Think Family - Leicestershire Partnership NHS Trust

Perinatal Maternal Mental Health

Guidance to Support Health Visitors and their

Teams

Key Words:

Version:

Adopted by:

Maternal Mental Health and Perinatal

Period, Screening, Treatment and

Referral. Health Visitors

V8

Date adopted:

Name of originator/author:

Filippa Howells

Mandy Amin

Name of responsible committee:

Date issued for publication:

Review date:

Maternal Mental Health Task and

Finishing Group 2013

LM/MA/JP/AD

Expiry date:

Target audience: Trust Board, Directors of FYPC; Head of

Services, Locality Managers, Team

Leaders Health Visitors V/SN, Lead

Practice Teachers, Clinical Team

Leaders Liaison Psychiatry, CAMHS,

Type of Policy

(tick appropriate

Name Nurses Safeguarding.

Clinical

Yes 

Non Clinical box)

NHSLA Risk Management

Standards if applicable:

State 00Relevant CQC

Standards:

Held on the Trust’s Clinical

Policies.

Guidance to support Health Visitors and their Teams with Perinatal Maternal Mental Health Page 1

CONTRIBUTION LIST

Key individuals involved in developing the document

Name

Mandy Amin(Pathway Lead)

Filippa Howells

Katherine Hammond

Linda Mills

Julie Pepper

Asha Day

Designation

Practice Educator

Practice Educator

Lead Practice Teacher



Health Visitor

Acknowledgement – Previous originator Filippa Howells and individuals involved in developing the document version 5

– Predicting detecting and managing maternal mental illness in pregnancies and post natal period – guidance for HV service. And also for their current contribution

Circulated to the following individuals for comments

Name

Theresa Farndon

Dr Renuka Lazarus

Dr Lina Gatsou

Chris Buzzard

Nicy Turney

Anthea Brooks

Kam Gill

Maureen Curley

Chris Davies

Dorothy Sebuliba

Filippa Howells

Review Contribution List

MA/LM/JP/AD/FH/KH

Designation

Locality Manager

Consultant Psychiatrist for Perinatal Services

Consultant Psychiatrist for Adult Services

HV and SN Service Manager

Senior Nurse Professional Lead for HV

Locality Manager

Locality Manager

Locality Manager

Locality Manager

Senior Primary Mental Health Manager

Practice Educator

Perinatal Maternal Mental Health Guidance to support Health Visitors and their Teams Page 2

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5

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7

Section

1

2

3

CONTENT

Content

Definitions and Abbreviations

Equality Statement

Corporate Responsibilities and Governance

Monitoring Compliance and Effectiveness

Summary

Introduction

Service Delivery

Purpose

Roles and Responsibilities

8

Appendix 1 Pathway for Identification, Management and Treatment of Perinatal Maternal Mental Health for HV Service

Appendix 2 Edinburgh Postnatal Depression Scale (EPDS) for

Postpartum Depression

Appendix 3 Edinburgh Postnatal Depression Scale (EPDS) Form

Appendix 4 Perinatal Psychiatry Service Referral Form

Appendix 5 Think Family (Whole Family Approach for LPT outline)

Checklist for Review and Approval

Board Adoption Template

Signature Sheet for Approved Policies and Procedures

Table for Process for Monitoring Compliance and

Effectiveness

References and Associated Documents

Page No

6

8

8

8

9

9

12

12

13

15

16

29

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19

20-21

22

25

26

27


Version Control and Summary of Changes

Version number

Version 2

Version 3

Version 4

Version 5

Version 6

Version 7

Version 8

Date

April 2012

May 2012

June 2012

Comments

(description change and amendments)

Fuller title and re-arrangements of the chapter and definition – agreement to include wider interventions.

To include signs and symptoms list indicating mild moderate and severe depression based on a number of symptoms. Acknowledgement of limitation to non-

English speaking clients and how to manage this.

Clearly define the training elements required and evidence based intervention included so that it was n ot a totally passive intervention of solely ‘listening’.

Agree to put a flowchart into VISIO and define it as a pathway.

Highlight the proactive promotion of bonding and attachment via ‘Solihull’ approach.

Define how training will be taken forward and to keep the ‘Think Family’ and FNP as an evidence base interventions.

Strengthen levels of support required and by whom on ‘Roles and Responsibilities’. The intervention section highlights the wider determinants of health.

August 2012 Amended to reflect comments received.

9.8.2013 Title review and re-arrangements of the chapters and definitions. Acknowledgement of limitation to non –

English speaking clients and how to manage this.

Clearly defined the training elements MMH champions DH 2013

Revised pathway flow chart.

Content updated

Stronger integration of the ‘Think Family’ (Whole

Family Approach)



Includes amended flow chart/pathway

 Includes ‘Think Family’ Whole Family and

‘Troubled Family’ into the Pathway



Addresses language barriers by using a likert scale to express the level of feeling unwell.



