
POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

6.3 SOURCES OF FURTHER INFORMATION FOR HEALTH PROFESSIONALS

The Marcé Society
An international society for the understanding, prevention and treatment of mental illness related
to childbearing. PO Box 30853, London, W12 OXG; email: [email protected]
The Royal College of Psychiatrists
17 Belgrave Square, London SW1X 8PG; Tel: 020 7235 2351, Fax: 020 7245 1231
http://www.rcpsych.ac.uk/
Society for Reproductive and Infant Psychology
Department of Psychology, University of Hull, Hull, HU6 7RX.
Membership secretary: Ms Sue Weaver, Tel: 01482 465010; email: [email protected]
Suggested Reading:
n Community Practitioners’ and Health Visitors’ Association (CPHVA). Postnatal depression
and maternal mental health, a public health priority. Borough Green: McMillan Scott; 2001.
£5 for CPHVA members, and £7.50 otherwise.
n Singh D, Newburn M, editors. Access to maternity information and support: the experiences
of women before and after giving birth. London: National Childbirth Trust; 2000.
n Clark G. Postnatal depression: in non-English speaking women and those from diverse
cultures: a collection of abstracts. London: Community Practitioners’ and Health Visitors’
Association; 2001.

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 7 DEVELOPMENT OF THE GUIDELINE

7 Development of the guideline

7.1 INTRODUCTION
SIGN is a collaborative network of clinicians, other health care professionals and patient
organisations, funded by the Clinical Resource and Audit Group (CRAG) of the Scottish Executive
Health Department. SIGN guidelines are developed by multidisciplinary groups using a standard
methodology based on a systematic review of the evidence. Further details about SIGN and the
guideline development methodology are contained in SIGN 50: A guideline developer’s handbook,
available at www.sign.ac.uk.

7.2 THE GUIDELINE DEVELOPMENT GROUP

Mrs Patricia Purton Director, Royal College of Midwives Scottish Board, Edinburgh
Chairman
Dr Roch Cantwell Consultant Psychiatrist and Honorary Senior Lecturer, Gartnavel Royal
Methodologist Hospital, Glasgow
Professor Beth Alder Director of Research, Faculty of Health and Life Sciences, Napier University
Dr Barbara Ballinger Consultant Psychiatrist (retired), Dundee
Dr Roddy Campbell Consultant Obstetrician and Gynaecologist, Borders General Hospital, Melrose
Ms Francesca Chappell Information Officer, SIGN
Mr Robert Crawford Community Psychiatric Nurse, Hawick
Ms Vivienne Dickinson Project Manager, Church of Scotland Postnatal Depression Project, Edinburgh
Ms Tania Dignan Patient Representative, Edinburgh
Ms Catriona Hendry Lecturer in Midwifery, Glasgow Caledonian University
Dr Mary Hepburn Consultant Obstetrician, Royal Maternity Hospital, Glasgow
Ms Liz Kearney Health Visitor, Coatbridge
Dr Eilis Kennedy Specialist Registrar, Child Psychiatry, Glasgow
Dr Gerry McPartlin General Practitioner, Edinburgh
Ms Evelyn McPhail Chief Pharmacist, Fife Primary Care NHS Trust
Ms Kim Milledge Health Visitor, Fife Primary Care NHS Trust
Miss Christine Puckering Senior Research Fellow, Child & Adolescent Psychiatry, Yorkhill Hospital, Glasgow
Mrs Marion Shawcross Social Work Officer, Mental Welfare Commission for Scotland, Edinburgh
Dr Imogen Stephens Consultant in Public Health Medicine, Argyll & Clyde NHS Board
Ms Joanne Topalian Programme Manager, SIGN
Dr Sara Twaddle Health Economist, Stobhill Hospital, Glasgow
Ms Jenny Williams Health Visitor, Edinburgh
Mrs Noreen Wright Patient Representative, Edinburgh

The membership of the guideline development group was confirmed following consultation
with the member organisations of SIGN. Declarations of interests were made by all members
of the guideline development group. Further details are available from the SIGN Executive.
7.3 SYSTEMATIC LITERATURE REVIEW
Literature searches were initially conducted in Medline, Embase, Cinahl, PsychLit, Healthstar,
and the Cochrane Library using the year range 1991-2000. The literature search was updated with
new material during the course of the guideline development process. Key websites on the Internet
were also used, such as the National Guidelines Clearinghouse and the Marcé Society. The literature
search was then extended back to as far as was available in each of the databases and extra
searches were supplied in areas such as complementary medicine and health economics. These
searches were supplemented by the reference lists of relevant papers and group members’ own
files. A lack of good evidence was identified by the searches, these results are similar to those of
the Cochrane Library. Overall, a total of 3,900 abstracts were identified by the literature searches,
over 300 papers were assessed resulting in the final reference list of 171 papers.

