Mental health problems in pregnancy

Conception rates in women with mental disorder (with the exception of severe learning disability and anorexia nervosa) are the same as the general population. Antenatal depression and anxiety are therefore common and as common as after delivery, affecting 10–20% of all women. In addition, women with personality disorders, panic disorder, obsessive compulsive disorder, psychoses, substance misuse and eating disorders will become pregnant.

The incidence (new onset) of serious mental illness (schizophrenia, psychoses and bipolar disorder) during pregnancy is markedly reduced compared with other times. However, serious mental illness does sometimes occur for the first time during pregnancy and poses particular management problems. A more frequent situation is that of a woman who already has a chronic serious mental illness and becomes pregnant. Approximately two per 1000 births are to women with chronic serious mental illness. Pregnancy is not protective against a relapse of these conditions, particularly if patients stop taking their medication. However, continuing medication may pose problems for management during labour and for the care of the newborn, and a careful risk–benefit analysis must be undertaken before any decision is made whether to continue or not.

Mental health problems after delivery

By contrast, there is a dramatic increase in the incidence of serious affective illness following delivery. Women face a relative risk of 32 of developing a psychotic illness in the first 3 months following delivery. These illnesses are thought to belong to the bipolar group of illnesses. There is also an increased risk (relative risk 10) of developing a severe unipolar depressive illness. There is no increase in risk of developing schizophrenia. Women who have a previous history of bipolar illness, schizoaffective disorder, puerperal psychosis or severe postnatal depression (PND) have at least a 50% risk of recurrence of this condition following delivery, even if they have been well for many years and are in comfortable social circumstances. Fifty percent of puerperal psychoses will have presented by day 7, 75% by day 14 and all by 42 days. Women without a personal history but with a family history of bipolar illness, particularly if it is of postpartum onset or who have a first-degree relative who has had a puerperal psychosis, also face an elevated risk of developing a serious mental illness following delivery.

These serious postpartum mental illnesses, which become manifest in the early days following delivery, are life threatening. Although the early symptoms can be nonspecific (e.g. insomnia, irritability and/or agitation), women can very quickly become acutely disturbed, very frightened and bewildered, and the illness poses a risk both to their physical health and safety. They require urgent psychiatric assessment and treatment and should be admitted to a mother and baby unit rather than to a general psychiatry ward.

Severe, but nonpsychotic, depressive illness tends to develop more gradually and present later in the first 12 weeks following delivery. While it benefits from specialist psychiatric care, it can frequently be managed at home with the usual treatments for severe depressive illness, modified by whether or not the woman is breastfeeding.

The more common mild to moderate depressive illness, often associated with marked features of anxiety (PND), is in fact no more common following childbirth than in women who have not given birth. These conditions usually present later in the postpartum year, after 3months, and are best managed in primary care involving the local Improving Access to Psychological Treatment Service (or equivalent) where appropriate. For these conditions, psychosocial treatments are often as effective as antidepressants.

Confidential Enquiries into Maternal Deaths

The triennial reports of the CEMD over the period from 1997 to 2005 revealed that if late deaths are included, then up to 25% of maternal deaths were caused by psychiatric disorder and 15% by suicide, with suicide identified as the leading cause of maternal death in the UK. The 2006–08 report only includes late deaths up to 6 months, so direct comparisons cannot be made with previous figures. This report also highlighted the fact that many of the psychiatric deaths that occurred took place shortly after a child protection case conference, or a child being removed into care, and a third of the women who committed suicide, and half of the women who were substance misusers, appeared to be avoiding maternity care. Furthermore, substandard care associated with psychiatric deaths is present in approximately 50% of patients. The psychiatric deaths since 2009 are being reported in the 2015 MBRRACE report so the following is learning from the previous reports.

The most important findings from these enquiries for obstetricians and midwives are: