BMJ 2016;352:i1547 doi: 10.1136/bmj.

i1547 (Published 24 March 2016) Page 1 of 9

Clinical Review

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CLINICAL REVIEW

Depression in pregnancy
1
Simone N Vigod assistant professor, psychiatrist, and Shirley Brown clinician scientist , Claire A
2 2
Wilson academic clinical fellow , Louise M Howard NIHR research professor professor in women’s
2
mental health, and consultant perinatal psychiatrist

Department of Psychiatry, Faculty of Medicine, University of Toronto; Women’s College Hospital and Women’s College Research Institute, Ontario,
1

Canada M5S 2B1; 2Section of Women’s Mental Health, King’s College London, London, UK

Depression in pregnancy affects up to 10% of women, with 2 lists the risk factors for depression in pregnancy, although
higher rates in low and middle income countries, a rate only women can present with none. The National Institute of Health
slightly lower than in the postpartum period.1 2 Yet, as few as and Care Excellence recommends that all health professionals
20% of pregnant women with depression receive adequate discuss physical and mental health with women at each contact
treatment.3 4 This is problematic because depression can during pregnancy.23 Standardised tools recommended by NICE
profoundly affect a woman’s sense of wellbeing, relationships, that may help identify depression include:
and quality of life. Untreated or incompletely treated depression • a two question screen: “During the past month, have you often
can also have adverse consequences for the offspring. Systematic been bothered by feeling down, depressed, or hopeless?” and
reviews show an increase in markers of infant morbidity such “During the past month, have you often been bothered by little
as preterm birth, childhood emotional difficulties, behaviour interest or pleasure in doing things?” (a validation study of this
problems, and, in some studies, poor cognitive development.5 6 tool for depression in pregnancy is currently under way)24 25
Antenatal depression also is one of the strongest risk factors for
• the 10 question Edinburgh postnatal depression scale, where
postnatal depression, a condition linked to developmental
in a recent review of validation studies for antenatal depression,
problems in children.6 7 Severe depression can result in suicide,
estimates for sensitivity and specificity varied between 64%
a major cause of maternal death.8 9 Perinatal suicides have been
and 100% and 73% and 100%, respectively, suggesting
associated with lack of active treatment.10 Barriers to treatment
acceptable validity.26 27
include stigma, lack of provider training on perinatal mental
health, and limited access to the evidence based psychological Tools with questions about appetite, fatigue, or sleep (eg, patient
treatments that patients prefer.11-13 Women report that conflicting health questionnaire, PHQ9) must be interpreted cautiously, as
information from professional and non-professional sources impairment might reflect the physical effect of pregnancy rather
about antidepressant drugs in pregnancy impedes decision than depression.28 Regardless of the screening tool used, a
making and may reduce treatment uptake.14-19 This review clinical diagnostic interview is required to confirm depression
presents evidence for health professionals to enable shared and identify comorbid problems requiring management. In
management of depression in pregnancy with patients.20 particular, clinicians should identify and treat any medical
problems that could be causing or contributing to the depressive
How is depression in pregnancy symptoms, such as thyroid abnormalities, iron deficiency, and
identified? nausea and vomiting of pregnancy.
The core features of a depressive episode are a sustained low Depression can coexist or overlap with other conditions, such
mood or loss of interest in pleasurable activities for at least two as anxiety, obsessive-compulsive disorder, trauma, and stressor
weeks (box 1). This persistence of symptoms helps to distinguish related disorders. In women with depression, health
depression from sadness or a temporary response to stress. The professionals must establish whether there is a history of
mood disorders chapter of ICD-10 (international classification hypomanic or manic symptoms, as the management of
of diseases, 10th revision) has no antenatal specifier for depression with bipolar disorder differs.29 Psychosis, in the form
depression. However, there is a separate code for disorders of psychotic depression or a primary psychotic disorder such
occurring in the puerperium (six weeks after delivery). This as schizophrenia would also require specialised management.
contrasts with the Diagnostic and Statistical Manual of Mental Factors such as domestic violence, obesity, smoking, and
Disorders, fifth edition (DSM-5), which denotes a “with substance misuse are also associated with depression. These
perinatal onset” specifier for major depressive episodes with may need to be addressed to reduce the risk of a negative effect
onset during pregnancy or within four weeks post partum.22Box on offspring.7 30 NICE has produced guidelines on the assessment