Includes the symptoms list to help gauge the severity of the illness and how it affect the individual.


All LPT Policies can be provided in large print or Braille formats, if requested, and an interpreting service is available to individuals of different nationalities who require them.

Did you print this document yourself?

Please be advised that the Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version.

For further information contact:

Filippa Howells

Practice Educator: filippa.howells@leicspart.nhs.uk

Mandy Amin

Practice Educator: mandy.amin@leicspart.nhs.uk


Antenatal

Perinatal

Whooley

FNP

Definitions and Abbreviations that apply to this Policy

This is described as the period between conception and birth. The care provided during this period is varied in nature, but focuses on assessing whether the unborn baby is developing normally as well as monitoring the health of the mother http://www.drfosterhealth.co.uk/ medical dictionary

The perinatal period begins from the onset of pregnancy and extends to a year after birth.

The Whooley questions referred to in this document are named after

Dr Mary Whooley whose research in 1997 focused on the detection and treatment of depression in patients (screening of Veterans from the Vietnam War) (screening tool)

Family Nurse Partnership

– evidence based programme for teenage young parents (American Model).

E.I.S. Early Implementer Site (DH) programme.

Think Family This term refers to a variety of interventions with the focus on the effect of parental mental illness (PMI) on wider family members (in

LPT) and with child focus being paramount.

Think Family

Whole

Family

Approach

This is an LPT led piece of work offering early identification and intervention to support

‘children of parent’s with mental illness’.

(COPMI)

Think Family

– Troubled

Families

Agenda

This approach is led by the Local Authority which is government backed with payment by results. There is a criteria for receiving this level of service;



Criminal behaviour



Anti-social behaviour,



Being out of work



School attendance

EPDS also known as

EPNDS

This term refers to the Edinburgh Postnatal Depression Scale. It is an additional established evidence based tool which is to be used by skilled trained staff as part of a full assessment to support the screening identification and management of perinatal maternal mental health.

Listening

Visit

A listening visit gives individuals an opportunity to have their emotions ‘contained’ by the professionals involved. In addition it is an opportunity to increase a sense of wellbeing by exploring the issues causing the stressors.



That is non-directive counselling delivered in the home /clinic situation deemed suitable by the professional and acceptable to the service user.



This includes a contract between mother and professional.




Agreed timings are essential.



Positive outcome for mother as the stressors are identified and managed constructively to alleviate possible compounding factors



This should be a time banded piece of work with a view to evaluate the effectiveness of continuation and further referral considered to more appropriate services.

Abbreviations

CPN Community Psychiatric Nurse

CMHT

NICE

CBT

IPT

Community Mental Health Team

National Institute for Clinical Excellence

Cognitive Behaviour Therapy

Interpersonal Psycho Therapy

OCD

PD

HV

CNN

Obsessive Compulsive Disorder

Personality Disorder

Health Visitor

Community Nursery Nurse

Perinatal Maternal Mental Health PMMH


Equality Statement

Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and advances equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation.

In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including policy development, review and implementation.

1.0 Corporate Responsibilities and Governance

1.1.1The Trust Board has a legal responsibility for ensuring this Trust policy is effectively carried out.

1.1.2 Trust Board should have key responsibility for partnership alignment with key stakeholders (including CCG, LETBS, LPT, Patient Public involvement and health watch) and ratifying this policy.

1.1.3 The Directors and Heads of Service are responsible for ensuring that staff are supported to access maternal mental health training and updates.

1.1.4 Managers and Team Leaders will be responsible for ensuring the staff competencies are reviewed through personal development review which demonstrates evidence into the governance process.

1.1.5 It is the individual responsibility of staff to refer to policy and ensure they have the competence to undertake various activities screening identification, management and treatment.

2.0 Monitoring Compliance and Effectiveness

2.1 Building upon existing audit.

Clinical audit cycle must be built in order that compliance and effectiveness is clearly demonstrated. Monitoring tools must be built in to all procedural documents in order that compliance and effectiveness can be demonstrated.

2.2 Ensure a baseline audit prior to the commencement of the PMMH training.

Regular audit will then be undertaken as per Trust policy.

Future clinical audits will have to be in line with national indicators including NICE and quality standards.


3.0 Summary

This Policy supports the early intervention of the prediction, detection and management/treatment of mental disorder in women during perinatal period. All staff working within Families, Young P eople and Children’s Services have a duty of care to assess prospective mothers for possible signs of mental illness at the earliest opportunity (refer to pathway in appendix 1).

4.0 Introduction

During pregnancy and the year following birth, women may be affected by one or more of a range of mental health problems, including anxiety and depression and postnatal psychotic disorders (though the more serious illnesses are rarer). These are collectively called perinatal mental illnesses.

