Mental health in pregnancy

Pregnancy is often a very happy and exciting time. But not every woman feels this way. You may have mixed, or even negative, feelings about being pregnant. You may find it more difficult than others to cope with the changes and uncertainties which pregnancy brings. Many things can affect how you feel in pregnancy. These include physical symptoms (e.g. morning sickness), the support you have (or don’t have), and stressful events in your life.

 Women often worry about how they will cope with pregnancy or having a baby.  It’s normal to feel stressed or anxious at times. When you are pregnant, it is common to worry about:

• The changes in your role (becoming a mother, stopping work).
• The changes in your relationships.
• Whether you will be a good parent.
• Fear that there will be problems with the pregnancy or the baby.
• Physical health problems and pregnancy complications.
• Fear of childbirth.
• Lack of support and being alone.

As many as 1 in 5 women have mental health problems in pregnancy or after birth.^1-3 It can happen to anyone. Depression and anxiety are the most common mental health problems in pregnancy. These affect about 10 to 15 out of every 100 pregnant women. ^4-5  Just like at other times in life, you can have many different types of mental illness and the severity can vary.  You may already have had a mental illness when you became pregnant.  

Mental health problems you have had in the past can be worrying because they can increase the risk of becoming unwell, particularly after birth. However, with the right help this can often be prevented.  You can also develop mental health problems for the first time in pregnancy or after birth. How your mental health is affected during pregnancy depends on many things. These include:

• The type of mental illness you have had already.
• Stopping medication for a mental health problem - you have a high risk of relapse if you do this when you become pregnant. This is more likely if you have had a severe illness ^6-7, several episodes of illness or a recent episode.⁸
• Recent stressful events in your life (such as a death in the family or a relationship ending).
• How you feel about your pregnancy - you may or may not be happy about being pregnant.
• Upsetting memories about difficulties in your own childhood.

Symptoms of mental illness in pregnancy are similar to symptoms you have at other times, but some may focus on the pregnancy. For instance, you may have anxious or negative thoughts about your pregnancy or your baby. You may find changes in your weight and shape difficult, particularly if you have had an eating disorder.

 Sometimes symptoms caused by your pregnancy can be confused with symptoms of mental illness. For example, broken sleep and lack of energy are common in both pregnancy and depression.

You should be referred to a mental health service if you are pregnant and have ever had⁹:

• A serious mental illness, like schizophrenia, bipolar disorder, schizoaffective disorder or severe depression.
• Treatment from mental health services.
• Postpartum psychosis or severe postnatal depression.
• A severe anxiety disorder such as Obsessive Compulsive Disorder.
• An eating disorder, such as anorexia or bulimia.

It is important to get specialist advice even if you are well during this pregnancy. Women who have had these illnesses have a high risk of becoming unwell after birth.  Your midwife or GP can refer you to a perinatal mental health service if there is one in your area, or otherwise to a community mental health team. Mental health professionals can discuss care and treatment choices with you. They will help you make a plan for your care, with your midwife, obstetrician, health visitor and GP.

If you have had any other mental health problems, talk to your GP. Even if you don’t need to see a mental health team it helps to get advice and support, so you can stay as well as possible. Often your GP will be able to advise about care and treatment. This will depend on the illness you have had and how severe it has been. You can also get support from some of the organisations listed at the end of this page.

It’s just as important to have treatment for mental health problems as it is for physical health problems in pregnancy. The best treatment for you will depend on your illness and how severe it has been. Both medication and psychological therapies (talking treatments) can help.^9-10

Medication

Any woman may need to take medication for many different physical and mental health problems before, during and after pregnancy. Decisions about whether to continue, change or stop medications in pregnancy are not straightforward or easy. Some medications have been used in pregnancy for many years. A few medications, such as Valproate, are known to cause problems in some babies and so should not usually be used at all in pregnancy.^9-11 In many cases, we simply do not have enough information to be absolutely sure that a treatment is safe. It is important to weigh up the risks and benefits of taking medication in your individual case.  Your GP or psychiatrist can help you decide what is best for you and your baby.

If possible, you should talk to your doctor before you become pregnant. However, many pregnancies are unplanned. This means it’s common to have to make decisions about medication when you are already pregnant. In that case, you should see your doctor as soon as possible. It is very important that you don’t stop your medication suddenly, unless your doctor tells you to. Stopping treatment suddenly can make you relapse and can cause unpleasant side-effects. 

