Perinatal Mental Health Assessment and Management Mia Wren, Health Visitor, PND Champion November 2010

What are we going to talk about? What is perinatal depression? Importance of perinatal mental health to: Women Children and families Policy guidance Assessment of maternal health Management of perinatal depression Issues for community staff nurses

What is perinatal depression? A clinical depression occurring at any time during pregnancy and the first post natal year The Blues: Usually mild and transient disturbance affecting 50% of new mothers and lasting 5-10 days Puerperal psychosis: Rare but severe mental condition usually requiring hospital treatment Perinatal depression: Persistent and pervasive low mood of varying severity and duration, affects at least 10-15% of mothers

Depression and Anxiety are the most prevalent psychiatric disorders in the perinatal period Depression: –Sadness –Loss of pleasure, interest –Sleep, appetite disturbance –Agitation, retardation –Feelings about self –Concentration,decision making –Suicidal thoughts Anxiety: –Excessive anxiety, worry –Worry difficult to control –Sleep disturbance –Restless, on edge –Easily fatigued –Irritability –Concentration –Muscle tension

Importance of perinatal health Women: Reduced breast feeding Difficulties in bonding Reduced self-efficacy Increased risk of further depression Difficulties in relationships with others

Importance of perinatal health Children and families Women are the foundation of family life –If mothers are unhappy, other family are affected –Infants particularly vulnerable Needs are not met – affects brain growth Compromised emotional, social, cognitive development Increased risk of physical and mental ill-health Increased risk of neglect/abuse

Fathers –Increased risk of depression (50%) –Marital difficulties Siblings –Behaviour difficulties

Policy 1999 NSF Mental Health 2004 Women’s Mental Health Strategy 2004 NSF Children, Young People and Maternity Services 2007 Maternity Matters 2008 Updated Child Health Promotion Plan

NICE Guidelines Oct 03 NICE Guideline 6. Routine Antenatal Care Jul 06 NICE Guideline 37. Routine Postnatal Care Feb 07 NICE Guideline 45. Antenatal and Postnatal Mental Health March 08 Partial update of NICE Guideline for Routine Antenatal Care

NICE Guideline 45 Antenatal and postnatal Mental Health (Feb 2007) Key elements –Prediction and detection –Psychological treatments –Explaining risks –Management of depression –Organisation of care

Assessment of maternal health When? –Antenatal visit –Postnatal visit –4-6 week and 3-4 months postnatally How ? –Whooley questions (NICE 2007) –EPDS –Clinical interview

When? See perinatal mental health flow chart –Antenatal contact Feelings about pregnancy Support available Anticipated changes in family/relationships Self-perceptions Anticipations of unborn child / delivery/ feeding Finances and environment Life events: bereavement Previous mental health

When? Postnatal contact – New Birth Visit –Emotional wellbeing with regard to birth experience –Adaptation to motherhood –Raise awareness of postnatal depression –Information about screening

When? Postnatally –4-6 weeks Determine emotional wellbeing of mother and infant –3-4 months Further opportunity

HOW? Whooley questions p.7 NICE guideline –Short screen for detection of depression only To be asked in private May lead to further screening Can be used antenatally or postnatally

How? Edinburgh post natal depression screen (EPDS) –10 item self report questionnaire, allow detection of depression and anxiety –Allows women to talk about feelings –Specifically designed for primary care use Brief Straightforward Acceptable

Benefits Of EPDS Easy to use Universal Explores all aspects of depression Non stigmatised Can be audited

Limitations of EPDS False positives or negatives –EPDS is a screen not a pass/fail tool Literacy and Cultural issues –English/comprehension may be poor Individual interpretation –Particularly Q10 Possible misuse –Where is EPDS completed? –What happens to it?

How? Clinical interview –Ask about Depressed mood Diminished interest or pleasure Appetite Sleep Reslessness/slowed down Fatigue/loss of energy Feelings about self Concentration/decision making Recurrent thoughts of death

Clinical interview –Will detect depression and/or anxiety –Not a questionnaire –For discussion between professional and client –First two questions must be positive, and two others for a positive screen –Symptoms need to be present for more than two weeks.

Management of perinatal depression Referral to GP –For assessment to determine whether medication is appropriate Referral to mental health service –For severe depression or psychosis Support by health visiting team –Information in Birth to Five Book –Listening visits –Support groups

Listening visits Initial offer of 4 visits Planned, time-limited, focussed support –Using contract/agreement –Appropriate use of “active reflective listening” and cognitive behavioural techniques –Encouraging mother/infant relationship –Recognising own limitations –Supervision is essential

Listening visits General rules for listeners –Be on time, or let the mother know that you will be late, her world may be out of control, you may be the one reliable point –At each session remind how may more sessions –At each session say how long you have together, this will help pace session –Remind the mother when you have 5 mins left

Listening visits A suggested structure for each visit –Settling in, getting a feel for how the mother is –Feedback- what has been achieved this week, if nothing, what is happening –Set agenda: what is to be addressed –Carry out agenda be mindful of time –Summarise what has been discussed –Agree goals- action, task, next session

Key messages You are not alone You will get better

Issues for community staff nurses Where do we go from here? –Follow protocol in workbook –Attend further training in: Assessment of perinatal mental health Management of perinatal mental health to gain further training in listening visits and cognitive behaviour techniques Any questions?