Studies estimate that more than 1 in 10 women are affected by perinatal mental illness; however maternal mental illness also impacts on the infant and the rest of their families and pose an important public health challenge. (See appendix 5)

Maternal mental illness has important consequences for the impact on infant health and future behaviour and learning, and is one of the key factors determining life chances for children. Early identification, support and treatment can prevent the onset and escalation of maternal mental illness and limit the impact on the family to improve the wellbeing, health and achievement of the child (Hogg, 2013).

Mental Health for Children and Adolescents, Adults and Older Adults are considered separately in relevant guidance documents for LPT.

4.1 Facts, figures and trends



10% of all recently delivered women experience a mild or minor depressive illness (4.3 below)



Between 3% and 5% of delivered women meet the criteria for moderate to severe depressive illness as assessed by national and international studies.



2 per thousand delivered women are admitted to hospital with puerperal psychosis



Women with a history of obsessive compulsive disorders, social anxiety and panic disorder are at risk of relapse in the postnatal period.



There is gathering evidence that traumatic childbirth can cause posttraumatic stress disorder.



Antenatal mental illness is becoming more widely researched, highlighting that 15% of women will suffer from a psychiatric illness in the first trimester of pregnancy – mostly anxiety and depression



Baby Blues – This is experienced by an average of eight out of ten women, 3 to 4 days after the birth. The symptoms include feeling upset, mood swings, feeling mildly depressed and wanting to cry for no particular reason. These feelings tend to disappear after a few days.




Postnatal mental illness often occurs four to six weeks after birth, generally resembling the baby blues at first but is more intense and longer lasting. It can take up to 12 months to present. (RCN, 2013)

4.2 Risk factors associated with increased risk of perinatal mental illnesses



History of mental illness



Family history of mental illness



Antenatal psychological disturbance – e.g. anxiety or depression



Lone parent or poor couple relationships



Low levels of social support



Stressful life events



Low social status



Teenage parenthood



Early emotional trauma/childhood abuse



Unwanted pregnancy

(Hogg, 2013)

4.3 Indicators Regarding Severity

For most families the birth of a child is a joyous occasion; bringing new hope for the future. But, for some, events take a difficult turn a few weeks after birth (or sometimes before birth), when mothers start to feel one or more of the following symptoms:



Low mood/miserable most of the time



Constantly exhausted



Feeling unable to cope



Feeling guilty about not being able to cope about



not loving the baby enough



Overwhelming anxiety about the baby



Tearful for no reason



Difficulty in sleeping



No appetite or the urge to eat



Difficulties in bonding with the baby



Difficulties in their relationship with their partner



Low energy levels



Low sex drive



Withdrawal from family or friends

These are the most common symptoms for postnatal depression and can lead to a period of considerable uncertainty, anxiety and disruption. These are not just baby blues. ‘Baby blues’ is experienced by an average of eight out of ten women three or four days after birth and the symptoms include feeling upset, mood swings, being mildly depressed and wanting to cry for no particular reason. These feelings tend to disappear within a few days (ten days) after birth. Conversely, postnatal depression is an illness which occurs between four and six weeks after birth, resembles the symptoms of ‘baby blues’ at first, but is more intense and longer lasting.

If a new mother is experiencing around three of the above symptoms, she is considered to have mild postnatal depression. Having five or six of the symptoms is


considered moderate postnatal depression, and experiencing more than five or six is considered severe postnatal depression.(ref: www.givemestrength.org.uk)

4.4 The impact of perinatal mental illness



Mental illness is one of the leading causes of maternal deaths in the UK. The number of new mothers committing suicide during pregnancy, or in the 6 months after, has not fallen over the past decade. Psychiatric disorder is also associated with maternal deaths from other causes. (Oates, 2011)



Relapse or recurrence of previous post-partum mental illness is well established and believed to be a risk of between 33% and 55%.



Research shows that perinatal mental illness, most commonly depression, increases the likelihood that:



The baby will be premature or have a low birth weight



The baby may not develop a secure attachment relationship with the

mother



The child will experience behavioural, social or learning difficulties



The child will develop depression in adolescence (CHIMAT)

Maternal depression increases the risk of mental illness in children to the extent that they are five times more likely to have a mental health problem, more than three times more likely to have an emotional problem that persists for at least three years and almost seven times more likely to have conduct problems that persist for at least three years (DH, 2011).


