Download Topic Summary - Lewisham`s Joint Strategic Needs Assessment

Antenatal and Postnatal Mental Health Services in
Lewisham: A Health Care Needs Assessment
Maternal mental health problems pose a huge human, social and economic
burden to women, their infants, their families and society, and constitute a major
public health challenge. This needs assessment explores the mental health
needs of women during pregnancy and postnatally, and the services that are
currently available to help them in Lewisham. Throughout the document related
services will be referred to as perinatal mental health services as used by NICE.
Purpose of the Needs Assessment
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To provide an overview of the epidemiology of perinatal mental illness in
Lewisham and nationally.
To review the evidence and recommendations for effective management
of perinatal mental illness and quality care services.
To identify current service provision.
To identify gaps in current service and make recommendations for local
planning and strategy formulation
What do we know?
Facts and Figures
Lewisham is home to over 266,500 residents from a range of diverse
communities, neighborhoods and localities and the local population is forecast to
rise to over 290,000 over the next twenty years1.
Children and young people (0-19 years) make up 25% of the population, whilst
elderly residents (over 75) make up just 5%, with the average age of the
population in Lewisham being 34.7 years, young compared to other London
boroughs1.
The most widely adopted measure of deprivation in England is the Index of
Multiple Deprivation (IMD). Using this measure, Lewisham is the 31st most
deprived Local Authority in England and relative to the rest of the country
Lewisham’s deprivation is increasing. The highest deprivation is particularly
found in Evelyn ward in the North and Downham in the South and along the A2
corridor. The map below shows how uneven the distribution of deprivation is
across Lewisham.
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Figure 1 The distribution of IMD 2010 in Lewisham by national quintile.
Source: http://www.lewishamjsna.org.uk/health-inequalities/index-of-multiple-deprivation
(accessed 04/05/2012)
Perinatal mental illness covers a wide range of disorders, and affects one in six
mothers during the antenatal and postnatal period2. The chronic illnesses that
occur pre-pregnancy such as chronic depression, bipolar disorder and
schizoaffective disorders can be exacerbated by pregnancy. There are also those
disorders more specific to the antenatal and postnatal period such as antenatal
depression and anxiety, postnatal depression and puerperal psychosis.
The epidemiology quoted in this document comes from the NICE guidelines and
the referenced studies from there. Further detail can be found by going directly
to the NICE guidelines. Depression and anxiety are approximately twice as
prevalent globally in women as in men, and are at their highest rates in the
lifecycle during the childbearing years from puberty to menopause. Of the
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perinatal mental illnesses, postnatal depression is the most common, with over
11% of mothers experiencing it during the postnatal period3. Depression and
anxiety often occur together, making it difficult to find an accurate prevalence for
anxiety, although studies have shown that up to 20% of women in the perinatal
period can suffer from a combination of anxiety and depressive symptoms.
Puerperal psychosis, the most severe of the perinatal disorders is relatively rare
and occurs in 0.1-0.2% of postnatal women and approximately 4 women per
10,000 births will require admission to a specialist unit pre or postnatally for
severe mental illness3.
It has been estimated that 50% of people with depression, not just those in the
perinatal period are not identified4. This means that only around half of the
pregnant or postnatal women who develop depression may present to primary
care mental health services each year. A similar or lower figure might reasonably
be expected for anxiety disorders, with fewer disorders being identified than for
depression.
For the vast majority of these women, professional help will be provided solely
by primary healthcare services. However, this is not always the case with around
3% to 5% of women giving birth having moderate or severe depression, and
about 1.7% being referred to specialist mental health services5,6. Thus, around
17 women per 1,000 live births would be referred to specialist mental health
services with depression postnatally. Again, it is reasonable to expect the figures
for anxiety disorders to follow the national trend, with a lower rate of referral
through to specialist services.
Common mental health problems during the antenatal and postnatal period
include depression and anxiety disorders, such as panic disorder, OCD and PTSD.
An estimated 10% to 15% of women suffer from depression after the birth of an
infant; in England and Wales this is between 64,000 and 94,000 women a year
and is equivalent to between two and three women per year on the average GP
list and 100 to 150 per 1,000 live births7,8. Prevalence data for anxiety disorders
during the perinatal period are not as reliable. The Office for National Statistics
estimates that the prevalence of anxiety is around 4% of men and 5% of
women9. This would mean that around 30,000 women giving birth per year in
England and Wales are also likely to be suffering from anxiety, with two or three
women per year on the average GP list; 50 per 1,000 live births.
First presentations of severe mental illness, primarily schizophrenia and bipolar
disorder, in the perinatal period are rare, with a rate in the region of two per
thousand resulting in hospital admissions10. These episodes are associated with
a clustering of admissions in the first month after the birth; 1 per 2,000 live
births. More common, particularly with bipolar disorder, is the exacerbation of
an existing disorder, with some studies reporting relapse rates for bipolar
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disorder approaching 50% in the antenatal period and 70% in the postnatal
period11, 19. These women, along with others suffering from severe depression
and other severe disorders such as severe anxiety disorders or personality
disorders, will benefit from referral to specialist mental health services.