Correspondence to: S N Vigod [email protected]

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CLINICAL REVIEW

What you need to know

• Offer all women education about mental health problems in pregnancy, treatment options, and the effect on themselves and their

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offspring
• Offer women with mild or moderate depression psychological treatments if they have access to them and can commit time to therapy
• Consider antidepressant drugs such as selective serotonin reuptake inhibitors (SSRIs) for women with current or past severe or
recurrent depression
• For pregnant women who have not used antidepressants, any SSRI (with the exception of paroxetine) is a reasonable first choice
• For former antidepressant users, information on efficacy and tolerability must be considered when selecting an antidepressant during
pregnancy
• Switching antidepressants during pregnancy or lactation is not recommended (even with paroxetine) as there is no clear evidence
that the safety profile of one drug is superior to that of another. Switching away from an effective drug could increase the risk of relapse

Sources and selection criteria

We searched PubMed, Embase, PsycINFO, and the Cochrane Library without language restrictions. Searches were done between 1 January
2003 and 17 October 2015 using the key search terms “pregnancy”, “prenatal”, “antenatal”, “postnatal”, “postpartum”, “perinatal”, “puerperal”,
“breastfeeding”, “birth”, “weaning”, “childbirth”, “trimester”, “peripartum”, “lactation”, “ante-natal”, “post-natal”, “post-partum” and “mood
disorder” (exploded MeSH term), “depression”, and “treatment”, “intervention”, “prevention”, “trial”, “therapy”, “therapeutic”, “treat”, “medicine”,
“medication”, “prescribe”, “prescription”. Using date restrictions based on the amount of research output in each area, between 1 January
2010 and 16 October 2015 we combined these search terms with specific terms for antidepressant drugs commonly used in primary care
for selective serotonin reuptake inhibitors, serotonin-norepinephrine (noradrenaline) reuptake inhibitors, and other first line antidepressant
drugs. We supplemented the search with information from the authors’ personal libraries and evidence based national guidelines.

Box 1: Criteria for depressive episode

ICD-10 criteria for depressive episode21
At least two weeks (but shorter periods may be reasonable if symptoms are severe and of rapid onset) of the following core symptoms
experienced with severe intensity for most of every day:
• Depressed mood. The mood change is normally accompanied by an overall change in level of activity
• Loss of interest and enjoyment
• Reduced energy leading to increased fatigue and diminished activity (this also could be a physical symptom of pregnancy)
Other common symptoms:
• Reduced concentration and attention
• Reduced self esteem and self confidence
• Ideas of guilt and unworthiness
• Bleak and pessimistic views of the future
• Ideas or acts of self harm or suicide
• Disturbed sleep
• Diminished appetite

DSM-5 criteria for depressive episode22

A: For the same two week period at least five of the following symptoms have been present, where at least one is either depressed mood
or loss of interest or pleasure in activities.
• Depressed mood most of the day or almost every day, indicated by subjective self report or by reports of others. This mood might be
characterised by sadness, emptiness, or hopelessness
• Noticeably diminished interest or pleasure in all or almost all activities most of the day, nearly every day
• Clinically significant weight loss when not dieting, or weight gain
• Inability to sleep or oversleeping nearly every day
• Psychomotor agitation or retardation nearly every day
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day
• Diminished ability to think or concentrate, or indecisiveness, nearly every day
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or specific
plan for committing suicide
B: Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
C: The episode is not due to the effects of a substance or a medical condition
DSM-5 denotes a “with perinatal onset” specifier for major depressive episodes with onset during pregnancy or within four
weeks post partum

and management of these conditions, including during an example of a stepped care framework. Box 3 outlines
pregnancy.23-33 suggestions to determine the severity of the depression. A
woman’s treatment may begin at any step in the pathway,
How is it treated? depending on the severity of her illness. The NICE guidelines
on antenatal and postnatal mental health recommend that all
Treatment for depression is based on the severity of the pregnant women with depression, regardless of severity, receive
presenting illness, as recommended in the NICE pathway for education from their treating provider about depression,
common mental disorders in primary care.34Figure 1⇓ provides including how to recognise symptoms and the short and long