5 Service Delivery

Universal Service

These are services for all families. Health visitors deliver the Healthy Child Programme to ensure a health start for children and families, including immunisations, health and development checks, support for parents and access to a range of community services/resources. The current health visitor contacts in the first year include:



Antenatal



New birth visit



6 weeks



10 months to 1 Year

5.1 Universal Plus

Targeted according to assessed or expressed needs, universal plus gives a rapid response from the health visiting team when families need specific expert help, for example all women identified with a mild to moderate mental health problems to be offered a range of support. For example, wellbeing advice, short term guided self-help such as solution focus approaches, motivational interviewing, cognitive behaviour therapy, ‘Think Family’ Whole Family Approach, (appendix 5) promotional interviewing, medication and baby massage. (Guidance (DH 2012) (Appendix 1)

5.2 Universal Partnership Plus

Targeted according to identified need. Universal Partnership Plus provides on-going support from the team or family nurse partnership plus range of local services working together with families to deal with more complex issues over a period of time. These include services from Sure Start Children’s Centres, the third sector, specialist mental health services, GP, housing, welfare and social care. (Appendix 1)

5.3 Safeguarding

This is a high level core objective. Safeguarding is of paramount importance and local areas need to ensure there are clear protocols in place, which offer clarity regarding the roles and responsibilities of health visitors and midwives.

6.0 Purpose

This document supports national strategy for Health Visiting and the Healthy Child programme (DH 2009) supporting mothers during perinatal period and extending to one year post delivery. This also includes use of assessment tools e.g. Whooley questions (NICE), (EPDS) Edinburgh Postnatal Scale as per LPT Standard

Operational Procedures (2012)(SOP)

Prediction and Detection

At a woman’s first contact with services in both the antenatal and the postnatal periods, all health care professionals should ask questions about:



Past or present severe mental illness including schizophrenia, bipolar disorder, puerperal /psychosis and severe depression.



Previous treatment by a psychiatrist/specialist mental health team including inpatient care.



A family history of perinatal mental illness (including puerperal psychosis).




Other specific predictors, such as poor relationships with her partner, should not be used for the routine prediction of the development of the mental disorder. (NICE,45)

At a woman’s first contact with the health visiting service at the antenatal contact and in the postnatal period (at new birth visit and 6 weeks), health care professionals should ask two questions to identify possible depression. The woman should be informed of the reasons for asking the NICE 2007 questions and what is recorded on her records. Consent must be obtained in-line with Leicestershire Partnership Trust protocols with due regard to safeguarding and vulnerable adult priorities

Questions



During the past month, have you often been bothered by feeling down, depresses or hopeless?



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

A third question should be considered if the woman answers “yes” to either of the initial questions.



Is this something you feel you need or want help with? (NICE, 45)



The health visitor may also use the EPDS tool at this stage

When asking these questions the practitioner should consider the following;



The practitioner should ensure privacy



If there are language/cultural or communication difficulties that would make it difficult to ask the ‘Whooley’ questions verbatim, other methods of assessing maternal mental health should be considered. For example on a scale of 1 to 10 how are you feeling (10 being the worst) Many cultures express their emotional distress through physical symptoms.



If any serious mental health problems are identified women should be referred to their GP please see Pathway (appendix 6)



A risk assessment needs to be made to determine whether the mother is at risk of harming herself or her children. This should be done using the knowledge and skill acquired via the MMH training with the help of the various recommended assessment tools to help support your clinical judgment. (See pathway appendix 6)



If a woman has a pre-existing mental illness, she may need to continue input from the CMHT

7.0 Roles and Responsibilities

Evidence based mandatory specialist training and education for health visitors in early assessment, screening, treatment and management of postnatal depression is essential. All health visitors are expected to keep up to date with this sphere of practice. The health visitors will remain the key named health professional and will undertake any on-going assessments. It will be the Health V isitor’s clinical decision to refer to GP, other agencies, specialist and other support services, such as MIMS.


Standards to be achieved in the development of procedural documents

For Nursery Nurses (within the health visitor team) to be able to screen mothers at any contact where they may see the mother during the first year, for example at a weaning teaching session ; by appropriately asking the ‘Whooley’ questions they must be competent in interpreting the non-verbal responses as well as the verbal response and recording and reporting back any factors to the health visitor. They must not undertake this role unless they have undertaken the training.

The health visitors must respond in a timely manner to make an assessment of the predictive risk factors taking into account historical as well as present indicators of maternal mental health; including wider determinants of health that may be compounding the issues involved. The HV must take appropriate action to address the various issues documenting the rationale and action plans in concordance with the client and child/children being paramount and central in line with LSCB and early intervention expectation.

Mandatory Training



All Health Visitors will receive a two day Perinatal Maternal Mental Health recognised training programme as outlined nationally by Department of Health

(DH 2013) for Health visitors. Trainers who deliver the training will have undertaken the official training package (PND Champions

– IHV 2013, DH

2013).



