The Royal College of Psychiatrists in Scotland A PERINATAL AND INFANT MENTAL HEALTH ACTION PLAN FOR SCOTLAND

The Royal College of Psychiatrists in Scotland A PERINATAL AND INFANT MENTAL HEALTH ACTION PLAN FOR SCOTLAND

Contents I. Background II. Framework III. Explanatory tables IV. Recommendations on service organisation and development V. Evaluation and outcome measurement VI. Cost implications VII. Potential savings to the health service and wider society VIII. Next steps IX. Further reading This action plan was developed by a short-life Working Group Group Members Dr Roch Cantwell (Co-Chair), Consultant Psychiatrist in Perinatal Psychiatry, NHS GG&C and Chair of the RCPsych in Scotland Perinatal Psychiatry Faculty Dr Anne McFadyen (Co-Chair), Consultant Psychiatrist in Child and Adolescent Psychiatry, NHS Lanarkshire and Chair of the RCPsych in Scotland Child and Adolescent Psychiatry Faculty Elaine Clark, Chair, Maternal Mental Health Scotland Lynn Cuddihy, Primary Mental Health Lead, CAMHS, NHS Dumfries and Galloway Dr Jennifer Cumming, Higher Trainee in Child and Adolescent Psychiatry, NHS Lothian 2

I. BACKGROUND For mothers - Pregnancy does not protect against the onset or continuation of mental illness 1 in 5 women (over 11,000 per year in Scotland) will experience mental ill health during pregnancy or in the first postnatal year. The early time after childbirth is a period of greater risk for severe mental illness than any other time in a woman s life. Effective treatments are available and, in nearly all circumstances, women will make a full recovery from early postpartum illness provided they receive prompt attention. When women at high-risk are identified in pregnancy or through pre-pregnancy assessment, there are effective interventions that can prevent the onset of new postpartum episodes. We know that if mental illness in pregnancy remains untreated there may be significant adverse effects for the woman, her infant, her partner and family. In the most severe instances women may die mental illness is one of the leading causes of maternal death in the UK and one in 7 women who die, will die by suicide. Pregnancy and the early postnatal period is a time of great change. Women with poor experiences of being parented, and those with adverse childhood experiences, significant economic disadvantage, alcohol/substance misuse or other vulnerabilities, may find adapting to parenthood particularly challenging. Difficult decisions around use of medications in pregnancy and breastfeeding place additional strain on the woman and her family. There is clear evidence and expert consensus on how services should be organised to prevent, detect and manage maternal mental illness. Specialist community perinatal mental health provision and joint mother-baby inpatient facilities, working with universal services, are core to such provision. For infants and children - The transgenerational transmission of attachment difficulties and mental health problems is well recognised. It is mediated through wider environmental influences, genetic and biological factors. Social relationships in early life are likely to have a crucial influence on the infant brain. Brain development is dependent on strong, early bonds with an infant s main caregiver most often the mother. Research identifies critical time periods in early life where specific brain pathways develop optimally. Later on it becomes increasingly difficult to bring about change. The interaction with the primary caregiver in the first year of life shapes the infant s social, emotional, cognitive and language development, facilitating development of good mental health through childhood and into adulthood. Untreated maternal mental illness, alcohol/substance misuse, and other parental vulnerabilities, may be associated with problems in pregnancy and in the developing relationship between mother and infant, and may have longer-term effects on cognitive and emotional development as a child grows up. Even where maternal mental ill health is effectively treated, additional work may be required to help strengthen the mother infant relationship. Prompt treatment of mental ill health in pregnancy can bring about improvements for a child growing up, as well as help to develop a child s ability to manage stress in later life. There is increasing evidence to favour interventions that improve the mother-infant relationship, where mother and child face additional vulnerability. A number of specific programmes have demonstrated efficacy but more research is needed. Specialist Child and Adolescent Infant Mental Health Services (CAMHS-IMH) should be organised to take account of the wider environment, including kinship carers and foster families. For fathers and other family members - Where a woman experiences maternal mental illness, her partner is more vulnerable to ill health. Addressing partner, family and older children s needs is essential to the woman s recovery. Attention to an infant s bond with his or her father and other caregivers, and the impact of paternal mental ill health on the child s attachment and development, is core to good family functioning. For society - Effective interventions, delivered through evidence-based programmes, with appropriately trained staff, working collaboratively in services structured to meet women s, children s, partners, and families needs, can not only reduce vulnerability and treat ill health for women, but can prevent the onset of ill health, improve outcomes for children growing up, and deliver better health to future generations. Early intervention and prevention is cost-effective. It is critically important to recognise that targeted interventions have a better evidence base than those aimed at the whole population, that access to interventions must be equitable across Scotland, and that underlying whole population factors leading to poor mental health, particularly poverty and social exclusion, cannot be addressed by the interventions suggested here. 3

