In recent years there has been confusion on the use of mental health medication during pregnancy and postnatal. Mixed messages may be given, resulting in women and birthing people stopping medication unnecessarily. In this article Laura Bridle, Senior Midwife Maternal Mental Health Services, Kings College Hospital NHS Foundation Trust, shares how an information tool was created to improve information giving across the multi-disciplinary team.
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Developing an information tool around medication for mental health in pregnancy and beyond
Women and birthing people who are prescribed medication in pregnancy often face the dilemma of whether or not to continue their treatment out of fear of safety for their unborn or baby post birth.
Often what I was seeing in practice, was that women and birthing people were stopping their medication for mental ill health, often medication that had kept them well for many years, after seeing their GP or from pressure from family about the safety of taking medication.
I had the privilege of completing a fellowship with Health Education England (HEE) surrounding population health and one of my projects was open for me to decide its theme. I wanted to explore the use of selective serotonin reuptake inhibitors (SSRIs) in pregnancy and what the barrier was to women not continuing on this medication. SSRI’s are recommended because they are less toxic than other classes of antidepressants (NICE 2020).
Using I was able to see that over 60% of women who were on SSRI’s or anti-psychotics had stopped their medication in the first three months of pregnancy.
A cohort study found that discontinuing antidepressant medication during pregnancy (but not before) is associated with an increased risk of psychiatric emergency compared to continuing treatment throughout pregnancy (Liu et al. 2022). A further systematic review found that women with severe or continuing depression should be aware of the increased risk of relapse when stopping antidepressant medication, and furthermore those who do chose to stop antidepressants should be observed for relapse (Bayrampour et al. 2020).
I was then linked with a GP, Sonya Ghatahora, who was also undertaking a fellowship and assisted to co-lead a working group. This consisted of two psychiatrists, a specialist pharmacist, a specialist mental health visitor and family nurse partnership midwife (all of whom are based in SE London). We agreed that a tool would be beneficial and got to work on how to create this.
Sonya sent a questionnaire to 33 GP’s to explore how a tool could be of benefit and possible barriers. We surveyed a further 37 UK perinatal mental health midwives, 23 Health Visitors, and importantly 29 women with lived experience in Lewisham through the maternity voice partnership (MVP).
The survey found that 98% midwives thought a tool would be helpful, health visitors wanted the inclusion on breastfeeding advice and GP’s wanted to know how to refer to perinatal mental health teams and increase confidence in prescribing.
Women and birthing people were really keen to have evidence based information and where to read about alternatives in care. One woman stating, “This would be a great idea, I was given conflicted advice between midwives and doctor and ended up feeling too guilty and confused to take medication I really .” From this we decided to make a poster for women and birthing people that would help direct them to evidence based resources and to encourage them to seek advice prior to stopping any medication.
I reached out to UKTIS, Tommy’s charity and the breastfeeding network to see if we could use their logo’s and link to their resources, to which they all agreed. This was added as a hyperlink to the poster, to enable women and birthing people to get the advice and information they wanted. The poster also encouraged them to speak to their GP or pharmacist prior to making a decision. Medication is not the right choice for everyone, but there does need to be a safe way to stop SSRI’s and the ability to be reviewed if mental wellbeing starts to deteriorate.
The GP tool gave a broad guidance on information regarding prescribing SSRI’s for women currently on and not taking medication, care when birth planning and for the postnatal period and breastfeeding. It importantly linked GP’s with the appropriate perinatal mental health team, to allow for earlier referrals to be sent where appropriate and the ability to speak to a specialist pharmacist for advice.
I was able to secure funding for the tool and poster to be designed through Friends of Lewisham and the design team at Lewisham and Greenwich Trust helped us to bring our inclusive and interactive tool to life. This was then sent to Trust communication teams in SE London for input and was lastly approved by IMOC . This was a very long project that continued long past fellowship placements, in all it was over 2 years to get to this point.
We are in the process of having the GP tool added to SE London intranet for ease of access, perinatal mental health midwives and health visitors are sharing this with staff and women and birthing people. We are presenting at a conference for General Practice in April of this year as part of the maternal medicine network. This will allow for continued awareness of the tool and allowing for evidence based information sharing.
We have shared this tool nationally, so that other Trusts and perinatal mental health teams can adapt the tool for their local area and have received positive feedback already. One woman stating, “I had to message. It will make a difference to so many women and birthing people who face similar situations. They will feel heard and will feel able to make an informed decision.”
MBRRACE (Knight et al. 2018; 2021; 2022) has repeatedly advised on the importance of medication decision making and the most recent report has highlighted that this requires improvement. Women and birthing people who are deciding whether to continue, stop or alter medication for mental illness in pregnancy should be made only after cautious review of the benefits and risks of doing so, to both mother and infant (Knight et al. 2018). If a decision was made to stop medication in advance of, or during, pregnancy, it is important that women and birthing people have an early postnatal assessment to decide whether they should be advised to recommence medication (Knight et al. 2021). This should be carried out either by the GP or perinatal mental health service depending on the level of pre-existing mental health provision. We hope this tool will help to ensure these recommendations are made visible and supported.
The online link to the GP tool is available here: https://www.selondonics.org/wp-content/uploads/Anti-depressant-in-pregnancy-Guidance-for-GPs.pdf
References:
Bayrampour H, Kapoor A, Bunka M, et al. The risk of relapse of depression during pregnancy after discontinuation of antidepressants: a systematic review and meta-analysis. J Clin Psychiatry. 2020;81(4):19r13134.
Knight, M. Bunch, K., et al., Eds. (2018). Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014-16. Oxford, National Perinatal Epidemiology Unit, University of Oxford.
Knight, M. Bunch, K., et al., Eds. (2021). 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. Oxford, National Perinatal Epidemiology Unit, University of Oxford.
Knight M, Bunch K, Patel R, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care Core Report – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2022.
Liu X, Molenaar N, Agerbo E, Momen NC, Rommel A-S, Lupattelli A, et al. (2022) Antidepressant discontinuation before or during pregnancy and risk of psychiatric emergency in Denmark: A population-based propensity score– matched cohort study. PLoS Med 19(1): e1003895.
National Institute for Health and Care Excellence. (2020b). “NG113: Generalised anxiety disorder and panic disorder in adults: management.” Retrieved 30/07/2022, from www.nice.org.uk/guidance/ng113.
Thanks:
Huge thanks to the working group: Sonya Ghatahora, Shubhra Mace, Louise Quigley, Suzy Hall, Livia Martucci, and Mano Manoharan. Many thanks to my supervisor and support at Lewisham Health and Care Partners; Rachael Crompton, Simon Nash, Pauline Cross and Helen Buttivant. Many thanks to Toyin Adeyinka and Lewisham MVP. Thanks to the GP’s, UK perinatal mental health midwives forum, health visitors, and women of Lewisham who helped shape the tool and poster.
Anyone wishing to access the tool can contact me on [email protected] please note that the GP tool will need adapting to link to your local perinatal mental health team.
Laura Bridle
Senior Midwife Maternal Mental Health Services
Kings College Hospital NHS Foundation Trust
January 2023
