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? Pre-conception advice Prevention of relapse in high risk women Treatment of women who develop new onset of illness in perinatal period Management of women with SMI
Why is it important? Mental health problems in the perinatal period: Common Can be serious Suicide is one of the leading causes of maternal death in the UK Can have long lasting effects on the mother, child and the family Sometimes predictable and preventable Treatable
Who to refer to mental health services? RCOG Good Practice Guidance Refer all: Current symptoms of SMI History of BPAD, Schizoaffective disorder & Schizophrenia. Previous puerperal psychosis Complex psychotropic medication regimens Inpatient psychiatric admissions (screening) Anyone on an antipsychotic or mood stabiliser. Consider referring: New anxiety/depression of moderate severity in T3 or early postpartum. Current illness of mild or moderate severity where there is a first degree relative with BPAD or PP. No current illness but FH Communication with GP, and? CSC, for women who decline referral to perinatal services.
Antenatal Depression Biological signs/symptoms of major depression are present in in pregnancy (poor sleep, decreased appetite, low energy, reduced libido etc). Look for low mood, anhedonia, guilt, hopelessness, suicidal thoughts. Anxiety. Pregnancy does not protect against relapse when medication discontinued. 75% relapse rate in one study, typically in first trimester. (Cohen et al 2004)
Postpartum Mood Disorders Blues (50-85%, within first week) Postnatal depression (10-20%, insidious, within 3 months) Puerperal psychosis (0.2%, dramatic, within 3 weeks) Continuum of severity Vs Separate disorders
Postnatal Depression 10-15% of women experience depression in year following birth. 3-5% will have moderate to severe symptoms. Anxiety may be first symptom Look for irritability, depressive cognitions, loss of interest, anhedonia. Women may express negative/ ambivalent feelings towards infant and have doubts about ability to care for child/ren. As severity increases level of function decreases. Ask about suicidal and infanticidal thoughts.
Postpartum Psychosis Sudden onset, rapid deterioration. Symptoms can change very quickly from hour to hour and from one day to the next. Present soon after birth: 50% in first week Symptoms of depression or mania or a mixture of these with psychotic features. 0.2% in general population but >50% in BPAD, Schizoaffective 50-90% recurrence of PP
Postpartum Psychosis Feeling high, manic or on top of the world Low mood and tearfulness Anxiety or irritability Rapid changes in mood Severe confusion Being restless and agitated Racing thoughts Behaviour that is out of character Being more talkative, active and sociable than usual Being very withdrawn and not talking to people Finding it hard to sleep, or not wanting to sleep Losing inhibitions Feeling paranoid, suspicious, fearful Feeling as if they are in a dream world Delusions (odd thoughts or beliefs that are unlikely to be true)
An individual tragedy The tragic death of Dr Daksha Emson and her daughter Psychiatry SpR with history of Bipolar Disorder Lithium stopped to get pregnant Stabbed baby and then set fire to baby and herself
Confidential Enquiries into Maternal Deaths
Maternal deaths 2006-08 51 Cardiac 26 Sepsis 19 PET 18 Thromboembolism 13 Suicide (29 if count up to 6 mo) 13 AF embolism
Maternal suicide: method 2006-08 Cause of death n % Hanging Jumping from a height Cut throat/stabbing Self immolation Drowning Carbon monoxide Ingesting of bleach Overdose Total 9 9 1 3 2 1 1 3 29 31 31 3 10 7 3 3 10 100 90% violent death 1997 2005 74%
Maternal suicide: psychiatric diagnosis 2006-08 Diagnosis n % Psychosis Severe depressive illness Adjustment/grief reaction Drug dependency Total 11 6 3 9 29 38 21 10 31 100 59% serious illness- consistent 1997 2005 ½ wrong initial diagnosis
Maternal suicide: demographic characteristics 30 yrs (16 43) median age 76% married / stable cohabiting 76% employed 41% educated A level (28% professional) 90% white Care needs to be taken not to equate risk of suicide with socio-economic deprivation
Overview of Postpartum Psychosis Distinctive clinical picture - sudden onset and rapid deterioration. Often misdiagnosed. Risk of suicide, infanticide. With a few exceptions the women who die have been cared for by non-specialised psychiatric teams unfamiliar with these conditions. Ideally specialist OPD team and MBU
How do we predict who is at risk becoming unwell? Prediction definitely possible for severe mental illness (BPAD, SA, PP) 50-90% will become unwell following delivery without treatment. Ideally preconception planning Screening at Antenatal clinics for personal & family hx of illness More difficult in less severe depressive illnesses
Close relationship to delivery 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 Percent 10 0 1st week 2nd week 3rd week 4th week 6th week Percent 10 0 1 2 3 4 5 6 Onset of pp by week Onset of pp in days Heron, et al 2007
Prevention High risk women High risk period post delivery Advise prophylactic medication Start immed post-delivery or in pregnancy Planning meeting at 32/40 Assess before discharge from maternity ward Relapse may be very sudden and severe Adequate sleep Support with care of infant High contact with mental health service (perinatal, HTT, care co-ordination, prophylactic admission, MBU etc) Assertive, effective, prompt treatment