Risk factors for perinatal mental illness include3, 17, 25:
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Recent migration
Exposure to violence (domestic, sexual and gender-based)
Emergency and conflict situations such as war and natural disasters
Poor social support and being a single mother
Past history of mood and anxiety disorders including postnatal depression
(30% relapse rate with subsequent births)
Family history of perinatal illness
Childhood abuse
Low income
Unplanned pregnancy
Large number of existing children
Young age of the mother
Traumatic delivery
Perinatal death
Live births in Lewisham residents have risen annually in the last few years, and
the majority of the deliveries occur at University Hospital Lewisham. In 2010
there were 723,165 live births in the UK, and 4,982 to Lewisham women. Using
the prevalence figures above, it can be estimated that in 2010 approximately
1000 mothers would have been affected by a perinatal mental illness, with 600
of these having symptoms diagnostic of postnatal depression. 85 women would
have required referral to the Perinatal Mental Health team and approximately
two women would have required admission to the mother and baby unit for
treatment. Many of the risk factors listed above, including recent migration, poor
social support, being a single mother, low income, young age of the mother and
perinatal death, are more common in Lewisham than in England and Wales,
therefore greater numbers of women may require care in Lewisham. This is
particularly evident in that seven Lewisham women were admitted to a mother
and baby unit between 2011 and 2012 as apposed to the predicted two, and
between 2010 and 2011 there were 193 women from Lewisham referred to the
specialist Perinatal Mental Health service as apposed to the predicted 85.
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Figure 2 A chart to show the number of referrals to the Lewisham Perinatal
Mental Health Team, and from where the referrals originated.
Sample of Lewisham Referrals to Perinatal
Outpatients Service April 2010-March 2011
Lewisham
Social Services
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Other 19
Lewisham
Antenatal Clinic
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GP 55
CMHT 22
KCH Antenatal
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Consequences of Maternal Mental Illness
The overall prevalence of mental disorders is similar in men and women.
However, women’s mental health requires special consideration in view of
women’s greater likelihood of suffering from depression and anxiety disorders
and the impact of the mental health problems on childbearing and childrearing12.
Many women with chronic mental illness stop taking their psychotropic
medication when they become pregnant due to concerns about potential harm to
the developing foetus, and this underlies the high rates of relapse in pregnancy.
Women suffering from mental illness who become pregnant are at a high risk of
obstetric complications with poorer outcomes for themselves and their babies13.
It is therefore clear that women with mental health problems have specific
obstetric treatment needs in addition to psychiatric treatment needs during the
perinatal period, and this care should be delivered in a structured and cohesive
manner.
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During pregnancy, women with mental illness may be less likely to eat and sleep
well, gain adequate weight, not attend antenatal care, fail to seek help for the
birth, use harmful substances such as alcohol, cigarettes and drugs, and self
harm or commit suicide12.
In developed countries suicide causes 10% of maternal deaths in the year
following delivery12. The Confidential Enquiry into Maternal Deaths (2001, 2004)
showed that over half of the women who commit suicide after childbirth had a
previous psychiatric history, but this risk factor was neither identified nor acted
upon by involved health professionals14.
Stress hormones are also raised during maternal mental illness and may have
physical effects on the mother predisposing her to high blood pressure, preeclampsia and an early and difficult labour12. Babies may also be small for age.
After the birth mothers may fail to eat, bathe or care for themselves, increasing
the risk of infection and anaemia18. Mental illness can hamper the mother-infant
attachment, breastfeeding and infant care, and mothers may be less likely to
understand their babies cues for hunger, happiness or distress12,15.
Studies have shown that infants of chronically depressed mothers show less
sociability with strangers, fewer facial expressions, smile less, cry more and are
more irritable than infants of well mothers23. Children do not perform as well on
thinking and intelligence tests at 18 months, and they are more distractible, less
playful and less social up to the age of 522. Effects on older children have been
shown to include neglect, abuse, slower social, emotional and cognitive
development and higher rates of school and behaviour problems12,21.
There is also an increase in the disruption of the marriage and/or spousal abuse
by either partner16,24.
For women with a mental disorder during pregnancy and postnatally, the clinical
context can be complicated by the needs of the foetus and infant, and by the
women’s psychological adjustment to pregnancy, motherhood or having an
additional child whilst experiencing mental illness. Services also need to take
into account the needs of the father/partner, carers and other children in the
family.
National Guidelines
The Royal College of Psychiatrists recommends that health professionals should
advise women to talk about their feelings, get support with practical tasks from
family and friends and to try and catch up on sleep and get time away from the
baby26.
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However, talking about and confronting the issue of mental illness during
pregnancy or the postnatal period still poses challenges for healthcare
professionals. Motherhood is loaded with emotive expectations, and not to
conform to the idealised image of the ‘blissfully happy, blooming mother-to-be or
new mother’ is widely regarded as a taboo. This contributes to a large number
of perinatal mental illnesses going undiagnosed.
70-80% of women with perinatal mental disorders can be successfully treated
and recover12. To a large extent the identification and management of most of
these mental disorders can be done at a primary care level. One challenge faced
by those involved in the care of these women is the wide range of services that
women use at this time. This requires close communication between all the
services. Poor communication has often been identified as the reason for poor
quality of care.
Current specialist provision for women with perinatal mental illness is patchy.
Only approximately 25% of Primary Care Trusts have a fully developed and
implemented policy for perinatal mental health26. Determining the need for
specialist services, including perinatal teams and the number of inpatient
facilities, their size and location is difficult. Firstly, the incidence of severe
mental illness requiring inpatient care varies across the country, with much
higher morbidity in the inner city areas compared with suburban or rural areas.
Bed usage by Primary Care Trusts reveals a bed use approximately 1.7 times
higher in urban than in rural areas, although this may not simply be the result of
higher urban morbidity but due to women living in rural areas being reluctant to
travel long distances to the nearest inpatient facility. The presence of crisis and
home treatment teams may also impact significantly on the use of inpatient
services27.
