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Depression in Pregnancy Treatment — MRCPsych Paper B MCQ

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HardPerinatal PsychiatryDepression in Pregnancy TreatmentMRCPsych Paper B

A woman in the first trimester of pregnancy has bipolar disorder and is taking no psychotropic medication. She is admitted with a severe depressive episode and has made a medically serious suicide attempt during the current episode. Following medical stabilisation, she continues to express persistent suicidal intent and her life remains at serious risk despite intensive inpatient support. According to NICE CG192, which treatment should now be considered?

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Correct answer: A — Consider electroconvulsive therapy with specialist perinatal input

NICE CG192 recommends considering ECT during pregnancy for severe depression when the physical health of the woman or fetus is at serious risk. Persistent suicidal intent following a medically serious attempt meets that threshold, so ECT should be considered through specialist perinatal, psychiatric and obstetric care. Pregnancy, including the first trimester, is not in itself a reason to defer ECT. Sertraline monotherapy is not a NICE-recommended treatment for bipolar depression; bipolar-specific treatment is required. CBT may be useful adjunctively but is inadequate as the sole acute intervention when life is at immediate risk. Lithium is neither the mandatory first-line treatment nor risk-free in the first trimester, and delaying effective treatment would leave a potentially fatal illness untreated.

Reference: National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance (CG192), recommendation 1.8.22, 2014, last updated 2020. https://www.nice.org.uk/guidance/cg192/chapter/Recommendations