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BMJ 2016;352:i1547 doi: 10.1136/bmj.i1547 (Published 24 March 2016) Page 3 of 9

CLINICAL REVIEW

Box 2: Risk factors for antenatal depression

Several risk factors for depression in pregnancy have been identified.7 Clinicians should remember that depression in pregnancy can occur

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in the absence of any of these risk factors.
Risk factors with medium and large associations with antenatal depression, and strong evidence in systematic reviews:
• History of mental disorders
• Domestic violence
• Life stress and major or negative life events
• Low socioeconomic status
Risk factors with smaller or inconsistent associations with antenatal depression in systematic reviews:
• Poor social support
• Young maternal age

term effects on mothers, children, and families.23 Clinicians How should antidepressants be used?
should explore the severity of depressive symptoms with the
women, and review treatment preferences to make shared Owing to concerns about fetal safety, the threshold for drug
decisions about treatment. Invite partners and other members interventions is higher during pregnancy. However, for women
of the support system to join management discussions whenever with current (or former) severe depression (many of whom are
possible. taking antidepressants before pregnancy), or for those who do
not respond to psychological therapies alone—or do not want
to wait the 12 or more weeks for treatments typically to take
Which non-drug treatments are effective? effect—antidepressants will usually be necessary.23 Selective
Women with mild depression may benefit from psychological serotonin reuptake inhibitors (SSRIs) are first line drugs in
treatments such as guided self help, whereas women with mild pregnancy for unipolar depression, but serotonin-norepinephrine
and moderate depression may benefit from higher intensity (noradrenaline) reuptake inhibitors, buproprion, and mirtazapine
psychological treatments such as cognitive behaviour therapy are also commonly used when there is historical response to
(CBT) or interpersonal therapy.36 Primary care and antenatal these drugs or non-response to SSRIs.23 Women who do not
care providers must be aware of the referral systems in their respond to first line treatments, have multiple psychiatric
jurisdictions. Assessment should be offered in a timely manner comorbidities, or have bipolar disorder may require referral and
as delays in treatment result in more maternal distress and longer management in secondary (specialty) psychiatric care. In severe
exposure of the fetus to depression. Access to psychological depression, hospital stay may be required, particularly for
therapies is often limited in low resource settings. Efforts to women with active suicidal ideation, treatment resistance, or
train peers and community members to deliver some lower psychotic clinical features.
intensity psychological treatments for perinatal depression in
developing countries have been successful.22-39 Research is under Women not taking antidepressants before
way to explore novel modes of delivery of psychological care pregnancy
for perinatal depression, including guided self help for mild Antidepressants should be offered for severe and moderate
symptoms and telephone based interpersonal therapy for mild depression when psychological therapy is not, or has not been,
and moderate depression.40 41 effective or where such therapy is not available.23
Few studies have focused specifically on the efficacy of Antidepressants should be used along with psychological
psychosocial and psychological therapies in pregnant women therapies whenever possible because combination therapy may
with depression. Systematic reviews of high quality trials in lead to higher remission rates and lower relapse rates compared
non-pregnant women found face to face structured time limited with either therapy alone.24 52 People with moderate and severe
psychotherapies such as CBT and interpersonal therapy to be depression benefit most, and symptoms can begin to improve,
as effective as drugs for mild, and sometimes moderate, within two weeks of starting drugs.53 54 For women with no
depression.42 43 Similarly, randomised controlled trials in previous antidepressant use, any SSRI is a reasonable first
postpartum women have shown these treatments to be more choice, with the possible exception of paroxetine owing to its
effective at reducing depressive symptoms than usual postpartum higher risk of neonatal adaptation syndrome (NAS, see box 4)
care.44 Several small pilot studies of CBT and interpersonal and withdrawal symptoms in the mother.56 57 For former
therapy for pregnant women in high income countries are antidepressant users, previous efficacy and tolerability must be
promising, showing a moderate effect on depressive symptoms, considered when selecting antidepressants during pregnancy.
but larger studies are required to be able to generate stable
estimates of efficacy.36-49 Two recent pilot randomised controlled Women with a history of depression and
trials reported improved infant outcomes in CBT treated versus receiving maintenance antidepressants
non-treated groups.49 50 In low and middle income countries,
Evidence suggests that continued antidepressant use may prevent
meta-analyses of psychosocial and psychological interventions
relapse of depression in pregnancy, although the greatest
delivered during pregnancy and post partum by trained primary
prophylactic effect is in women with severe or recurrent
care and community health workers showed similar efficacy.7
depression.58 59 Switching antidepressants during pregnancy or
A Cochrane systematic review evaluated bright light therapy,
lactation is not recommended (even with paroxetine) as there
acupuncture, massage, and supplementation with omega-3 (six
is no clear evidence that the safety profile of one drug is superior
randomised controlled trials) but concluded that evidence was
to that of another, and switching from an effective drug could
insufficient to recommend these in clinical care.51
increase the risk of relapse.

