• All pregnant women who have bipolar disorder and experience a depressive episode require referral or possibly admission.
• Admit urgently those women who are considered to be a danger to themselves or others.
• If admission is thought to be necessary but the woman refuses, see Compulsory admission.
• Refer urgently for specialist mental health assessment those women:
• For whom the degree of risk is increasing such that they are likely to become a danger to themselves or others.
• With severe depression.
• In a mixed episode.
• With rapid cycling.
• For all other women, arrange an appointment with a psychiatrist as soon as possible to discuss treatment options.
• Whilst awaiting specialist assessment, do not start or change treatment without specialist advice.

• The treatment that may be offered by a psychiatrist will depend upon the severity of the depression. Treatments that might be considered include:
• Self-help approaches such as guided self-help and computerized cognitive behavioural therapy.
• Brief psychological interventions.
• Antidepressant medication.
• Combined medication and structured psychological interventions for severe depression.
• Quetiapine alone.
• Selective serotonin reuptake inhibitors (but not paroxetine) in combination with prophylactic medication.

These recommendations are based on published guidelines from the National Institute for Health and Clinical Excellence (NICE), Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, primary care and secondary care [National Collaborating Centre for Mental Health, 2006].

• Referral or admission may be required so that the woman can have an expert assessment and the most appropriate treatment initiated.