NICE issued clinical guidance in 2007 about the treatment and management of
women with perinatal mental illness. It recommends that healthcare
professionals ask the Whooley questions at a women’s first contact with primary
care, again at her booking visit, and again postnatally, at 4-6 weeks and again at
3-4 months28, 29, 30.
These questions are:
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During the past month have you been bothered by feeling down,
depressed or hopeless?
During the past month, have you been bothered by little interest or
pleasure in doing things?
If yes to either question:
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Is this something you feel you need or want help with?
At a women’s first contact with services in both the antenatal and postnatal
period, healthcare professionals should also ask questions about past or present
severe mental illness, previous treatment by a psychiatrist/specialist mental
health team and whether there is a family history of perinatal mental illness.
These questions act as a screening tool to try and help identify those women
that may be mentally unwell, or may become unwell during or after their
pregnancy, which will then allow them to be properly monitored and managed.
Studies have shown that continuity of midwifery care throughout the antenatal
and early postnatal periods does not have an effect on depression symptoms,
even in women with a history of depression. However, continuity in the
postnatal period seemed to result in fewer women with depression at 7 weeks
postnatally compared with standard care31, 32.
According to guidelines, treatment options should depend on the severity of the
illness, past psychiatric history, and maternal preference. Due to the possible
risks associated with medication during pregnancy and breastfeeding, the
threshold for use of psychological treatments is much lower. Women requiring
psychological treatment should be seen within one month of initial assessment,
and no longer than three months afterwards. Treatment options
include3,33,34,35,36:
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Watchful waiting
o For mild depression
o For those patients already on antidepressants, they should be
withdrawn gradually and monitored.
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Self-help such as computerised CBT (C-CBT) and exercise
o For mild to moderate illness without a previous history of mental
illness
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Interpersonal psychotherapy (IPT) and CBT
o For mild illness with episodes of severe illness in the past
o The time to response is longer than with medication
o Useful in moderate to severe illness in conjunction with medication
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Psychotropic drugs
o For moderate to severe illness
o Mild illness with a past history of severe illness
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ECT
o Severe or treatment resistant illness
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Referral to perinatal psychiatric services
o For recurring illness or bipolar disorder at the outset of pregnancy
o Where there is a risk of suicide, self harm or self neglect
o Where there are psychotic or manic features
o Where there is a family history of severe depression, puerperal
psychosis, suicide or bipolar illness
NICE guidelines also state that clinical networks should be established for
perinatal mental health services and these networks should provide:
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A specialist perinatal service in each locality, able to provide direct
services, consultation and advice to maternity services, other mental
health services and community services. In areas of high morbidity these
services may be provided by separate specialist perinatal teams.
Access to specialist advice on the risks and benefits of psychotropic
medication during pregnancy and breastfeeding. It is important that
women not only understand the risks involved in taking psychotropic
medications during pregnancy and breastfeeding, but also the risks of an
inadequately or untreated disorder.
Clear referral and management to ensure effective transfer of information
and continuity of care.
Pathways of care for service users, with defined roles and competencies
for all professional groups involved.
Advantages of these clinical networks include the effective concentration of
expertise and the identification of dedicated time and explicit responsibility for
the delivery of appropriate care to mentally ill women and their families. This
should then lead to a more favourable outcome in terms of reduced mortality
and morbidity and increased patient satisfaction. The identification of clear
pathways, a threshold for referrals and evidence-based protocols will support
healthcare professionals in identifying and managing the most serious disorders.
Clarity about treatment thresholds should also improve access to psychological
therapies, which are seldom available quick enough.
Postnatally, services must be able to respond rapidly to emerging illness and link
effectively with obstetricians, midwives and health visitors expressing concern.
Clinical networks can also play a key role in training, education and raising
awareness.
A model of a clinical network is set out below. It shows that women identified by
general medical services such as maternity services or through their GP, as
having a mental disorder can be referred directly to the part of the network that
can give them the most appropriate care, or their GP can source appropriate
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information and advice from colleagues in other parts of the network to provide
adequate care themselves.
Figure 2 A model of a perinatal clinical network
Source: http://www.nmhdu.org.uk/silo/files/full-nice-guideline-on-antenatal-and-perinatalmental-health.pdf
(accessed 10/05/2012)
Each managed perinatal mental health network should also have designated
specialist inpatient services and cover a population of between 25-50,000 live
births per year depending on the local psychiatric morbidity rate20.
Each specialist perinatal inpatient service should:
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Provide facilities specifically for mothers and infants
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Be staffed by specialist perinatal mental health staff
Be staffed to provide appropriate care for infants
Have effective liaison with general medical and mental health services
Have available the full range of therapeutic services
Be closely integrated with community based mental services to ensure
continuity of care on discharge and minimum length of stay
Current activities and services in Lewisham
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Perinatal Mental Health Team
Lewisham does currently have a small perinatal mental health team. It consists
of one consultant who does one session per week, one full time perinatal
psychiatric nurse, one specialist registrar who works for one day and does one
clinic session per week, and one full time co-ordinator.
Any health professional may refer a woman to the team. This is done by faxing
a referral form to Kings College Hospital where it is signposted to the correct
boroughs team. Currently any woman who is pregnant or within one year
postpartum with moderate to severe mental illness, or a history of moderate to
severe mental illness can be referred. If a woman is already under the care of
the Community Mental Health Team the Perinatal Mental Health Team will
provide advice but will not take over the care.