II. FRAMEWORK Target population (refers to the mother and fetus/infant/child, and other family members) Scottish prevalence Preconception Pregnancy LEVEL 1 UNIVERSAL PROMOTION AND PREVENTION Whole population LEVEL 2 VULNERABLE PROMOTION AND PREVENTION Vulnerable populations, e.g., teenage pregnancy, socioeconomic deprivation, domestic abuse, adverse childhood experiences, history of being looked after or accommodated, families of children born with disability LEVEL 3 DISTRESS DISTURBANCE PREVENTION AND CARE In parents: mild to moderate mental ill health, e.g., alcohol and substance misuse, depression and anxiety disorders managed in primary care In infants/children: fetal alcohol effects, mild neurodevelopmental delay or disorder, prematurity, attachment disorder, mild to moderate mental ill health One in 5 of the population One in 10 of the population 11,000 mother-infant dyads/year 5,500 mother-infant dyads/year ç Maternal mental health anti-stigma/awareness measures è ç Professional education/awareness on maternal mental health and infant mental health è ç Preparation for parenthood and infant mental health awareness è LEVEL 4 DISTURBANCE DISORDER PREVENTION AND CARE In parents: moderate to severe mental ill health, e.g., current or past severe mental illness, alcohol and substance dependence, complex personality difficulties In infants/children: fetal alcohol syndrome, moderate to severe neurodevelopmental delay or disorder, prematurity, attachment disorder, moderate to severe mental ill health One in 20 of the population 2,250 mother-infant dyads/year Universal education-based programmes Enhanced programmes for those in contact with services ç Prioritised access to sexual health services è ç Prioritised access to psychological services è Primary care mental health Maternal and infant mental health ç Medication advice in relation to pregnancy è ç Prioritised access to addictions services è Specialist perinatal mental health services ç Maternal mental health anti-stigma/awareness measures è ç Professional education/awareness on maternal mental health and infant mental health è ç Preparation for parenthood and infant mental health awareness è ç Prioritised access to psychological services è Primary care mental health Maternal and infant mental health ç Medication advice in relation to pregnancy è ç Prioritised access to addictions services è ç Specialist perinatal mental health services è 4

Postnatal (mother and infant) Pre-school / early years (mother and child) LEVEL 1 UNIVERSAL PROMOTION AND PREVENTION LEVEL 2 VULNERABLE PROMOTION AND PREVENTION LEVEL 3 DISTRESS DISTURBANCE PREVENTION AND CARE LEVEL 4 DISTURBANCE DISORDER PREVENTION AND CARE ç Maternal mental health anti-stigma/awareness measures è ç Professional education/awareness on maternal mental health and infant mental health è ç Preparation for parenthood and infant mental health awareness è ç Prioritised access to sexual health services è ç Prioritied access to psychological services è Adult primary care mental health Maternal and infant mental health CAMHS* primary mental health ç Prioritised access to specialised neuropaediatric and genetics services è ç Medication advice in relation to breastfeeding/parenting è ç Prioritised access to addictions services è ç Specialist perinatal mental health and CAMHS-IMH** services è ç Maternal mental health anti-stigma/awareness measures è ç Professional education/awareness on infant mental health and early relationships è ç Parenthood and baby brain education and awareness è ç Whole population parenting programmes è ç Enhanced parenting programmes è ç Prioritised access to sexual health services è ç Prioritised access to specialised neuropaediatric and genetics services è ç Specialist perinatal mental health and CAMHS-IMH** services è *Child and Adolescent Mental Health Services ** Child and Adolescent Infant Mental Health Services 5

