Non-Psychotic Mental Disorders in The Perinatal Period

Series
Perinatal mental health 1

Non-psychotic mental disorders in the perinatal period
Louise M Howard, Emma Molyneaux, Cindy-Lee Dennis, Tamsen Rochat, Alan Stein, Jeannette Milgrom
Mental disorders are among the most common morbidities of pregnancy and the postnatal period, and can have
adverse eects on the mother, her child, and family. This Series paper summarises the evidence about epidemiology,
risk factors, identication, and interventions for non-psychotic mental disorders. Although the phenomenology and
risk factors for perinatal mental disorders are largely similar to those for the disorders at other times, treatment
considerations dier during pregnancy and breastfeeding. Most randomised controlled trials have examined
psychosocial and psychological interventions for postnatal depression, with evidence for eectiveness in treating and
preventing the disorder. Few high-quality studies exist on the eectiveness or safety of pharmacological treatments in
the perinatal period, despite quite high prescription rates. General principles of prescribing of drugs in the perinatal
period are provided, but individual riskbenet analyses are needed for decisions about treatment.
Introduction
Non-psychotic mental disorders are among the
commonest morbidities of pregnancy and the
post-partum period (the perinatal period). Research
about perinatal mental disorders so far has largely
focused on depression, particularly postnatal depression.
However, increasing evidence shows substantial
morbidity from other disorders. In this Series paper, we
also review the available evidence base for the
epidemiology and treatment of anxiety disorders,
post-traumatic stress disorder (PTSD), eating disorders,
and personality disorders.
Epidemiology
Depressive disorders
Depressive disorders are common during pregnancy
and in the post-partum period and generally have the
same phenomenology as non-childbearing depressive
disorders (panel 1).13 Somatic symptoms can result from
normal physiological changes in pregnancy and the
early post-partum period, so therefore need to be
assessed with care. However, these symptoms are more
common in women with depression than in women
who do not have depression in the perinatal period (with
the exception of appetite change), suggesting that they
might be valid markers of the disorder.3 Somatic
symptoms are particularly frequent presentations of
depression (and anxiety) in non-perinatal periods in
women in low-income and middle-income countries
(LMICs).4 In an Ethiopian cohort, there was a moderately
high correlation between perinatal total somatic
symptoms and depression or anxiety scores, supporting
the importance of somatisation of mental distress in the
perinatal period.5
A systematic review6 of studies, predominantly in
high-income countries (HICs), estimated the point
prevalence of major depressive disorder to be between
31% and 49% during pregnancy and 47% in the rst
3 months post partum. Point prevalence including minor
depression (panel 1) was estimated to be up to 11% in
www.thelancet.com Vol 384 November 15, 2014
pregnancy and 13% in the rst 3 months post partum

(period prevalence rates are 184% and 192%,
respectively).6 A higher prevalence of antenatal and
postnatal depression (major and minor) is generally
reported in women in LMICs than in women in HICs.7 A
meta-analysis8 of the point prevalence of non-psychotic
common mental disorders (including depression,
anxiety, adjustment, or somatic disorders) in LMICs
reported values of 156% during pregnancy and
198% post partum, with substantially higher8 and lower9
rates in specic countries.8 Pregnancy was traditionally
Key messages
Health-care professionals need to be aware that when
doing psychosocial assessments in the perinatal period,
mental disorders across the diagnostic spectrum can occur
during pregnancy and post partum
Psychological and psychosocial interventions are eective
treatments for postnatal depression; evidence from
low-income and middle-income countries showed that
these can be provided eectively by trained non-specialist
workers
Little research exists about the epidemiology or
eectiveness of interventions for perinatal non-psychotic
mental disorders, other than postnatal depression
To what extent interventions that are developed and used
outside the perinatal period need modication for the
perinatal period is unclear; nevertheless, practitioners
need to be aware of dierences in context when treating
women during this time
Individualised risk benet analyses are needed when
judging use for psychotropic drugs in the perinatal period,
accounting for the risk of untreated illness on the mother
and fetus or infant
Evidence for risks of psychotrophic drugs is restricted
because it is based on observational studies that can only
establish associations and not causality; however, absolute
risks from meta-analyses are small and residual
confounding is likely
Lancet 2014; 384: 177588

This is the rst in the Series of
three papers about perinatal
mental health
Health Service and Population
Research Department, Institute
of Psychiatry, Psychology, and
Neuroscience, Kings College
London, London, UK
(Prof L M Howard MRCPsych,
E Molyneaux MSc); University of
Toronto and Womens College
Research Institute, Toronto,
ON, Canada
(Prof C-L Dennis PhD); Africa
Centre for Health and
Population Studies, University
of KwaZulu-Natal, Durban,
South Africa (T Rochat PhD);
Department of Psychiatry,
University of Oxford, Oxford,
UK (Prof A Stein FRCPsych);
MRC/Wits Rural Public Health
and Health Transitions
Research Unit (Agincourt),
School of Public Health,
University of the
Witwatersrand, Johannesburg,
South Africa (Prof A Stein); and
Melbourne School of
Psychological Sciences,
University of Melbourne,
Melbourne, VA, Australia
(Prof J Milgrom PhD)
Correspondence to:
Prof Louise M Howard, Health
Service and Population Research
Department, Kings College
London, London SE5 8AF, UK
louise.howard@kcl.ac.uk
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Series
Search strategy and selection criteria