All Health Visitors are expected to keep up to date with this sphere of practice with their continual practice development (The Code, Nursing Midwifery Council

2008)



Community Child Health Nurse and Community Nursery Nurse will receive one day (Day 1) awareness training to support HV’s on early screening and referring to family health visitors

Supervision

 HV’s can access specialist clinical supervision. (LPT Clinical Supervision

Policy, 2012)



Partnership alignment with perinatal psychiatric team to provide joint specialist supervision with approved PND champion trainers. This supervision sits in line with existing trust’s supervision policy.



Any health professional that requires additional support must seek advice and support from their line manager or named nurse if required.


Appendix 1

Pathway for Identification, Screening, Management and Treatment of Perinatal Maternal

Mental Health for Health Visiting Services.

Universal Healthy Child Programme Contacts

Assessment as per Standard Operating Procedure.

Low Risk

(Universal)

Moderate Risk

(Universal Plus)



Agreed package of care



Up to 4-6 listening visits



Liaise with GP



Offer other support activities local to the

Neighbourhood

Monitor progress using professional judgment in line with Perinatal Mental

Health Guidelines using

Whooley Questions, EPDS

High Risk (Universal

Partnership Plus)

Emergency action:

Tel: 0300 3001010

Assess the risk of suicide

Get immediate specialist advice from

GP or Crisis team.

Take appropriate action:

Liaise with GP

CPN, CMHT, and

Psychiatrist and agree lead professional

No Improvement, refer to GP/Health Visitors can refer to Perinatal

Psychiatry Service

(appendix 4) using their professional judgment and a clear rationale.

The GP should always be notified

Situation improved / resolved - back to

Universal Services

Non-Emergency

Action

Liaise with GP within 24 hours

Liaise with

Psychiatric services as required

Mother’s mental health should be assessed at all Universal Contacts in the perinatal period


Appendix 2

Edinburgh Postnatal Depression Scale (EPDS) for Postpartum Depression

Edinburgh Postnatal Depression Scale (EPDS) was developed by J.L. Cox and J.M.

Holden in 1987 for screening postpartum women in outpatient, home visiting settings, or at the 6 – 8 week postpartum examination. It has been utilised among numerous populations, including USA and Spain. The scale has since been validated, and evidence from a number of research studies has confirmed the tool to be both reliable and sensitive in detecting depression.

The EPDS consists of 10 questions and can usually be completed in less than 5 minutes.

Validation studies have utilised various threshold scores in determining which women were positive and in need of referral. Cut – off scores range from 9 – 13 points. A woman scoring

9 or more points or indicating any suicidal intention

– that is, she scores 1 or higher on question 10 – should be referred immediately.

The EPDS score should not override clinical judgement. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week. In doubtful cases it may be useful to repeat the tool after 2 weeks.

The scale will not detect mothers with anxiety neuroses, phobias, or personality disorders.

SCORING

Questions 1, 2, and 4 (without an *) are scored 0, 1, 2, or 3, with the top score as a 0 and the bottom box scored as a 3.

Question 3 and 5-10 (marked with an *) are reverse – scored, with the top box scored as a 3 and the bottom box as 0.

Maximum score: 30

Possible Depression: 10 or higher

Always look at question 10, which indicates suicidal thoughts. If this is highlighted immediate action is required

INSTRUCTIONS

1. The mother is asked to underline 1 of 4 possible responses that comes the closest to how she has been feeling the previous 7 days.

2. All 10 items must be completed.

3. Care should be taken to avoid the possibility of the mother discussing her answers with others.

4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading.

*Source: Cox JL, Holden JM, Sagovsky R. Detection of Postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. BR J Psychiatry. 1987;150:782-786.

Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title, and the source of the paper in all reproduced copies.


Appendix 3

Edinburgh Postnatal Depression Scale (EPDS) Form

Name:____________________________________

Address:__________________________________

Your Date of Birth:__________________________

Baby’s Date of Birth:________________________

Phone:___________________________________

SIMPLE QUESTION:

As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

Here is an example, already completed.

□

I have felt happy:

□

Yes, all of the time

□

Yes, most of the time

□

No, not very often

□

No, not at all

ₓ

This would mean: “I have felt happy most of the time” during the past week. Please complete the other questions in the same way.