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POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

7.4 CONSULTATION AND PEER REVIEW

A national open meeting is the main consultative phase of SIGN guideline development, at which
the guideline development group present their draft recommendations for the first time. The
national open meeting for this guideline was held in June 2001 and was attended by all of the key
specialties relevant to the guideline. The draft guideline was also available on the SIGN web site
for a limited period at this stage to allow those unable to attend the meeting to contribute to the
development of the guideline.

The guideline was reviewed in draft form by a panel of independent expert referees, who were
asked to comment primarily on the comprehensiveness and accuracy of interpretation of the
evidence base supporting the recommendations in the guideline. SIGN is grateful to all of these
experts for their contributions to this guideline.
Ms Cheryll Adams Professional Officer, Community Practitioners’ and Health Visitors Association
Dr Mac Armstrong Chief Medical Officer, Scottish Executive
Dr James Beattie General Practitioner, Inverurie
Professor Ian Brockington Professor of Psychiatry, University of Birmingham
Ms Cynthia Clarkson UK Trustee, National Childbirth Trust, Edinburgh
Ms Asha Day Director of Diversity, East Midlands Work Force Confederation
Ms Patricia Dawson Head of Policy, Royal College of Nursing, Edinburgh
Ms Lesley Edwards Community Psychiatric Nurse, West Calder Medical Practice
Dr Sandra Elliot Senior Lecturer in Psychology, University of Greenwich, London
Dr Cathryn Glazener Senior Clinical Research Fellow, Health Services Research Unit, Aberdeen University
Dr Annie Griffiths General Practitioner, Inverness
Dr Margaret Hannah Consultant in Public Health Medicine, Fife Health Board
Professor Dale Hay Professor of Psychology, Cardiff University
Ms Jennifer Holden Psychology Lecturer (retired), Edinburgh
Dr Moira Kennedy General Practitioner, Wallacetown Health Centre, Dundee
Mr Martin Kettle Area Services Manager, Possilpark Health Centre, Glasgow
Ms Ann Lees Health Economist, Argyll and Clyde Acute Trust
Ms Joyce Linton Practice and Policy Development Midwife, Cresswell Maternity Hospital, Dumfries
Dr John MacDonald General Practitioner, Hawick
Dr Una McFadyen Consultant Paediatrician, Stirling Royal Infirmary
Dr Patricia McEllarton Teratologist, National Teratology Information Service, Newcastle
Professor John McLeod Professor of Psychology, University of Abertay, Dundee
Dr Margaret Oates Senior Lecturer in Psychiatry, University of Nottingham
Ms Nicola Ring Nurse Co-ordinator, Scottish Clinical Effectiveness Programme
Ms Karen Robertson Perinatal Nurse Consultant, Gartnavel Royal Hospital, Glasgow
Professor Debbie Sharp Professor of Primary Health Care, University of Bristol
Ms Janet Trundle Prescribing Advisor, Renfrewshire and Inverclyde Primary Care Trust
Dr Hugh Whyte Primary Care Directorate, Scottish Executive
Dr Agnes Wood General Practitioner, Penicuik

The guideline was then reviewed by an Editorial Group comprising relevant specialty representatives
on SIGN Council, to ensure that the peer reviewers’ comments had been addressed adequately
and that any risk of bias in the guideline development process as a whole had been minimised.
The Editorial Group for this guideline was as follows:
Dr Lesley Macdonald Faculty of Public Health Medicine
Dr Adrian Lodge Royal College of Psychiatrists
Professor Gordon Lowe Chairman of SIGN
Ms Juliet Miller Director of SIGN
Dr Gillian Penney Royal College of Obstetrians and Gynaecologists
Dr Bill Reith Royal College of General Practitioners
Ms Ruth Stark British Association of Social Workers
Dr Bernice West National Nursing, Midwifery and Health Visiting Advisory Committee
Dr Peter Wimpenny Robert Gordon University, School of Nursing & Midwifery

24
 7 DEVELOPMENT OF THE GUIDELINE

7.5 ACKNOWLEDGEMENTS
SIGN is grateful to the following former members of the guideline development group and others
who have contributed to the development of this guideline:
Ms Rhona Hotchkiss Director, Nursing and Midwifery Practice Development Unit
Dr Iain Mathie General Practitoner, Cairneyhill, Fife
Dr Alasdair Philp Improving Mental Health Information Project Manager,
NHSScotland Information and Statistics Division
Ms Anne Silcock Health Visitor, Aboyne

25
POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS

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28
Quick reference guide POSTNATAL DEPRESSION AND PUERPERAL PSYCHOSIS SIGN 60

