Headline change
The guideline strongly recommends routine, systematic case identification for PMADs throughout the perinatal period, moving beyond symptom-triggered assessment.
Bedside action
Begin implementing routine PMAD screening using validated tools like the EPDS or PHQ-9 once per trimester, at postpartum obstetrical follow-up, and in family practice up to 12 months postpartum.
The Canadian Network for Mood and Anxiety Treatments (CANMAT) has released its inaugural comprehensive guideline for Perinatal Mood, Anxiety, and Related Disorders (PMADs). This document consolidates evidence-based recommendations for identification, prevention, and treatment, addressing a critical gap in perinatal mental healthcare. The core message for clinicians is a decisive move towards proactive, systematic screening and integrated care models to improve maternal and infant outcomes.
How It Compares Across Societies
While both CANMAT and NICE aim to improve perinatal mental health outcomes, their approaches to screening and specific pharmacological interventions show notable differences, reflecting varying interpretations of evidence and healthcare system contexts.
NICE 2020
NICE 2020
NICE recommends considering asking two depression identification questions and the GAD-2 at first contact and during the early postnatal period, then using EPDS or PHQ-9 for further assessment if positive (1.5.4, 1.5.5).
This guideline
CANMAT recommends routine, systematic case identification of PMADs throughout the perinatal period (e.g., once per trimester, at postpartum follow-up, up to 12 months postpartum) using validated tools like EPDS or PHQ-9 (Level 4).
CANMAT explicitly advocates for routine, systematic screening based on evidence for improved identification and outcomes, while NICE suggests a more tiered approach starting with brief questions before full screening tools.
Clinicians following CANMAT should proactively screen all perinatal patients, whereas NICE suggests a more targeted screening approach based on initial brief questions or clinical concern.
NICE 2020
NICE 2020
NICE states, 'Do not offer valproate for acute or long-term treatment of a mental health problem in women or girls of childbearing potential... unless other options are ineffective or not tolerated and the pregnancy prevention programme is in place' (1.2.3).
This guideline
Valproic acid is not recommended in pregnancy due to substantially increased risk for congenital malformations and neurodevelopmental delay (Level 3).
Both guidelines strongly advise against valproate, but CANMAT's stance is an absolute 'not recommended' in pregnancy, while NICE allows for use only if other options fail and a pregnancy prevention program is in place, indicating a slightly more conditional prohibition.
CANMAT's recommendation is a stricter prohibition of valproate in pregnancy, whereas NICE allows for highly restricted use under specific circumstances.
NICE 2020
NICE 2020
NICE states, 'Do not offer carbamazepine to treat a mental health problem in women who are planning a pregnancy, pregnant or considering breastfeeding' (1.4.30).
This guideline
Carbamazepine is downgraded to third-line for acute mania in pregnancy due to increased risk for congenital malformations and vitamin K deficiency (Level 3).
CANMAT allows for carbamazepine as a third-line option with caveats, acknowledging its risks but potentially useful in specific scenarios. NICE issues a stronger recommendation against offering it at all in the perinatal period.
Clinicians following CANMAT might consider carbamazepine in select, complex cases as a third-line option, while NICE's guidance discourages its use entirely in this population.
NICE 2020
NICE 2020
NICE states, 'Do not offer lithium to women who are planning a pregnancy or pregnant, unless antipsychotic medication has not been effective' (1.4.33).
This guideline
Lithium is downgraded to second-line for acute mania in pregnancy due to concerns about safety and complexity in its use, but remains an important option (Level 3).
CANMAT places lithium as a second-line option, acknowledging its effectiveness despite complexities. NICE positions it as a last resort, only if antipsychotics are ineffective, indicating a higher threshold for its use.
CANMAT allows for earlier consideration of lithium in pregnancy for acute mania compared to NICE, which reserves it for cases unresponsive to antipsychotics.