In the past 7 days:

I have been able to laugh and see the funny side of things

□

As much as I always could

□

Not quite so much now

□

Definitely less than I used to

□

Not at all

I have looked forward with enjoyment to things

□

As much as I ever did

□

Rather less than I used to

□

Definitely less than I used to

□

Hardly at all

I have blamed myself unnecessarily when things went wrong

□


□

Yes, some of the time

□

Not very often

□

No, never

I have been anxious or worried for no good reason

□

No, not at all

□

Hardly ever

□

Yes, sometimes

□

Yes, very often


I have felt scared or panicky for no good reason

□

Yes, quite a lot

□

Yes, sometimes

□

No, not much

□

No, not at all

Things have been getting on top of me

□ Yes, most of the time I haven’t been able to cope at all

□ Yes, sometimes I haven’t been coping as well as usual

□

No, most of the time I have coped quite well

□

No, I have been coping as well as ever

I have been so unhappy that I have had difficulty sleeping

□


□

Yes, sometimes

□

No, most of the time I have coped quite well

□

No, I have been coping as well as ever

I have felt sad or miserable

□


□

Yes, quite often

□

Not very often

□

No, not at all

I have been so unhappy that I have been crying

□


□

Yes, quite often

□

Only occasionally

□

No, never

The thought of harming myself has occurred to me

□

Yes, quite often

□

Sometimes

□

Hardly ever

Administered/Reviewed

By:__________________________________

Date:_________________________________


Appendix 4

PERINATAL PSYCHIATRY SERVICE REFERRAL FORM

Request for: Maternity ward assessment / Out-Patient appointment (Please delete as appropriate)

PLEASE COMPLETE ALL THE SECTIONS BELOW IN DETAIL AND IN BLOCK LETTERS

Title: ………. Surname:…………………… GP Name:……………………………………...

Forename:…………………………………... GP Address…………………………..…….....

Address:…………………………………….. ………………………………………….…….....

………………………………………………… ………………………………………………......

Patient’s Postcode:………………………. GP’s Post code:……………………………….

Patient’s Phone No:……………………… GP’s Phone No:……………………..……......

Dob:………………………………………… NHS No……………………………….…….......

Ethnicity:…………………………………… Weeks Pregnant/Postnatal:.…………….......

Religion:……………………………………. Expected date of delivery:…………………..

Marital Status:…………………………….. Expected place of delivery:…………………

Main Language:…………………………… Translator Needed: Yes / No

Current Medication:…………………………………………………………………………………

Reason for Referral (Please continue on separate sheet if necessary):

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

Referred by: GP / Midwife / Consultant / HV / Other…………

Name of referrer:……………………………………………

Contact Address:……………………………………………

…………………………………………………………………

Contact Phone No……………………Date……………………

.

Please fax completed form to:

O116 2314833

Dr R Lazarus

Consultant, Perinatal Psychiatry

Farm Lodge, c/o Bradgate Unit

Glenfield Hospital

Tel. 0116 2256846


Appendix 5

Think Family (Whole Family Approach)

Think Family/Whole Family: Supporting Mentally Ill Parents and their Children

Significance for Maternal Mental Health and Health Visitors Practice

(Summary document for inclusion in the Perinatal Maternal Mental Health Guidance document for Health Visitors)

Leicestershire Partnership Trust (LPT) Think Family/Whole Family Approach (definition): An

Approach used to support Parents with Mental Illness and their Children through multiagency collaboration and work with the whole family

Lead: Dr Lina Gatsou, Consultant Child and Adolescent Psychiatrist and LPT Named Doctor for Safeguarding Children

Summary of theory, research, and relevant policies:

Parental Mental Illness is a family matter – the presence of a parent and especially a mother with mental illness in the family with dependent children may lead to many alterations in its system

– such as changes in family structure and interpersonal relationships that can cause adverse outcomes for children (Rose et al., 2002). Several studies indicate that children where a mother has a mental illness may be at twice the risk of developing a mental illness diagnosis compared to other children (Black et al., 2003; Park et al., 2003; Cunningham et al., 2004; Leschied et al., 2005; Edwards et al., 2006) and might face a range of behavioural, interpersonal, academic and other difficulties (Rutter & Quinton 1984; Farahati et al. 2003;

Maughan et al. 2007; Reupert & Maybery 2007; Reupert et al. 2011). In turn

– since maternal and children’s mental health and emotional wellbeing are intertwined and closely related, particularly during the early years of child’s life – difficulties with parenting, mother–child relationship, and children’s behavioral, emotional and social difficulties can cause worsening of the maternal mental health (Falkov, 2012). Similarly, the NICE Clinical Guideline 45:

‘Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance’ (2007) states: ”Mental disorders during pregnancy and the post natal period can have serious consequences for the health and wellbeing of a mother and her baby, as well for her partner and other family members”.


In conclusion, any attempt to improve the life chances for the mentally ill mothers and their babies must consider their family context and must be based on a good understanding of the needs of children and their mentally ill parents (Falkov, Royal College of Psychiatrists, 2011).

The above noted issues surrounding living with a mother with mental illness emphasise the need for programmes that recognise parental responsibilities of adults with mental illness and assess and support the whole family (Oscouie et al., 2011). Such programs have benefits for the parent with mental illness, the children, and other family members, and they can reduce future costs to the health care system (Mi-halopoulos, Magnus, Carter, & Vostanis, 2004).