Once a woman has been referred to the service she will either be seen in clinic,
or a home visit can be organised by a member of the team. More and more of
the patients are now seen at home, as the number of non-attendances at the
Ladywell Unit was previously high. The team can organise referrals for
psychological therapies if necessary, prescribe and monitor medication, and
generally offer support for these vulnerable women. All these women will also
have a detailed psychiatric plan in their maternity notes so when they are seen
by the midwives, or admitted to the labour ward to deliver, the plan, and contact
details for the team are readily available.
The team works very closely with the midwifery caseload team, but a weekly
joint clinic has been closed because of poor attendence. However, joint home
visits do occur. The team also works very closely with GPs, health visitors and
social services. Regular letters are sent to the women’s GPs to update them of
their patients’ progress and are also sent to named caseworkers where relevant.
Currently there is no 24 hour cover for perinatal mental health at Lewisham, and
if an emergency develops and a patient needs to be seen urgently, then it falls to
liaison psychiatry to review and manage the patient until a member of the
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perinatal psychiatry team is back on site. This means that there are concerns
amongst the obstetric teams that it can be very difficult to identify and contact a
consultant psychiatrist when needed.
 Mother and Baby Unit
Approximately four women per 10,000 births will require admission to a specialist
unit pre or postnatally for severe mental illness. 75% of trusts do not currently
have a specialist MBU or access to one, and 12% of trusts still admit mothers
and babies to general psychiatric wards20, although this has never occurred
within Lewisham.
The most local Mother and Baby Unit to Lewisham is the unit at The Bethlem
Royal Hospital in Beckenham, Kent. It is a thirteen bedded unit that accepts
referrals from consultant psychiatrists or community mental health teams from
across the country.
It specialises in the treatment of antenatal and postnatal mental illnesses,
predominantly for women who develop or have a relapse of serious mental
illness during pregnancy, and women who develop postnatal depression,
puerperal psychosis or have had a relapse of serious mental illness following the
birth of their baby.
They support the mother in developing a relationship with her baby in order to
reduce the impact of the mother’s illness on the child. They offer a holistic
treatment programme, and encourage the involvement of fathers or partners in
the process. Mothers tend to be admitted with their baby where it is the wish of
the mother and it is clinically safe to do so. However, they are also able to take
mothers without their babies, and offer a programme of gradual reintroduction to
the mother on the ward.
Some of the interventions that the Mother and Baby Unit provide are:
o Psychiatric assessment
o Medication, if needed
o Specialist psychological assessment, including impact of history of trauma
and child abuse, mother-infant relationship and assessment of cognitive
functioning
o Risk assessments for mother, baby, husband, partner, carers and siblings
o Psychological therapies including psychotherapy, CBT, CAT family therapy
and couple therapy
o Mother-infant relationship support, including baby massage, video
feedback, infant’s physical and emotional development, parenting skills,
promotion of attachment, play stimulation and development
o Occupational therapies for mother and baby include:
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1. life skills such as shopping, cooking, negotiating public transport,
budgeting and assessment of home environment
2. health skills such as diet, physical activities, dancing and swimming
3. work skills including IT skills
4. leisure skills such as art, photography, pottery and woodwork
o Pre-conception advice
They also provide a parenting assessment service, providing a unique and highly
specialised service to local and national authorities across the United Kingdom.
They undertake assessments of women or couples and their infant, where there
is potential risk or safeguarding issues arising from the parents’ mental health
problems.
In the last 12 months they have not had to refuse a referral due to a lack of
beds. However, on the very rare occasions that this does occur, they will
signpost the referrer to the next closest unit, and when a bed becomes available
they will then transfer the patient over if they still wish to come to the unit.
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IAPT (Improving Access to Psychological Therapies)
The Improving Access to Psychological Therapies (IAPT) programme supports
the frontline NHS in implementing NICE guidelines for people suffering from
depression and anxiety disorders. It was created to offer patients a realistic and
routine first-line treatment, combined where appropriate with medication which
traditionally had been the only treatment available. The programme was first
targeted at people of working age, but in 2010 was opened to adults of all ages.
It currently does not offer any services specifically designed for women suffering
from mental illness during the perinatal period. These women can be seen by
IAPT and offered a course of CBT, but specific, targeted treatments are not
currently provided.
If a woman in the perinatal period is referred to IAPT for psychological therapy
she is made a priority and will go to the top of the waiting list.
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Caseload Team
The midwifery caseloading team has been running since 2010 when it received
funding from commissioners. It originally received funding for six fulltime
midwives, and they currently have five and a half full time midwives.
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Women are referred to the caseloading team from the booking visit or by their
GP if it is felt that they will benefit from more continuity of care throughout their
pregnancy. These women are those that tend to have chronic mental illness, or
had severe mental illness in the past, or in previous pregnancies, or are
vulnerable for another reason such as domestic violence. When the caseloading
team was first set up commissioners suggested that 50% of their caseload
should be normal low risk pregnancies, and 50% should be vulnerable women.
However, this has not proved possible, and the team currently have a caseload
of approximately 90% vulnerable women and 10% low risk pregnancies. They
see these women up to 28 days postpartum.
The team meet once a month to discuss the caseload, and they also hold a meet
and greet once a month where all the women on the caseload can attend and
meet all the midwives on the team and other expecting mothers. This ensures
that the women get to know and feel comfortable with all the midwives who may
be looking after them during their pregnancy.
