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Perinatal Mental Health

Introduction

Perinatal mental health refers to the mother's mental health in the antenatal period up to the birth and for a year after the baby is born.

Maternal mental health is critical in the antenatal period and for the first year of life for her baby, as it can affect attachment and communication between the mother and baby.

There is a large body of evidence which show a small but significant association between perinatal mental illness and an increased risk of poor child psychological and developmental outcomes (Stein, et al., 2014).

What do we know?

More than 1 in 10 women develop a mental illness during pregnancy or within the first year after having a baby. Examples of perinatal mental illness include: antenatal depression, postnatal depression, maternal obsessive compulsive disorder, postpartum psychosis and post-traumatic stress disorder (PTSD). These illnesses can be mild, moderate or severe, requiring different kinds of care or treatment (Maternal Mental Health Alliance, 2014). If untreated, perinatal mental illnesses can have a devastating impact on the women affected and their families.

National Institute for Health and Care Excellence clinical guidance 192 (NICE, 2014) states that women should be assessed for levels of anxiety and depression in pregnancy and after birth. Midwives and health visitors are required as part of the maternal mental health pathway to ask two key questions about depression called the Whooley questions , for example:

  • During the past month, have you often been bothered by feeling down, depressed or hopeless?
  • During the past month, have you often been bothered by having little interest or pleasure in doing things?

Then, if concerned, the practitioner is required to ask a further two questions from the generalised anxiety and depression (GAD-2) scale.

  • During the past month, have you been feeling nervous, anxious or on edge?
  • During the past month have you not been able to stop or control worrying?

Then, if high scores remain high, a further set of questions are asked; either from the Edinburgh Depression score or from the GAD-7.

Whatever the level of anxiety and depression the mother should be supported with evidence based prevention or treatment interventions as set out in the latest NICE guidance.

Women with severe anxiety or depression in pregnancy should be referred to psychological therapies for cognitive behaviour therapy yet midwifery teams note anecdotally that about half of these do not attend as they need support to attend such services or different approaches that allow them to engage with the therapy services.

As part of the Royal College of Nursing Pressure Points Campaign they have published a report on maternal mental health (RCM, 2014). 25% of mothers surveyed reported feeling significantly depressed or down after the birth of their baby with a further 35% reporting feeling a little bit depressed or down. 25% of student midwives felt that they had not enough theoretical knowledge about maternal mental health and 27% felt that they would no feel confident in recognising the signs of emotional health issues in women they care for. The vast majority of midwives felt that the focus of postnatal care should be on emotional support, compared to clinical observation and health promotion. 75% of mothers report been asked how they were coping during postnatal visits though some reported feeling that this was a "tick box exercise". 35% of midwives would like to do more to support the emotional wellbeing of new mums.

Local CAMHS Transformation Planning Guidance (NHS England, 2015) based on the recent Future in Mind report clearly states that local plans should place high emphasis on improving perinatal mental health.

For further information around perinatal mental health please see the dedicated area of the Child and Maternal Health Intelligence Network.

Facts, Figures, Trends

The "Guidance for commissioners of perinatal mental health services" (JCPMH, 2012) estimated the numbers of women affected by perinatal mental illnesses in England each year:

  • Postpartum psychosis - 2 per 1,000 maternities - approximately 1,380 women
  • Chronic serious mental illness - 2 per 1,000 maternities - approximately 1,380 women
  • Severe depressive illness - 30 per 1,000 maternities - approximately 20,640 women
  • Post traumatic stress disorder - 30 per 1,000 maternities - approximately 20,640 women
  • Mild to moderate depressive illness and anxiety state - 100-150 per 1,000 maternities - approximately 86,020 women
  • Adjustment disorders and distress - 150-300 per 1,000 maternities - approximately 154,830 women

As yet, we do not have any local baseline data or trends in perinatal mental health problems assessed antenatally or postnatally, as this data is collected on individuals who are then referred by local midwifery and health visiting teams to 'Introducing Access to Psychological Therapy' services (IAPT) commissioned by CCGs.