Implementing such programs can improve medication adherence and reduce symptom relapse of the parents with mental illness (Re-upert, Green, & Maybery, 2008); in addition, by working on childparent interactions, such programs can reduce the child’s burden and eventually improve their functioning (Miklowitz, George, Richards, Simo¬neau, & Suddath,

2003) and prevent further decline in their emotional wellbeing.

Leicestershire Partnership Trust approach in supporting mentally ill parents and their children has been named Think Family/ Whole Family Approach. The development of the programme started in 2010, and its implementation started in 2011. This approach is crucial in supporting maternal mental health and its relevant elements to the health visitors practice, in summarised form, are the following:

1. Strategic Development: Think Family /Whole Family Strategy and Think Family /Whole

Family Divisional Action Plans (2011/2012)

2. Screening, Assessment and Service Delivery Review for Parents with Mental Illness and their Children: Think Family/ Whole Family Audit of CAMHS, AMHS and LD

(2012-2013)

•

•

•

3. Workforce Development and Training: Think Family / Whole Family Training and

Intervention

Basic training incorporated in the LPT Induction & Safeguarding Training / Interagency

Training for all LPT staff (started in 2011)

½ day Awareness Training for newly qualified and existing Health Visitors (started in

2012)

2-day HIEC Think Family/ Whole Family Multi-agency Training and Family Intervention

(100 multi-agency professionals – and amongst them a substantial number of HV – have been trained in 2012); ongoing role and roll out of the training is being discussed

(LPT safeguarding and divisional leads)

February 2014

Dr Lina Gatsou (Consultant Child and Adolescent Psychiatrist and LPT Named Doctor for

Safeguarding Children)

Filippa Howells (Practice Educator for FYP&C)


Checklist for the Review and Approval of Procedural Document

To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.

Title of document being reviewed:

Yes/No/Not applicable

Comments

Will any sections of this Policy satisfy one or more criteria of the NHSLA Risk Management Standards?*

If Yes – Have you attached the relevant self-assessment(s) for those criteria as an appendix?*

* for further guidance consult the Trust Lead for Corporate Risk Assurance:

Richard.Apps@leicspart.nhs.uk

1. Title

2.

Is the title clear and unambiguous?

Is it clear whether the document is a guideline, policy, protocol or standard?

Key Points / Changes to the Policy

Yes

Yes

States it is guidance on the title

3. Rationale

4.

5.

Are reasons for development of the document stated?

Development Process

Does the front page include a sentence which summarises the contents of the policy?

Is the method described in brief?

Are people invited in the development identified?

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?

Is there evidence of consultation with stakeholders and users? (with representatives from all relevant protected characteristics)

Content

Is the objective of the document clear?

Is the target population clear and unambiguous?

Are the relevant CQC outcomes identified?

Are the intended outcomes described?

Yes

Yes

N/A

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Develop proficiencies in this specialised area of work

It is in the title

Flowchart

Wide range evident

Audit undertaken in the

County

In the introduction

Training will reinforce this

Care

Pathway

From A3 copy


Are the statements clear and unambiguous? Yes

6. Evidence Base

Is the type of evidence to support the document identified explicitly?

Are key references cited?

Are the references cited in full?

Is there evidence to show that there has been due regard under the Equality Act 2010, and in working towards the

Trust’s equality objectives? (e.g. attach the equality analysis as summary of evidence)

Are supporting documents referenced?

Yes

Yes

Yes

7. Approval

Does the document identify with committee/group will approve it?

If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?

8. Dissemination and Implementation

Is there an outline/plan to identify how this will be done?

Does the plan include the necessary training/support to ensure compliance?

9. Document Control

Does the document identify where it will be held?

Have archiving arrangements for superseded documents been addressed?

10. Process to Monitor Compliance and Effectiveness

Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document?

Is there a plan to review or audit compliance with the document?

11. Review Date

Is the review date identified? 3 years. 2016

12. Overall Responsibility for the Document

Is it implicit who will be responsible for co-ordinating the dissemination, implementation and review of the document?

Is the frequency of review identified? If so it is acceptable?

No

Individual Approval

Perinatal Maternal Mental Health Guidance to support Health Visitors and their Teams

It has been widely circulated

It is fully referenced

Page 23

If you are happy to approve this document, please sign and date it and forward to the chair of the committee/group where it will receive final approval.

Name Date

Signature

Committee Approval

If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisation’s database of approved documents.

Name Date

Signature


Board Adoption Template

The following documents have been reviewed by the Policy Group to ensure compliance with relevant standards and legislation.

Name of Policy Committee Responsible for Approving Policy

Identification, screening, treatment and referral of perinatal MMH Policy for the HR

Service.