III. EXPLANATORY TABLES MATERNAL MENTAL HEALTH ANTI-STIGMA/AWARENESS MEASURES Materials should be available Advertising / leafleting NHS Health Scotland General public Assess staff and wherever members of the Webpages women s knowledge general public are likely to access Social media Education Scotland information on pregnancy and Events Third sector agencies childbearing. Evidence briefings Maternal Mental Health Scotland/Change Agents PROFESSIONAL EDUCATION/AWARENESS ON MATERNAL MENTAL HEALTH AND INFANT MENTAL HEALTH Online learning modules NHS Education Scotland Proportion of staff (maternal and infant mental completing mandatory health) integrated into Professional bodies training curricula / NHS mandatory Universities Proportion of specialist training Scottish Children s Reporter staff completing Specialist training targeting Administration specialist training different professional Local authorities groupings and specialised Proposed National Managed services Clinical Network for Perinatal and Infant Mental Health All health and social care professionals should have mandatory training on maternal and infant mental health. General Practitioners Health visitors/family Nurse Partnership Obstetricians Midwives Psychiatrists Mental health nurses Nursery nurses Clinical psychologists Educational psychologists Paediatricians Allied mental health staff Social workers Early years workers Third sector 6

PREPARATION FOR PARENTHOOD AND INFANT MENTAL HEALTH AWARENESS School-based programmes (Levels 1 / 2) All school pupils and those attending further education colleges should have education on preparation for parenthood and infant mental health. Vulnerable teenagers and women, including those with mental ill health or addictions, or past experience of disrupted family life, should have access to enhanced programmes on preparation for parenthood and infant mental health. Education programmes NHS Health Scotland Education Scotland Maternity services Health visiting/family Nurse Partnership Personalised education-based interventions (brief professional intervention and/or peer support) Teenagers school/further education colleges Enhanced programmes for those in contact with services (Levels 3 / 4) NHS Health Scotland Education Scotland Local authorities Mental health services Maternity services Health visiting/family Nurse Partnership Third sector Looked After and Accommodated nurses Residential care staff Teenagers and women with preexisting mental ill health or addictions, and those with a history of being looked after or accommodated, being at risk, experiencing hardship, e.g., domestic violence, having parents with mental health issues Audits of curriculum content Feedback regarding knowledge, skills and behaviours Audits of improvement in maternal knowledge and mother-infant sensitivity PRIORITISED ACCESS TO SEXUAL HEALTH SERVICES Personalised sexual health Tracked changes in consultation, advice and knowledge, attitudes intervention, including access and behaviours to long-acting reversible contraception Vulnerable teenagers and women, including those with mental ill health or addictions, or past experience of disrupted family life, should have facilitated access to sexual health services in locations appropriate to their need. Services should work together to ensure prioritised, timely access. NHS Health Scotland Sexual health services Maternity services Health visiting/fnp Mental health services Proposed National Managed Clinical Network for Perinatal and Infant Mental Health 7 Vulnerable teenagers school /further education colleges Women with vulnerabilities, preexisting or current mental ill health, or addictions, and those with a history of being looked after or accommodated, being at risk, experiencing hardship, e.g., domestic violence, having parents with mental health issues