We searched PubMed, Embase, PsycINFO, and the Cochrane Library without language
restrictions. Searches were done using the key search terms pregnancy, prenatal,
antenatal, postnatal, postpartum, perinatal, puerperal, breastfeeding, birth,
weaning, childbirth, trimester, peripartum, lactation, ante-natal, post-natal,
postpartum, and mood disorder (exploded MeSH term), anxiety disorder (exploded
MeSH term), eating disorder (exploded MeSH term), depression, anxiety, eating
disorder. These search terms were combined with the following specic terms using date
restrictions based on the amount of research output in each area: prevalence,
incidence, relapse, course (searched for systematic reviews between Jan 1, 1993, and
April 3, 2013; searched for epidemiological or experimental studies between Jan 1, 2008,
and April 3, 2013); screening, screen, identication, scale(searched for systematic
reviews between Jan 1, 1993, and May 16, 2013; searched for epidemiological or
experimental studies between Jan 1, 2008, and May 16, 2013), Amitriptyline,
Hydrochloride, Iproniazid, Citalopram, Duloxetine, Amoxapine, Isocarboxazid,
Escitalopram, Flupentixol, Butriptyline, Moclobemide, Fluoxetine L-tryptophan,
Clomipramine, Phenelzine, Fluvoxamine, Mirtazapine, Desipramine,
Tranylcypromine, Paroxetine, Nefazodone, Dibenzepin Hydrochloride,
Triuoperazine, Sertraline, Reboxetine, Dosulepin, Tryptophan, Dothiepin,
Hydrochloride, Venlafaxine, Doxepin, Imipramine, Iprindole, Lofepramine,
Maprotiline, Mianserin, Nomifensine Hydrogen Maleate, Nortriptyline, Opipramol
Hydrochloride, Protriptyline, Trazodone, Trimipramine Maleate, Viloxazine,
Zimeldine Hydrochloride, Chloral Hydrate, Alprazolam, Clomethiazole,
Bromazepam, Dipenhydramine, Buspirone Hydrochloride, Flunitrazepam,
Chlordiazepoxide Hydrochloride, Flurazepam, Chlormezanone, Loprazolam,
Diazepam, Lormetazepam, Ketazolam, Melatonin, Lorazepam, Methyprylone,
Medazepam, Nitrazepam, Meprobamate, Nitrados, Oxazepam, Promethazine,
Prazepam, Temazepam, Sardiazepam, Triazolam, Zaleplon, Zolpidem,
Tartrate, Zopiclone (between Jan 1, 2010, and May 15, 2013), paternal, father,
fathers, men, husband, partner (between Jan 1, 2003, and May 15, 2013),
hormone(s), oestrogen, progesterone, estriadol, and treatment, intervention,
prevention, trial, therapy, therapeutic, treat, medicine, medication,
prescribe, prescription (between Jan 1, 2003, and July 11, 2013).
viewed as a time when women are protected against

depression, but the latest systematic review6 and a large
US epidemiological study10 do not report a signicant
dierence in the prevalence or incidence of depression
between pregnant and non-pregnant women. However,
rates of identication and treatment of depression might
be lower in pregnant than non-pregnant women,11
contributing to the perception of reduced prevalence
reported. Studies using non-childbearing comparators
might also underestimate risks associated with the
perinatal period because women who become mothers
might be mentally healthier and have a lower baseline
vulnerability to depression than those who do not
have children.
Whether the incidence of depression peaks in the
postnatal period has been greatly debated. A low mood is
common, aecting around 50%12 in the rst weeks after
delivery (so-called baby blues), but is usually mild and
transient. Investigators of longitudinal studies using
medical records have noted an increase in incidence of
depression during the rst 5 months13 and 9 months14
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post partum by comparison with rates pre-pregnancy,

during pregnancy, or at the end of the rst post-partum
year; however, the estimates are based on the proportion
of women newly seeking treatment rather than
community-based measurement of incidence. Poor
identication and measurement of depression during
pregnancy could lead to many women being misclassied
with post-partum onset. Results from a US study15
suggested 33% of postnatal depression begins in
pregnancy and 27% in pre-pregnancy. Additionally, some
evidence suggests that there might be a higher
prevalence of depressive symptoms during pregnancy
than in the post-partum period.16 Women with postnatal
depression often recover within a few months from
onset, but around 30% of women still have depression
beyond the rst year after delivery17 and there is a high
risk of around 40% of subsequent postnatal and nonpostnatal relapse.18,19
Anxiety disorders
Anxiety disorders in the perinatal period are often
overlooked but are commoneg, a large US
population-based study10 reported a prevalence of 13% in
the past year of any anxiety disorder in currently pregnant
or post-partum women, comparable with non-pregnant
women. Similar rates of anxiety disorders are reported in
African countries8,20 and there is substantial comorbidity
with depressive disorders.15 Little research has been done
into the course of anxiety disorders in the perinatal
period; however, some evidence suggests a reduction in
the prevalence of generalised anxiety disorder, and
anxiety symptoms, during the course of pregnancy and
the post-partum period.16,21
A meta-analysis22 reported a signicantly higher risk
of obsessive compulsive disorder in pregnant and
post-partum women than in non-pregnant women.
Ruminations in the post-partum period can include
ruminations of harm to the infant, but these are not
associated with actual harm (unlike the delusions in a
psychotic disorder); therefore, health-care professionals
need to distinguish obsessive ruminations from delusions.
PTSD
Increasingly, authors recognise that women can have
PTSD in the perinatal period triggered by traumatic
experiences during pregnancy or childbirth, or by
traumatic events before conception.23 Estimates of PTSD
prevalence after delivery vary but are often estimated to
be around 12% in HICs23 with many more women
experiencing subthreshold symptoms;23 a higher prevalence is reported in LMICs (eg, 59% in Nigeria).24 Most
studies underestimate the total prevalence of PTSD in
the postnatal period by only examining PTSD related to
traumatic childbirth experiences; higher rates are noted
in pregnancy when diverse trauma experiences are
included (point prevalence 68%).25 Perinatal PTSD is
highly comorbid with depression.25
Series
Panel 1: DSM-5 and ICD-10 diagnostic criteria for depression

DSM-51
Major depression
At least ve symptoms present for at least 2 weeks, for most of
nearly every day
ICD-102
Severe depression
At least seven symptoms, usually present for at least 2 weeks,
experienced with severe intensity for most of every day
A symptom must be:

Depressed mood
Markedly diminished interest or pleasure in all or most
activities
All three key symptoms associated should be present:

Persistent sadness or low mood
Loss of interests or pleasure
Fatigue or low energy
Other symptoms:
Substantial weight loss when not dieting or weight gain, or
increase or decrease in appetite
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Diminished ability to think or concentrate or indecisiveness
Recurrent thoughts of death or suicidal ideation (with or
without a specic plan)
At least four associated symptoms should be present:

Disturbed sleep
Poor concentration or indecisiveness
Low self-condence
Poor or increased appetite
Suicidal thoughts or acts
Agitation or slowing of movements
Guilt or self-blame
Individual unable to continue with social, work or domestic
activities, except to a very restricted extent
Symptoms cause clinically signicant distress or impairment in

social, occupational, or other important areas of functionality
Moderate depression
At least two key symptoms and three associated symptoms
should be present
Symptoms not due to direct physiological eects of a substance

or another medical condition
The occurrence of a major depressive episode is not better
explained by schizoaective disorder or other psychotic
disorders and there has never been a manic or hypomanic
episode
Depressive episode with insucient symptoms*
Depressed aect and at least one other of the above symptoms
associated with clinically signicant distress or impairment
persisting for at least 2 weeks
With peripartum onset
Onset of mood symptoms happens during pregnancy or in the
4 weeks after delivery
Eating disorders
Women with eating disorders have an increased rate
of fertility problems, although many still become
pregnant, sometimes with fertility treatment.26 The
expectation of weight gain during pregnancy can be
considered healthy, and women are sometimes more
accepting of their body size at this time. However,
symptoms of eating disorders can persist during
pregnancy for mothers who have had a recent
episode.27 A Norwegian prospective population study of
41 157 women reported substantial remission rates
during pregnancy between 29% and 78% depending on
the type of eating disorder; incident cases of eating
disorder during pregnancy were rare, other than binge
eating disorder (11 incident case per 1000 person-weeks)
which was associated with low socioeconomic status.28
Binge eating can be common. In a Brazilian study,29 a
Minor depression
At least two key symptoms and two associated symptoms
should be present, with no symptoms present to an intense
degree
With postpartum onset
Disorder commencing within 6 weeks of delivery
ICD=international classication of diseases (published by WHO2). DSM=diagnostic and statistical manual of mental disorders. *Changed from minor depression in DSM-4 (two to
four depressive symptoms experienced for at least 2 weeks, one symptom should be depressed mood or loss of pleasure). Changed from with postpartum onset in DSM-4 (onset of mood symptoms within rst 4 weeks after delivery).
prevalence of binge eating of 173% was reported and

associated with anxiety and pre-pregnancy binge
eating disorder.
In a large population study,30 77 807 women were assessed
for eating disorders in the perinatal period; 3550% rates
of remission were recorded at 18 months post partum,
suggesting higher remission rates in the community than
in clinical samples. Nevertheless, a substantial proportion
of women with pre-pregnancy eating disorders have
continuation or recurrence of symptoms post partum.30
The disruption in sleep and mealtimes and the need to
adapt to the babys routines, especially around feeding,
makes it challenging for many mothers to establish and
maintain their own eating patterns.31 The risk of postnatal
depression is increased in women with eating disorders by
comparison with women with a history of an eating
disorder but not active symptoms.32
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Antenatal depression
Social risk factors
Socioeconomic status
Exposure to trauma, negative life
events and stress
Domestic violence
Migration status
Relationship and social support
Reproductive intention
Psychological risk factors

Personality traits:
high neuroticism
Prior psychopathology: depression,
anxiety, PTSD, substance misuse
Biological risk factors
Domestic violence (HIC, LMIC)35

Life stress and major/negative life events
(HIC, LMIC)8,20,34
Low socio-economic status (LMIC, small
association in HIC)8,20,34
Absence of social or relationship support
(HIC, LMIC)8,20,34
Intention to get pregnant
(HIC, small to medium in LMIC)8, 20,34
Domestic violence, previous abuse

(HIC, LMIC)35,37,40
Negative life events, low social support
(HIC, LMIC)8,20,36,39,40
Low partner support, marital diculties
(LMIC, small to medium in HIC)8,20,36,39,40
Migration status (HIC)43
Low socio-economic status
(LMIC, small in HIC)8,20,40,41
Prior history of psychopathology

(HIC, LMIC)8,20,34
Anxiety during pregnancy
(HIC, LMIC)8,20,34
Depression or unhappiness in pregnancy

(HIC, LMIC)8,20,36,39,40
Anxiety in pregnancy* (HIC)36
History of depression
(HIC, LMIC)8,20,36,39,40
Neuroticism* (HIC)36,39
Substance misuse* (HIC)37
Family history of any psychiatric illness* (HIC)8,20,36,39
Young age (HIC, LMIC)8, 20,34
Increased parity (rural LMIC context)8,20,40

Multiple births* (HIC)38
Chronic illness or medical illness (HIC, LMIC)37
Preterm birth, low birth weight (HIC, LMIC)42
No association with use of assisted reproductive
technologies* (HIC)38
Age
Genetic and hormonal susceptibility
Chronic diseases
Medical illness
Pregnancy complications
Key
Risk characterised as strong
Risk characterised as medium to strong
Risk characterised as medium
Risk characterised as small
Postnatal depression
if systematic evidence listed the risk factor to be strong, signicant, or top ranked
if some systematic evidence listed the risk factor to be medium, while others listed strong, or top ranked
if systematic evidence listed the risk factor to be medium, moderate, or intermediately ranked
if systematic evidence listed the risk factor to be small association, inconsistently signicant, low ranked, or low rated
Figure 1: Risk factors for antenatal and postnatal depression: systematic review evidence
Risk factors for antenatal and postnatal depression are categorised by strength of risk in HICs and LMICs. Extent of risk indicated for HIC and LIC. HIC=high-income
countries. LMIC=low-income and middle-income countries. PTSD=post-traumatic stress disorder. *Evidence only available from one setting.
Personality disorders
To our knowledge, only one epidemiological study has
been done of personality disorders in the perinatal
period. The prevalence of personality disorders in
pregnancy, based on a self-report measure in a Swedish
study was 6%, but the prevalence of specic personality
disorders was not reported.33 Personality disorders in
the perinatal period are often comorbid with other
non-psychotic disorders, such as depression, and
emerging evidence suggests that they are associated
with an increased risk of adverse outcomes and poor
response to treatment.33
Risk factors
Despite substantial research into risk factors for
perinatal disorders, particularly depressive disorders,
there are few systematic reviews and a paucity of
research using diagnostic measures, longitudinal
approaches, and comparison groups. Studies often
exclude women with a history of mental illness or
particular groups of women, such as those who are
infected with HIV or are chronically ill, which restricts
our understanding of overlapping risks and
1778
comorbidities. However, a history of any psychopathology

and psychosocial adversities, including the spectrum of
low social support and abuse, are predictors of mental
disorders during and after pregnancy with little
diagnostic specicity and should inform prevention,
identication, and treatment. Figure 1 shows a summary
of systematic review evidence of risk factors for antenatal
and postnatal depression8,20,3443 (which have a substantial
literature, unlike other disorders).
Although most risk factors are not specic to the perinatal
period or specic disorders, some epidemiological18,44 and
experimental45 results support a reproductive subtype of
depression, characterised by a particular sensitivity to
changes in reproductive hormones, increases in risk of
premenstrual, postnatal, and perimenopausal depression46
and a personal or family history of postnatal depression.18,47
Additionally, PTSD after childbirth has been associated
with obstetric complications, particularly with severe
morbidity, preterm birth, high subjective distress, and
infant complications, although the evidence is inconsistent and quality of studies is moderate-to-low.48,49
Psychopathology (particularly depression and anxiety)
during pregnancy is strongly associated with an increased
Series
Panel 2: Assessment to detect postnatal depression by use of Edinburgh postnatal depression scale51
As you have recently had a baby, we would like to know how you
are feeling. Please underline the answer that comes closest to
how you have felt in the past 7 days, not just how you feel today.
In the past 7 days:
1) I have been able to laugh and see the funny side of things
As much as I always could
Not quite so much now
Denitely not so much now
Not at all
2)
I have looked forward with enjoyment to things

