Mental health and motherhood. Why is this important? Are we doing enough? What more could we do?

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Osborn Dalton
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2 Mental health and motherhood Why is this important? Are we doing enough? What more could we do?

4 Why is this important?

5 Why is this important?

6 Why is this important?

7 Why is this important?

8 Confidential Enquiries into Maternal Deaths

9 Confidential Enquiries into Maternal Deaths Data on deaths from psychiatric causes over 17 years One of the leading causes of maternal death The majority had mood disorders

11 Confidential Enquiries into Maternal Deaths Data on deaths from psychiatric causes over 17 years One of the leading causes of maternal death The majority had mood disorders 2/3rds of women who died received care that was sub-optimal

Theme 1 Timing Cause Pregnancy undelivered Up to 42 days after end of pregnancy Late deaths 43-182 days after end of pregnancy Total Suicide 4 9 16 29

13 Theme 1 Timing Cause Pregnancy undelivered Up to 42 days after end of pregnancy Late deaths days after end of pregnancy Total Suicide Accidental overdose from drugs misuse Medical conditions, including those associated with substance misuse Accidents Total

14 Theme 1 Timing pre_104w pre_100w pre_96w pre_92w pre_88w pre_84w pre_80w pre_76w pre_72w pre_68w pre_64w pre_60w pre_56w pre_52w pre_48w pre_44w Pregnancy pre_36w pre_32w pre_28w pre_24w pre_20w pre_16w pre_12w pre_8w pre_4w Childbirth post_4w post_8w post_12w post_16w post_20w post_24w post_28w post_32w post_36w post_40w post_44w post_48w post_52w post_56w post_60w post_64w post_68w post_72w post_76w post_80w post_84w post_88w post_92w post_96w post_100w post_104w Aadmission per week

15 Case example Timing Older woman, no past psychiatric history Day 7 Day 11 Day 12 Day 13 weepy and anxious crisis team involved; agitated; not sleeping; overvalued ideas of guilt and incompetence midwife has problems contacting psychiatrist death by violent means

16 Theme 2 Prediction and prevention Cause of death Past history Yes No Identified Yes No Yes Plan No Suicide

17 Theme 2 Prediction and prevention Cause of death Past history Yes No Identified Yes No Yes Plan No Suicide

18 Theme 2 Prediction and prevention Cause of death Past history Yes No Identified Yes No Yes Plan No Suicide

19 Theme 3 Serious illness Cause of death n % Hanging Jumping from a height Cut throat/stabbing Self immolation Drowning Carbon monoxide Ingesting of bleach Overdose Total

20 Theme 4 Mistaken diagnosis Symptoms Attributed to Underlying diagnosis Distress/pain Anxiety/depression Aortic aneurysm/pe Weight loss/cough/sweating Weight loss/poor appetite Opiate use Anorexia nervosa Lymphoma Confusion Depression Encephalopathy Agitation Depression Eclampsia TB

21 Key findings Failure to recognise suddenness of onset Poor information sharing between primary care, maternity and mental health services, Lack of detailed enquiry and nai ve management for women with substance misuse Women who died of underlying physical illness had their symptoms downplayed or diagnosis delayed because of misattribution to mental disorder.

23 Causes of maternal death

24 Late Maternal Deaths

25 Mental health-related deaths

26 Theme 1 Booking assessments 11% inadequate or no enquiry about mental health history or current mental health Huge variation in questions asked Even where questions were in the booking proforma, they remained blank

27 Theme 2 Symptom pattern/progression Anxiety at first presentation Lack of recognition of escalating symptom pattern Assessments of serial presentations in the moment Use of terms such as impulsive and no planning when assessing suicide risk behaviour Reliance on patient reports despite evidence to the contrary

28 Case example Symptom pattern/progression Depression prior to 1 st pregnancy & PND HV dep. within 3 weeks postnatal + suic. id. GP ongoing thoughts of self-harm A/E presentation with overdose impulsive OOH primary care with self-harm impulsive Crisis team no need for follow up Death by suicide 4 weeks later

29 Theme 3 Precursor violent thoughts/acts Lack of recognition or downplaying of violent thoughts/acts of self-harm 19/101 (1/5 th ) of women Almost half had acted in violent manner already

30 Case example Precursor violent thoughts/acts Prior history of PND and again after this child Found on bridge with rope few weeks after birth A/E no ongoing suicidal intent CIR death completely unexpected

31 Theme 4 Estrangement from the infant 7 women expressed strong ideas of incompetence or estrangement from their babies Some arranged for infant to be cared for by others

32 Case example Estrangement from the infant No previous history GP within 12 days depressed mood and wishing baby adopted; repeated to HV Talked of going overseas, killing herself, not loving baby but evidence to contrary Death by violent means within a few weeks of birth