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CLINICAL REVIEW

Box 3: Determining the severity of a depressive episode using ICD-10 criteria35

Assessment of severity relies on clinical judgment and the number, type, and severity of symptoms:

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• Mild depression—presence of at least two core symptoms and two additional common symptoms (see box 1)
• Moderate depression—presence of at least two core symptoms and three (preferably four) additional symptoms
• Severe depression—presence of all three core symptoms and at least four additional symptoms, some of which should be severe.
There is a greater risk of suicidality and somatic symptoms (changes to appetite and sleep are common). A severe episode may or
may not be accompanied by psychotic symptoms, but the presence of such symptoms generally indicates a more severe presentation
• Another useful indicator of severity is the degree of functional impairment experienced by the patient

Box 4: Neonatal adaptation syndrome

Symptoms of neonatal adaptation syndrome (NAS) tend to begin within 48 hours of birth, are usually short lived (median three days), and
last no longer than four weeks from birth.55 Symptoms can include:
• Insomnia
• Agitation, tremors, or shivering
• Altered tone
• Restlessness or irritability
• Poor feeding, vomiting, or diarrhoea
• Dysregulated temperature control
• Tachypnoea, respiratory distress, nasal congestion, or cyanosis (rare)
• Seizures (rare)

Dosage in pregnancy with women without depression.66-68 Well conducted studies

For all antidepressants, offer the lowest but most effective dose. also suggest no increased risk for stillbirth or perinatal death
The aim of treatment with antidepressants is to achieve complete with antenatal use of SSRIs.69 70 Two large population based
remission of symptoms. There is no evidence that reducing studies found no increased risk for hypertensive disorders in
antidepressant dose before delivery reduces the risk of neonatal pregnancy from use of SSRIs in pregnancy among women with
adaptation syndrome60 (see box 4). Pharmacokinetic changes psychiatric disorders, although serotonin-norepinephrine
of pregnancy may alter drug metabolism and the impact of this reuptake inhibitors were associated with a small increased risk
is variable and unpredictable. As such, changes to dosage should in one study.71-73 Serotonergic antidepressants may increase the
only be made in the case of symptom relapses where a dose risk for postpartum haemorrhage, but in one study blood loss
may be too low or, in the case of side effects or toxicity, too volume was only slightly greater in women using SSRIs
high. SSRIs are considered compatible with breast feeding as compared with non-users (484 v 398 mL).74 75
less than 10% of maternal dose passes into breast milk (5-10
times less than in utero exposure).61 Therefore, the choice of Fetal development
antidepressant during pregnancy need not be influenced by plans Data on infant outcomes are reasonably reassuring. Antenatal
for lactation, except in the case of women who have never used use of antidepressants does not seem to be associated with an
antidepressants who may want to start sertraline given that it increased risk of major congenital malformations. Early studies