Antenatal appointments can either happen in the woman’s home or at the
hospital, depending on what is preferable for the woman. There is no set
schedule for appointments unlike in normal midwifery care, and the women are
seen as often as necessary, whether it be a couple of times a week, or once
every couple of weeks. The midwives are also on call for Labour Ward 24 hours
a day, so when one of their women goes into labour they can attend and be
there to support throughout the labour and delivery. The midwives will also
attend scans with the women if they would like, and if they require admission,
they will see them in the Mother and Baby Unit.
The team works very closely with the perinatal mental health nurse, who can
then signpost the women to further services and the perinatal mental health
team if required. They also have close links with social services, health visitors
and GPs, and liaise with them if appropriate.
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Pregnancy Support Team
The pregnancy support team is a new team that was developed at Lewisham in
May 2012 by the Safeguarding midwife, with the aim to link in with the NICE
Complex Social Care guidelines. It is a multidisciplinary team that meets
fortnightly to discuss all women with vulnerabilities at around the 28th week of
their pregnancy. The aims of the group are to assess any risk to the pregnant
woman, her unborn child and any existing children, to formulate a care plan to
address vulnerabilities and reduce risk factors, to communicate effectively with
other agencies as required and to identify instances and areas where action
should be taken in order to ensure that children are safeguarded.
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Members of the team include:
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Lead Midwife
Safeguarding Advisor
Perinatal Mental Health Nurse
Social Worker
Family Support Team
Lands Team
Midwives from various teams including the antenatal clinic, the caseload
team and the teenage pregnancy team
Midwifery Manager
Women can be referred to the team by GPs and community midwives by filling in
the referral form. Criteria for referral include:
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Currently/Previously known to Social Care
Substance misuse
Known mental health concern that is not severe enough to require referral
to the caseload team
Domestic Violence
Alcohol abuse
Older child with Special Needs
Young Woman under age of 20
Disability
Previous postnatal depression
Female genital mutilation
Previous late miscarriage or stillbirth
Once referred the woman will be discussed around her 28th week of pregnancy
at the multidisciplinary meeting and a plan will be made regarding her care. If
necessary she will be signposted to other services that may be able to offer help
and support. A letter is written to her GP detailing what the plan has been. The
woman will then be re-discussed at 34 weeks to see how she is progressing, and
to see whether she requires any further input. Again, a letter will be sent to the
GP outlining the plan.
Prior to this pregnancy support team, many women who did not fulfil the criteria
to be referred to the caseload team, but would have required some extra support
throughout their pregnancy and after, may have fallen through the cracks. This
team has now filled the gap, so far more women will get the support and help
they need.
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Figure 4 The referral pathway for the Pregnancy Support Team
Provided by the Pregnancy Support Team, Lewisham Healthcare Trust
First disclosure: Client discloses current events or a history
which could put her or her unborn child at risk. Consider
severity of risk. Act promptly!
www.nice.org.uk/guidance/CG110
RISK IDENTIFICATION
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History or current
Serious mental illness
Domestic Abuse
Young Woman under the age of 20
Learning Disability
Physical Disability (impact on parenting)
Previous involvement with social services
Previous children & not currently caring for them
PND/Depression
FGM
Alcohol or Substance misuse
Previous late miscarriage or stillbirth
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Referrals from other agencies
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GP’s (check letter/email/fax)
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Social Services –Child or adult
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A&E / NBC/other hospital ward
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Police
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‘Other’ –voluntary agencies
CONSIDER REFERRAL
Get maximum information – main notes /GP/HV
Unsure? Discuss with Lead Midwife Safeguarding/Perinatal
Psychiatry Team/Senior staff
REFERRAL
CAF form to Lewisham Assessment & Referral Team at Lawrence
House – email: Referral&[email protected],
fax:02083143447. CC or hardcopy to [email protected]
If it is an urgent Child Protection issue, please call a Duty Social
Worker on 020 8314 6660 or 020 8314 8018 or 020 8314 6294
Follow up referral response from Children’s Social Care within ONE
week
Refer to appropriate team or clinics to ensure all midwifery needs are
met.
Send a referral to the Pregnancy Support Team asap so the case can
be discussed by 28/40
Woman’s named midwife/representative attend Pregnancy Support
Team meeting with updated plan of care
Ensure Safeguarding Plan is in main notes / Safeguarding Folders in
departments/teams
Ensure a flag is put on Terra Nova and PIMS if appropriate.
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Strategies provided elsewhere
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St George’s NHS Trust
At St George’s the perinatal psychiatry service works closely with the midwives
and obstetricians to try to screen and identify mothers who are at risk of mental
illness. The specialist midwife post was created to provide focused care to
pregnant women with mental illness. The midwife is an important point of
liaison between the other midwives, health visitors, child and family social
services, obstetricians and mental health services. The mental health midwife is
also a vital link to the local mother and baby unit.
A member of the perinatal psychiatric team attends the weekly midwifery team
meeting, where all community and labour ward teams meet to discuss the
caseload, providing a valuable opportunity for potential referrals to be discussed.
Understandable, many women will prefer and only require additional support and
advice from a specialist midwife or their GP, rather than see a psychiatrist.
However, some pregnant women will need to see a psychiatrist for expert input.
To reduce the stigma, and make it a more integral part of routine antenatal care,
the perinatal psychiatric clinic at St George’s has been relocated to the Foetal
Medicine Unit where pregnant women go routinely for antenatal ultrasounds and
booking appointments.