As much as I ever did
Rather less than I used to
Denitely less than I used to
Hardly at all
3)
I have blamed myself unnecessarily when things went wrong*

Yes, most of the time
Yes, some of the time
Not very often
No, never
4)
I have been anxious or worried for no good reason

No, not at all
Hardly ever
Yes, sometimes
Yes, very often
5)
I have felt scared or panicky for no very good reason*

Yes, quite a lot
Yes, sometimes
No, not much
No, not at all
risk of postnatal PTSD48 and might increase a womans

distress during labour. Additional risk factors identied
include previous traumatic experiences and low support
during childbirth.48
Identication
Because perinatal mental disorders can have serious
consequences in terms of maternal morbidity and
mortality and adverse infant outcomes,50 there is much
interest in improvement of identication of disorders to
increase treatment rates. Most research and debate has
focused on the identication of postnatal depression,
whether or not to use screening instruments routinely in
the post-partum period, and which methods to use. The
most frequently used screening method is the Edinburgh
postnatal depression scale (EPDS),51 which is a self-report
ten item questionnaire (including one on self-harm;
panel 2), validated for both antenatal and postnatal
use.51,52 Although the positive predictive value for
postnatal major depression can range between 9% and
64% (cuto between 9 and 10) or 17% and 100% (cuto
6)
Things have been getting on top of me*

Yes, most of the time I havent been able to cope at all
Yes, sometimes I havent been coping as well as usual
No, most of the time I have coped quite well
No, I have been coping as well as ever
7)
I have been so unhappy that I have had diculty sleeping*

Yes, sometimes
Not very often
No, not at all
8)
I have felt sad or miserable*

Yes, quite often
Not very often
No, not at all
9)
I have been so unhappy that I have been crying*

Yes, quite often
Only occasionally
No, never
10) The thought of harming myself has occurred to me*

Yes, quite often
Sometimes
Hardly ever
Never
*Response categories are scored as either 0, 1, 2, or 3 according to increased severity of the
symptom. Items marked with an asterisk are reverse scored (ie, 3, 2, 1, and 0). The total score
is calculated by adding together the scores for each of the ten items. Reproduced from Cox
and colleagues51 by permission of The Royal College of Psychiatrists.
between 12 and 13) and for antenatal major depression

between 60% and 80% (cuto between 14 and 15), this
range depends on the population, prevalence, translation,
and cuto point,52 and the diagnostic performance of the
EPDS seems quite good in most studies.53
The EPDS has been translated and validated in many
settings. A systematic review54 of studies in Africa
suggested a pooled sensitivity of 094 (95% CI 068099)
and specicity of 077 (059088) at a cuto of more
than a score of eight. However, the authors emphasised
the low quantity of research into local understandings of
perinatal depression syndromes in dierent African
countries.54 Although two recent studies suggested that
very brief screens might be eective in identication of
depression or anxiety post partum in HICs55 and LMICs,56
additional research is needed.
Only ve comparative studies have been published,
which together provide low-to-moderate strength of
evidence57 for the clinical ecacy of screening in reduction
of morbidity in post-partum women. However, the
strongest evidence is for combined identication and
treatment programmes, mainly from three cluster
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Series
randomised controlled trials in HICs that reported

improvement in maternal mental health for women
who received integrated post-partum screening and
management strategies by trained health professionals.5860
Although results from cost-eectiveness modelling have
suggested that formal identication methods for postnatal
depression would not meet willingness-to-pay thresholds,61
assumptions made in the model might not represent
present practice and two large RCTs58,62 suggest that
systematic identication with enhanced support can be
cost eective. Most women and health professionals deem
screening acceptable, although small qualitative studies
report that women can experience screening as potentially
stigmatising and intrusive.63 Although questions have
been raised about the appropriateness of the EPDS for
some ethnic groups and the screening context (eg, rural
LMIC setting)63,64 it is widely used internationally.
Although there is scope for harm through
non-identication and thus no access to eective treatment, concerns about other potential harms associated
with screening (such as misdiagnosis, labelling, and
stigma) are particularly pertinent if a clinical decision
about the presence or absence of a mental disorder is
made only on the basis of a screening result. However,
as international guidelines emphasise, a central
principle is that the screening techniques are not
designed to diagnose depressive disorders, but aim to
identify women for whom further comprehensive
psychosocial and clinical assessment is needed.65,66
Appropriate training is therefore necessary for health
professionals in the skilful interpersonal process for
psychosocial assessment with appropriate referral and
care pathways for identied risk factors. An evidence
gap remains as to whether screening is clinically
eective and cost eective during pregnancy, or in
LMICs where few eective treatment resources
are available.
or psychological preventative interventions for postnatal