seems to pass least into breast milk.61 62 reported a small absolute increased risk for specific cardiac
defects (especially with paroxetine),76 but this is not supported
What advice should be given about by more rigorously conducted studies.77 78 Associations with
both preterm birth and low birth weight have been observed,
antidepressant use in pregnancy? but a recent meta-analysis found the magnitude of the effect to
Women should be reminded that no pregnancy is without risk, be small (mean difference −0.45 weeks’ gestation, 95%
irrespective of drug use, and that decisions about antidepressants confidence interval −0.64 to −0.25 weeks’ gestation; and −74
involve weighing the benefits and harms of all treatment options, g birth weight, 95% confidence interval −117 g to −31 g).66 79
including no drugs. Pregnant women with depression, and their Persistent pulmonary hypertension of the newborn is rare (1 per
infants, may be at higher risk of poorer outcomes than the 1000 live births) but is a potentially fatal condition for the
background population and this should be considered during neonate. In pregnancies exposed to SSRIs the absolute risk is
any conversation about antidepressant treatment.5 Data on safety 2 or 3 per 1000 live births, although one well conducted study
come from observational studies of variable quality. Even the found that the risk increase attributable to SSRIs (as opposed
most high quality studies are imperfect, so it is important to to confounding factors) was likely to be small.80 81
make women aware that some degree of uncertainty remains A neonatal adaptation syndrome (NAS) has been consistently
about the absolute safety of antidepressants in described with use of most antidepressants during late pregnancy
pregnancy.63 64Figure 2⇓ shows an approach that clinicians can (box 4). Incidence ranges from 5% to 85% as symptoms are
use to help women weigh potential benefits and harms of variably defined across studies.82 NAS is usually mild and self
antidepressant treatment in pregnancy. limiting; a meta-analysis reported mean Apgar scores 0.2 points
lower for infants exposed compared with not exposed to
Effects of antidepressants in pregnancy antidepressants.66 Severe complications such as neonatal
convulsions are rare (<0.1% of births).35 There is no known
Maternal health and pregnancy outcomes method for preventing NAS due to exposure to antidepressants
To date it seems that women who take antidepressants in during pregnancy. Lowering the dose of antidepressants before
pregnancy have a similar risk for spontaneous abortion compared delivery does not seem to lower the risk for NAS.60 Reduction

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BMJ 2016;352:i1547 doi: 10.1136/bmj.i1547 (Published 24 March 2016) Page 5 of 9

CLINICAL REVIEW

of antidepressant dosage before delivery is therefore not LMH receives funding from the National Institute for Health Research
generally recommended since this may also render the dose (NIHR), including for two randomised controlled trials mentioned herein
ineffective for protecting the mother against relapse of (NCT02308592; http://public.ukcrn.org.uk/search/StudyDetail.aspx?