NICE 2020
NICE 2020
NICE recommends 'high-intensity psychological intervention (trauma-focused CBT or eye movement desensitisation and reprocessing [EMDR])' for PTSD (1.9.5) and does not list specific pharmacological first-line agents for PTSD in pregnancy.
This guideline
For PTSD, sertraline is first-line in pregnancy, venlafaxine second-line, and paroxetine third-line due to its risk profile (Level 3).
CANMAT provides specific pharmacological recommendations for PTSD in pregnancy, drawing from non-perinatal guidelines and safety data, whereas NICE prioritizes psychological interventions and does not detail specific medication lines for PTSD in this context.
Clinicians following CANMAT have clear pharmacological pathways for PTSD in pregnancy, while NICE emphasizes psychological therapies first.
Where they agree
- Both guidelines emphasize shared decision-making with patients regarding treatment options, risks, and benefits during the perinatal period.
- Both acknowledge the importance of comprehensive assessment, including psychosocial factors and risk to self/infant, in managing PMADs.
- Both highlight the importance of multidisciplinary collaboration and integrated care for perinatal mental health.
Practice Notes
Key considerations for immediate clinical application and patient safety.
Do not miss
Routinely screen all perinatal patients for PMADs up to 12 months postpartum.
Early and systematic identification using validated tools (EPDS, PHQ-9) improves treatment rates and clinical outcomes, even in the absence of overt symptoms.
Stop doing this
Avoid valproic acid in women of childbearing potential, especially during pregnancy.
Valproic acid carries a substantially elevated risk of congenital malformations and neurodevelopmental delay in offspring, making it generally contraindicated in this population.
Caution
Carefully manage lithium in pregnancy and postpartum, monitoring levels closely.
Lithium is effective but has complex safety considerations, including a small risk of cardiac malformations in the first trimester and neonatal effects. Dose adjustments are often needed due to physiological changes.
Monitoring
Monitor infants for neonatal adaptation syndrome (PNAS) if exposed to SSRIs/SNRIs in the third trimester.
PNAS symptoms (jitteriness, respiratory distress) are transient and usually resolve within days, but require supportive care and awareness.
Red flag
Immediately assess and manage any signs of postpartum psychosis.
Postpartum psychosis is a psychiatric emergency with high risks of maternal suicide and infanticide, requiring urgent inpatient treatment and expert mental health referral.
Shared decision point
Engage patients in comprehensive discussions about treatment risks and benefits, especially regarding medication use during pregnancy and lactation.
Decision-making should be collaborative, balancing maternal psychiatric stability with potential fetal/infant exposure, respecting patient values and preferences.
Key Recommendations
The CANMAT 2024 guideline provides comprehensive, evidence-based recommendations covering the full spectrum of PMAD management. These key recommendations address identification, non-pharmacological and pharmacological interventions, and management of high-risk situations, guiding clinicians through critical decision points in daily practice.
Key recommendations15 highlighted
01
In all perinatal patients (pregnancy up to 12 months postpartum), implement routine PMAD case identification using validated tools.
Level of EvidenceLevel 4
EvidenceWhile there is Level 2 evidence that standardized questionnaires improve identification and outcomes for depression, the recommendation for routine identification across all PMADs and the specific timing is based on expert consensus and the importance of early detection.
Integrate EPDS or PHQ-9 into routine care at least once per trimester and up to 12 months postpartum.
Questionnaires alone do not make a diagnosis; further assessment is always required.
p. 11 · Identification of PMADs
02
In patients experiencing 'baby blues/pinks', monitor carefully until symptoms resolve.
Level of EvidenceLevel 4
EvidenceLongitudinal studies show most cases spontaneously remit, but some suggest a higher risk of PPD. The recommendation for monitoring is based on expert consensus to ensure resolution and detect progression to more severe conditions.
Educate patients on the transient nature of 'baby blues/pinks' but maintain vigilance for symptom worsening or persistence.
