Perinatal Mental Health Flashcards
MW role in PMH and the statistics of women who develop a mental illness during pregnancy?
More than 1 in 10 women develop a mental illness during pregnancy or within 1 year postpartum, with suicide being the leading cause of death during pregnancy and one year after birth. 7 in 10 women hide or underplay the severity of their condition, showing the importance of the midwife’s role in assessment and treatment of mental health. Depression and anxiety are the most common mental health problems in pregnancy (12% depression, 13% anxiety).
- Midwives therefore have a key responsibility in ensuring they have the assessment and communication skills to enable them to identify and deliver mental healthcare to this group of clients.
- Establish a trusting relationship
- Advice regarding smoking cessation, diet and exercise, breastfeeding
What are baby blues
- Common experience
- When the hormones and prolactin hormone increase. These hormones come across each other causing the feelings
- Normally occur for 2-3 days
- Should resolve in 48 hours
How common is psychosis?
- Psychosis can re-emerge or be exacerbated during pregnancy and the postnatal period.
- Postpartum psychosis affect between 1 and 2 in 1000 women who have given birth.
- Women with bipolar disorder are at a particular risk, but postpartum psychosis can occur in women with no previous psychiatric history.
Infertility and mental health
- Evidence suggests that women who become pregnant through assisted reproduction treatment (ART) are more at risk of poor mental health than those who experience spontaneous conception.
- In particular, infertility and its treatment are regarded as severe stressors, although their effect can be mediated by healthy coping strategies, and of course by giving birth to a live healthy baby.
- However, repeated ART can take its toll on the mental well-being of women, even if the treatment is successful, and continuous mental health assessment and support is important to identify women suffering depression and anxiety as a result of their experiences.
The risk factors for tokophobia and PTSD
- Previous adverse medical/surgical experience
- Previous traumatic experience of witnessing childbirth either personally (for example family member) or professionally (for example as healthcare staff)
- Pre-existing anxiety or mood disorder
- History of sexual abuse or rape
- History of sexual dysfunction
- Previous miscarriage, stillbirth or neonatal death
Antenatal psychiatric disorders may be associated with?
- Poor attendance in antenatal clinic
- Smoking and substance misuse
- Poor general health and nutrition
- Deliberate self-harm and suicide
How do you assess MH?
- History of any mental health problem
- Physical wellbeing
- Alcohol and drug misuse
- The woman’s attitude towards the pregnancy, including denial of pregnancy
- The woman’s experience of pregnancy and any problems experienced by her, the fetus or the baby
- The mother–baby relationship
- Any past or present treatment for a mental health problem, and response to any treatment (NICE, 2017).
- Social networks and quality of interpersonal relationships
- Living conditions and social isolation
- Family history (first-degree relative) of mental health problems
- Domestic violence and abuse, sexual abuse, trauma or childhood maltreatment
- Housing, employment, economic and immigration status
- Responsibilities as a carer for other children and young people or other adults.
What are the challenged with mental health assessment?
Recognise that women who have a mental health problem (or are worried that they might have) may be:
- unwilling to disclose or discuss their problem because of fear of stigma, negative perceptions of them as a mother or fear that their baby might be taken into care
- reluctant to engage, or have difficulty in engaging, in treatment because of avoidance associated with their mental health problem or dependence on alcohol or drugs. (NICE, 2017)
What are the nice guidelines?
- Consider initiating a multi-agency needs assessment including safeguarding issues, so that the woman has a coordinated care plan
- respect confidentiality and discuss fears in a non-judgemental manner
- tell women when and why their information may need to be shared with other agencies
NICE recommend at a woman’s first contact with services in pregnancy and the postnatal period, health professionals should:
Ask about:
• 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)
Refer to a secondary mental health service (preferably a specialist PMH service) for assessment and treatment, all women who:
• Have or are suspected to have severe mental illness
• Have any history of severe mental illness (during pregnancy or the postnatal period or at any other time)
Ensure that the woman’s GP knows about the referral
Stepped care model
- Overarching model of primary care for individuals with mental health issues NICE (2004)
- Recommends the relevant intensity of treatment for the level of distress and impact on functioning women
- Treatment should be monitored systematically and can be changed if proved ineffective
- Recognising that a woman has a current mental health issue or is at risk of developing one is a fundamental step in ensuring effective mental healthcare.
- It is usually the primary care team who carry out this initial assessment, for example, the woman’s GP or her community midwife.