Kings College Hospital
Kings College Hospital has a dedicated Perinatal Mental Health team, and a clear
referral pathway. In 2009 5,900 women booked for maternity care and 708
(12%) of them disclosed that they had a history of, or current mental disorder.
Of these women 254 met the criteria for referral to the Perinatal Psychiatric
Team. These included those with psychotic illness, severe depression, eating
disorders, attempted suicides and serious self harm.
Women who present with a history of depression or psychiatric problems; this
can be past or present, are offered psychiatric referral by the midwife at the
booking appointment. The midwife then completes a CAF form, SLAM form
(Kings Perinatal Psychiatry Form) or GP assessment letter depending on the
severity of the psychiatric problem. If a referral is being made to SLAM, a CAF
referral to children’s social care in the borough of the mother’s residence should
also be completed. Parental mental illness does not always have an adverse
impact on a child’s development but it is essential to always assess it’s
implications for each child in the family.
17
The Perinatal Psychiatry team should then respond directly to the referring
midwife within 7 days and the referring midwife has the responsibility to ensure
that any referral is followed up, information is shared with colleagues and actions
documented.
Women are then reviewed in the Department of Psychological Medicine Clinic at
King’s or at The Maudsley Hospital. If a woman does not attend a planned
appointment, the Perinatal Psychiatry Liaison Team are responsible for informing
the named midwife for this woman and the relevant midwifery team.
Those women for whom Perinatal Psychiatry Liaison Team and/or CAF referrals
have been completed are booked to be discussed at the weekly Safeguarding
Meeting. This is a multiagency meeting where women are discussed and actions
resulting from the meeting are documented in the mother’s main hospital notes
and a copy emailed to the relevant midwifery team.
Each month a list of women who will need review following birth is also
generated by the Safeguarding Meeting. These are women who are recognised
at being high risk of exacerbating a pre-existing mental illness in the postnatal
period. The list is emailed to all clinical areas within the maternity service, and it
identifies the woman’s details and the recommended action plan. If admission to
the Mother and Baby Unit at The Maudsley is planned, the Perinatal Psychiatrist
will liaise directly with them during the pregnancy.
Those women who have no previous mental illness and will therefore have no
contact with the psychiatric team during their pregnancy may later require a
referral to be made. This is especially applicable in the case of acute postpartum
mental illness.
18
Figure 3 The referral pathway for referring to perinatal mental health at Kings
College Hospital.
Provided by Kings College Hospital Perinatal Team
First disclosure of history of or current mental illness at
booking/first contact at any time during maternity care
 Complete Referral Form
 Decide which referral Option – Perinatal or GP
 Gain consent. If refused and Option 1 discuss with Perinatal
Team / Named Midwife /Consultant Midwife or Consultant
Obstetrician
Option 1
SLAM Perinatal Psychiatry Team
 Complete & Fax
 Unsure – Discuss with Team
Member Ext 0203 299 3277
Option 2
GP Letter request mental
health assessment
 Follow up referral in ONE
MONTH
Consider CAF referral if
safeguarding concerns re unborn
or previous children
 Discuss with Named Midwife or
Perinatal Team if unsure
Referring midwife/doctor
 Follow up referral in ONE WEEK
 Document plan of care
*communicate plan to new lead
professional/named midwife if care
transferred
Referring midwife/doctor
Follow up referral in ONE
month
 Document plan of care
*communicate plan to new lead
professional/named midwife if
care transferred

What is this telling us?
What are the key gaps in knowledge and/or services?
It was important to get the views and opinions about the service from the
service providers and from the women using it.
19
GPs were asked about how they link in with the perinatal mental health service.
Although the opinions expressed are probably personal reflections of the GPs
themselves and can’t necessarily be broadened to all GPs, it gives a snapshot of
how they feel about the service.
GPs currently feel that they do not become hugely involved with the perinatal
mental health service. Most referrals to the service of women suffering from
mental illness during their pregnancy come from the midwives, and those women
suffering from postnatal illness tend to get looked after by the GPs, or get
referred to IAPT (Improving Access to Psychological Therapies) services. If they
do refer to the service they feel that communication back is very poor, with few
updates on their patient’s progress.
Interestingly, the GPs also said that they tend not to assess a woman for
psychiatric illness, domestic violence or any other vulnerability at her first
presentation during her pregnancy, as they tend to leave this to the midwives at
the booking visit.
There is also concern from the women using the service and the perinatal mental
health team that GPs are not confident in their knowledge about the use of
psychotropic drugs during pregnancy. Because of this, when a woman sees her
GP at the start of her pregnancy and is currently on medication for a mental
illness, a large number of GPs stop the medication immediately. This can then
lead to relapse, and the woman becoming more unwell very quickly.
A further problem with the service that was mentioned by both the perinatal
mental health team and the caseloading team is the difficulty with caring for
women who are out of area, or live just across the border, but have still booked
at Lewisham to have their baby. At the moment these women cannot be looked
after by the caseloading team, or the Lewisham perinatal mental health team
even if they fit the referral criteria. These women are therefore not necessarily
getting the best possible care and support that they may need through their
pregnancy.
Psychological treatments have been shown in numerous studies to help reduce
the impact and severity of perinatal mental illness, and aid recovery. In
Lewisham, and elsewhere throughout the country, there is a huge problem with
accessing these services, due to long waiting lists, or not being available in a
certain area. The introduction of IAPT was meant to improve this, and in some
instances it has. However, in Lewisham there is no specific psychological
treatment service for perinatal mental illness, so women are referred to IAPT.