Symptoms should be mild and not impact daily functioning; otherwise, further assessment is needed.
p. 8 · Diagnostic Considerations
03
In perinatal patients with depressive and anxiety disorders, utilize collaborative care models for treatment.
Line / StrengthFirst-line
Level of EvidenceLevel 2
EvidenceCollaborative care models have shown effectiveness for depressive and anxiety disorders in perinatal settings in some trials, leading to high treatment satisfaction. These models integrate mental healthcare into primary or obstetrical settings.
Advocate for or implement interdisciplinary collaborative care, especially in primary or obstetrical settings, to improve access and continuity.
Effectiveness can vary, and not all trials show consistent results.
p. 13 · Organization and Delivery of Healthcare Services
04
In non-clinical perinatal populations, recommend low to moderate-intensity exercise to prevent depressive symptoms.
Line / StrengthFirst-line
Level of EvidenceLevel 2
EvidenceEvidence supports exercise interventions in preventing depressive symptoms in pregnancy and postpartum in non-clinical populations, with at least moderate intensity and >150 min/week appearing most effective.
Counsel patients on the benefits of regular, moderate exercise for mental health prevention during the perinatal period.
Exercise recommendations should be tailored to individual circumstances and health risks.
p. 15 · Lifestyle Interventions
05
In perinatal individuals with depressive symptoms, offer trained peer support to reduce depressive symptoms.
Line / StrengthFirst-line
Level of EvidenceLevel 1
EvidenceStrong evidence from meta-analyses and replicated RCTs demonstrates the efficacy of trained peer support (face-to-face, telephone, or online) in reducing depressive symptoms during pregnancy and postpartum, including in at-risk populations.
Integrate trained peer support programs as a first-line psychosocial intervention for patients with depressive symptoms.
Optimal frequency appears to be at least once per week, with effective lengths less than 3 months.
p. 16 · Psychosocial Interventions
06
In perinatal individuals at risk for depression, offer CBT and Interpersonal Psychotherapy (IPT) for prevention of perinatal depression.
Line / StrengthFirst-line
Level of EvidenceLevel 1
EvidenceBoth CBT and IPT are effective in preventing perinatal depression in individuals with a prior history of depression, subsyndromal symptoms, or psychosocial risk factors, supported by high-quality evidence.
Refer at-risk patients for CBT or IPT as primary prevention strategies.
These are manualized therapies, requiring trained practitioners.
p. 16 · Psychological Interventions
07
In pregnant and postpartum individuals with Major Depressive Episodes (MDE), offer CBT, IPT, mindfulness-based therapies, and behavioral activation as first-line psychological treatments.
Line / StrengthFirst-line
Level of EvidenceLevel 1
EvidencePsychological treatments, particularly manualized therapies like CBT, IPT, mindfulness-based therapies, and behavioral activation, are effective in treating MDEs in pregnancy and postpartum, with or without comorbid anxiety symptoms.
Prioritize access to these psychological modalities for patients with MDEs.
Severe forms of illness may require pharmacotherapy in addition to psychological treatments.
p. 17 · Psychological Interventions
08
In perinatal patients with moderate-to-severe or severe depressive, anxiety, OCD, and PTSD symptoms, or when non-pharmacological therapies are ineffective, initiate pharmacological interventions.
Line / StrengthFirst-line
EvidenceMedications are considered first-line for moderate-to-severe/severe symptoms or when non-pharmacological options fail, based on clinical experience and the need for effective symptom management in significant illness.
Do not delay pharmacological treatment for patients with significant symptom severity or inadequate response to non-pharmacological approaches.
Decision-making must balance benefits against potential risks of medication exposure in pregnancy/lactation.
p. 19 · Pharmacological Interventions
09
In pregnant individuals with MDD, prescribe citalopram, escitalopram, or sertraline as first-line antidepressants.
Line / StrengthFirst-line
Level of EvidenceLevel 1
EvidenceThese SSRIs are first-line outside the perinatal period, generally well-tolerated, and have the most reassuring safety data in pregnancy regarding congenital malformations and other adverse outcomes.