Step 1: Recognition
General wellbeing questions
- Patient Health Questionnaire-2 (PHQ-2): the first two items of the full depression scale of PHQ-9
o During the last month have you often been bothered by feeling down, depressed or hopeless?
o During the last month, have you often been bothered by having little interest or pleasure in doing things?
o Evidence suggests high false positive rates with PHQ-2, but used as a way to enhance routine evaluation of depressive symptoms in pregnant women (Vlenterie et al, 2017)
- 2-item General Anxiety Disorder Scale (GAD-2)
o Over the last 2 weeks, have you been feeling nervous, anxious or on the edge?
o Over the last 2 weeks, have you not been able to stop or control worrying ?
- Edinburgh Depression Scale (EDS)
o A validated 10 item self-reported questionnaire to screen for prenatal and postnatal depression.
o Questions related to emotional health and well-being, with four possible responses for each statement
o Total scores range between 0 and 30, with a values of 13 or more indicative of depression.
- General Anxiety Disorder (GAD-7)
o Self-administered questionnaire used as a screening tool and severity measure for General Anxiety Disorder (GAD)
o Score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of ‘not at all’, ‘several days’, ‘more than half the days’, and ‘nearly every day’, respectively, and adding together the scores for the seven questions.
o Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate and severe - If symptoms mild, watchful waiting for two weeks may be appropriate
- Collaborative process in that woman will be monitoring her own symptoms/ problems as well as the midwife
- If they feel the situation is worsening, they should contact their midwife as soon as possible
- Make sure you do the screening tool before discussing whether to come back in two weeks.
Step 2- Offer treatment in primary care
- Provision of information, including self-help resources and sign-posting
- May need language, literacy or IT support
- Mental health promotion also to include exercise recommendation and referral to support groups if appropriate because evidence suggest that it helps mental health.
o Support groups:
Mindful Mums:
• Preventative
• All pregnant women & new mums (perinatal)
• Safe, non-judgemental support
• Open to all, regardless of MH diagnosis
• Connections with other mums
• Free
• Resilience building& coping
• Befriending 1-1 peer support, confidence building and connection mum to community.
• Local
• Peer led- Referral by GP/HV/Midwives or self-referral
- Cocoon Family Support
• Peer support model for mild- moderate perinatal MH and recovering severe
• No professional referral or diagnosis needed
• Information and sign-posting
• Counselling
• Walking groups
• Workshops and events
• Service user engagement and co-production - Family Action
Step 3- Review and offer alternative treatment
- Repeat assessments, and depending on results offer:
- NICE recommendations are to make sure they see someone before they delivery. When making the referrals makes sure you tell them that they are pregnant.
- Psychological therapies (talking therapies)
o For those experiencing stress, low mood, depression or anxiety
o Depending on level of need (and local availability) will be offered counselling or psychotherapy
o May be with psychological wellbeing practitioners (PWPs) – have received postgraduate level training in working with people with common mental health problems, and in offering psycho-educational treatments. ]
IAPT Options
- Foundation options: online learning, workshops, specialist courses
- Follow-up options, e.g.: CBT, EMDR, counselling, IPT, DIT, couples therapy. Follow-up workshops, e.g.: CBT group workshops, mindfulness drop-in sessions
Cognitive behavioural therapy (CBT)
- A form of therapy which focuses on developing strategies for tackling the thoughts and behaviours which can affect how we feel.
- Is a NICE-recommended therapy for depression and anxiety disorders.
- Particularly with people who have OCD- rethink about the thought they think about
- Usually involves 6 to 12 weekly sessions lasting for 50-60 minutes, depending on the nature of the problems.
- Client and therapist work collaboratively together and agree from the outset goals for therapy.
- Like coaching -> what is it you want help with
- Sessions are fairly structured, with an agenda being set at the start of the session.
- Clients helped to actively look at what thoughts are occurring that increase feelings of anxiety, and then actively to address thoughts and behaviours.
Eye Movement Desensitization and Reprogramming (EMDR)
- EMDR is a NICE-recommended therapy for post-traumatic stress disorder (PTSD)
- Works by facilitating the brain to process traumatic memories and file them away into the past. It uses bi-lateral stimulation (typically eye-movements) to help the brain to do this. It appears to mimic what the brain does naturally during dreaming or REM (Rapid Eye Movement) sleep in order to integrate incoming information.
- Can be an intense and emotional process
Interpersonal Psychotherapy (IPT)
- IPT understands symptoms of depression as a response to significant life changes and / or current difficulties in relationships.
- Therefore focus is on relationship difficulties, i.e.: conflict; life changes; grief and loss; starting or keeping relationships
- The main focus of IPT is on relationship problems and on helping the person to identify how they are feeling and behaving in their relationships. When a person is able to deal with a relationship problem more effectively, their psychological symptoms often improve.
