The chance for many generations: reversing the spiral

Dr Alain Gregoire

The chance for many generations: reversing the spiral Dr Alain Gregoire, DRCOG, MRCPsych Consultant/Hon. Senior Lecturer in Perinatal Psychiatry, Southampton Member of NICE APMH Guideline Group and NHS Perinatal ERG Chair, Maternal Mental Health Alliance

Depression: the most common major complication of maternity 14% 12% 10% 8% 6% 4% 2% 0% major depression hypertension PPH preterm diabetes preclampsia IUGR lacental abruption

Global Burden of Disease: DALYs (life years lost through death or illness) for women aged 15 44

Admissions Maternity: the highest ever risk of psychosis 20 18 16 14 12 10 8 6 4 2 36 34 32 30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 Weeks before Birth 1 2 3 4 5 6 7 8 9 10 Weeks after Kendell, 1987 Puerperal psychosis: more rapid onset, more severe, and higher risk than at any other time (Oates, 1996; Appleby et al 1998)

Infant needs: good enough care Physical needs (food, heat, health, motor) Protection from harm (accidental & deliberate) Emotional needs (comfort, control, stability) Social needs (peer & other, experience & modelling) Cognitive and intellectual needs Consistency Adaptability, learning and generalising

Demands of good enough parenting Available & sensitive to cues (serves) Rapidly interpret and respond (return) Test out, check response, retest, learn, generalise Pleasure from success, contentment, activity, learning Anticipate social, emotional, intellectual, physical needs & risks Measured, timely, consistent, effective response Maintain own wellbeing, activity, social contact

Childhood maltreatment: the most important predictor of antenatal depression (x10) No antenatal depression Antenatal depression 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Low childhood abuse High childhood abuse χ2(1) = 23.76, p <.001; OR = 10.00; CI: 3.57, 28.01 Plant et al, 2013

Mothers childhood maltreatment has an impact on their children Collishaw et al 2007- ALSPAC

Maternal antenatal depression: 3.6x risk of maltreatment in offspring Pawlby et al, 2011

Transgenerational trauma ration 0 od trauma + antenatal ession and poor mental health Generation 1 Childhood trauma + Maternal antenatal depression Generation 2 Childhood trauma + Maternal antenatal depression Generation 3 Childhood trauma + Maternal antenatal depression Generatio Childhood t + Maternal an

Adult legacy: what maltreated children learn Be wary Trust nobody Any little thing could mean big danger (sudden extreme changes in mood, thinking, behaviour) No control over what happens Self blame and self harm Self preservation through detachment from reality: dissociation, non-psychotic voices

The adult effects of childhood trauma Borderline personality disorder Emotionally unstable personality disorder Complex Post Traumatic Stress Disorder Developmental Trauma Disorder Childhood Heroes

Perinatal period: the most efficient time for detecting depression in women no exposure 34% pregnancy 34% yrs 11-16 5% yrs 4-11 1% yrs 1-4 12% yr 1 pp 14% (Sharpe et al 2006)

Perinatal telephone advisory service to professionals Perinatal triage and assessment process Emotional wellbeing in pregnancy care pathway History of mental illness and current mental health assessed at first contact and booking Support from GP, HV and MW, plan continued close monitoring in the early postnatal period. Obtain specialist advice as necessary. Coping with daily living problems NB! At every stage assess and enhance motherinfant relationship Routine antenatal care Any positive responses to questions (communicate for information) Routine postnatal care Current mild illness Current moderate illness Current severe illness i News History of possible severe mental illness or current severe illness, identified by any service Communicate for information Talking therapies Other agencies Support from GP, HV and MW GP assessment for medication and talking therapies & continued support from GP, HV and MW Commissioning for mental health If persists or worsens If persists or worsens Mental health care General adult MH services Translate Perinatal MH services Specialised perinatal care pathways: Bipolar disorder Schizophrenia Complex PTSD Depression Anxiety OCD Q Perinatal specialist inpatient care (mother and baby unit)

Postnatal depression care (Gavin, Meltzer-Brody, Glover, and Gaynes in press) 100% 80% 60% 40% 20% 0% Prevalent PND Cases 40% Recognized Clinically 24% Any Treatment 10% Adequate Treatment 3% Achieved Remission

Specialist Perinatal Community Care

Economic costs (LSE, 2014) Cost if we don t act 8.1bn 337m Cost of taking action