The opinion of the perinatal mental health team is that IAPT does not have the
experience or the expertise to deal with these women, particularly those with
20
severe mental illness. However, the opinion of many at IAPT is that they do
have the skill set to help these women, but that they do not have the funding or
the time to offer a specialised service. They would be keen to become more
involved in standard antenatal care, and perhaps attend antenatal classes to
speak to women and assess whether any may benefit from input antenatally.
There have also been problems with getting women reviewed on the maternity
or postnatal wards urgently, either out of hours or not. This is because the
perinatal team at Lewisham is so small, and are often not on site. On these
occasions it falls to the liaison psychiatry team to review the woman and to come
up with an initial management plan. Problems have occurred with this when the
liaison psychiatry state they are too busy, or do not deal with perinatal mental
health, and the women can be left on the ward with no review for a few days.
What should we be doing next?
Recommendation
More formal training for midwives,
health visitors and obstetricians
regarding mental illness, so that they
are more likely to recognise the signs,
and are aware of the services and
referral pathways available for these
women.
Further education for GPs regarding
psychotropic medication during
pregnancy. This could include
mandatory training.
Improve counselling given to women
prescribed psychotropic medication
about when to seek advice about
stopping or changing medication if they
plan on becoming pregnant, or when
they do become pregnant.
Encourage GPs to use the Whoolley
questions when a woman presents to
them when pregnant.
Consider employment of a single
named midwife with an interest in
mental illness to work closely alongside
the perinatal mental health team.
Improve access and quality of
To discuss with
Lewisham Healthcare Trust
Primary Care Team
Lewisham Healthcare Trust, SLAM and
Primary Care Team
Primary Care Team
Lewisham Healthcare Trust
Mental Health Commissioners
21
psychological therapies for women with
perinatal mental illness, in particular, to
consider in some depth how IAPT
might be used for this purpose.
Develop a pathway for the care of
SLAM and SEL Maternity Network
women who have booked at Lewisham
for their maternity care, but are from
out of area so can not be looked after
by the caseloading team, or the
perinatal mental health team.
Develop a formal agreement between
SLAM and Lewisham Healthcare Trust
perinatal mental health and liaison
psychiatry so that in the case of an
urgent referral when the perinatal team
are not available, the liaison psychiatry
team review the patient urgently and
initiate management if necessary.
Increase the number of sessions
SLAM
provided at Lewisham by the
consultant psychiatrist and specialist
registrar.
Conclusion
It would appear that the services for women suffering from perinatal mental
illness in Lewisham are currently meeting demand, and although some
improvements need to be made the provision for these women is adequate and
provides a vital and necessary service.
Ideally, the perinatal mental health service would be a service with a full time
consultant psychiatrist and at least one full time specialist registrar within
Lewisham. However, this is currently impossible, and the staff are providing an
overall efficient service with limited resources.
As with any service there are going to be shortcomings and the perinatal mental
health service is no different, as documented by the recommendations above.
However Lewisham Healthcare Trust is already trying to bridge some of the
gaps, such as the limited provision for those women with mild to moderate
mental illness, by the introduction of the pregnancy support group, and this will
go a long way to improving the quality of care this vulnerable group of women
receive.
22
It is also this group of women with mild to moderate mental illness that often
most benefit from psychological treatment, as the impact of the illness on the
woman, baby and her family can be just as devastating as those suffering with
severe mental illness. Further improvement to the service targeted to this group
could also be made if greater use of specific IAPT services were agreed.
Acknowledgements
Dr Donal O’Sullivan, Public Health Consultant
Pauline Cross, Consultant midwife in Public Health
The Public Health Team at Lewisham
Miss Billett, perinatal mental health obstetric lead
Jessica Ormerod, NCT volunteer who spoke to me at length about the service
provision and put me in touch with some service users
Jill Demilew, consultant midwife at Kings College Hospital
Dr Judy Chen, Principal GP and Safeguarding Children Lead
Eleanor Davies, Associate Director of Joint Mental Health Commissioning
Shirley Petersen, Community Services Manager for Maternity Services
Sarah Buck, Lead Midwife on the Caseloading Team
Vita Shrinarine, Perinatal Mental Health Nurse
Dr Trudi Seneviratne, Consultant Psychiatrist, Perinatal Mental Health Team
Jackie Ganley, Consultant Clinical Psychologist at IAPT
Ailsa Ward, Mental Health Nurse, Mother and Baby Unit, The Bethlem Royal
Hospital
References
1. Lewisham Strategic Partnership Website
http://www.lewishamstrategicpartnership.org.uk/borough.asp
2. Out of the blue? Motherhood and depression (2006)
3. NICE (2007) Antenatal and postnatal mental health. London: National Institute
for Health and Clinical Excellence.
4. Williams JW Jr, Kerber CA, Mulrow CD, et al. Depressive disorders in primary
care: prevalence, functional disability, and identification. Journal of General
Internal Medicine. 1995;10:7–12.
5. Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and
prevalence of postnatal depression. The British Journal of Psychiatry.
1993;163:27–31.
23
6. O’Hara MW, Swain AM. Rates and risk of postpartum depression – a metaanalysis. International Review of Psychiatry. 1996;8:37–54.
7. Brockington IF. Motherhood and Mental Health. Oxford; Oxford University
Press; 1996.
