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Common Mental Health Problems in the Perinatal Period

Updated May 2023

Topic Introduction

"For ease and clarity of writing we use the terms woman/women within these documents. Within this we acknowledge that not all birthing people identify as women"

Topic Introduction:

Common mental health problems in the perinatal period are mental health problems that occur during pregnancy (antenatal) and within one-year after birth (postnatal). This overall timeframe is referred to as the perinatal period. These presentations, commonly depression and anxiety disorders, show a high degree of comorbidity (e.g. coexisting perinatal depression and anxiety), have strong predictive capacity (e.g. antenatal depression a predictor of postnatal depression) ⁽¹⁾, and are an important public health problem that requires immediate attention ⁽²⁾.

The management of common mental health problems in the perinatal period involves addressing a wide range of often interconnected challenges. These include the risk of harm (to mother and foetus/ baby) associated with untreated mental health disorders ⁽³⁾; possible risks associated with the use of psychotropic medication in the perinatal period ⁽⁴⁾; and some degree of uncertainty as it pertains to the benefits, risks, and harm of interventions for perinatal mental health disorders ⁽²⁾. Hence, health care professionals should have the capacity to understand these challenges, as well as to recognise, routinely assess, refer, and provide interventions for perinatal mental health disorders as required. A coordinated care approach should be adopted, inclusive of service user preference and acceptability of interventions during pregnancy and post-natally, particularly in terms of pharmacology. This approach should include the development of an integrated care plan that specifies the treatment plan for the mental health disorder, and the roles of healthcare professionals involved in coordinating care, monitoring schedules, and providing treatment ⁽²⁾. Addressing the psychological impact of a woman’s maternity journey not going as planned and/or the impact of neonatal complications can help prevent mental health difficulties and reduce the detrimental impact on infant brain development and parent infant relationships.

Click here to view Good Practice Principles for Perinatal Mental Health

Prevalence rates

The prevalence of perinatal mental health disorders varies in relation to both the mental health condition and the perinatal period. In the UK, prevalence estimates for perinatal depression have ranged from 7.4% to 14.8% for antenatal depression (higher levels reported in the third trimester), with prevalence estimates of 7.4% - 12.8% reported in the postnatal period ⁽⁶⁾. Prevalence estimates for perinatal anxiety disorders, across its multiple classifications, have ranged between 11.8% to 15.3% for antenatal anxiety, with an estimated 8% prevalence rate reported for postnatal anxiety ⁽⁶⁾.The considerable prevalence estimates, the likely co-occurrence of these disorders ⁽⁶⁾, and the impact of perinatal mental health disorders on child outcomes ⁽⁶⁾ warrant the critical evaluation of interventions that can effectively manage them.

Intended Audience and Scope

Information within this page will be relevant to healthcare professionals who care for women with mental health disorders in the perinatal period, social services and other non-NHS services, commissioners, and women in the perinatal period or those of childbearing potential with previous or existing mental health disorders and their families.

This topic page covers approaches that can help prevent and treat non-psychotic mental health disorders in the perinatal period, with particular focus on common mental health difficulties such as depression and anxiety. Full guidance on identifying, assessing, and managing mental health disorders in the perinatal period can be found in the NICE guidance ⁽²⁾. The management of psychosis and bipolar disorder in the perinatal period is covered in section [Matrix - A guide to delivering evidence-based psychological]. The evidence base for interventions in the perinatal period exists largely in relation to Anxiety and Depression. Please refer to Scottish Matrix recommendations for the management of specific mental health conditions not covered within the perinatal recommendations.

For PTSD and birth related trauma [from miscarriage, traumatic birth, stillbirth, or neonatal death] the evidence tables for PTSD apply [Matrix PTSD table]. However, it should be noted that trauma symptoms are often overlooked or mis-identified as depression. Prevention of trauma and PTSD in the perinatal period is contingent on psychologically informed maternity care ⁽⁵⁾. Single-session high-intensity psychological interventions that focus on ‘re-living’ are not recommended for women who have experienced traumatic births ⁽²⁾.

The use of psychotropic medicines for the treatment of perinatal mental health disorders is not covered, nor is the wider impact of these disorders on family interactions [NES - Early Intervention Framework].

Overview of Evidence - Prevention

Prevention

The antenatal and postnatal periods provide a window of opportunity for health care providers to identify women who might be at risk of developing mental health problems, or women with presentations that might be of concern to health care practitioners. The perinatal period therefore presents an opportunity to deliver psychological interventions for the prevention, early intervention, and treatment of mental health disorders.

There is high-level evidence to support the delivery of cognitive behavioural based approaches for universal prevention of antenatal depression. The moderate effect sizes demonstrated by these interventions make these approaches viable options for the prevention of depression in the antenatal period without the need to identify high-risk pregnant women.