PRIORITISED ACCESS TO PSYCHOLOGICAL SERVICES Primary care mental health (Levels 2 / 3) Vulnerable teenagers and women, and those with mental ill health or addictions, or past experience of disrupted family life, should have prioritised access to psychological therapies, which takes into account the circumstances, time demands and developmental needs of pregnancy, the postnatal period and early infancy. Services should work together to ensure access is prioritised and timely. Women with mental ill health or addictions should have prioritised access to specialist maternal and infant psychological therapies, which take into account the circumstances, time demands and developmental needs of pregnancy, the postnatal period and early infancy. Services should work together to ensure access is prioritised and timely. Online self-help resources Local self-help groups Brief psychological therapies Infant massage Parenting programmes Brief psychological therapies Infant massage Video feedback Individual and group psychotherapies, including specialised mother-infant interventions NHS Health Scotland Education Scotland Local authorities Primary care mental health teams CAMHS Primary Mental Health Teams Health visiting/family Nurse Partnership Third sector Proposed National Managed Clinical Network for Perinatal and Infant Mental Health Maternal and infant mental health (Levels 3 / 4) Psychotherapy services CAMHS- IMH services Proposed National Managed Clinical Network for Perinatal and Infant Mental Health Vulnerable teenagers and women with vulnerabilities, preexisting or current mental ill health, or addictions, and those with a history of being looked after or accommodated, being at risk, experiencing hardship, e.g., domestic violence, having parents with mental health issues Women with current mental ill health or addictions - this may be in the context of adverse childhood experience +/or past mental health difficulties (may be previously known to CAMHS or social services) Audits of time from referral to treatment Equity audit Audits of time from referral to treatment Equity audit 8

MEDICATION ADVICE IN RELATION TO PREGNANCY/BREASTFEEDING/PARENTING Expert advice and medication management Specialist advice on prescribing in pregnancy and breastfeeding (and while parenting) should be available to health professionals involved in the care of pregnant and postnatal women who experience mental ill health. Women on complex psychotropic regimes who are planning a pregnancy, or who are pregnant or breastfeeding, should have access to specialist services. NHS Education Scotland Pharmacology services Specialist perinatal mental health services Proposed National Managed Clinical Network for Perinatal and Infant Mental Health General Practitioners Obstetricians Psychiatrists Women with current mental ill health or addictions Audits of use of e- resources for professionals Proportion of women with severe mental illness who have had a specialist perinatal mental health assessment PRIORITISED ACCESS TO ADDICTIONS SERVICES Specialist addiction Women with harmful or psychological and dependent substance use pharmacological interventions Women who are planning a pregnancy, pregnant, or who are postnatal, and who have harmful or dependent substance use, should have prioritised access to addiction services. This should include low thresholds for inpatient alcohol detoxification. Services should work together to ensure access is prioritised and timely. Addiction services Local authorities Third sector Proposed National Managed Clinical Network for Perinatal and Infant Mental Health Proportion of women with harmful or dependent substance use who have had a timely addictions assessment Indicators of stability of substance use in pregnancy and postnatal period 9

SPECIALIST MENTAL HEALTH SERVICES PERINATAL MENTAL HEALTH SERVICES Women who are planning a pregnancy, and who have enduring severe mental ill health, should have pre-pregnancy advice provided by specialist perinatal mental health services. Pregnant and postnatal women who have moderate to severe mental ill health, should be assessed and treated by specialist perinatal mental health services. All women requiring admission for treatment of mental illness within one year of childbirth should have the option of admission to a specialist mother and baby unit, where this is also in the infant s best interests. Children with attachment difficulties, early signs of (neuro)developmental delay or disorder, abstinence or fetal alcohol syndrome, or other developmental challenges (e.g., disability, prematurity, maternal epilepsy) should have timely access to specialist CAMHS (incl. CAMHS-IMH) diagnostic and intervention services Specialist perinatal mental health assessment, psychological and pharmacological interventions Inpatient mother and baby facilities Maternity liaison services Specialist multidisciplinary assessment and intervention Parent-infant psychotherapy Specialist neurodevelopmental assessment and intervention Close working with specialist paediatricians Specialist perinatal mental health services community, inpatient and maternity liaison Proposed National Managed Clinical Network for Perinatal and Infant Mental Health INFANT MENTAL HEALTH (CAMHS-IMH SERVICES) Specialist multidisciplinary CAMHS/CAMHS-IMH services Local authorities Proposed National Managed Clinical Network for Perinatal and Infant Mental Health 10 Women with moderate to severe mental ill health Infants (and their parents) with early signs of neurodevelopmental, attachment or mental health disorders Proportion of pregnant women with severe mental ill health who have received specialist pre-pregnancy advice Proportion of pregnant women with severe mental ill health who have received specialist perinatal mental health care Proportion of women admitted to mental health inpatient care within one year of childbirth, who were admitted to specialist Mother and Baby Unit care Proportion of under 5s on Child Protection Register/supervision order/accommodated, who are attending specialist CAMHS-IMH services Proportion of under 5s, as above, whose parents/carers attend parenting/enhanced parenting programmes