33 Theme 5 Grade of assessor Assessments made by junior medical or nursing staff Lack of breadth of experience Failure to recognise herald symptoms Inability to see pattern of escalating behaviours Misattribution to normal emotional changes Unawareness of pattern of rapid deterioration in perinatal mental illness

34 Theme 6 Care by multiple teams Multiple teams Fragmentation of care In some cases, lack of clarity about who had overall care Sometimes different teams not aware of each other s involvement Crisis resolution/home treatment teams

35 Case example Care by multiple teams Death by violent suicide in mid-pregnancy Evidence of psychotic depression in months before death; 2 overdoses with suicidal intent Seen by at least 5 different mental health teams, each reaching different conclusions E.g., 3 consecutive days: Day 1 (Team A) symptoms of psychosis Day 2 (Team B) no role for mental health team Day 3 (Team C) admission with suicidal thoughts

36 Theme 7 Consideration of inpatient care 13 women with significant risk identified but no offer of inpatient care Emphasis placed on keeping women in the community in some cases in the face of direct appeal by the woman/family Funding issues

37 Case example Consideration of inpatient care Estranged from infant Asked to be admitted to MBU on 2 occasions but family resisted joint admission Then requested admission to general ward but dissuaded by mental health worker

38 Theme 8 Mental capacity issues 3 women had compromised ability to make decisions about their physical care No evidence of awareness of capacity legislation among non-mental health staff

40 Are we doing enough?

41 Perinatal Mental Health Services MBUs Community services

42 And the cost?

45 Mental illness in pregnancy No evidence that pregnancy is protective Possible increase in minor mental health problems in 1 st and 3 rd trimester Pre-existing mental illness doesn t go away Mood problems in pregnancy increase risk postnatally

46 Mental illness in pregnancy Up to 20% of women will experience a mental health problem in pregnancy Majority are mood disorders Range in severity from mild, self-limiting to severe with suicidality and psychotic symptoms

47 Postnatal mental illness Illness in pregnancy predicts postnatal illness Postnatal depression Increased risk : Life adversity Woman s perception of support Postpartum psychosis Increased risk: Personal history of postpartum psychosis or bipolar disorder Family history of postpartum psychosis or bipolar disorder

53 It takes all the running you can do to stay in the same place. If you want to run somewhere else, you must run at least twice as fast as that!

54 Communication GP to maternity Maternity to GP and mental health Adequate booking assessments completed! Pathway for action on high risk findings

55 Red Flag Presentations Recent significant change in mental state or emergence of new symptoms New thoughts or acts of violent self-harm New and persistent expressions of incompetency as a mother or estrangement from the infant

56 Consider inpatient care Rapidly changing mental state Suicidal ideation (particularly of a violent nature) Pervasive guilt or hopelessness Significant estrangement from the infant / new or persistent beliefs of inadequacy as a mother Evidence of psychosis

59 What should the UK have? All women in the UK should have equitable access to: Specialist community perinatal mental health services Inpatient mother and baby unit beds Interventions which promote good maternal and infant mental health

60 What are the nations of the UK doing? England 290+ million over 5 years MBUs in areas of need Nationwide specialised community perinatal mental health teams Perinatal clinical networks in every region Wales 1.5 million over 5 years Specialised community perinatal mental health networks Perinatal community of practice

61 Scotland? No new committed monies But only country in the world to enshrine joint mother and baby care for mental illness

62 NSPCC & MMHS Local, specialised perinatal mental health services Local, multi-professional perinatal mental health networks Rapid access to talking therapies Ill and high-risk women seen by specialist services Up to date knowledge for professionals

Royal College of Psychiatrists in Scotland Increased provision of community maternal mental health services in each NHS board area Evaluation of different models of

63 Royal College of Psychiatrists in Scotland Increased provision of community maternal mental health services in each NHS board area Evaluation of different models of community maternal mental healthcare provision in remote and rural areas A national maternal mental health clinical network to coordinate the delivery of highquality specialised care

64 NHS Education for Scotland e-modules Maternal Infant

66 The children left behind Any child whose mother dies must face a far poorer start to family life. The fact that so many of the children were already living in complex circumstances with vulnerable families, or were in care, continues to underscore the important public health dimension of this Enquiry. Gwyneth Lewis OBE

Perinatal Mental Health

Perinatal Mental Health Dr. Tara Lawn Consultant Psychiatrist Sasha Singh Modern Matron Dr Sarah Jones ST5 Perinatal Mental Health at E9 City & Hackney Centre for Mental Health What is Perinatal Psychiatry?