Consider the family and a multidisplinary approach Good liaison between teams Medication Psychology Safeguarding children Mother & Baby Unit Treatment
Schizophrenia Management Pregnancy Pregnancy collaboratively managed by Obstetrician and Psychiatrist Prompt referral to a Perinatal team Perinatal Pre Birth planning Early involvement of Children Social Care Need for MBU/Parenting assessment
Schizophrenia - Parenting As many as 50% of women with Schizophrenia become mothers Very few are sole carers Effect of positive and negative symptoms on capacity to parent Effect of anti psychotic medication on capacity to parent Maternal sensitivity and responsiveness to the infant s signal can be impaired Often single mothers, not much social support
Pre-birth Planning Meeting 32/40 (Dr, CNS, patient, family, MW, HV, CSC) Relapse indicators Effect of babies arrival Prophylactic medication (in labour bag) Adequate sleep & support (Side room?) Plan will be in notes and alert on EPR Assess before d/c by perinatal/liaison High contact post dc with perinatal, HTT, CCO,PHMW.?MBU Relapse can be sudden and dramatic
Perinatal Services in Hackney: 6,000 live births, population of 275 000 Community services: Part-time consultant, 2 Clinical nurse specialists, Psychologist, Junior medical staff Pre-conception advice Referrals from primary and secondary care New patient assessments done weekly Consultant oversees medical management Joint working between MDT Pre-birth planning meeting at ~ 32 weeks Review post-birth Care up to one year post-partum
Margaret Oates MBU Specialist Inpatient Unit
Our Service On average, women are admitted for seven weeks. Whilst promoting the relationship between mother and infant and maintaining the social system of the mother infant unit, we aim to achieve a speedy recovery in the mother s mental health. Our approach is to actively facilitate the mother s recovery through multidisciplinary working. We actively support with and encourage care of the baby; helping mothers to develop their parenting skills and confidence. We are accountable for standards of care provided on the unit and this is dictated by the standards set by the Royal college of Psychiatrists Accreditation Program and the Care Quality Commission standards.
The service we offer: A comprehensive medical, nursing, social and psychological assessment of mothers A individualised care plan to meet the mothers needs throughout admission that specifically addresses pregnancy, delivery, breastfeeding or known physical health concerns Culturally sensitive, person-centred care for all mothers One-to-one support for mothers in order to help meet the development, physical and emotional needs of their baby Support for the whole family. We actively encourage the involvement of partners, family members and friends. A well thought-through, personalised discharge plan in keeping with the Care Program Approach.
The service is for: Women with a pre-existing mental illness who suffer a relapse during pregnancy or after giving birth, such as bi-polar affective disorder, schizophrenia, recurrent depressive disorder, severe anxiety disorder and schizo-affective disorder Women who develop an acute mental illness such as puerperal psychosis or depression during or after pregnancy Women who are at significant risk of becoming unwell in the perinatal period (prophylactic admissions) who have established diagnosis of mental illness and are already known to mental health services- referrals will be considered from 32 weeks gestation Women can be admitted from the age of 18 years old (referrals for women aged 16 years will be considered on a case by case basis) The aim of the unit is to ensure that all women who have young infants and who require admission can remain with their baby, enabling the special bond between mother and baby to be unbroken at a critical time in the life of a young family.
Referrals Criteria The service is available to women who may be either experiencing a mental health condition or at risk of becoming mentally unwell in the Perinatal period. Women can be admitted from 32 weeks into pregnancy or with infants up to 10 months old Referrals can be made at any time to the unit and will be considered for urgency and clinical need. Our senior nurse and medical staff are happy to arrange assessments where clinically appropriate. The senior nurse on duty on site has the authority to accept admissions in emergencies and out of hours. We welcome referrals from mental health professionals including secondary levels of care. (this could be the professional who has responsibility for the coordination of the mental health care for the woman at the time of referral). The unit does not offer formal parenting assessments. Women with primary substance misuse, alcohol misuse or personality disorders with co-morbid mental illnesses will be considered on a case by case basis.
Therapies available Medical review and input Parent Infant Psychotherapy Psychology Dance Movement Therapy Art Therapy Occupational Therapy Pharmacist advice and information Parenting skill- support and advice Maternity and midwifery care and treatment Health visiting and paediatric support for the infants
Discharge Process The unit ensures all discharges are co-ordinated and planned with families and community services local to the mother s address. Discharge plans will include follow up advice and treatment and also reflect individualised crisis and contingency plans. For mothers discharged from the unit there is the option for them to contact the unit up to 4 weeks post discharge for advice and support.