New Horizon Mother and Baby Centre. Perinatal mental health service Christine Munday Speciality Doctor

Transcription

1 New Horizon Mother and Baby Centre Perinatal mental health service Christine Munday Speciality Doctor

2 Learning Outcomes Service organisation Importance of perinatal mental illness Ante natal depression Post natal depression Puerpural psychosis

3 New Horizon Mother and Baby Centre Southmead

4 Conference Room

5 Children s Play area

6 The Lounge

7 A Bedroom

8 Staff Nurses -Ward Manager -Psychiatric nurses -Nursery nurses Occupational Therapist Doctors- Consultant, Staff Grade and junior doctor

9 Types of Treatments Psychological therapies Pharmacological treatment Social interventions Baby care and attachment

10 Who is admitted? Women with mental health disorder or distress > 36 weeks pregnant with baby < I year Women in high risk group for relapse for 2 weeks after birth

11 Admissions by diagnosis

12 Who do we see? Women with SMI planning pregnancy In pregnancy -past history SMI -previous care mental health services Post natally -post natal depression -puerpural psychosis

13 How to refer Telephone or for referral form

14 Who refers? Nationwide - mental health services Locally -community - GP midwives health visitors social workers mental health hospital obstetric services mental health services

15 NICE guidelines (2014) Women are unwilling to discuss mental health issues Stigma Fear of having baby removed

16 Recognising mental health problems During the past 1/12 have you been bothered by feeling down, depressed or hopeless? During the past month have you been bothered by having little interest or pleasure in doing things? NICE 2014

17 Recognising mental health problems During the past month have you been feeling, anxious or on edge? During the past month have you not been able to stop or control worrying? Also use EPDS or PHQ-9 Refer to GP or mental health services if severe problem suspected NICE 2014

18 Assessing mental health problems Previous mental health hx and response to treatment Physical health Alcohol/drug misuse Mother and baby interaction FH Social support Living conditions NICE 2014

19 Assessing mental health problems Risk Self neglect Self harm Suicidal thoughts Assess severity, arrange help, advise about seeking further help if needed Risk to others Consider safe-guarding if children at risk!

20 Pre-conception counselling New service Referrals from GP, mental health services 12 women seen each year Mostly with partners 80% with bipolar disorder Discussion of medication in pregnancy and breast feeding and risks of relapse

21 Preconception counselling Uncertainty of benefits, risks and harms of treating mental health problem Previous response to treatment Risk of harm of no treatment Sudden onset of illness post natally (first 2 weeks)

22 Case Study A 34 year old woman Unplanned pregnancy Already on fluoxetine What next?

23 Intervention - prescribing NICE-2014 Don t necessarily stop medication Explore options, including risks Involve partner Monotherapy Lowest effective dose Previous response to treatment Dose adjustment in pregnancy

24 Pregnant women and therapy Pregnant women often stop taking medication Explore reasons why Alternative of psychological therapy Consider re-starting Change to alternative drug Ensure mother aware of risks

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26 Antenatal depression Epidemiology Rate depends on population and timing of study 9% O Hara (1984) used controls showed AND predictor of PND 20% ALSPAC (EPDS at 32-weeks) 26

27 Antenatal depression Depressed Mood Tears DSH Seeking termination Biological symptoms EMW Appetite Libido DVM Somatisation Worries over foetus Anxiety symptoms Palpitations Diarrhoea Vomiting Sweating Tremor

28 Antenatal depression High rates of antenatal depression in community studies Impact on maternal and child health Placental abruption Premature labour Low APGAR scores and low BW Cohen et al 1989, Crandon 1979 & Istvan 86 28

29 Antenatal depression Poor antenatal care High rates of smoking, drug and alcohol use Deliberate self-harm / suicide Risk taking behaviour Poor bonding / attachment Longer term effects on child

30 Antenatal depression Maternal childhood maltreatment Antenatal depression Maltreatment of children Antisocial behaviour

31 Risk factors for antenatal depression Woman who have experienced abuse Previous depression Young- under 22 years Relationship problems F.H. mental illness

32 Antenatal Liaison Adhoc telephone or advice re: medication and management Women under care of recovery team Advice about medication Pre-birth planning Planned admission if required Consider referral to PCLS

33 BMJ personal story March 2012 Mood disorder in perinatal period Mrs X had depression since teens Bipolar disorder diagnosed early 20s Admitted with mania Then 18 months depression on lithium Became pregnant Referred to perinatal team

34 BMJ Personal story Overall thoughts Perinatal team helpful assessing women at risk and supporting them What helped? Good communication between professionals Compassionate midwife 2 week admission postnatally with daily visits from perinatal team