depression (all but three were undertaken in HICs).
Women who received an intervention were signicantly
less likely to develop postnatal depression than were those
who received standard care (relative risk [RR] 078, 95% CI
066093). Protective interventions included intensive,
individualised post-partum home visits provided by health
professionals (two RCTs), lay (peer)-based post-partum
telephone support (one RCT), and interpersonal
psychotherapy (ve RCTS), particularly for studies
focusing on women at-risk of postnatal depression
(RR 066, 95% CI 050088), and for postnatal
interventions compared with interventions in the antenatal
period (073, 059090). However, no signicant
preventive eect on depressive symptomatology was
recorded for psychological structured debrieng (ve RCTs,
n=3050; RR 057, 95% CI 031103) or cognitive
behavioural therapy (one RCT, n=150; RR 074, 029188).
Additionally, there was no clear evidence to recommend
antenatal and post-partum classes, psychoeducation, or
sleep strategies (although they might be benecial for
other maternal outcomes). The use of oestrogens and
progestins72 or dietary supplementation with selenium or
docosahexaenoic acid has little supportive evidence.73,74
Treatment of women with antenatal depression might
prevent postnatal depression but this is better conceptualised as treatment rather than prevention.75
No consistency exists for the identication of women atrisk of postnatal depression and there is no measure with
acceptable predictive validity to accurately identify
asymptomatic women who will later develop the disorder.76
Although several potential biomarkers have been
investigated (eg, raised corticotropin-releasing hormone
during pregnancy,77 genetic variants in the glucocorticoid
receptor, corticotropin-releasing hormone receptor 1,78 and
serum leptin),79 all need replication. Future research might
also benet from investigations of predictive techniques
that include psychosocial risk factors and biomarkers.
Other disorders
Many EPDS positive screens that prove false for unipolar
depression at diagnostic interview could be indicative of
another mental disorder;67 data from studies suggest
around 13% of screen positive women in pregnancy68 and
23% in the post-partum period15 have bipolar disorder. At
present the evidence about screening instrument
accuracy, clinical eectiveness, acceptability, potential
harms, and cost-eectiveness of screening for disorders
other than depression is inadequate. Nevertheless, there
is general agreement about the desirability of training of
front-line professionals to identify and treat disorders
other than depression in the perinatal period.65,69,70
Prevention
Not much research has investigated the prevention of
antenatal depression, whereas a Cochrane systematic
review71 identied 28 RCTs (n>16 000) about psychosocial
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Anxiety disorders
Much less research has been done in relation to the
prevention of perinatal anxiety than depression.
Two small trials of group cognitive behavioural therapy
(CBT; n=61 pregnant women with subclinically raised
stress and anxiety levels;80 132 women with
mild-to-moderate symptoms or at risk of developing
depression or anxiety81) had methodological limitations
and equivocal results. Another small trial82 (n=71)
suggested that incorporation of CBT-based prevention
programme into childbirth education classes for women
at risk of developing OCD was associated with
signicantly lower levels of postnatal obsessions and
compulsions compared with women receiving general
psychoeducation about anxiety.82 An antenatal self-guided
workbook intervention with weekly telephone support
might reduce symptoms of postnatal depression and
anxiety,83 and prenatal parenting education could reduce
Series
post-partum anxiety and improve marital adjustment.84

A Cochrane review85 reported limited evidence for the
eectiveness of other interventions (eight trials; n=556)
assessing hypnotherapy (one trial), imagery (ve trials),
autogenic training (one trial), and yoga (one trial) for
prevention or treatment of anxiety during pregnancy.
PTSD
Controversy has surrounded postnatal debrieng for the
prevention of PTSD. The term debrieng is used to
describe a range of provision from the opportunity
to discuss childbirth experiences, particularly if they
were perceived to be traumatic, to highly structured
debrieng interventions. Most trials have shown no
evidence that formal structured debrieng is helpful, and
one trial showed potential risk of harm.86 Women do
benet from the opportunity to discuss the delivery, but
formal debrieng interventions are not supported by
present evidence.
Eating disorders
No trials have been done on prevention in women at risk
of a recurrence of an eating disorder even though
guidelines recommend identication of women with a
history of an eating disorder. Professionals can help
women during pregnancy and the postnatal period to
maintain regular eating patterns and optimise nutritional
intake for the mother and fetus, and support them in
development of realistic goals for body shape.
Psychosocial and psychological treatments

Because of maternal treatment preferences and potential
concerns about fetal and infant health outcomes,
non-pharmacological treatment options are particularly
important in the perinatal period. Evidence on the
treatment of antenatal depression is limited to small
trials (with 3653 women) of interpersonal therapy,
culturally relevant brief interpersonal psychotherapy, and
CBT,8789 and a Cochrane review (six trials, n=406) of other
types of non-pharmacological interventions such as
massage, acupuncture, bright light, and omega-3 oils
reported inconsistent results.90
More evidence is available for postnatal depression,
particularly from HICs, and a Cochrane review91 found
that psychosocial and psychological interventions were
eective for reducing depression symptoms within the
rst year postpartum (RR 070, 95% CI 060081).
Psychosocial interventions, such as peer support and
non-directive counselling, show a decrease in depressive
symptomatology (ve trials, n=506; RR 061, 039094),
conrmed by a recent large cluster trial58 in which
assessment and non-directive or cognitive behavioural
counselling were delivered by health visitors compared
with standard care. CBT and interpersonal psychotherapy
were also benecial in reducing post-partum depressive
symptomatology (six trials, n=602; RR 075, 95% CI
063088). Insucient data prevented comparisons

between individual-based and group interventions.
Two systematic reviews assessing the eectiveness of
interventions to improve the mental health of women in
the perinatal period in LMICs showed 17 trials
(undertaken in predominantly middle-income countries
such as China and Chile with only one trial in a
low-income country [Uganda])92,93 that reported a
benecial eect of delivery of a psychosocial or
psychological intervention during routine perinatal care
(pooled eect sizes: 038, 95% CI 056 to 021;91
034, 053 to 01692). The reviews show that training
is feasible for non-specialist workers, such as community
health workers or local women to deliver perinatal
mental health interventions including home visits or
facilitated group sessions with a focus on parenting,
maternal and child health, psychoeducation, social
support, or supportive listening adaopted to the
circumstances the women who are being treated live
in. However, interventions should be adapted to the
circumstances in which the women being treated live.
Other disorders
Treatments for other perinatal disorders have been
scarcely researched, so management largely relies on
extrapolation from the evidence base established for other
times in womens lives such as CBT for eating disorders.
The extent to which interventions need modication for
the perinatal period is unclear and needs additional
research. Restricted evidence from a case series suggests
that intensive outpatient CBT that is modied for women
with postnatal OCD could reduce symptoms.94
Pharmacological treatment
The mainstay of pharmacological treatment for
non-psychotic mental disorders in the perinatal period is
antidepressants. Data suggests that in Europe around 3%
of pregnant women take an antidepressant at some point
in their pregnancy, mostly selective serotonin reuptake
inhibitors (SSRIs), with rates of around 10% reported in
the USA.95 Antidepressants are eective treatments for
depression, particularly for severe cases, and
meta-analyses have shown that ecacy compared with
placebo increases with severity of depression.96
Antidepressants are also eective for PTSD, anxiety
disorders, and bulimia nervosa.9799 However, partly
because of the diculties in undertaking RCTs in
perinatal women, no trials have been done for perinatal
disorders except for postnatal depression. These trials
provide evidence of signicantly higher response and
remission rates for women taking SSRIs than for
placebo. A Cochrane systematic review100 pooled data
from three studies comparing SSRIs with placebo and
reported signicantly higher response (RR 143 [95% CI
103203]) and remission rate (RR 179 [108298]) for
participants taking SSRIs than in those in the placebo
group. However, the evidence-base is restricted because
1781
Series
General principles of prescribing in the perinatal period:

It should not be assumed that it is always better to avoid psychotropic
drugs
Use the lowest eective dose
Use the drug which is eective for women and has the lowest known
risk to mother and fetus
Prescribe the least number of drugs as possible
Document all decisions
Ensure that the mother and partner or family are as involved as possible
in all decisions
In discussions about drugs include:

Womans level of distress from untreated symptoms
Severity of previous episodes, previous response to treatment and the womans
preference
Potential eects of an untreated mental disorder on the fetus or infant (and the
need for prompt treatment)
Risks of relapse or discontinuation symptoms from stopping drug abruptly
Background risk of fetal abnormalities for pregnant women without a mental disorder
Uncertainty with regards to possible increased risk of harm associated with drug
treatments during pregnancy and the postnatal period; include the risk in overdose
The possibility that stopping a drug with known risk during pregnancy might not
remove the associated risk
Absolute and relative risks should be discussed using natural frequencies and
common denominators (eg, 20 in 100 and 25 in 100, not 1 in 5 and 1 in 4)
Where possible, written material (preferably individualised) should be provided
to explain the risks
Pre-pregnancy
During pregnancy
Postnatal and breastfeeding
Discuss the possibility of pregnancy (including

unplanned)
Where possible use non-drug treatments
In each case, weigh up the benets of breastfeeding

to the mother and infant against the risk of drug
exposure in the infant (which is much lower than in
utero); usually inappropriate to withhold treatment
to allow breastfeeding when mother is at high risk
of relapse; treatment of maternal illness is the
highest priority
Avoid using contraindicated drugs eg, valproate

unless only eective drug; women should be made
fully aware of their risks
Carefully review need for drugs; choose drugs
most likely to achieve clinical stability and of
low risk (note risk of relapse with stopping
or changing drug)
Consider discontinuation of treatment
(potentially switching to psychological treatment)
if the woman is well and at low risk of relapse
Use lowest eective dose of drug if needed; avoid

changing drug regimen and use drugs with the
largest up-to-date evidence of safety for the mother
or fetus, taking previous response into account
Titrate doses as pregnancy progresses and drug
handling is changed
Be aware of potential problems with individual
drugs around the time of deliveryinform the
obstetric team of psychotropic use and possible
complications (including neonatal adaptation
symptoms in infants)
Where possible, suitable treatment options should

be used for women who wish to breastfeed rather
than recommending avoidance of breastfeeding
Where a mother had taken a particular drug during
pregnancy, continuation with the drug while
breastfeeding will usually be appropriate to
minimise withdrawal symptoms in the infant
Infants should be monitored for any adverse
eects of the drugs used, for example feeding
patterns and growth and development; premature
infants and infants with renal, hepatic, cardiac,
or neurological impairment are at high risk of
exposure to drugs
Time of pregnancy
Figure 2: Guidelines to prescribe in the perinatal period

Adapted from The Maudsley prescribing guidelines (11th edn),108 by permission of David Taylor.
the three studies were very small, underpowered, and

generally focus on women with mild-to-moderate
postnatal depression.100 RCTs have so far not reported
evidence of additional improvement with addition of a
psychological intervention to antidepressants,101,102 nor for
addition of sertraline by comparison with placebo
for women given a psychotherapeutic intervention
for postnatal depression, although the trials were underpowered.100 An RCT103 (n=61) reported signicant
improvements in EPDS scores in women given
17-oestradiol skin patches (with dydrogesterone tablets
for 12 days per month) compared with women given
placebo, but adverse events were reported and there is
therefore insucient evidence to support use of
oestrogens for postnatal depression.
Women often stop antidepressants during pregnancy104
and there is conicting evidence on whether discontinuation is associated with an increased risk of relapse of
depression,105,106 probably because of the dierent levels of
1782
severity of depression in the dierent study populations.

However, recurrence after discontinuation consistently
seems to be more likely in women with a history of several
episodes or a recent episode.105
As a general principle, drugs in pregnancy should be
minimised, and many women with perinatal mental
disorders can be treated with non-pharmacological
interventions. However, drugs will be clinically indicated
for women with more severe mental disorders in which
there are substantial risks to the mother, the pregnancy,
and the fetus or infant.50,107 Clinicians and women
therefore need to assess the benets and risks of
pharmacological interventions in pregnancy using key
principles of prescription in the perinatal period
(gure 2).108 Unlike other times in a womans life, risks of
illness versus risks of drugs do not only aect the women
themselves, the fetus and infant can also be aected
through exposure to psychotropic drugs across the
placenta or through breastfeeding, and side-eects
Series
potentially aect the mothers ability to parent (eg,