IV. RECOMMENDATIONS ON SERVICE ORGANISATION AND DEVELOPMENT Organisation of services should ensure that intervention is delivered at the level appropriate to need, with links across Health Boards and regions to make best use of resources. Joint working between mental health and partners in maternity services, primary care, social services, child health, education and the third sector will be essential to the delivery of promotion, prevention and early recognition of those in need of specialist mental health services for both parents and children. For the most vulnerable families, GIRFEC ( Getting it Right for Every Child ) systems (Children and young People (Scotland) Act, 2014) will provide a structure for coordination of professional input and monitoring of the child and family. There are twin means, both essential, to achieve the standards and outcomes outlined in this Action Plan: 1. Help current services to work better together to provide timely, seamless care: This may entail any, a combination, or all of the following: a. Improved joint working between services b. Prioritising or fast-tracking access to services for pregnant and postnatal women, and for infants c. Reconfiguration of services where current service design does not best respond to the needs of mother, infant and family 2. Identify gaps in provision and new service requirements: This will require: a. Service mapping and gapping. It is proposed that a quality improvement initiative supports a mapping and gapping exercise across Scotland to identify areas of best practice and areas of need. i. The mapping and gapping exercise for maternal mental health will use, as gold standard, evidence-based guidance from SIGN (Scottish Intercollegiate Guidelines Network), NICE (National Institute for Health and Clinical Excellence), Royal College of Psychiatrists Perinatal Quality Standards and other sources, which detail the structure and function of specialist perinatal mental health services. ii. For infant mental health interventions, the gold standard will be established in association with the forthcoming NHS Education for Scotland review of infant mental health interventions and other evidence-based resources, taking into account a proposed model outlined in Appendix 2. b. New service development. It is already clear that there are significant gaps in the provision of equitable perinatal and infant mental health services in all areas of Scotland. To achieve the goals of the Action Plan, and in addition to other gaps which may be identified, investment in new service development will be required in the following areas: i. Community specialist perinatal mental health services ii. Additional joint mother-infant admission facilities iii. Specialist CAMHS-IMH services 11

V. EVALUATION AND OUTCOME MEASUREMENT Provisional outcome indicators are given in the explanatory tables. The plan will include an outcomes workstream to develop and refine these further. Principles of evaluation and outcome are: A. The woman and her child are at the centre of a network of dedicated, coordinated services designed to meet their needs in a timely, evidence-based and cost-effective manner B. The principles of GIRFEC ( Getting it Right for Every Child ) underpin the evaluation of effectiveness for children and will be used to reflect clinical improvement derived through interventions 12