From October 2015, anonymised postcode level data on risk will be collected by health visiting teams allowing better targeting of prevention and treatment services. The introduction of the Maternity and Children's Dataset will improve data on all aspects of maternal and child need and service provision.

An estimated prevalence level of perinatal mental illnesses can be made for Reading Wards, shown in Figure 1 below, based on the general prevalence rate of 1 in 10 women developing a mental illness during pregnancy or within the first year after having a baby.

Figure 1: Crude estimated prevalence of perinatal mental illness in Reading

Ward Name

Number of children aged under 1 year

(Census 2011)

Crude estimated numbers of perinatal mental illnesses

Abbey

248

25

Battle

265

27

Caversham

188

19

Church

131

13

Katesgrove

175

18

Kentwood

164

16

Mapledurham

28

3

Minster

197

20

Norcot

181

18

Park

196

20

Peppard

109

11

Redlands

124

12

Southcote

131

13

Thames

139

14

Tilehurst

120

12

Whitley

205

21

Source: Office for National Statistics (2011); Maternal Mental Health Alliance (2014)

National & Local Strategies (Current best practices)

Public Health England (2015) recently published a rapid review of evidence for the healthy child programme. This has highlighted the best practice for perinatal mental health.

NICE clinical guideline (CG192) for antenatal and postnatal mental health recommends that at a woman's first contact with services in pregnancy and the postnatal period, practitioners should ask two questions about depression and subsequent questions about generalised anxiety. Key risk factors are:

  • any past or present severe mental illness
  • past or present treatment by a specialist mental health service, including inpatient care
  • any severe perinatal mental illness in a first-degree relative (mother, sister or daughter)

If high risk scores are identified, women should be referred to a secondary mental health service (preferably a specialist perinatal mental health service) for assessment and treatment. This will include women who have or are suspected to have severe mental illness, as well as those that have any history of severe mental illness, whether during pregnancy, in the postnatal period or at any other time. In both cases, the woman's GP should know about the referral.

Where a woman has any past or present severe mental illness, or there is a family

history of severe perinatal mental illness in a first-degree relative, practitioners should be alert for possible symptoms of postpartum psychosis in the first two weeks after childbirth.

If a woman has sudden onset of symptoms suggesting postpartum psychosis, she should be referred to a secondary mental health service (preferably a specialist perinatal mental health service) for immediate assessment (within four hours of referral).

When a woman with a known or suspected mental health problem is referred in pregnancy or the postnatal period, she should be assessed for treatment within two weeks of referral and provided with psychological interventions within one month of initial assessment.

Current local activities and strategies include:

Public Health funding has been allocated to engage a local expert(s) to:

  • Review existing workforce training.
  • Create/ identify an evidence based training package and identify a mechanism for multiagency delivery. Training would be provided to midwives, Children's Centre staff, family workers, social workers, Health Visitors, FNP practitioners, PVI settings staff, school nurses, voluntary sector workers.
  • Identify outcomes e.g. increase in mothers attending Talking Therapies/ improvement in speech, language and communication at the 2 year check/ mothers reporting that they felt comfortable discussing mental health with members of the children's workforce.
  • Test the training in the field
  • Based on the results of the training, provide an options appraisal for mainstreaming the training across the children's workforce.

What is this telling us?

NICE guidelines provide a clears statements of what is required.

For prevention

Women who receive a psychosocial or psychological intervention designed to prevent postnatal depression during pregnancy or the post-partum period are significantly less likely to develop postpartum depression compared with those who receive standard care.  Promising interventions include interpersonal psychotherapy, intensive home visiting by professionals, and telephone support (though evidence on the latter is inconsistent).

For treatment NICE recommends that women with persistent sub threshold depressive symptoms, or mild to moderate depression, in pregnancy or the postnatal period should be offered facilitated self-help. Where women with a history of severe depression initially present with mild depression in pregnancy or the postnatal period, pharmacological therapies should be considered.