sedative drugs). However, concerns about risks to
the fetus or a failure to titrate the dose through
the pregnancy (to address the changes in drug
concentrations) might lead clinicians to prescribe
subtherapeutic doses.109
Risks to the fetus are dicult to assess because of the
absence of RCTs and the resultant diculties in
interpretation of the evidence base. Many studies are
small, with biased samples, low-quality study design, little
adjustment for important confounders (such as smoking),
and an almost invariable absence of adjustment for
confounding by indication. Initial reports of risks have
frequently not been substantiated or are shown to be
smaller once larger studies and meta-analyses have been
done. For example, despite early reports, a meta-analysis110
did not nd an increased risk of spontaneous abortion
associated with exposure to antidepressant drugs, and two
large population studies111,112 (29 228 and 12 425 SSRI
exposures, respectively) have not found associations with
antenatal SSRIs and stillbirths or neonatal deaths after
adjusting for confounders. Similarly, two meta-analyses113,114
showed paroxetine exposure is associated with only slightly
increased risks of cardiac malformations (odds ratio [OR]
14) rather than the large ORs initially reported, and
residual confounding is possible. Confounding by
indication also needs to be considereda study comparing
outcomes in infants of women who stopped SSRIs before
pregnancy and women who continued with SSRIs reported
a similar increased risk of cardiac malformations in both
groups,115 suggesting that the association is due to
depression rather than the drug itself.
Antidepressant exposure in pregnancy is signicantly
associated with gestational age at birth (pooled mean
dierence in weeks, 045, 95% CI 064 to 025),
preterm delivery (<37 or <36 weeks depending on the
individual studies included; pooled OR 155, 95% CI
138174), and Apgar score at 1 min (mean dierence of
037 points) and 5 min (mean dierence of 018 points),
although some might be of restricted clinical signicance.110
Meta-analyses have previously reported associations with
birthweight, but no signicant association with reduced
birthweight was reported in the 2013 meta-analysis when
the comparison group was limited to depressed mothers
without antidepressant exposure.110
A consistent signicant association exists between
exposure to antidepressants during pregnancy and
occurrence of poor neonatal adaptation syndrome
(PNAS; OR 507, 95% CI 325790), and individual
clinical signs (respiratory distress, OR 220, 181266;
tremors, 789, 3331873).116 The use of observational
study designs means causality cannot be inferred; the
results could suggest measurement bias, selection bias,
and confounding, but since abrupt discontinuation of
antidepressants in adults is associated with withdrawal
symptoms, infants might be at risk after birth. Whether
the symptoms reect withdrawal or toxicity is under
debate. Symptoms noted are usually mild and

self-limiting, but one study reported that infants who
developed PNAS were at an increased risk of
social-behavioural abnormalities even though they had
normal cognitive ability.117 Whether tapering of
antidepressants the week before expected labour would
reduce the occurrence of PNAS is unclear; some authors
have argued that the balance of evidence suggests that
discontinuation of clinically needed antidepressants in
women near term is unwarranted because neonatal
symptoms only occur in a small number of cases and are
self-limited, but the risk to a womans mental health will
be increased.109 Evidence on how long to observe the
neonate for PNAS symptoms is scarce. If no symptoms
emerge within the rst 72 h after birth, PNAS is unlikely;
when PNAS symptoms are present it is advisable to
observe the infant until symptoms are resolved in case
supportive treatment is needed.118
Some PNAS symptoms can suggest a spectrum of
eects with mild respiratory signs potentially showing
sub-clinical persistent pulmonary hypertension of the
newborn (PPHN). A systematic review and meta-analysis119
reported an increased risk of PPHN associated with late
pregnancy SSRI exposure (OR 250, 95% CI 132473;
absolute risk dierence 2935 per 1000 infants).
Although individual studies used dierent diagnostic
criteria and possible moderating variables such as
caesarean section, body-mass index, or preterm delivery
these could not be included in the meta-analysis.
Serotonin has a role in the development and modulation
of the lungs and this could be a factor in the development
of PPHN. Evidence also shows that prenatal SSRIs are
associated with neurobehavioural disturbances in early
infancy including stress or pain regulation; the severity of
these symptoms seems to be associated with high drug
concentrations and pharmacogenetic metabolic factors.120
Fewer data exists for long-term outcomes of infants
exposed to antidepressants in utero. However, studies are
similarly dicult to interpret because of methodological
problems and the known associations between maternal
depression, impaired motherinfant interactions, and
adverse infant or child outcomes.50 Some studies reported
a range of normal neurodevelopmental outcomes
including cognitive, behavioural, and emotional
outcomes while also noting adverse outcomes
(eg, behavioural problems measured by the strengths
and diculties questionnaire121) in children exposed to
maternal depression in utero in the comparison
groups,122124 but others have reported small delays in
developmental milestones in children exposed to
antidepressants in utero. A study125 using Danish
National Cohort data reported that 415 children exposed
in the second or third trimester in utero to antidepressants
sat 159 days (95% CI 68250) and walked 289 days
(95% CI 150427) later than children who were not
exposed to antidepressants (although still within the
normal range of development); fewer children with
1783
Series
exposure to antidepressants in utero were able to sit

without support aged 6 months (OR 21, 95% CI
123360), and fewer were able to occupy themselves
aged 19 months (21, 109402) than children who were
not exposed.125 A study of 31 infants exposed prenatally to
SSRIs scored signicantly lower than the 52 non-exposed
infants on gross motor (p=003), social-emotional
(p=004), and adaptive behaviour (p=005) subscales of
the Bayley Scale of Infant Development.126 Two nested
case-control studies have reported an association between
antidepressant exposure in pregnancy and autism
spectrum disorders,127,128 but no signicant association
was shown in a large cohort study.129
Although most studies focus on adverse outcomes with
some inconsistent results, there is new evidence, albeit
with small samples, that SSRI use in pregnancy could
have a positive eect. For example, prenatal antidepressant
treatment mitigates the eect of maternal anxiety on P50
sensory gating (associated with increased vulnerability to
attentional decits),130 and infants exposed to SSRIs in
utero show more readiness to interact during a toy session
than do a non-SSRI group exposed to high levels of
maternal depressive symptoms.131 Prenatal antidepressant
exposure might account for some neurobehavioural
outcomes in early childhood, but maternal and infant
genetic and environmental factors (including maternal
depressive symptoms in pregnancy and the postnatal
environment) will also shape childhood behaviours.50,120
Antidepressant exposure in breastfed infants is lower by
ve to ten times than is exposure in utero. The milk drug
concentration can be used to estimate the daily drug dose
ingested by the infant, assuming an average milk intake of
150 mL/kg bodyweight per day.132 The infant dose per kg
can be expressed as a percentage of the maternal dose per
kg and a relative infant dose of less than 10% is deemed a
negligible exposure. A review132 reported low relative
infant doses for uvoxamine, paroxetine, sertraline,
duloxetine, reboxetine, bupropion, and mirtazapine, and
an earlier review133 reported a low relative infant dose for
nortriptyline. Relative infant doses around 10%, and in
some cases higher than 10% for citalopram, uoxetine,
and venlafaxine, with somewhat lower relative infant dose
for escitalopram have been reported.132 When high
concentrations have been reported, infants have been
aged younger than 34 months, when infants are still
developing hepatic function. Metabolic capacity is not well
developed in preterm babies and those with genetically
determined impairment in antidepressant metabolism via
cytochrome P-450 enzymes (CYP2D6 and CYP2C19).132
Reassuringly, indirect biological evidence shows that
serotonin transmitters are not aected because no platelet
serotonin eects are noted in infants of breastfeeding
mothers treated with sertraline or uoxetine.134
Some adverse but non-specic events in infants
exposed to antidepressants via breast milk have been
reported in case reports and case series, more often
after exposure to uoxetine (eg, irritability and poor
1784
feeding) and citalopram (eg, poor sleep) than after

