Perinatal mental health

Public Health England (2015) recently published a rapid review of evidence for the healthy child programme. This has highlighted the best practice for perinatal mental health.

National Institute for Health & Care Excellence (NICE) guidelines for antenatal and postnatal mental health recommends that at a woman's first contact with services in pregnancy and the postnatal period, practitioners should ask two questions about depression and subsequent questions about generalised anxiety. Key risk factors are:

Any past or present severe mental illness 

Past or present treatment by a specialist mental health service, including inpatient care

Any severe perinatal mental illness in a first-degree relative (mother, sister or daughter)

If high risk scores are identified, women should be referred to a secondary mental health service (preferably a specialist perinatal mental health service) for assessment and treatment. This will include woman who have or are suspected to have severe mental illness, as well as those that have any history of severe mental illness, whether during pregnancy, in the postnatal period or at any other time. In both cases the woman's GP should know about the referral.

Where a woman has any past or present severe mental illness or there is a family history of severe perinatal mental illness in a first-degree relative, practitioners should be alert for possible symptoms of post-partum psychosis in the first two weeks after childbirth.

If a woman has sudden onset of symptoms suggesting post-partum psychosis, she should be referred to a secondary mental health service (preferably a specialist perinatal mental health service) for immediate assessment (within four hours of referral).

When a woman with a known or suspected mental health problem is referred in  pregnancy or the postnatal period, she should be assessed for treatment within two weeks of referral and provided with psychological interventions within one month of initial assessment.

More than 1 in 10 women develop a mental illness during pregnancy or within the first year after having a baby, Examples of perinatal mental illness include antenatal , depression, postnatal depression, maternal obsessive compulsive disorder, post-partum psychosis and post-traumatic stress disorder, (PTSD). These illnesses can be mild, moderate or severe, requiring different kinds of care or treatment  (Maternal Mental Health Alliance 2014)  if untreated perinatal, mental illnesses can have a devastating impact on the women affected and their families.

         
For example maternal mental health problems are associated with 33 percent to 50 percent of all children presenting to social care as children in need or children at risk of being taken into care.
 

National Institute for Health and Care Excellence (NICE) guidance states that women should be assessed for levels of anxiety and depression in pregnancy and after birth. Midwives and health visitors are required as part of the maternal mental health pathway to ask two key questions about depression called the Whooley questions for example:

• During the past month have you often been bothered by feeling down depressed or hopeless
• During the past month have you often been bothered by having little interest or pleasure in doing things?

Then if concerned the practitioner is required to ask a further two questions from the Edinburgh Depression score or from the GAD-7.
 

Whatever the level of anxiety or depression the mother should be referred to psychological therapies for cognitive behaviour therapy yet midwifery teams note anecdotally that about half of these do not attend as they need support to attend such services or different approaches that allow them to engage with the therapy services.  
 

As part of the Royal College of Nursing Pressure Points Campaign they have 

published a report on maternal mental health. 25 percent of mother surveyed reported feeling significantly depressed or down after the birth of there baby with a further 35 percent reporting feeling a little bit depressed or down. 25 percent of student midwives felt that they had not enough theoretical knowledge about maternal mental health and 27 percent felt that they would not feel confident in recognising the signs of emotional health issues in the woman they care for. The vast majority of midwives felt that the focus of postnatal care should be on emotional support compared to clinical observation and health promotion. 75 percent of mothers report been asked how they were coping during postnatal visits though some reported feeling that this was a "tick box exercise". 35 percent of midwives would like to do more to support the emotional wellbeing of new mums.
 

Local CAMHS Transformation Planning Guidance based on the recent Future in Mind report clearly states that local plans should place high emphasis on improving perinatal mental health.
 

For further information around perinatal mental health please see the dedicated area of the Child and Maternal Health Intelligence Network
 

The Thames Valley Children and Maternity Strategic Clinical Network and the Oxford Academic Health Science Network have collaborated to establish The Thames Valley Perinatal Mental Health Network (TVPMHN) in 2015. Membership is comprised of NHS Provider and commissioner from each locality along with patient. Family and Third Sector representation the network provides professional links and a mechanism to share local developments and challenges with regional colleagues. 
 

In 2015/2016 TVPMHN have hosted a series of teaching events on perinatal mental health with local and international speakers.
 

The referral pathway for perinatal care has changed so that mid wives can now refer at booking rather than waiting for the GP or Health Visitor to refer following the birth so that early intervention can be implemented where needed. Training has been delivered to Midwife's and Health Visitors. 
 

The Thames Valley Children and Strategic Network carried out a broad brush scoping exercise and produced a report which recommended:

• Developing training and specialisms in perinatal mental health across different services 

• Commissioning specialist perinatal services in line with NICE guidance

• Establishing a regional network of professional stakeholders

• Improving data collection relating to perinatal mental health by all providers 

Following on from these recommendations TVPMHN have supported a deep dive into perinatal mental health services in the region. This will report on provisions for pregnant and postnatal women in generic health services and will evidence data relating to the perianal population in the locality.

The Joint Commissioning Panel for Mental Health (2012) estimated the numbers of women affected by perinatal mental illnesses in England each year:

• Postpartum psychosis – 2 per 1,000 maternities – approximately 1,380 women
• Chronic serious mental illness – 2 per 1,000 maternities – approximately 1,380 women    
• Severe depressive illness – 30 per 1,000 maternities – approximately 20.640 women    
• Post traumatic stress disorder – 30 per 1,000 maternities – approximately 20,640 women    
• Mild to moderate depressive illness and anxiety state – 100-150 per 1,000 maternities - approximately 86,020 women    
• Adjustment disorders and distress – 150-300 per 1,000 maternities – approximately 154,830 women

As yet we do not have any local baseline data or trends in perinatal mental health problems assessed antenatally or postnatally, as this data is collected on individuals who are then referred by local midwifery and health visiting teams to ‘Introducing Access to Psychological Therapy’ services (IAPT) commissioned by CCGs.
 