For a woman with moderate or severe depression in pregnancy or the postnatal period, options should include a high-intensity psychological intervention, for example:

  • cognitive behaviour therapy (CBT); or
  • tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRI) or Serotonin and norepinephrine Reuptake Inhibitors (S)NRI; or
  • high-intensity psychological intervention in combination with medication.

Inconclusive evidence from reviews of interventions other than pharmacological, psychosocial and psychological for treating antenatal/postnatal depression include:

depression-specific acupuncture, maternal massage, bright light therapy or omega-3 fatty acids to treat antenatal depression. There is no evidence to support the use of group CBT, exercise interventions, or omega-3 fatty acids for the treatment of postnatal depression.

NICE recommends that a woman with persistent sub threshold symptoms of anxiety in pregnancy or the postnatal period should be offered facilitated self-help. This should consist of the use of CBT-based self-help materials over 2-3 months with support (either face to face or by telephone) for a total of 2-3 hours over 6 sessions

Women with anxiety disorders in pregnancy or the postnatal period should be offered a low-intensity psychological intervention (such as facilitated self-help) or a high-intensity psychological intervention (such as CBT) as initial treatment in line with the recommendations set out in the NICE guideline for the specific mental health problem.

Public Health England (2015)  in their summary of the evidence of what works identified that NICE guidance recommends that the nature of the mother-baby relationship should be assessed, including verbal interaction, emotional sensitivity and physical care, at all postnatal contacts.  Practitioners should discuss any concerns that the woman has about her relationship with her baby and provide information and treatment for identified mental health problems. Practitioners are recommended to consider further intervention to improve the mother-baby relationship if any problems in the relationship have not resolved.

What are the key inequalities?

Apart from a present or current history of mental health problems vulnerable women at additional risk of mental health problems in pregnancy or postnatally include those who are abused, have sought asylum, have English as an additional language, are misusing drugs and alcohol, are living in poverty, are homeless or who have had a traumatic birth.

What are the unmet needs / service gaps?

There is no commissioned perinatal mental health service in Berkshire as yet, although service specifications are being developed. However, as mentioned above, Reading BC public health has funded a worker to review existing activity and to make recommendations for a future service.

Data should be collected from health visiting and maternity services to enable a geographic assessment of needs as well as a personal assessment of needs.

Outcomes of perinatal mental health interventions should be reported geographically through the Joint Strategic Needs Assessment, as well as through commissioned services in future.

This section links to the following sections in the JSNA:

Maternity

Children & Adolescent Mental Health

Mental health

Poverty

Migration

References

Department of Health (2015). Future in Mind. London: HMSO. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/414024/Childrens_Mental_Health.pdf

Joint Commissioning Panel for Mental Health (2012). Guidance for commissioners of perinatal mental health services. London: Joint Commissioning Panel for Mental Health. Available at: http://www.jcpmh.info/resource/guidance-perinatal-mental-health-services/

NHS England (2015). Local Transformation Plans for Children and young People's Mental Health and Wellbeing. London: NHS England. Available at: https://www.england.nhs.uk/wp-content/uploads/2015/07/local-transformation-plans-cyp-mh-guidance.pdf

NICE (2014). Clinical guidance 192: Antenatal and postnatal mental health. London: UCL. Available at: http://www.nice.org.uk/guidance/cg192

Public Health England (2015). Rapid Review to Update Evidence for the Healthy Child Programme 0-5. London: HMSO. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/429740/150520RapidReviewHealthyChildProg_UPDATE_poisons_final.pdf

Royal College of Midwives (2014).Maternal mental health: improving emotional wellbeing in postnatal care. Available at: https://www.rcm.org.uk/sites/default/files/Pressure%20Points%20-%20Mental%20Health%20-%20Final_0.pdf

Stein, et al. (2014).'Effects of perinatal mental disorders on the fetus and child'. The Lancet. 384(9956), pp.1800-1818. Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61277-0/abstract

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