E-health interventions have also been shown to be effective in the universal prevention of perinatal depression. The emerging evidence supporting the use of e-health interventions, as well as the advantages of anonymity and increased access to care, could make this remotely accessed intervention particularly attractive for mental health disorders characterised by high prevalence ⁽⁷⁾.

In addition to universal preventive interventions, there is evidence to support the delivery of psychological interventions to prevent depression in women at high-risk, e.g. women with a history of depression, or those facing socioeconomic situations that place them at high risk of depression. Such interventions include psychoeducation and counselling interventions based on Cognitive Behavioural Therapy (CBT)/ Interpersonal Psychotherapy (IPT).

Other CBT based interventions include facilitated self-help interventions (recommended by NICE) for women in the perinatal period with subthreshold depressive or anxiety symptoms. Based on NICE’S recommendations, guided CBT based interventions can be delivered either face-to-face or remotely; consist of six to eight sessions; and be supported by a trained practitioner.

Ambiguity exists as to what is classed as prevention or early intervention. To ensure consistency and clarity in this topic introduction, interventions are classed as preventive if; (I) explicitly stated in evaluation studies; (II) delivered universally as preventive interventions; (III) delivered to women (in the perinatal period) at high-risk of depression or anxiety. Interventions are classed as early interventions if delivered to women (in the perinatal period) with subthreshold symptom levels. Given the ambiguity and overlap prevention/early intervention are combined in the table.

Table of recommendations - Prevention of Common Mental Health Problems in the Perinatal Period

Recommendation	Who for?	List of Interventions	Type of Psychological Practice	Evidence	Efficacy
First Line Intervention	Prevention/ Early Intervention of mental health problems in the perinatal period	Psychoeducation to prevent postnatal depression in at risk women ⁽⁸⁾	Informed/Skilled	A	N/A
First line intervention	Prevention/ Early Intervention of mental health problems in the perinatal period	Psychoeducation to prevent postnatal depression ^(7,9)	Informed/Skilled	A	N/A
First line intervention	Prevention/ Early Intervention of mental health problems in the perinatal period	Individual or group delivered IPT for postnatal depression ^(10-12)	Enhanced/Specialist	A	N/A
First line intervention	Prevention/ Early Intervention of mental health problems in the perinatal period	Individual or group delivered CBT for postnatal depression ^(12-14)	Enhanced/Specialist	A	N/A
First line intervention	Prevention/ Early Intervention of mental health problems in the perinatal period	Counselling interventions based on CBT / IPT for perinatal depression in at risk women ^(13,15)	Skilled/Enhanced	A	N/A
First line intervention	Prevention/ Early Intervention of mental health problems in the perinatal period	CB-based approaches for universal prevention of antenatal depression ⁽¹⁶⁾	Informed/Skilled	A	N/A
First line intervention	Prevention/ Early Intervention of mental health problems in the perinatal period	E-health interventions for universal prevention of perinatal depression ⁽⁷⁾	Informed/Skilled	A	N/A
First line intervention	Prevention/ Early Intervention of mental health problems in the perinatal period	Facilitated/ guided self-help interventions based on CBT principles for perinatal depression ⁽¹⁷⁾	Skilled/Enhanced	A	N/A
Alternative (evidence less established)	Prevention/ Early Intervention of mental health problems in the perinatal period	Group delivered mindfulness-based CBT for postnatal depression in at risk pregnant women ⁽¹⁸⁾	Enhanced/Specialist	B	N/A
Alternative (evidence less established)	Prevention/ Early Intervention of mental health problems in the perinatal period	Acceptance and Commitment Therapy for antenatal anxiety ⁽¹⁹⁾	Enhanced/Specialist	C	N/A

Overview of Evidence

In this topic overview, interventions are classed as treatment if; (I) explicitly stated in evaluation studies; (II) delivered to women (in the perinatal period) with above threshold symptom levels; or (III) delivered to women with diagnosis of depressive or anxiety disorder. Psychological interventions with medium to high levels of evidence have been included in the evidence table below. This is to be consistent with the aim to focus on interventions with the highest levels of efficacy and the strongest levels of evidence where this exists.

There are a range of interventions with enough evidence to be included in the treatment tables for common perinatal mental health problems. This includes high-level evidence for facilitated self-help based on CBT principles for the treatment of perinatal depression and anxiety. For such interventions, NICE recommends the use of self-help materials, with in-person or remote support provided by a trained practitioner ⁽²⁾. This approach to delivery of care provides a flexible, cost-effective option that has the potential to increase choice for women in the perinatal period with common mental health problems and be provided primarily in Part 1 services as part of a stepped/stratified approach to the treatment. There is also high-level evidence for psychologically informed sessions (based on cognitive behavioural or person-centred principles) for the treatment of postnatal depression ⁽²⁰⁾. This offers another first-step alternative for use in primary care settings.