From October 2015 anonymised postcode level data on risk will be collected by health visiting teams allowing better targeting of prevention and treatment services. The introduction of the Maternity and Children’s Dataset will improve data on all aspects of maternal and child need and service provision.

     

The estimated number of women who will require support during pregnancy due to poor mental health in Wokingham is 233 (Public Health England, 2012). An estimated prevalence level of perinatal mental illnesses can be made for Wokingham Wards, based on the general prevalence rate of 1 in 10 women developing a mental illness during pregnancy or within the first year after having a baby. 

 

Table 1 - Estimated prevalence of perinatal metal illness at Ward level

Berkshire Healthcare NHS Foundation Trust tags all referrals on the patient data system which meet the perinatal pathway criteria. In 2014/15 there were 72 new referrals in Wokingham and in the last 9 months there have been 60 new referrals with 3 months yet to run. This was in secondary care.

     

Wokingham Community Mental Health Service has 2 staff with expertise in perinatal mental health. This includes some joint work with Children’s centres.

 

National Institute for Health & Care Excellence (NICE) guidelines provides a clear statement of what is required.

For prevention, women who receive a psychosocial or psychological intervention designed to prevent postnatal depression during pregnancy or the post-partum period are significantly less likely to develop postpartum depression compared with those who receive standard care.  Promising interventions include interpersonal psychotherapy, intensive home visiting by professionals, and telephone support (though evidence on the latter is inconsistent).

 

For treatment NICE recommends that women with persistent sub threshold depressive symptoms, or mild to moderate depression, in pregnancy or the postnatal period should be offered facilitated self-help. Where women with a history of severe depression initially present with mild depression in pregnancy or the postnatal period, pharmacological therapies should be considered.

For a woman with moderate or severe depression in pregnancy or the postnatal period, options should include a high-intensity psychological intervention, for example:

• cognitive behaviour therapy (CBT)

• tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRI) or Serotonin and norepinephrine Reuptake Inhibitors (S)NRI

• high-intensity psychological intervention in combination with medication

Inconclusive evidence from reviews of interventions other than pharmacological, psychosocial and psychological for treating antenatal and postnatal depression include:     

• depression-specific acupuncture

• maternal massage

• bright light therapy 

• omega-3 fatty acids to treat antenatal depression

There is no evidence to support the use of group CBT, exercise interventions, or omega-3 fatty acids for the treatment of postnatal depression.

 

NICE recommends that a woman with persistent sub threshold symptoms of anxiety in pregnancy or the postnatal period should be offered facilitated self-help. This should consist of the use of CBT-based self-help materials over 2-3 months with support (either face to face or by telephone) for a total of 2-3 hours over 6 sessions .

Women with anxiety disorders in pregnancy or the postnatal period should be offered a low-intensity psychological intervention (such as facilitated self-help) or a high-intensity psychological intervention (such as CBT) as initial treatment in line with the recommendations set out in the NICE guideline for the specific mental health problem.      

Public Health England (2015)  in their summary of the evidence of what works identified that NICE guidance recommends that the nature of the mother-baby relationship should be assessed, including verbal interaction, emotional sensitivity and physical care, at all postnatal contacts.  Practitioners should discuss any concerns that the woman has about her relationship with her baby and provide information and treatment for identified mental health problems. Practitioners are recommended to consider further intervention to improve the mother-baby relationship if any problems in the relationship have not resolved. 

Apart from a present or current history of mental health problems vulnerable women at additional risk of mental health problems in pregnancy or postnatally include those who are abused, have sought asylum, have English as an additional language, are misusing drugs and alcohol, are living in poverty, are homeless or who have had a traumatic birth. 

In 2015 an agreed 166K of funding was made available by The Berkshire West CCG to deliver perinatal services in Berkshire West. Perinatal clinicians will be part of a West of Berkshire Perinatal Mental Health Service. The staff will be managed by the Perinatal Mental Health Services but will be aligned to localities Staffing.

• 1WTE band 6 RMN
  
• 1 WTE band 6 equivalent Social Worker
  
• 0.8WTE band 7 RMN and CBT therapist
  
• 1.0 WTE band 6 RMN operating within Wokingham CMHT

Interventions

 

• Assessment
• Medication with advice from pharmacy and prescribing advice from CPE or Locality Psychiatrist
• Psychological intervention
• Support clinicians in the generic community services
• SHaRON - Online support service commenced December 2015
• Operate during office hours only

Data should be collected from health visiting and maternity services to enable a geographic assessment of needs as well as a personal assessment of needs.

Outcomes of perinatal mental health interventions should be reported geographically through the Joint Strategic Needs Assessment, as well as through commissioned services in future Health Education Thames Valley (HETV) is part of the Thames valley Perinatal network and has undertaken a survey of training in perinatal mental health for various professional groups in the region. HETV will be making recommendations for training staff.

 

• That the CCGs who have responsibility for the commissioning of adult mental health services collect data on women referred to IAPT services both antenatally and postnatally

• Commission a full perinatal mental health service

• Collection of data from children’s centres where parents have a mental health need