DEFINITIONS MANAGEMENT PRESCRIBING

Postnatal depression (PND) is regarded as any non-psychotic B PND and puerperal psychosis should be treated.
depressive illness of mild to moderate severity occurring during the The following general principles governing prescription of
first postnatal year. It is important to distinguish PND from “baby new medication or the continuation of established therapy
blues”, the brief episode of misery and tearfulness that affects at least D PND should be managed in the same way as depression at during pregnancy and in breast feeding apply to all
any other time, but with the additional considerations recommendations in this guideline.
half of all women following delivery, especially those having their
regarding the use of antidepressants when breast feeding and establish a clear indication for drug treatment (i.e., the
first baby. Puerperal psychosis, is a mood disorder accompanied by n
in pregnancy. presence of significant illness in the absence of acceptable
features such as loss of contact with reality, hallucinations, severe
thought disturbance, and abnormal behaviour. or effective alternatives)
þ St John’s Wort and other alternative medicines should not be n use treatments in the lowest effective dose for the
used during pregnancy and lactation until further evidence as
DIAGNOSIS, SCREENING AND PREVENTION shortest period necessary
to their safety in these situations is available.
n drugs with a better evidence base (generally more
A Procedures should be in place to ensure that all women are þ The use of hormonal therapies in the routine management of
established drugs) are preferable
routinely assessed during the antenatal period for a history of assess the benefit/risk ratio of the illness and treatment for
patients with PND is not advised. n
depression. both mother and baby/fetus.
There is no evidence to support routine screening in the antenatal B Psychosocial interventions should be considered when
period to predict development of PND. deciding on treatment options for a mother diagnosed as
suffering from PND. B The risks of stopping tricyclic or SSRI antidepressant
medication should be carefully assessed in relation to the
D All women should be screened during pregnancy for previous
puerperal psychosis, history of other psychopathology C The effects of a mother’s PND on other family members and mother’s mental state and previous history. There is no
(especially affective psychosis) and family history of affective their subsequent needs should be considered and treatment indication to stop tricyclic or SSRI antidepressant medication as
psychosis. offered to them as appropriate. a matter of routine in early pregnancy.

þ When assessing women in the postnatal period it is important C Interventions that work with more than one family member C There is no clinical indication for women treated with TCAs
to remember that normal emotional changes may mask at a time should be considered when assessing the treatment (other than doxepin) paroxetine, sertraline, or fluoxetine to
depressive symptoms or be misinterpreted as depression. options available. stop breast feeding, provided the infant is healthy and its
progress monitored.
þ The psychosocial treatment option chosen should reflect both
þ Primary care teams should be aware that with decreasing clinical judgement and the mother’s and family’s preferences
duration of stay in postnatal wards, puerperal psychosis is
where possible. FURTHER INFORMATION
more likely to present following a mother’s discharge home.

C The EPDS should be offered to women in the postnatal period D Puerperal psychosis should be managed in the same way as
psychotic disorders at any other time, but with the additional The National Childbirth Trust, Alexandra House, Oldham
as part of a screening programme for PND.
considerations regarding the use of drug treatments when Terrace, London W3 1BE. Enquiry line: 0870 444 8707.
breast feeding and in pregnancy. Web site: www.nctpregnancyandbabycare.com
C The EPDS is not a diagnostic tool.
Diagnosis of PND requires clinical evaluation. Depression Alliance Scotland, 3 Grosvenor Gardens, Edin-
MOTHER AND BABY UNITS burgh, EH12 5JU. Tel: 0131 467 3050.
þ A cut-off on the EPDS of 10 or above is suggested for whole
population screening. Manic Depression Fellowship Scotland, Mile End Mill, Studio
D The option to admit mother and baby together to a specialist 1019, Abbey Mill Business Centre, Seedhill Road, Paisley,
unit should be available. Mothers and babies should not be PA1 1TJ. Tel/fax: 0141 560 2050.
þ The EPDS should be used at approximately six weeks and three admitted to general psychiatric wards routinely.
months following delivery and should be administered by
trained Health Visitors or other health professionals. Action on Puerperal Psychosis, Jackie Benjamin, Queen
þ A multiprofessional assessment, including social work, and Elizabeth Psychiatric Hospital, Birmingham B15 2QZ.
involving family members, should take place to review the Tel: 0121 678 2361; Web site: www.bham.ac.uk/app
þ In high risk women it may be effective to have postnatal visits, decision to admit mother and baby to a specialist unit either
interpersonal therapy and / or antenatal preparation. before or shortly after admission. The Scottish Association for Mental Health, Cumbrae House,
15 Carlton Court, Glasgow, G5 9JP. Tel: 0141 568 7000;
þ Women identified at high risk of puerperal psychosis should þ Clinical responsibility for the baby whilst the mother is an Email: [email protected];
receive specialist psychiatric review. inpatient needs to be clearly determined. Web site: www.samh.org.uk