VI. COST IMPLICATIONS True costs can only be determined following a full evaluation of current service gaps. However, the estimated costs of establishing a national managed network, community specialist perinatal mental health services and specialist CAMHS-IMH provision across Scotland are: SERVICE PROVISION Perinatal National Managed Network (see Appendix 1) Specialist community perinatal mental health teams Additional joint mother-infant admission facilities Specialist CAMHS-IMH provision Total estimated additional costs of specialist service provision INDICATIVE COSTS 180,000.00 per year Approx. 5 million per year Approx. 2 million per year Approx. 2.5 million per year 9.68 million per year VII. POTENTIAL SAVINGS TO THE HEALTH SERVICE AND WIDER SOCIETY The long-term cost of untreated maternal mental illness is estimated at 8.1 billion/year in the UK equivalent to 577 million/year for Scotland (Bauer et al, 2014). This includes downstream adverse consequences for children growing up. The cost to the public service alone of perinatal mental health problems is 5 times the cost of improving services. VIII. NEXT STEPS In line with recommendations from SIGN Guideline 127 ( Perinatal Mood Disorders ), NICE Guideline 192 ( Antenatal and Postnatal Mental Health ), NSPCC (National Society for the Prevention of Cruelty to Children)/MMHS (Maternal Mental Health Scotland) Getting it Right for Mothers and Babies report, the Royal College of Psychiatrists in Scotland Healthy Start Healthy Scotland goals, and other guidance, the first step in implementation of the Action Plan is the establishment of a National Managed Network, which can then be tasked with undertaking work to achieve the Action Plan outcomes. DEVELOPMENT PLAN Steps Indicative timetable 1. National Managed Network establishment Early 2017 2. Mapping and Gapping exercise Jan-Mar 2017 3. Service interface and integration workstream Mar-Jun 2017 4. Service development workstream maternal mental health Mar-Jun 2017 5. Service development workstream infant mental health Mar-Jun 2017 6. Awareness and education workstream Mar-Jun 2017 7. Outcomes workstream Jun-Aug 2017 8. Staging report on progress to date in implementation of objectives Sep 2017 13

Confidential Enquiries into Maternal Deaths (2011) Effects of perinatal mental disorders on the fetus and child (2014) http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2010.02847.x/full Stein A, Pearson RM, Rapa E et al (2014) Effects of perinatal mental disorders on the fetus and child. Lancet, 384, 1800-1819. Economic benefits of intervention to improve perinatal and infant mental health The Costs of Perinatal Mental Health Problems (2014) https://www.centreformentalhealth.org.uk/costs-of-perinatal-mh-problems Investing in early human development (2009) Skill formation and the economics of investing in disadvantaged children (2006) Mental health and mental illness prevention (2011) Doyle O, Harmon CP, Heckman JJ et al (2009) Investing in early human development: timing and economic efficiency. Economics and Human Biology, 7, 1-6. Heckman JJ (2006) Skill formation and the economics of investing in disadvantaged children. Science, 312, 1900-1902. Knapp M, McDaid D, Parsonage M (Eds.) (2011) Mental health and mental illness prevention. Personal Social Services Resource Unit. London School of Economics. Getting it Right for Mothers and Babies (2015) Recommendations on service provision https://www.nspcc.org.uk/globalassets/documents/research-reports/getting-it-right.pdf Prevention in Mind: All Babies Count (2013) Guidance for Commissioners of Perinatal Mental Health Services (2012) NICE Antenatal and Postnatal Mental Health Guideline (2014) Royal College of Psychiatrists Report on Recommendations for the Provision of Services for Childbearing Women (2015) SIGN Perinatal Mood Disorders Guideline (2012) IX. FURTHER READING Prevalence and consequences of perinatal and infant mental health problems Confidential Enquiries into Maternal Deaths (2015) https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/mbrrace- UK%20Maternal%20Report%202015.pdf Growing up in Scotland (2010) http://www.gov.scot/resource/doc/310476/0097973.pdf https://www.nspcc.org.uk/globalassets/documents/research-reports/all-babies-countspotlight-perinatal-mental-health.pdf http://www.jcpmh.info/resource/guidance-perinatal-mental-health-services/ https://www.nice.org.uk/guidance/cg192/resources/antenatal-and-postnatal-mentalhealth-clinical-management-and-service-guidance-35109869806789 http://www.rcpsych.ac.uk/files/pdfversion/cr197.pdf http://www.sign.ac.uk/guidelines/fulltext/127/ 14