Article is concerningBMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39220.447708.3A (Published 24 May 2007) Cite this as: BMJ 2007;334:1072
- Dave Tomson, chair1,
- Rachel Burbeck, systematic reviewer2,
- Stephen Pilling, director2,
- Liz McDonald, consultant perinatal psychiatrist3
- 1NICE Antenatal and Postnatal Mental Health Guideline Development Group, National Institute for Health and Clinical (NICE). London WC1V 6NA
- 2National Collaborating Centre for Mental Health, University College London, London WC1E 7HB
- 3NICE Antenatal and Postnatal Mental Health Guideline Development Group
As the developers of the recent NICE guideline on antenatal and postnatal mental health1 we found some aspects of the article by O'Keane and Marsh on depression during pregnancy of concern.2 Firstly, by focusing only on depression it perpetuates the myth that depression is the only important mental disorder of pregnancy and the postpartum period, when other disorders are also important, notably, anxiety disorders. Secondly, it is written from a secondary care perspective when the burden of care for women with common mental disorders during the antenatal and postnatal periods falls on primary care. Thirdly, the article and the recent NICE guideline are inconsistent.
The authors focus almost exclusively on antidepressant treatment. They do not mention that for mild to moderate depression and anxiety a range of interventions such as various forms of guided self-help, and brief psychological treatments (including listening visits) are effective.1 3 4 The risk:benefit ratio for antidepressants does not normally support their use in mild depression.4
Pregnant women are often reluctant to take drugs and so are unlikely to complete a course of antidepressants, but this is not acknowledged by the authors, who recommend antidepressants for women with moderate depression. In contrast, the guideline recommends that equally effective psychological therapies are to be preferred.1 Mindful of the potentially negative consequences of untreated depression and anxiety in pregnancy, the guideline also sets out recommendations for prompt access for pregnant women to psychological therapies.
O'Keane and Marsh say that women with an affective disorder who are planning a pregnancy should be referred to specialist psychiatric services, and that those with a history of recurrent depression or bipolar disorder should be referred to perinatal psychiatric services where these exist. Although this should be carefully considered for women with bipolar disorder or recurrent depression, referring women with any affective disorder is impractical and unnecessary, and may lead to an inappropriate use of specialist services.
Finally, O'Keane and Marsh say that women taking antidepressants should gradually stop breast feeding to reduce withdrawal phenomena in the newborn. This is not recommended as routine practice in the guideline. Difficulties for the infant may arise not just from withdrawal symptoms but also from serotonin toxicity (the symptoms are similar5 ),in which case the strategy they advise is not appropriate.
Competing interests: SP receives funding from NICE for the development of NICE clinical guidelines in mental health.