It may be best for you to continue medication during pregnancy. But - there are many things you need to think about when making decisions about using medication in pregnancy. These include:

• How unwell you have been in the past
• How quickly you become unwell when you stop medication
• Medications you have taken:
  • which treatments have helped you most?
  • have some medicines caused side-effects?
• Up-to-date information about the safety of specific medications in pregnancy (see the link below to the Best Use of Medicines in Pregnancy website.
• If you are unwell during pregnancy:
  • You might not take good care of yourself.
  • You might not attend appointments with your midwife – so you don’t get the care you need.
  • If you use drugs and alcohol, you may use more when unwell. This can harm your unborn baby.
  • You may need a higher dose of medication if you become ill. Sometimes you may need two or more medications to treat a relapse. This might be more risky for your unborn baby than if you take a standard dose of medication throughout pregnancy.
  • You may need in-patient treatment.
  • You may still be unwell when your baby is born. You may then find it more difficult to care for your baby. It may also affect your relationship with your baby.
  • If your illness is not treated, this may be more harmful for your baby than the effect of medication. Untreated mental illness can cause a number of problems. For example, some research studies have found babies are more likely to have low birthweight if their mother has depression in pregnancy. Untreated mental illness can also affect a baby’s development later on.
  • Unfortunately, 2-3 in every 100 babies are born with an abnormality^12-13, even when the mother has not taken any medication. 

Psychological therapies

A talking treatment may be helpful.⁹ For some women this can be used instead of medication. Others may need a talking treatment as well as medication.

Psychological therapies services should see you more quickly if you are pregnant.⁹ Your doctor can advise you about referral in your local area.

A number of services and professionals offer help and support during pregnancy and early parenthood.  They will help you to stay as well as possible and to manage any illness and the recovery process.

Maternity services

Your midwife will ask questions about your physical and mental health (9). You should tell your midwife if you have had mental health problems. She can ensure you get the care and support you need.

It is important that you attend your antenatal appointments during pregnancy. In some areas midwives can visit you at home.

Your GP

You should talk to your GP if you are worried about mental health problems in pregnancy. Your GP can provide information, advice and treatment. He/she can refer you to a mental health or psychological therapies service if needed.

Improving Access to Psychological Therapies (IAPT) 

IAPT offers short-term talking therapies. The types of therapy offered will vary depending on your local IAPT service. These may include guided self-help sessions with a therapist, cognitive behaviour therapy, couples therapy and counselling. IAPT services offer individual and group therapies. Women who are pregnant or have recently had a baby are usually given priority.  You can often bring your baby to appointments. Some IAPT services also have groups just for women who are pregnant or for new mums.  You can self-refer to your local IAPT service. Your GP, midwife or health visitor can also make a referral for you.

Community Mental Health Teams (CMHTs) and Specialist Perinatal Mental Health Services

If you are already under the care of a CMHT, you should tell your care co-ordinator that you are pregnant. She/he can tell you about treatment and support available for pregnant women, and new mothers, in your area.

All the professionals involved in your care during pregnancy will work together with you and your family. They will aim to make sure you have all the care and support you need.  This will help you stay as well as possible. It will also mean that you and your family have a plan and know how to access help and support quickly if you become unwell. 

If you have had a severe mental illness, it is helpful to have a meeting to plan your care during pregnancy. This is called a Pre-Birth Planning Meeting. It can be organised by the perinatal mental health service or your community mental health team. It usually happens when you are 30-32 weeks pregnant. You can choose who to bring to this meeting – this may be your partner, a family member or a close friend. All the professionals involved in your care will be invited. 

 The Pre-Birth Planning meeting helps everyone to understand the care and support you and your family need. It helps everyone identify how to recognise that you are becoming unwell in case this happens. You and your family can tell the professionals about any extra support you need so this can be arranged before your baby is born. Everyone at the meeting can agree a plan for your care and treatment during pregnancy, delivery, and for the first few months after birth. This plan will be individual and can include many different things, depending on what you and your family need. It will usually include: 

• Your current treatment and any treatment you plan to start after birth, or if you become unwell.
• Who will support you at home.
• Key professional contact details.
• Who to contact if you become unwell.
• How to get help quickly.
• Who will visit you after your baby is born and how often.
• Local mother and baby groups in your area.

• Eat a healthy, balanced diet.
• Reduce your alcohol intake. You should stop drinking if possible.
• Stop smoking (ask your midwife or GP about 'stop smoking' services).
• Find some time each week to do something which you enjoy, improves your mood or helps you to relax.
• Meditation or mindfulness – either through a class or an App such as Headspace
• Let family and friends help you with housework, shopping etc.
• Exercise (ask your midwife about exercise in pregnancy and local exercise classes).
• Discuss any worries you may have with your family, your midwife or GP.
• Get regular sleep.
• Make a Wellbeing Plan – this helps you to start thinking about the support you might need in  your pregnancy and after the birth. You can download a Wellbeing Plan template from the Tommy’s charity website (www.tommys.org/pregnancy-information/health-professionals/free- pregnancy-resources/wellbeing-plan)

Tommys

• Original Authors: Dr Lucinda Green and Dr Ajoy Thachil
• Service User involvement: Cocoon Family Support
• Series Editor: Dr Phil Timms  
• Series Manager: Thomas Kennedy