Perinatal Mental Health Services In patient Care & Community Teams

From Daksha’s last note Finding it difficult to hand on to positive things anyone says, can’t hang on to it for long – hits me in early hours of morning – thoughts churn round + round. Starting to think that Dave hates me, wants me out the way, wants me to go crazy so he can get another wife who’s better for him. Finding it difficult to hang on to reality - am I bad + wicked? I don’t deserve good things, who am I kidding? Is this all a bad dream or really happening? Is there really hope for the future? I’ve tried to put a smile on, to hand on to positive but getting more + more difficult to know what’s real. Losing reason? Losing sanity? Freya needs me, I can’t let her down. Need to get myself back to normal for her. She + Dave mean world to me – I need to sort myself out for them. Fear I’m cracking up.

Saving Mothers Lives Dr Daksha Emson, a psychiatrist, and her daughter, aged three months, died following an extended suicide on 9th October 2000. A Panel of Inquiry was set up to investigate the causes of the deaths, and the issues arising from the Part 8 Review under the Children Act 1989 commissioned by the London Borough of Newham into the death of Freya Emson. The Inquiry Panel was asked to produce a report and to make any relevant recommendations.

Perinatal Mental Health Definitions The "emotional and psychological wellbeing of women, encompassing the influence on infant, partner and family, and commencing from preconception through pregnancy and up to 12 months postpartum."

Function of a Specialist Perinatal Mental health Service 1. It will assess and manage those suffering from puerperal psychosis and other severe postnatal mental illnesses. 2. It will provide a range of facilities for their management including an in-patient mother and baby unit (or access to one), out-patient clinics, alternatives to admission (intensive home nursing and/or day hospital)and community treatment. 3. It will advise on and, if necessary, manage patients with continuing psychiatric disorder who become pregnant while under the care of other adult psychiatrists. 4. It will liaise with primary health care professionals to assist in the management of less serious psychiatric conditions. 5. It will provide an obstetric liaison service, assessing mental health problems associated with pregnancy and the post- partum period and dealing with emergencies. 6. It will provide prenatal counselling and high- risk management for women at risk of developing an illness post-partum owing to previous major mental illness. 7. It may undertake the assessment of women with severe chronic mental illness in respect of their ability to parent their child. A specialist perinatal mental health service will also be in a position to play lead role in the development of services at all levels of health care provision, to contribute to the education and training of other health care professionals and to engage in clinical research and innovative clinical practice

Common Perinatal Mental Health Issues A range of conditions that effect at least 10% of new mothers Baby blues Depression Anxiety Puerperal psychosis Bi Polar Disorder OCD Pre existing Psychiatric conditions

Baby Blues The 'Baby Blues' The 'baby blues' is the most common and least serious condition found in the postnatal period, affecting up to 80% of new mothers. It usually lasts for one or two days and up to a week at most. Symptoms include: feeling tearful and sad feeling anxious and irritable having a 'low' mood feeling unwell having difficulty sleeping More often than not, the condition does not require any specific treatment other than reassurance, understanding and support from family, friends and health professionals. It will usually pass as a new mother catches up on rest and things start to settle down. However, if the symptoms continue longer than two weeks, it's a good idea to see what else might be affecting the mother: for example, symptoms of anxiety and/or depression.

Depression in the Perinatal Period Effects 10-14% 0f mothers are affected either during pregnancy or after birth of baby. Depression during the perinatal period is the same as clinical depression at other times. Symptoms persist for at least 2 weeks and can include: Low mood Lack of interest or pleasure in usual activities Feelings of inadequacy, failure, hopelessness, guilt and shame Sleeping a lot or having difficulty sleeping; nightmares Significant changes in appetite or weight Decreased energy and motivation Decreased concentration Persistent thoughts of death and/or suicide Depression can occur during pregnancy ('antenatal depression') as well as after the birth of the baby ('postnatal depression', or 'PND'). Prevalence rates for antenatal depression range from 8% to 15%, and for PND, from 10% to 15%. Mild to moderate cases of depression are sometimes unrecognised. If left untreated, depression in the perinatal period it can develop into a long-lasting depression, or return with subsequent pregnancies.

Anxiety in the Perinatal period Anxiety in the perinatal period has the same symptoms as anxiety at other times. The prevalence is not clear, however some studies have shown that anxiety is more common postnatally than depression. Anxiety is a core protective emotion which is helpful in situations of realistic danger. For some people anxiety can reach clinical levels and interfere with daily life. People may fear that they are going crazy or losing control. It may seem like the anxiety occurs for no particular reason, and the anxious reactions may be very difficult to contain. Symptoms can include: feeling restless, nervous or nauseous finding it hard to relax having a 'racing' mind having a churning stomach feeling a sense of dread If the anxiety is particularly debilitating it may meet the criteria for an anxiety disorder. These include Generalised Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, Obsessive Compulsive Disorder, Post-Traumatic Stress Disorder and the numerous Phobias. The anxiety disorders can be present in the perinatal period.

Puerperal (Postnatal) Psychosis Puerperal psychosis is the most serious and least common mental health issue found in the postnatal period. Only one or two mothers out of a thousand are affected by this condition. It is most likely to present in mothers who have a personal or family history of mental illnesses such as schizophrenia or bipolar disorder. Symptoms usually begin abruptly in the month following childbirth, and can include: confused or erratic behaviour hallucinations and delusions severe mood swings significantly reduced need for sleep There is a potential for women with puerperal psychosis to harm themselves or their babies, so immediate psychiatric intervention is necessary. Recurrences are common in subsequent pregnancies (25% to 75% of cases). It is important to note that puerperal psychosis is treatable, especially with early intervention.

Bi Polar Disorder Bipolar Disorder is classified into at least two subtypes: Bipolar I type presents as mania† with psychotic features that is often followed by major depression. Bipolar II type presents as depressive episodes or dysthymia (chronic low mood) and brief episodes of hypomania Rates of substance abuse and suicide are high in both subtypes 76 making diagnosis and treatment complex. In patients with a history of bipolar disorder the risk for relapse during and after pregnancy is high, especially if medications are ceased and after birth when some might develop psychotic symptoms 71. They must be monitored very closely in the first two weeks after delivery, with specialist psychiatric involvement if indicated. Risk remains high during the first four months after delivery 58. To date, psychosocial factors have not been demonstrated to affect the risk of developing a perinatal bipolar episode whilst biological factors have; these include early age of onset of bipolar disorder, experiencing an episode of mood disorder during the first pregnancy, and experiencing medical problems during the index pregnancy 77. Women who experience episodes around childbearing are less likely to have more children compared to women whose episodes are not related to childbearing 77. In the past, women with a known diagnosis of bipolar disorder were advised to avoid pregnancy. A recommended approach is to offer relevant information about treatment risks and benefits during a specialized preconception consultation so that women and their partners can make an informed decision 78. 13

Role of a Perinatal service Severe Mental Illness Bonding attachment Prevent separation Treat mothers mental illness EIS

What is a Perinatal Mental Health Team ? In Patient Care Community Team

Royal College of Psychiatrists In Patient Standards Peer review then Accreditation Community Standards Peer review then Accreditation

IN patient care Coming into hospital Recovery Focus on mother infant relationship Bonding attachment Safety/ safeguarding Therapeutic interventions incl medication Education/training Function Strengths / weakness Set up on the ward Routine, nursery nurse Psychology Link with community

Areas for development Parental mental health service Research/ education --stigma