These agents are preferred choices when initiating antidepressant therapy for MDD in pregnancy.
Patient preference and prior response should also guide selection.
p. 25 · Pharmacological Interventions - MDD in Pregnancy
10
In lactating individuals with MDD, prescribe citalopram, escitalopram, or sertraline as first-line antidepressants.
Line / StrengthFirst-line
Level of EvidenceLevel 1
EvidenceReassuring safety data for these antidepressants in lactation, with low relative infant doses (RID) and minimal adverse effects reported in breastfed infants.
These agents are preferred choices for antidepressant therapy in lactating patients with MDD.
Fluoxetine has a longer half-life and higher RID, making it a second-line option.
p. 27 · Pharmacological Interventions - MDD in Lactation
11
In pregnant individuals with acute mania, prescribe aripiprazole or quetiapine as first-line options.
Line / StrengthFirst-line
Level of EvidenceLevel 1
EvidenceThese antipsychotics have relatively reassuring safety profiles in pregnancy, despite some concerns about metabolic side effects with quetiapine and fewer data for aripiprazole.
These are the preferred antipsychotics for managing acute mania during pregnancy.
Metabolic monitoring is important, especially with quetiapine.
p. 31 · Pharmacological Interventions - Acute Mania in Pregnancy
12
In pregnant individuals with acute Bipolar I depression, prescribe lamotrigine or quetiapine as first-line options.
Line / StrengthFirst-line
Level of EvidenceLevel 1
EvidenceLamotrigine has a favorable reproductive risk profile, and quetiapine has reassuring safety data in pregnancy. Both are effective for bipolar depression.
These agents are the preferred mood stabilizers for acute Bipolar I depression in pregnancy.
Lamotrigine levels can decrease significantly in pregnancy, requiring close monitoring and dose adjustment.
p. 34 · Pharmacological Interventions - Acute Bipolar I Depression in Pregnancy
13
In pregnant individuals with severe acute depression (psychotic/catatonic features, acute suicidality, deteriorating physical condition), consider ECT as a first-line intervention.
Line / StrengthFirst-line
Level of EvidenceLevel 3
EvidenceECT appears relatively safe in pregnancy and is appropriate for severe, life-threatening depression where rapid response is needed, based on case studies and series, despite the absence of RCTs.
Do not hesitate to consider ECT for critically ill pregnant patients where rapid stabilization is paramount.
Requires close collaboration with anesthesia and obstetrical services due to potential adverse effects.
p. 37 · Neuromodulation
14
In individuals with acute postpartum psychosis, initiate antipsychotic medication, with or without intermittent benzodiazepines.
Level of EvidenceLevel 4
EvidencePostpartum psychosis is a high-risk condition requiring urgent treatment. The recommendation for antipsychotics and benzodiazepines is based on expert consensus for rapid symptom control and safety.
Promptly initiate antipsychotic therapy and consider benzodiazepines for agitation/insomnia in acute postpartum psychosis, ideally in an inpatient setting.
Treatment should occur in an inpatient setting, and lithium may be added for enhanced response and relapse prevention.
p. 39 · High-Risk Clinical Situations - Postpartum Psychosis
15
In co-parents (fathers, sexual/gender minority co-parents), clinicians should be attentive to the mental health of the co-parent and use standardized scales to aid detection of depression and anxiety.
Level of EvidenceLevel 4
EvidencePaternal depression and anxiety are common and associated with adverse child outcomes. The recommendation is based on expert consensus to address this often-overlooked area, despite limited RCTs on treatment.
Incorporate assessment of co-parent mental health into routine perinatal care, using tools like the EPDS (with adapted cut-offs for fathers).
Co-parents may be reluctant to disclose concerns due to stigma or lack of awareness.
p. 41 · Mental Health of Fathers/Co-parents