BMJ: first published as 10.1136/bmj.i1547 on 24 March 2016. Downloaded from http://www.bmj.com/ on 29 January 2019 by guest. Protected by copyright.
depression at the time of highest risk (early postpartum period). StudyID=17048) (NIHR research professorship in maternal mental health
Guidelines for fetal and infant monitoring vary, but generally (NIHR-RP-R3-12-011) and NIHR programme grant for applied research
involve a recommendation for monitoring for NAS around the (RP-PG-1210-12002) on the effectiveness of perinatal mental health
time of delivery.23 Simple supportive measures such as advice services). She chaired the NICE update on Antenatal and Postnatal
about regular feeding and reassurance are usually sufficient for Mental Health Guidance (CG192) and she is also the National Clinical
management. Parents should be encouraged to use skin-to-skin Advisor on the NICE/NCCMH technical advisory group for the NHS
contact to aid temperature regulation. Severe signs of toxicity, England access and waiting time perinatal mental health programme.
although rare, may warrant more proactive treatments, such as Provenance and peer review: Commissioned; externally reviewed.
anticonvulsants, fluid resuscitation, and respiratory support.
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events, such as perimenopause. health problems in the antenatal or postnatal period for women in the UK: a systematic
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Contributors: LMH and SNV planned the content of the manuscript. 20 Patel SR, Wisner KL. Decision making for depression treatment during pregnancy and
the postpartum period. Depress Anxiety 2011;28:589-95. doi:10.1002/da.20844 pmid:
CAW conducted the literature searches underlying evidence in the 21681871.
paper. SNV and LMH drafted the manuscript; all authors edited the 21 World Health Organization. The ICD-10 Classification of mental and behavioural disorders:
clinical descriptions and diagnostic guidelines. http://www.who.int/classifications/icd/en/
manuscript and approved the final version. SNV is the guarantor and bluebook.pdf.
accepts full responsibility for the work and/or the conduct of the study, 22 American Psychiatric Association. Diagnostic and statistical manual of mental disorders
(5th edition). American Psychiatric Publishing, 2013.
had access to the data, and controlled the decision to publish.
23 National Institute for Health and Care Excellence. Antenatal and postnatal mental health:
Competing interests: We have read and understood the BMJ policy on clinical management and service guidance. (Clinical guideline CG192.) 2014. https://www.
nice.org.uk/guidance/cg192.
declaration of interests and declare the following: SNV holds funding 24 UK Clinical Research Network Study Portfolio. Well-being in pregnancy: identification and
from the Canadian Institutes of Health Research and The Hospital for prevalence of common mental health problems. 2015; http://public.ukcrn.org.uk/search/
StudyDetail.aspx?StudyID=16403.
Sick Children Foundation to conduct two of the randomised controlled
trials mentioned in this manuscript (NCT02308592; NCT02116127).

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BMJ 2016;352:i1547 doi: 10.1136/bmj.i1547 (Published 24 March 2016) Page 6 of 9

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Questions for future research

• What is the effectiveness of psychological interventions for mother and infant?

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Treatment options being explored currently include facilitated self help and online psychological treatments for women with mild and moderate
depression41 97
• What is the effectiveness of non-invasive somatic interventions for mother and infant?
Treatments for women with previous or current severe depression in pregnancy that allow for effective treatment without systemic drug
exposure of the infant are currently being evaluated, including focal brain stimulation therapies such as repetitive transcranial magnetic
stimulation (rTMS), transcranial direct current stimulation (tDCS),98-100 bright light therapy, sleep deprivation, and sleep phase advance101
• Can an interactive electronic patient decision aid reduce decisional conflict about antidepressants and improve maternal outcomes?
Online and interactive patient decision support tools are being investigated that aim to enhance women’s knowledge about depression in
pregnancy and its treatment options, help women to clarify their values about the benefits and risks of each treatment, and support women
in decision making with their healthcare providers102 103
• How can we assess the risks and benefits of antidepressant treatment on infant and child outcomes, and what are the moderators of
treatment?
Most studies have focused on the safety of antidepressant treatment for infants and children, without addressing how treatment might benefit
infant and child outcomes. Studies that deal with both of these issues, as well as research that identifies who is likely to benefit most from
which treatment are essential to informing the risk-benefit discussion about the use of antidepressants in pregnancy. Current trials include
a randomised controlled trial of women randomly allocated to relapse prevention cognitive therapy with gradual, guided discontinuation of
SSRIs under clinical management (intervention group) compared with continuation of SSRIs (control group)104
• What role can technology play in screening for depression in pregnancy?
Administering screening tools through mobile devices is currently being trialled.105 This may provide greater access to screening tools to
identify the high numbers of women who go undiagnosed and provide prompt access to treatment
• Can cost effective psychosocial interventions be delivered within resource poor settings?
Methods currently being evaluated include task sharing to community health workers to deliver a counselling intervention in South Africa106

