Executive summary
- Mental health problems are the leading cause of maternal death in the UK when indirect causes are included. Psychiatric mortality (suicide, substance misuse) accounts for more deaths than haemorrhage or sepsis. Perinatal mental illness is a clinical emergency that requires vigilance.
- Postpartum psychosis is a psychiatric emergency — rapid onset (often within days of delivery), psychotic features, and a risk of self-harm and infanticide. Same-day emergency referral to psychiatric services is mandatory.
- Screening is recommended at booking and postnatally: Use the Whooley questions (low mood, anhedonia) and the Edinburgh Postnatal Depression Scale (EPDS) at 4–6 weeks and at 3–4 months postnatally.
- Safe prescribing in pregnancy and breastfeeding is possible: Untreated severe mental illness poses greater risk to mother and baby than carefully considered pharmacotherapy. Sertraline is the preferred SSRI.
Screening and identification
- Whooley questions (at every antenatal and postnatal contact): "During the past month, have you often been bothered by feeling down, depressed, or hopeless?" and "During the past month, have you often been bothered by having little interest or pleasure in doing things?" A positive response to either warrants further assessment.
- EPDS (Edinburgh Postnatal Depression Scale): 10-item validated tool. Offer at 4–6 weeks and 3–4 months postnatally. Score ≥13 suggests probable depression requiring clinical assessment. Question 10 (self-harm ideation) must always be reviewed regardless of total score.
- Ask about history: At booking, enquire about past psychiatric history, previous perinatal mental illness, and family history of bipolar disorder or postpartum psychosis — these are the highest risk factors for severe perinatal illness.
- Do not miss the "baby blues": Transient weepiness, emotional lability, and irritability in the first 10 days postpartum is normal and does not require treatment. If it persists beyond 10 days, reassess for postnatal depression.
Postpartum psychosis — emergency recognition
- Onset: Typically within 2 weeks of delivery, often within the first 3–5 days. Rapid onset over hours.
- Features: Elated or depressed mood, confusion, disorganised thinking, hallucinations (auditory, visual), delusional beliefs (often relating to the baby), severe sleep disturbance, and bizarre or agitated behaviour.
- Action: This is a psychiatric emergency. Call the on-call psychiatric team or perinatal mental health team immediately. If risk to mother or infant is immediate, call 999. Admission to a specialist mother and baby unit (MBU) should be arranged to preserve the mother-infant relationship wherever possible.
- Risk factors: Previous postpartum psychosis (risk ~50% recurrence), bipolar disorder, first-degree family history of postpartum psychosis. These women should be on a perinatal mental health care plan antenatally.
Postnatal depression — management
- Mild–moderate PND: Psychoeducation, social support review, self-help resources. Offer a low-intensity psychological intervention (CBT-based guided self-help, facilitated by a Talking Therapies/IAPT practitioner).
- Moderate–severe PND: Offer psychological therapy (CBT, IPT) in addition to considering pharmacotherapy. Refer to the community perinatal mental health team if available.
- Pharmacotherapy: If medication is indicated, involve the woman in a shared decision — discuss risks of untreated illness alongside medication risks. Sertraline is the preferred SSRI in pregnancy and breastfeeding (low milk transfer, largest safety dataset). Paroxetine should be avoided in the first trimester (cardiac malformation signal). All SSRIs carry a small risk of neonatal adaptation syndrome — advise neonatal monitoring after birth.
- Do not abruptly stop antidepressants in pregnancy without a specialist review — the risk of relapse typically outweighs the risk of continuation.
Frequently asked questions
Is it safe to breastfeed while taking sertraline?
Yes, sertraline is the preferred SSRI during breastfeeding. It has low transfer into breast milk, low infant serum levels, and a large safety record. The UK Drugs in Lactation Advisory Service (UKDILAS) and LactMed can provide up-to-date guidance for less common medications.
When should I refer to the perinatal mental health team?
Refer if there is: a previous history of severe mental illness (bipolar disorder, psychosis, severe depression), new moderate-to-severe symptoms not responding to primary care management, risk to self or infant, or the diagnosis is uncertain. Many areas have community perinatal teams who can accept direct primary care referrals.
A woman with bipolar disorder is planning pregnancy — what should I do?
This warrants a pre-pregnancy medication review with her psychiatrist and/or perinatal mental health team before conception. Lithium and valproate carry significant teratogenicity risks (valproate is contraindicated in pregnancy). Early proactive planning significantly improves outcomes. Refer to the perinatal mental health team at the point of pregnancy planning, not at booking.
How long should postnatal depression be treated?
As with depression generally, antidepressants should usually be continued for at least 6 months after remission. Women with PND are at higher risk of recurrence in subsequent pregnancies, so a proactive plan for future pregnancies should be documented.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.