Mental Health

Question 1

What should all women be asked during a booking appointment?

Answer 1

• Women should be asked about past or present severe mental illness and previous treatment by a psychiatrist/ specialist mental health team
• They should be asked about a family history of perinatal illness
  ^^ women who have a history of serious psychiatric disorder should be referred for psychiatric assessment during AN period ^^
• Two questions should be asked to identify possible depression:
  . 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?
  If “Yes” to either question ask
  . Is this something you feel you need help with?

Question 2

What should happen at each antenatal appointment?

Answer 2

Women should be asked about their emotional well being, family, social support and how they cope with day to day matters

Question 3

What is the basic Stepped Care Model?

Answer 3

Step 1: RECOGNITION
- If symptoms mild, watchful waiting for two weeks
- Collaborative process in that women will be monitoring her own symptoms with midwife
Step 2: OFFER TREATMENT IN PRIMARY CARE
- Provide info including self help resources
- May need language, literacy or IT support
- Help promotion including exercise recommendations and referral to support group
Step 3: REVIEW AND OFFER ALTERNATIVE TREATMENT
- Brief psychological interventions e.g CBT
- Medication may be useful but problematic with pregnancy;
. establish clear indication for treatment
. use lowest dose for shortest period
. assess risk/ benefit
Step 4 & 5:
- At these stages specialist mental health services will normal be involved
Step 4: case manager involvement when 2 evidence based interventions have not been successful
Step 5: admission to an inpatient unit due to high level of risk and complex needs or where mental health problem has become chronic or treatment resistant

Question 4

What is the Stepped care model for depression?

Answer 4

Step 1: RECOGNITION
- Feeling of worthlessness, helplessness, hopelessness
- Loss of interest in people/ activities
- Poor concentration
- Fatigue
- Complains of physical aches and pains
- Sleep disturbances
- Suicidal thoughts, feelings and gestures
Step 2: OFFER TREATMENT IN PRIMARY CARE (MILD TO MODERATE)
- Watchful waiting and debriefing
- Non-directive counselling
- Psychodynamic therapy
- Broader interventions
Step 3: MEDICATIONS, PSYCHOLOGICAL INTERVENTIONS, SOCIAL SUPPORT (MODERATE TO SEVERE)
- Antidepressants (Fluoxetine and Tricyclic)
. Fluoxetine associated with LBW and respiratory distress
. Tricyclic considered to be safest in pregnancy but more dangerous in overdose
ANTIDEPRESSANT DIS-ADVS
Increased risk of…
- Spontaneous abortion
- Preterm labour
- Hypertension of neonate
- Jitteriness and poor feeding neonate
STEP 4 + 5
Combined treatment and interventions

Question 5

What is the Stepped care model for anxiety disorder?

Answer 5

Step 1: RECOGNITION
- Feelings of dread or uncomfortable anticipation
- Symptoms may be considered a disorder if persistent, excessive and life altering
- Primary symptoms = unrealistic + excessive worry or fear
Step 2: OFFER TREATMENT IN PRIMARY
- Encourage participation in support groups
- Provide interpreted written material if non english speakin
- Provide support + info for client + carers regarding best practice
- Monitor and review client progress
- Long term treatment = psychological therapy, self help
Step 3: MEDICATIONS, PSYCHOLOGICAL INTERVENTIONS, SOCIAL SUPPORT
- Benzodiazapines (sedatives) should be avoided in first trimester
- If one intervention doesn’t work reassure client that others will be tried
Step 4:
- If there has been 2 interventions provided and still significant symptoms - referral to special mental health service offered
Step 5:
- Specialist mental health services should conduct a thorough, holistic reassessment of individual, environment and services

Question 6

What is the care management of someone with a mental health disorder?

Answer 6

• Coordinated care with multidisciplinary team
• Develop an integrated care plan that sets out:
  . Care and treatment for mental health problem
  . Roles of health professionals
  . Providing woman agrees with interventions
• Think about most appropriate healthcare setting for AN provision
• Practice models for overcoming barriers and facilitating access
• Think about ways of communicating information to women so that they can make appropriate choices
• Respect confidentiality but discuss with women when information may need to be shared
• Discuss risks to women and baby concerning treatment
• Seek advise from specialist if uncertain