Preconception counselling from Priory
There are few decisions in life as significant as deciding to start a family and becoming pregnant. Exciting as this can be, it’s common to have many anxieties and questions. It’s likely that women with pre-existing mental health problems will find this time even more daunting, and can often have additional concerns and uncertainties.
We spoke to Consultant Perinatal Psychiatrist, Dr Lucinda Green, at Priory Hospital Roehampton about preconception counselling, which enables women to make informed decisions about treatment and to understand how their mental health problems/medication could affect them or their baby, if they became pregnant.
Preconception counselling focuses on the improvement of health education, and providing risk assessments and possible intervention before pregnancy, in order to reduce chances of poor perinatal outcomes.
Why is preconception counselling important?
- 20% of women have a mental health challenge during pregnancy and the postnatal period
- Depression and anxiety disorders are the most common, but other conditions can include bipolar disorder, eating disorders and personality disorders
- Untreated mental illness can have wide-ranging adverse consequences for the woman, her baby and family
- Suicide remains a leading cause of maternal death in the UK
- Decisions about psychiatric medication use in pregnancy can be complex. It may be too late to prevent any harmful effects of medication once a woman finds out she is pregnant. Some women stop medication suddenly when they become pregnant, increasing the chance of relapse
It is important that women with pre-existing mental health problems begin early with good preconception care, to help to prevent such occurrences and to provide effective treatment to improve outcomes for women and their families.
What questions does preconception counselling help answer?
The information and advice that women want will likely depend on their individual circumstances, their mental health history, and the treatment that is currently being undertaken. Some examples of questions which may arise include:
- Do I have to stop medication?
- Will my medication harm my baby?
- Will my medication increase the chance of a miscarriage?
- Can I breastfeed if I’m taking medication?
- I’m worried about getting unwell in pregnancy or after birth – how can I prevent this?
- Will people think I’m a bad mum because I have a mental health problem?
- If I get ill will my baby be taken away?
- What are the chances of my child having the same mental health problem as me?
How can GPs help?
The GP surgery is often the first port of call for women who are planning on getting pregnant or have just discovered that they are pregnant, and also for those who may be concerned about their mental health.
Spotting the signs and symptoms of someone struggling with both can be difficult but there are conversations you can have, and actions you can take, to ensure your patients are offered the correct support:
- Regularly ask all women with mental health problems about their contraception and pregnancy plans
Whilst some women seek advice when they want to get pregnant, over 50% of pregnancies are unplanned, the rates of which are higher for women with a severe mental illness
‘NICE antenatal and postnatal mental health’ guidelines (2014) emphasise the importance of discussing contraception and pregnancy plans with all women of childbearing potential who have a new, existing or past mental health problem
- Inform women about how pregnancy and birth may affect their mental health and their risk of becoming unwell in the perinatal period
There are many helpful resources that you can give to women so they can read about mental health in pregnancy, including postnatal depression, postpartum psychosis and perinatal obsessive compulsive disorder (OCD)
- Ensure that women who are prescribed psychiatric medication are informed about potential risks to them or their baby should they get pregnant
No psychiatric medication is licensed for use in pregnancy or breastfeeding, but don’t advise women just to stop medication because of this. Help each woman to weigh up the risks and benefits of continuing, stopping or changing medication in her individual case.
UKTIS information leaflets can be a helpful aid to this discussion
- Don’t prescribe sub-therapeutic doses of medication
It’s important that mental health problems are adequately treated. Exposing the baby to medication without adequately treating the mother is not helpful
- Refer women of childbearing age, who are prescribed Valproate for a mental health problem, to a psychiatrist for a review of their medication
Valproate is contra-indicated in pregnancy unless the terms of a special pregnancy prevention programme are followed
- Refer women with a current or previous severe mental illness, for a preconception appointment with a psychiatrist (preferably a perinatal psychiatrist)
The increasing numbers of NHS perinatal mental health services means that this is more widely available
- Refer women for psychological therapies
Therapies such as cognitive behavioural therapy (CBT) can help patients to deal with the ‘here and now’ and teaches rational thought processes which aim to reduce anxieties
- Advise women about physical health in pregnancy
- Give reassurance
It’s common for women to worry about stigma and how they will be judged as parents. Some women worry unnecessarily that their baby will be taken away.
Reassure these women that having care and treatment for a mental health problem means she is doing the best for her baby. Many women need treatment for physical and mental health problems in pregnancy and after birth so they are not alone.
Specialist preconception counselling
All of the following will be discussed at the preconception appointment to help women to make individualised, informed decisions about their care:
- Review of mental health history
A thorough understanding of the woman’s history informs the rest of the discussion at the preconception appointment. It ensures that information and advice is individualised and that the woman’s preferences and concerns are acknowledged.
