Prevention of Common Mental Health Problems in the Perinatal Period

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 (5). 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 (5).The considerable prevalence estimates, the likely co-occurrence of these disorders (5), and the impact of perinatal mental health disorders on child outcomes (5) warrant the critical evaluation of interventions that can effectively manage them.

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 and SIGN (2,6).  The management of psychosis and bipolar disorder in the perinatal period is covered in The Matrix 2015 tables. 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. 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 (7).  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 

Click here for the link to the NES - Early Intervention Framework.

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 (8).

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.

(1) Heron J, O'Connor TG, Evans J, Golding J, Glover V, ALSPAC Study Team. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord 2004 May;80(1):65-73.

(2) NICE. Antenatal and postnatal mental health: clinical management and service guidance Clinical guideline. 2014; Available at: https://www.nice.org.uk/guidance/cg192. Accessed September/6, 2021.

(3) Knight M, Bunch K, Tuffnell D, Patel R, Shakespeare J, Kotnis R, et al. MBBRACE Saving Lives Improving Mothers’ Care Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19. 2021.

(4) Biffi A, Cantarutti A, Rea F, Locatelli A, Zanini R, Corrao G. Use of antidepressants during pregnancy and neonatal outcomes: An umbrella review of meta-analyses of observational studies. J Psychiatr Res 2020 May;124:99-108.

(5) Centre for Mental Health LS of E. The Costs of Perinatal Mental Health Problems. 2014; Available at: https://www.centreformentalhealth.org.uk/publications/costs-perinatal-mental-health-problems, 2022.

(6) SIGN. Perinatal mental health conditions. 2023; Available at: https://www.sign.ac.uk/our-guidelines/perinatal-mental-health-conditions/. Accessed May 27, 2024.

(7) NHS England. Supporting mental healthcare in a maternity and neonatal setting: Good practice guide and case studies. 2021; Available at: https://www.england.nhs.uk/publication/supporting-mental-healthcare-in-a-maternity-and-neonatal-setting-good-practice-guide-and-case-studies/, 2021.

(8) Haga SM, Drozd F, Lisøy C, Wentzel-Larsen T, Slinning K. Mamma Mia - A randomized controlled trial of an internet-based intervention for perinatal depression. Psychol Med 2019 Aug;49(11):1850-1858.

(9) Lara MA, Navarro C, Navarrete L. Outcome results of a psycho-educational intervention in pregnancy to prevent PPD: a randomized control trial. J Affect Disord 2010 Apr;122(1-2):109-117.

(10) NHS Wales. Matrics Cymru-The Evidence Tables Evidence Tables Index. 2017; Available at: http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Matrics%20Cymru%20%28CM%20design%20-%20DRAFT%2015%. Accessed September/6, 2021.

(11) Sockol LE, Epperson CN, Barber JP. A meta-analysis of treatments for perinatal depression. Clin Psychol Rev 2011 Jul;31(5):839-849.

(12) Dennis C, Dowswell T. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database Syst Rev 2013 Feb 28;(2):CD001134. doi(2):CD001134.

(13) Clatworthy J. The effectiveness of antenatal interventions to prevent postnatal depression in high-risk women. J Affect Disord 2012 Mar;137(1-3):25-34.

(14) Sockol LE. A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression. J Affect Disord 2015 May 15;177:7-21.

(15) O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2016 Jan 26;315(4):388-406.

(16) Tandon SD, Ward EA, Hamil JL, Jimenez C, Carter M. Perinatal depression prevention through home visitation: a cluster randomized trial of mothers and babies 1-on-1. J Behav Med 2018 Oct;41(5):641-652.

(17) Yasuma N, Narita Z, Sasaki N, Obikane E, Sekiya J, Inagawa T, et al. Antenatal psychological intervention for universal prevention of antenatal and postnatal depression: A systematic review and meta-analysis. J Affect Disord 2020 Aug 1;273:231-239.

(18) Trevillion K, Ryan EG, Pickles A, Heslin M, Byford S, Nath S, et al. An exploratory parallel-group randomised controlled trial of antenatal Guided Self-Help (plus usual care) versus usual care alone for pregnant women with depression: DAWN trial. J Affect Disord 2020 Jan 15;261:187-197.

(19) Dimidjian S, Goodman SH, Felder JN, Gallop R, Brown AP, Beck A. Staying well during pregnancy and the postpartum: A pilot randomized trial of mindfulness-based cognitive therapy for the prevention of depressive relapse/recurrence. J Consult Clin Psychol 2016 Feb;84(2):134-145.

(20) Vakilian K, Zarei F, Majidi A. Effect of Acceptance and Commitment Therapy (ACT) on Anxiety and Quality of Life During Pregnancy: A Mental Health Clinical Trial Study. Iranian Red Crescent Medical Journal 2019;21(8).

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.