exposure to other drugs.132 Respiratory depression,
hypotonia, and vomiting have been associated with the
tricyclic doxepin. No studies have identied an increased
risk of adverse long-term outcomes. Most authors
conclude that if a mother was successfully treated for
depression during her pregnancy, the same drug should
usually be used in the post-partum period because
discontinuation or switching of an antidepressant
treatment could lead to relapse.
Perinatal mental disorders are common and can
adversely aect the mother and infant. However, they
are treatable and should therefore be identied early
to prevent adverse long-term eects. Where possible,
non-pharmacological treatments should be used but in
more severe cases, eective doses of antidepressants
will be needed after a careful collaborative analysis of
the ratio of risk versus benet.
Future research directions

Data for the epidemiology and prognosis of perinatal
mental disorders excluding postnatal depression, in both
high-income and low-income settings are scarce.
Similarly, there are few data for emerging risk factors
(such as migration and substance misuse), prevention,
and how and whether treatments (both psychological
and pharmacological) need to be modied in the
perinatal period. The eect of antidepressants on the
infant exposed in utero and breastfeeding, particularly
with respect to long-term outcomes, needs further
research. Future assessments of psychosocial
interventions should include distance, online selfhelp
interventions and selfhelp groups (ie, groups not
facilitated by a health professional), the potential role of
the father, and family-focused interventions. Finally,
trials of integrated models of service delivery including
identication, prevention, and treatment in high-income
and low-income settings could be used to inform
development of perinatal mental health services, which
are themselves in their infancy. In view of the rates of
perinatal disorders, the potential implications for the
mother, infant, and family, and that these disorders
happen at such an important time in the infants life,
these research initiatives need to be considered a priority.
Contributors
LMH, AS and JM developed the outline for the Series paper. EM did the
literature search. All authors contributed to the writing and editing of
the manuscript. LMH prepared the nal version of this Series paper,
which all authors approved.
Declaration of interests
LMH is Chair of the National Institute for Health and Care Excellence
(update) guideline on Antenatal and Postnatal Mental Health, and Chief
Investigator of an National Institute of Health Research (NIHR)
Programme Grant for Applied Research on the eectiveness of perinatal
mental health services (RP-RP-DG-110810012) which also supports JM.
LMH receives funding from an NIHR Research Professorship on
maternal mental health (NIHR-RP-R312011), and a grant from
Tommys baby charity (with the support of a corporate social
responsibility grant from Johnson and Johnson) on antipsychotics in
Series
pregnancy. LMH is also supported by the NIHR Mental Health

Biomedical Research Centre at the South London and Maudsley UK
National Health Service (NHS) Foundation Trust and Kings College
London. The views expressed are those of the author and not necessarily
those of the NHS, the NIHR, or the Department of Health. EM is
supported by a Medical Research Council PhD Studentship and
Tommys baby charity. TR receives salary support from Grand
Challenges Canada (Grant Number 006303), the Wellcome Trust (Grant
Number 097410/Z/11/Z) and National Institute of Health
(1R01HD07426701). AS has received many grants in relation to parental
perinatal health and child development including from the Wellcome
Trust (090139), Medical Research Council UK, Barclay Foundation,
Grand Challenges (Canada), and The Department of Education (UK). We
declare no other competing interests.
Acknowledgments
We thank the anonymous reviewers, Charlotte Hanlon and
Alan Gemmill for their helpful comments.
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Non-Psychotic Mental Disorders in The Perinatal Period

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Series

Perinatal mental health 1

pregnancy and 13% in the rst 3 months post partum

Lancet 2014; 384: 177588

Search strategy and selection criteria

viewed as a time when women are protected against

post partum by comparison with rates pre-pregnancy,

Panel 1: DSM-5 and ICD-10 diagnostic criteria for depression

A symptom must be:

All three key symptoms associated should be present:

At least four associated symptoms should be present:

Symptoms cause clinically signicant distress or impairment in

Symptoms not due to direct physiological eects of a substance

prevalence of binge eating of 173% was reported and

Psychological risk factors

Biological risk factors

Domestic violence (HIC, LMIC)35

Domestic violence, previous abuse

Prior history of psychopathology

Depression or unhappiness in pregnancy

Young age (HIC, LMIC)8, 20,34

Increased parity (rural LMIC context)8,20,40

comorbidities. However, a history of any psychopathology

I have looked forward with enjoyment to things

I have blamed myself unnecessarily when things went wrong*

I have been anxious or worried for no good reason

I have felt scared or panicky for no very good reason*

risk of postnatal PTSD48 and might increase a womans

Things have been getting on top of me*

I have been so unhappy that I have had diculty sleeping*

I have felt sad or miserable*

I have been so unhappy that I have been crying*

10) The thought of harming myself has occurred to me*

between 12 and 13) and for antenatal major depression

randomised controlled trials in HICs that reported

or psychological preventative interventions for postnatal

post-partum anxiety and improve marital adjustment.84

Psychosocial and psychological treatments

063088). Insucient data prevented comparisons

General principles of prescribing in the perinatal period:

In discussions about drugs include:

Postnatal and breastfeeding

Discuss the possibility of pregnancy (including

Where possible use non-drug treatments

In each case, weigh up the benets of breastfeeding

Avoid using contraindicated drugs eg, valproate

Use lowest eective dose of drug if needed; avoid

Where possible, suitable treatment options should

Figure 2: Guidelines to prescribe in the perinatal period

the three studies were very small, underpowered, and

severity of depression in the dierent study populations.

potentially aect the mothers ability to parent (eg,

debate. Symptoms noted are usually mild and

exposure to antidepressants in utero were able to sit

feeding) and citalopram (eg, poor sleep) than after

Future research directions

www.thelancet.com Vol 384 November 15, 2014

pregnancy. LMH is also supported by the NIHR Mental Health

www.thelancet.com Vol 384 November 15, 2014

Cooper PJ, Murray L. Course and recurrence of postnatal depression.

Lund C, Breen A, Flisher AJ, et al. Poverty and common mental

Brealey SD, Hewitt C, Green JM, Morrell J, Gilbody S. Screening

www.thelancet.com Vol 384 November 15, 2014