Audit of a perinatal psychiatric clinic

Maternal mental health is an important topic because of the high risk of relapse of women with mental illnesses after delivery, poorer obstetric outcomes (Lewis & Drife, 2004) and the complex clinical issues that arise in prescribing for pregnant or breastfeeding women. The National Institute for Health and Clinical Excellence (NICE) has recently published guidelines on antenatal and postnatal mental health (National Institute for Health and Clinical Excellence, 2007).

As part of our liaison psychiatry service, we instituted an out-patient clinic exclusively for pregnant women and new mothers with common mental health problems. Close links were developed with the maternity unit and referrals accepted from two specialist mental health midwives and a consultant obstetrician with a special interest in the field. Referral criteria included women with anxiety or depression who required advice around psychotropic use during pregnancy or the puerperium.

An audit of the clinic was conducted using audit criteria suggested in the 2007 NICE guidelines. Overall, 51 patients were referred over the first 7 months. A total of 27 (53%) patients were on a psychotropic prior to referral to our clinic. Of these, 19 (70%) were taking medications not recommended by NICE; citalopram was the most common (n=10, 53%).

Twenty-two patients (43%) were prescribed a psychotropic drug in our clinic and the most common choice in pregnancy was fluoxetine. This was used in 14 cases (14/22, 64%). Amitryptiline was used in 4 cases (4/22, 18%) and the remaining 4 cases were each given nortryptiline, dosulepin, sertraline and chlorpromazine respectively (the latter two for breastfeeding women). Dosulepin was used in pregnancy for one patient despite not being recommended by NICE. This was a joint decision with that individual after considering the risks and benefits.

Whenever the prescription of an antidepressant was recommended, the pros and cons should have been discussed at length with the patient and their family, yet only 16/22 cases (73%) had clear documentation in the notes that this had taken place. Moreover, we were dismayed to realise that no patients were presented with written material to assist them in understanding the risks of prescribing psychotropic drugs in pregnancy or breastfeeding, despite NICE guidelines that such visual aids should be considered standard.

The audit suggests the need to improve training in primary and secondary care to reduce the number of pregnant and puerperal patients prescribed inappropriate psychotropics. It also highlights the dilemmas in providing women with appropriate written information regarding antidepressants in pregnancy and breastfeeding. The greatest concern for women is around possible teratogenic effects but the evidence base in this area is both rapidly changing and limited, with small-scale, descriptive studies that need to be carefully interpreted. Information from the UK National Teratology Information Service (www.nyrdtc.nhs.uk/Services/teratology/teratology.html) is very helpful but is not presented in such a way that makes it easily accessible to patients.