Margaret Oates Maternal Mental Health and Liaison Mental Health

Transcription

1 Margaret Oates Maternal Mental Health and Liaison Mental Health

2 Most acute hospitals have Maternity Units Most maternity units do not have specific specialised perinatal mental health services Most liaison teams will serve maternity units All will do so out of hours DSH and other emergencies in pregnancy & after delivery may present to A&E

3 What is so special or different about maternal mental health? The context Epidemiology Rates of occurrence recurrence relapse Risk factors Symptomatology, course & progress Management 2 patients

4 Context 1. Liaison psychiatry hospital based Maternity care community based Midwifery led Most women only in hospital for delivery & less than 24 hours 20% - 30% additional consultant care 2. Baseline normal emotional changes commonplace concerns

5 At conception - those currently/recently seriously ill or maintained on medication (psychoses/bpi) high rates of relapse during pregnancy and following delivery Those on antidepressants who stop - high rates of relapse during pregnancy

6 % Remaining Stable Pregnancy (Weeks 1 40) (n=59) Nonpregnant Pregnant (n=42) Nonpregnant Postpartum Weeks at Risk Off Lithium Postpartum (Weeks 41 64) (n=20) Viguera AC. Am J Psychiatry. 2000;157: (n=25)

7 Effects of stopping medication Viguera et al. Am J Psychiatry. 2007

8 Most new onset conditions in pregnancy anxiety/depression 10%-15% may continue after delivery Beware moderate/severe last trimester

9 Women with PH severe depression BPI & psychoses Even if well for some time are at 50% risk of recurrence after delivery

10 Postnatal disorders Psychoses new onset 2/1000 births pre-existing 2/1000 births Severe depressive illness 30/1000 births Moderate depressive illness Mild depression/anxiety 100/1000 Distress/adjustment? Between 15 & 20% mental health problems

11 In General The most serious illnesses present early after birth Distinctive features - Acute onset - Fluctuating - Pleomorphic - Affect laden - Deteriorate rapidly Require specialist care

12 Is childbirth associated with increased risk? Number of admissions Weeks prior to delivery Weeks following delivery Onset of major functional disorders in the puerperium Kendell et al 1987

13 In General Psychological treatments (expert) are effective for mild/moderate conditions Some but not all mothers require additional or primary mother-infant therapeutic interventions Don t forget services & professionals for substance misuse

14 Reminder of risk Postnatal Serious affective disorder Gen mat pop 0.2% (DI 3%) Past history (well) 50% Past history p.p. illness 60% Past history (recent/ill) 90% Family history BPI 3% Family history postpartum 6%

15 Psychological issues in pregnancy Fears/anxieties relating to current/previous pregnancies PTSD phobias HEG Eating problems Reactions pregnancy loss Toco phobia

16 Issues Speed / time frame Availability of psychology/intervention Inadequacy of not mentally ill

17 Suicide Pregnancy 6 months postpartum n.s. change % suicides after delivery 83% well during pregnancy 87% died violently 60% seriously ill, ½ 1 st onset ½ recurrence Onset illness death median 9 days 66% previous psychiatric illness > ½ risk identified at booking, few managed No infanticides 30% substance misuse

18 Women who died by suicide Median 30 yrs (16 43) old 76% married / stable cohab 76% employed 41% educated A level (28% professional) 90% white 60% serious illness - 80% - 30yrs or older - married, educated employed 31% substance misuse - single, unemployed, young

19 Single mother late 20s relationship problems 2 nd child Bipolar illness 4 admissions mania Well 5 years on Valproate Not ill after 1 st baby but??? NDD Valproate stopped & discharged early pregnancy PH not identified by Maternity Services No psych care in pregnancy Day 3 seen by Liaison team odd no action Day 14 seen by GP c/o feeling depressed no action Day 27 died on railway line

20 Risk of recurrence Significance of mild/moderate symptoms with PH

21 Married professional woman 30s No previous history 1 st baby Admitted to Maternity Unit late pregnancy Distressed, anxious, hypochondriacal no action 4 week p.p. self presents to A&E lost use of legs notes describe agitation & depression Diagnosis anxiety state referred to CMHT 5 wks CMHT declines referrals Seen by independent psychiatrist depressed, suicidal needs urgent care Next day jumps to her death.

22 Misdiagnosis Minimising severity Standard service response out of character

23 Older married professional woman No psychiatric history 1 st baby Treated by GP + independent psychiatrist with A.D. 10 wks p.p. presents to A&E after overdose of A.D. Admitted overnight Notes reveal guilt, overvalued concerns about money & fleeting thoughts of cutting throat/toaster in bath no planning no intent good social support Referred to HTT & goes home Next day dies from cutting throat

24 Deteriorating Violent thoughts

25 Red flags Recent change/deterioration in mental state Thoughts of violent self harm Thoughts of maternal incompetence and guilt Estrangement from the baby Consider admission to MBU Scrutinise for symptoms of psychosis

26 Caution Early onset after delivery Out of character Moderate symptoms + past history fleeting no intent no planning protective factors Routine referral to safeguarding

27 Liaison Teams Knowledge & understanding of maternity context Familiar with commonplace emotional changes, distress & adjustments Knowledge & distinctive features of range of perinatal disorders Knowledge of distinctive risk & threshold for intervention Management protocol for serious mental illness Aware of local resources