Tips for non-specialists

• Although pregnancy is often a happy time, depression is common. Do not forget to ask how your patient finds being pregnant whenever
you see her and then ask specific questions about low mood, lack of enjoyment, and loss of interest
• See pregnant women alone at least once during the pregnancy as they may feel unable to tell you about problems with their partner
if the partner is present (particularly if domestic violence is occurring), and may not disclose depressive symptoms if friends or family
are present
• Reassure women that depression is common and treatable, and discuss the range of treatment options. When referring for psychological
interventions, ensure services know when a woman is pregnant so she is seen quickly (NICE guidance recommends assessment
within two weeks)
• Provide women with information resources (see resources for patients)

Additional educational resources

Resources for healthcare professionals
NICE. Antenatal and postnatal mental health: clinical management and service guidance for clinicians (www.nice.org.uk/guidance/cg192/
resources/antenatal-and-postnatal-mental-health-clinical-management-and-service-guidance-35109869806789)—guidance on treatment
of a range of perinatal conditions
Maternal Mental Health (www.knowledge.scot.nhs.uk/maternalhealth/learning/maternal-mental-health.aspx)—e learning resource for all
healthcare professionals working with pregnant women outlining the key principles in recognition and management of mental illness during
this period (requires free registration)
Bettercare Maternal Mental Health Handbook (http://ls.bettercare.co.za/maternal-mental-health/0-3-contents.html)—resource for all healthcare
professionals working with pregnant women
Maternal Mental Health: A Handbook for Health Workers (http://mhinnovation.net/sites/default/files/downloads/resource/PMHP%20Handbook%
202013.pdf)—advice of particular relevance to those professionals working in low and middle income countries
Thinking Healthy (http://mhinnovation.net/sites/default/files/downloads/resource/WHO_Thinking%20Healthy_eng.pdf)—a manual for
psychological management of perinatal depression—an evidence based approach to provision of low intensity psychological interventions
that can be implemented by community workers, particularly in low and middle income countries

Resources for patients and carers

NICE. Mental health in pregnancy and the year after giving birth (www.nice.org.uk/guidance/cg192/resources/mental-health-in-pregnancy-
and-the-year-after-giving-birth-250640652229)—information on treatment of a range of perinatal conditions
UK Royal College of Psychiatrists. Mental health in pregnancy (www.rcpsych.ac.uk/healthadvice/problemsdisorders/mentalhealthinpregnancy.
aspx)—fact sheet for women (also available in Urdu and Spanish)
Tommy’s. Your mental wellbeing in pregnancy (www.tommys.org/pregnancy/your-life/mental-health)—advice and resources produced by
the charity Tommy’s
US Department of Health. Depression during and after pregnancy (www.womenshealth.gov/publications/our-publications/fact-sheet/depression-
pregnancy.pdf)—useful fact sheet
Postpartum progress (www.postpartumprogress.com/)—a blog about emotional health around pregnancy and childbirth run by a non-profit
organisation in the United States

How patients were involved in creating this article

We asked women with experience of perinatal mental health problems who are on a perinatal service user and carer advisory panel funded
by a National Institute for Health Research research professorship (NIHR-RP-R3-12-011) to LMH and a patient representative in Canada
(advisory for SNV) to comment on the content of this article. Comments and suggestions were incorporated in the final iteration from Clare
Dolman, Sarah Spring, Maria Bavetta, Amanda Grey, Ceri Rose, Ben Parry, and S Farrell.

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CLINICAL REVIEW

Figures

BMJ: first published as 10.1136/bmj.i1547 on 24 March 2016. Downloaded from http://www.bmj.com/ on 29 January 2019 by guest. Protected by copyright.
Fig 1 Stepped care approach to management of depression in pregnancy

Fig 2 Summary of considerations for shared decision making between women and health professionals around antidepressant
use in pregnancy. (Based on a decision aid that is currently being evaluated in a randomised controlled trial.) Adapted from
Vigod et al 201665

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