35 Alternatives to antidepressants Exercise Supportive counselling CBT Marital work

36 Resources Counselling Green House Mothers for Mothers Couple work Relate Psychological therapy LIFT Bereavement Cruise Befriending Homestart Bluebell

37 Intervention Mild depression -Consider withdraw medication & monitor -Psychological therapies Moderate/severe depression -Pharmacological treatment -Psychological therapy

38 Antidepressants in pregnancy Previous responses Reproductive safety Risk of discontinuation Past history severe depression Preference for medication Sleeping difficulties use Promethazine (NICE 2014)

39 Anti-depressants Tricyclics Advantages/disadvantages Amitriptyline Impramine Nortriptyline Safe in pregnancy Fatality in overdose Side effects Avoid clomipramine in first trimester? teratogenic

40 Antidepressants - SSRI Sertraline, Citalopram & Fluoxetine VSD when taken in 1 st trimester Assc. With low Apgar scores Jensen 2013 Persistent pulmonary hypertension (after 20 weeks) Autism risk with AD use in antenatal depression Rai 2013 Neonatal withdrawal

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42 Post-natal depression 70,000 women annually in UK First recognised 1968 Brice Pitt 10 20% 13% - O Hara, study 12,000 women 15% - Cox et al ( 82) 20% - Paykel et al ( 80)

43 Post-natal depression Natural history First 3-months esp 4 6-weeks (Kumar, Cox) Then many recover but 6/12 ⅓ - ½ still depressed 1-year 10% still depressed Can become chronic

44 Presentation Depressed mood Tears, no enjoyment DSH, poor care Biological symptoms EMW Appt Libido DVM Somatisation Worries over parenting, guilt Anxiety symptoms Palpitations Diarrhoea Vomiting Sweating Tremor *fleeting or intrusive thoughts of harming baby common (41% post-natally depressed mothers) Jennings KD et al. Thoughts of harming infants in depressed and non-depressed mothers 1999

45 Risk Factors Personal and F.H. depression 2x more likely to have PND if relative has PND- Forty et al 2006 Losing mother before 11 years old Unsupported no confidence No employment outside home 2 or more children at home under 5 years old

46 Risk Factors Previous depression & FH Marital conflict Poor socio-economic status Life events Older women Infertility Previous loss, bereavement, stillbirth Separation from father in childhood

47 Complications Suicide and DSH in mother Non-accidental injury Infanticide (1 in 50,000 deliveries) Cognitive and emotional development of child Marital discord

48 Treatment Support- practical, emotional Supportive counselling CBT Marital work Antidepressant therapy- sertraline Antipsychotics Short term anxiolytics

49 Medication Risks in breast feeding BABY All psychotropic drugs excreted in breast milk Long term effects not known Safety difficult to establish Monitor baby for weight gain and irritability

50 Minimising risks in breast feeding Breast feed before medication at night Consider drug half-life Using mixed feeding-formula overnight

51 Case study B 37 year old woman 3/12 post partum Difficult pregnancy - abnormal scans Normal delivery - baby in special care At home - baby has apnoea needs admission Mother - tearful, anxious, feelings of failure

52 Case study B Thoughts about running away Worried about harming baby No sleep, poor appetite

53 Case study B Miscarriage 2011 Teacher happily married to supportive husband Mother also has anxiety and depression Past history-previous depression due to work related stress Anti-depressants for 6/12

54 Case study B Diagnosis-post natal depression Treatment Initial support at home and sertraline 50mg Admission to New Horizon Non directive, supportive counselling Psychological therapy CBT, positive thinking, goal setting Couple work meetings with husband

55 Case study B Support with baby care to enable sleep and rest Regular meals Activities such as gardening, cooking Nursery nurses advice regarding baby care Gradual return home Sertraline, Lorazepam & Zopiclone

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58 Andrea s Postpartum Psychosis Episode Out of the Blue The fourth day after the birth of my first baby was the start of my meltdown. I had no history or mental health issues. Confusion, extreme anxiousness and terror mounted and I hadn t slept for four days. It happened suddenly and severely, within hours. I was manic and couldn t walk, talk or think. I held my phone but couldn t work out how to call for help. Over two weeks, I had delusions and scribbled notes franticly. My mind was spiralling yet I had moments of clarity. My thoughts raced so fast, I developed a stutter. I felt like a baby re-learning how to eat, walk and talk. It was exhausting. I couldn t read or watch TV and was terrified by people moving or speaking too fast; I couldn t process thoughts quickly enough to understand. I was learning how to care for my baby at the same time as trying to survive myself. I was scared I d be separated from my baby. I wanted information but nothing was explained to me as they thought I was crazy. Severe depression developed. I was numb and rarely left the house. It took a year to bond with my baby and I was suicidal for three months. After two years I made a full recovery but chose not to have more children.