There is strong evidence of high efficacy for CBT and IPT for the treatment of perinatal depression. In contrast, there is evidence suggestive of potential benefits for CBT and IPT for the treatment of perinatal anxiety, but does not translate to significant efficacy, as evidenced by the small effect sizes in meta-analyses of between-group comparisons. The NICE Guideline Development Group considered it reasonable to extrapolate from a nonpregnant population ⁽²⁾, and recommended that low-intensity or high-intensity psychological interventions be offered in line with recommendations as set out in the NICE guidelines for Generalised Anxiety Disorder and Panic Disorder ⁽²¹⁾, Obsessive-Compulsive Disorder ⁽²²⁾, Social Anxiety Disorder ⁽²³⁾, and Post-Traumatic Stress Disorder ⁽²⁴⁾.

Systematic literature reviews and meta-analysis have assessed the effectiveness of mindfulness-based interventions for the treatment of non-psychotic perinatal mental health disorders. The results from these reviews were inconsistent and did not unilaterally report the efficaciousness of mindfulness-based interventions for this purpose. Understandably, deviation from traditional mindfulness-based interventions (i.e. cognitive therapy based (e.g. MBCT) and stress reduction based (e.g. MBSR)) may have contributed to some of the negligible effect sizes observed. However, based on the overview of results, a low efficacy level has been attributed to mindfulness-based interventions (in general) for the treatment of perinatal anxiety and depression. That said, there is also evidence that these interventions are acceptable to women and are reasonably well tolerated.

Evaluation of Acceptance Commitment Therapy (ACT) in women of in the perinatal period has shown promising results for depression outcomes, but these estimates are subject to substantial methodological variation. The absence of high-quality RCTs, systematic literature reviews and meta-analysis assessing ACT’s effectiveness limit the strength of evidence for this intervention. NICE recommends low-intensity psychological intervention (e.g. facilitated self-help) for anxiety disorders in the perinatal period. However, for specific anxiety disorders e.g., social anxiety disorder, high intensity interventions (e.g. CBT) are recommended as first-line treatment.

Table of recommendations - Treatment of Common Mental Health Problems in the Perinatal Period

Recommendation	Who for?	List of Interventions	Type of Psychological Practice	Evidence	Efficacy
First line intervention	All presentations	Psychologically informed sessions based on cognitive behavioural or person-centred principles for postnatal depression ⁽²⁰⁾	Skilled	A	N/A
First line intervention	Mild/Moderate	Individual guided self-help based on CBT principles (and including behavioural activation and problem-solving techniques) for perinatal depression ^(25-27)	Skilled/Enhanced	A	N/A
First line intervention	Mild/Moderate	Facilitated self-help for perinatal anxiety (includes e-health interventions) ⁽²⁸⁾	Skilled	A	N/A
First line intervention	Mild/Moderate	Mindfulness based interventions for perinatal anxiety and depression ^(29-31)	Skilled/Enhanced	A	N/A
First line intervention	Moderate/ Severe	CBT for perinatal depression ^(32-34)	Enhanced/Specialist	A	N/A
First line intervention	Moderate/ Severe	IPT for perinatal depression ⁽³⁵⁾	Specialist	A	N/A
First line intervention	Moderate/ Severe	CBT for perinatal anxiety ^(36-38)	Enhanced/Specialist	A	N/A
First line intervention	Moderate/ Severe	IPT for perinatal anxiety ⁽³⁵⁾	Specialist		N/A
Alternative (evidence less established)	Moderate/ Severe	Acceptance and Commitment Therapy for perinatal depression ^(39-42)	Specialist	B	N/A
Alternative (evidence less established)	Moderate/ Severe presentations featuring OCD	Individual CBT for postnatal OCD ^(36,43)	Specialist	B	N/A

References

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Acknowledgements

With thanks to the NICE team for their published clinical management and service guidance on antenatal and postnatal mental health ², and to Matrix Cymru team for their published evidence table ⁷. Thanks to the Advisory Group for Common Mental Health Problems in the Perinatal Period; Angus Mac Beth, Dwynwen Myers, Fiona Fraser, Paula Shiels, Josephine Stewart, Alison Robertson, Clare Thompson, Jenny Patterson, Jillian Taylor, Susan McConachie, Kirsten Coull, Marisa Forte, Justine Anderson, Leah Cronin, Hannah Welstead, Regina Esiovwa and Marie Claire Shankland.