History includes: the nature, frequency and severity of previous episodes of illness; any previous perinatal episodes; risk history; previous and current medication and response; psychological interventions; obstetric and physical health; family history of perinatal mental illness; the woman’s own experience of childhood, her relationships, any traumatic or abusive experiences; drug and alcohol history; personality related difficulties; current social circumstances, level of functioning and availability of support from partner, family and friends
- Clarify the mental health diagnosis
It’s important to clarify the diagnosis. This influences the discussions about treatment and the risk of relapse during pregnancy and the postnatal period
- General health advice
Women need all the usual recommended general health advice about smoking, alcohol, diet, weight loss, folic acid and vaccinations. Women with a mental illness have higher rates of smoking, alcohol and illicit drug use in pregnancy and higher rates of physical co-morbidity and poor obstetric and neonatal outcomes.
Referral for smoking cessation or to a substance misuse service prior to pregnancy can improve outcomes. It is also essential to clarify the need for specific preconception advice for any physical health conditions e.g. diabetes or epilepsy
- Obstetric history
Previous pregnancy losses, traumatic deliveries or difficulties conceiving, all impact on future pregnancies. It helps to clarify whether any additional care is needed e.g. psychological therapy for tokophobia, post-traumatic stress disorder (PTSD) or grief reactions
- Risk of relapse in pregnancy and after birth
The woman’s risk of relapse in pregnancy and the postnatal period depends on her diagnosis and treatment. Women who discontinue medication have high rates of relapse – as much as 70% of women who stop antidepressants due to becoming pregnant, relapse in the perinatal period.
Women need information about any increased risk of postnatal mental health disorders and how these may impact on parenting. Examples include:
- Postnatal depression affects 10-15% of women. Previous depression and other pre-existing mental health problems increase this risk
- Postpartum psychosis affects 1-2 in every 1000 women. Women with a history of bipolar or schizoaffective disorder have a greater risk of between 25-50%
- Risks and benefits of medications in pregnancy and breastfeeding
Decisions about medication use in pregnancy and breastfeeding are not straightforward. Each woman needs to weigh up the risks and benefits of using medication in her individual case, taking into account illness severity, associated risk and impact on functioning, as well as previous treatment response.
Even if a woman has been well on medication for many years, she may be at high risk of relapse if she discontinues. This is a complex area but the discussion will include:
- Up to date evidence about the risks associated with individual medications in pregnancy and breastfeeding, including areas of uncertainty
- The background risk of congenital abnormality
- Medications which affect fertility (e.g. antipsychotics causing hyperprolactinaemia)
- Medications which require specific monitoring in pregnancy (e.g. Lithium)
- The importance of avoiding sub-therapeutic doses, stopping medication abruptly, and minimising the number of medications
- Side effects, e.g. sedation which may make caring for a baby hard, or weight gain which can be a concern for women trying to lose weight after pregnancy
The risks of untreated illness – it’s essential to help women understand why it’s not only medication which can be harmful. Pregnancy is not protective against mental illness. Untreated illness can have many consequences including:
- Self-neglect - ranging from not eating healthily and not attending antenatal appointments to not being able to look after the baby safely without support
- Self-harm or suicide attempts
- Increased drug or alcohol use
- Needing higher doses of medications, multiple medications and sometimes even hospital admission for treatment
- Poorer obstetric and neonatal outcomes
- Psychological interventions
Many past experiences can potentially impact on a woman’s experience of pregnancy and parenting, attachment and family relationships. It’s preferable to refer for psychological therapies before the woman becomes pregnant to ensure that there is sufficient time to make changes.
Many women can benefit from psychological intervention, particularly those who have experienced trauma, abuse, loss, difficult relationships with their own parents, women who have been diagnosed with a personality disorder and women whose current mental health problems have not adequately responded to treatment with medication. Some women will choose psychological therapies in preference to medication for mild to moderate depression and anxiety disorders
- Risk of the child inheriting a mental health problem
Many mental health problems have a genetic component, with the highest risk associated with more severe disorders
- Partner and other family support
It helps for women to consider the practical and emotional support available from their partner and other family members. Women may need support or referral for relationship difficulties or domestic abuse. Partners with mental health problems may benefit from assessment and treatment prior to pregnancy
- Is there anything else that might make pregnancy difficult?
This can include current stresses, recent life events and potential safeguarding concerns
- Identify the woman’s strengths
Women often feel under a huge amount of pressure to live up to their own and others’ expectations. Many mental health problems are associated with low self-esteem. Helping women to identify their strengths and what they are likely to do well for their baby is important
Services involved in care and support during the perinatal period
It can be reassuring for women to know that there are many professionals and services with the expertise to support them during the perinatal period. These include specialist mental health midwives, perinatal mental health services, specialist health visitors and IAPT services (which prioritise women in the perinatal period).
It’s helpful to explain roles and how services work together locally. Information about local voluntary sector services and national charities, which offer peer support and information to women with specific perinatal mental health problems, is also useful.
If you would like to find out how Priory can provide you with assistance regarding mental health and pregnancy planning, please call 0800 078 3284 or click here to submit an enquiry form. For professionals looking to make a referral, please click here.
Other useful resources for GPs:
Useful resources for patients
- RCPsych perinatal mental health leaflets
- Medicines in pregnancy
- Tommy’s perinatal mental health information
- Bipolar disorder, pregnancy and childbirth
- Maternal OCD
- Action on postpartum psychosis
- PANDAS Foundation