59 Puerperal Psychosis (or post natal affective psychosis, post partum psychosis) 1-2 per 1000 deliveries -Kendal % in first post natal week 15% in second post natal week -Heron 2007 Symptoms- mood- mania, hypomania psychosis- delusions, hallucinations fluctuating perplexity Treatment- atypical antipsychotic ± antidepressant admission

60 Who? (psychosis post natally) Past history bipolar disorder Previous puerperal psychosis Past history schizophrenia Previous psychotic episode Family history post natal disorder

61 Who? Bipolar disorder- 250 per 1000 deliveries & F.H 570 per 1000 deliveries Previous P.P- 550 per 1000 deliveries Schizophrenia/ - relative increased risk of admission one schizoaffective month post partum 5x (but B.P 4x that) Childbirth- 20x risk of admission in first week post natal increased risk for 10 weeks-kendal 87 Approx ½ first onset approx ½ recurrence

62 Case study B 37 year old - 6 days post natal Concerns on post natal ward Thought baby was going to be removed At home - deterioration Seen in ED, admitted to New Horizon Really anxious 10 hours sleep since birth of baby

63 Case study B Overwhelmed Poor concentration Indecisive Not sure son is her baby Psychotic symptoms - thought TV referring to her Auditory hallucinations Suicidal thoughts of running under bus No thoughts of harming baby

64 Case Study B Family history mother had PND and treated with ECT Past history previous stress induced psychosis Treated in hospital under section MHA with olanzapine Husband unaware

65 Case Study B Admitted and detained under section MHA Treatment Medication antipsychotic olanzapine 10mg Antidepressant citalopram 20mg Support with baby care to enable rest and sleep Psychological therapy Couple work Nursery nurse advice

66 Sequelae of Serious Mental Illness Suicide and DSH in mother Infanticide (1 in 50,000 deliveries) Non accidental injury Cognitive and emotional development of child Marital discord

67 Mother and baby interactions in SMI Verbal interaction, emotional sensitivity, physical care Mother- over stimulating with toys, loud talk. - rough handling - irritable - angry Baby- distressed -withdrawn

68 Personal stories CIRCUS by Sarah Spring Roll up, roll up, I am the ringmaster. Marvel at my commands and ready wit, Beast and man dumb before me, lapping my pronouncements like poisoned condensed milk. No question who is in charge. I am taller than the tent pole, Wider than the tent. Roll up, roll up, and see the shocking show. Roll up, roll up, I am the strongman, Wondrous strength, both arms raised with bagfuls of books. Tearing and ripping furnishings, Withstanding the brute force of 40-plus stone of sinew bonehouse. Barracading myself from the enemy, I am invincible. Roll up, roll up, and see the shocking show. Roll up, roll up, I am the caged oddity, Psychic savant, possessing the meaning of life. Soul soars, while body stoops and mouth dribbles. Eyes stare with defiance and burn with knowledge beyond vision. Who dares challenge the seer? Watch me hug to death the pulse from my secret. Roll up, roll up, and see the shocking show.

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70 8 th CMACE Saving mother s lives Total deaths per 100,000 deliveries

71 Diagnosis of women who died from suicide Diagnosis n % Psychosis Severe depression 6 21 Adjustment/ grief 3 10 Drug dependency 9 31 TOTAL

72 Suicide past psychiatric history Past Psychiatric history n % No history, first illness Past psychiatric history Past psychiatric history identified 9 47 Past psychiatric history appropriately managed 4 21 Total

73 Women who died by suicide 76% married 76% employed 41% educated 90% white 2-3 per 1000 post partum psychosis But in substance misuse- young, single, unemployed

74 Case study - C 25 years separated, 2 nd baby died 9 th week post partum on railway line History bipolar disorder- well 5 years 4 previous admissions at onset of pregnancy stopped valproate discharged requested termination midwives not aware of history unwell 3/7 post partum 2 weeks sees GP 9 weeks family concerned- contact HV dies following day

75 Case study - D 02/04 30s married teacher, 2 nd baby died by hanging at 6 days post natal History 4 years ago depressive psychosis ECT after birth of first child - 2 nd pregnancy. P.H depression - day 4 midwife contacts CMHT - day 6 dies

76 Craig s story

77 Summary NICE guidelines highlight the importance of:- Early recognition Including those with previous mental health hx and awareness of risk factors Assessment Including of risk and safeguarding issues Intervention (incl. referral to PCLS and New Horizon)

78 References Saving Mothers Lives CMACE 2011 (deaths ) NICE guidelines 2014 Ante natal and Post natal Mental Health APP- action post partum psychosis National Teratology Service West Midlands Medical Information

79 Learning Outcomes Service organisation Importance of perinatal mental illness Ante natal depression Post natal depression Puerpural psychosis