8. Nonacs R, Cohen LS. Postpartum mood disorders: diagnosis and treatment
guidelines. The Journal of Clinical Psychiatry. 1998;59:34–40.
9. Office for National Statistics. 2006. http://www.statistics.gov.uk.
10. Kendell RE, Chalmers JC, Platz C. Epidemiology of puerperal psychoses. The
British Journal of Psychiatry. 1987;150:662–673.
11. Viguera AC, Nonacs R, Cohen LS, et al. Risk of recurrence of bipolar disorder
in pregnant and nonpregnant women after discontinuing lithium maintenance.
The American Journal of Psychiatry. 2000;157:179–184.
12. Maternal Mental Health and Child Health and Development
http://www.who.int/mental_health/prevention/suicide/MaternalMH/en/index.html
13. Louise Howard, Katherine Hunt, Mike Slade, Veronica O’Keane, Trudi
Seneviratne, Morven Leese, Graham Thornicroft and Malcolm Wiseman (2008)
CAN-M: Camberwell Assessment of Need for Mothers
14. The Confidential Enquiry into Maternal Deaths (2001, 2004)
15. Ammaniti, M., Speranza, A. M., Tambelli, R., et al. (2006) A prevention and
promotion intervention program in the field of mother-infant relationship. Infant
Mental Health Journal, 27, 70–90.
16. Boath, E. H., Pryce, A. J. & Cox, J. L. (1998) Postnatal depression: the impact
on the family. Journal of Reproductive and Infant Psychology, 16, 199–203.
17. Beck, C. T. (2001) Predictors of postpartum depression: an update. Nursing
Research, 50, 275–285.
18. Bonari, L., Pinto, N., Ahn, E., et al. (2004) Perinatal risks of untreated
depression during pregnancy. Canadian Journal of Psychiatry, 49, 726–735.
19. Gavin, N. I., Gaynes, B. N., Lohr, K. N., et al. (2005) Perinatal depression: a
systematic review of prevalence and incidence. Obstetrics and Gynecology, 106,
1071–1083.
24
20. Harlow, B. L., Vitonis, A. F., Sparen, P., et al. (2007) Incidence of
hospitalization for postpartum psychotic and bipolar episodes in women with and
without prior prepregnancy or prenatal psychiatric hospitalizations. Archives of
General Psychiatry, 64, 42–48.
21. Hay, D. F., Pawlby, S., Sharp, D., et al. (2001) Intellectual problems shown
by 11-year-old children whose mothers had postnatal depression. Journal of
Child Psychology and Psychiatry, 42, 871–889.
22. Horowitz, J. A., Bell, M., Trybulski, J., et al. (2001) Promoting responsiveness
between mothers with depressive symptoms and their infants. Journal of Nursing
Scholarship, 33, 323–329.
23. Jablensky, A. V., Morgan, V., Zubrick, S. R., et al. (2005) Pregnancy,
delivery, and neonatal complications in a population cohort of women with
schizophrenia and major affective disorders. The American Journal of Psychiatry,
162, 79–91.
24. Lovestone, S. & Kumar, R. (1993) Postnatal psychiatric illness: the impact on
partners. The British Journal of Psychiatry, 163, 210–216.
25. Robertson, E., Grace, S., Wallington, T., et al. (2004) Antenatal risk factors
for postpartum depression: a synthesis of recent literature. General Hospital
Psychiatry, 26, 289–295.
26. Oates, M. (2000) Perinatal Maternal Mental Health Services. Council Report
CR88 London: Royal College of Psychiatrists.
27. Killaspy H, Bebbington P, Blizard R, et al. The REACT study: randomised
evaluation of assertive community treatment in north London. British Medical
Journal. 2006;332:815–820.
28. Whooley, M. A., Avins, A. L., Miranda, J., et al. (1997) Case-finding
instruments for depression. Two questions are as good as many. Journal of
General Internal Medicine, 12, 439–445.
29. Arroll, B., Goodyear-Smith, F., Kerse, N., et al. (2005) Effect of the addition
of a ‘help’ question to two screening questions on specificity for diagnosis of
depression in general practice: diagnostic validity study. British Medical Journal,
331, 884.
30. Austin, M. P. & Lumley, J. (2003) Antenatal screening for postnatal
depression: a systematic review. Acta Psychiatrica Scandinavica, 107, 10–17.
25
31. Elliott, S. A., Leverton, T. J., Sanjack, M., et al. (2000) Promoting mental
health after childbirth: a controlled trial of primary prevention of postnatal
depression. The British Journal of Clinical Psychology, 39, 223–241.
32. Evans, J., Heron, J., Francomb, H., et al. (2001) Cohort study of depressed
mood during pregnancy and after childbirth. British Medical Journal, 323, 257–
260.
33. Altshuler, L. L., Cohen, L., Szuba, M. P., et al. (1996) Pharmacologic
management of psychiatric illness during pregnancy: dilemmas and guidelines.
The AmericanJournal of Psychiatry, 153, 592–606.
34. Appleby, L., Warner, R., Whitton, A., et al. (1997) A controlled study of
fluoxetine and cognitive-behavioural counselling in the treatment of postnatal
depression. British Medical Journal, 314, 932–936.
35. Miller, L. J. (1995) Use of electroconvulsive therapy during pregnancy.
Obstetrical and Gynecological Survey, 50, 10–11.
36. Spencer, J. P., Gonzalez, L. S., III & Barnhart, D. J. (2001) Medications in the
breastfeeding mother. American Family Physician, 64, 119–126.
26