Date Policies Adopted by Board:


Staff Authorise Document Receipt

Signature Sheet for Approved Policies and Procedures

Name of Policy:

Statement:

I have read the above and understand its contents. If there any difficulties regarding implementation or any training needs, I have raised and resolved these with my line manager.

I agree to implement the content of the above policy.

Staff Name Signature Date

On completion this sheet will be kept by the line manager and become part of the training record.


Table for Process for Monitoring Compliance and Effectiveness

Systems

Criteria Measurables Frequency

Monitoring and/or Audit

Reporting to

P.A.E. Systems in place to ensure that

Policy Leads follow the process outline in this guidance document

Systems in place for:

Distribution (including version control)

Monitoring of implementation

Plan

Implementation

Timely review of all policies and procedures including equality analysis

Archiving/Retention/Destruction of policies

Criteria for preliminary approval are met as per

Checklist

Database showing status of all current policies

How implemented?

Gaps in information

Timescales met?

How many achieved?

Result of Audit

As required by policy review

Quarterly P.A.E.


Action Plan / Monitoring

Monitoring/Action Plan

Monitoring/Action Plan

Systems

Criteria

Systems in place to monitor comments received regarding the viability of policy in the services

Measurables

Number of comments received

Frequency

Quarterly

Monitoring and/or Audit

Reporting to

P.A.E.

Action Plan/Monitoring

Action Plan to address comments


8.0 References & Associated Documentation

This policy was drafted with reference to the following:

Adams H (March 2012) Maternal Mental Health Pathway, can Health Visitors succeed in delivering maternal mental health service in the absence of fidelity to a model/pathway?

Barlow J, Coe C (2013) New ways of working: Promotional interviewing in health visiting practice. Journal of Health Visiting, 1(1), p44-50

Brugha TS, Morrell CJ, Slade P and Walters SJ (2011)Universal prevention of depression in women postnatally, cluster randomized trial evidence in primary care. Psychological

Medicine, v295, p449-507

Cowley S, Whittaker K, Grigulis A, Malone M, Donetto S, Wood H, Morrow E and Maben

J (2013)Why Health Visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. London: National

Nursing Research Unit, King’s College London.

Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression.

Development of the 10 item Edinburgh PND scale. BR J Psychiatry 150: 782-6

Cubison J and Munroe J (2005) Acceptability of using the EPDS as a screening tool for depression in the postnatal period. In Screening for Perinatal Depression (eds C

Henshaw and S Elliot), London: Jessica Kingsley Publishers.

Department of Health (DH) (2009) Healthy Child Programme: pregnancy and the

First five years of life. London: DH

Department of Health (2009) Healthy Child Programme; Pregnancy and the first five years of life

Department of Health (2011) No Health without Mental Health: A cross-Government mental health outcomes strategy for people of all ages. Analysis of the Impact on Equality

(AIE) Annex B - Evidence Base Supporting document

Dr Foster http://en.wikipedia.org/wiki/Category:Department_of_Health_(United_Kingdom)

Hogg,S. (2013) Prevention in Mind All Babies Count: Spotlight on Perinatal Mental Health.

NSPCC

Joint Commissioning Panel for Mental Health (2012) Guidance for commissioners of perinatal and mental health services

Leicestershire PT., Clinical Supervision Policy (2012)

Lewis G (ed) (2011) Saving Mothers’ Lives. Reviewing maternal deaths to make motherhood safer: 2006 –2008. Confidential Enquiries into Maternal Deaths in the UK –

Eighth report. Centre for Maternal and Child Enquiries (CMACE)

Murray L et al (2011)Maternal Postnatal depression and the development of depression in offspring up to 16 years of age. J of the American Academy of Child and Adolescent

Psychiatry. 50L5) 460-470

National Institute for Health and Clinical Excellence (2007) Antenatal and postnatal mental health: clinical management and service guidance. London NICE


National Institute for Health and Excellence (NICE) (2007) Antenatal and postnatal mental health: Clinical management and service guidance CG45.

National Mental Health Development Unit (2011) National Perinatal Mental Health Project

Report Perinatal Mental Health of Black and Minority Ethnic Women: A Review of Current

Provision in England, Scotland and Wales.

Nursing and Midwifery Council 2008, The Code, NMC

Oates M., & Cantwell, R. (2011). Deaths from psychiatric causes. Centre for Maternal and

Child Enquiries (CMACE), BJOG 118 (Suppl. 1) 132-203.

Perinatal mental health; Key aspects and evidence base Royal College of Nursing

Available at http://www.rcn.org.uk/development/communities/rcn_forum_communities/mental_health/f orums/womens_mental_health_group/specialist_pages_on_best_practice/perinatal_ment al_health.%20Accessed%20July%202013

Royal College of Obstetricians and Gynaecologists (RCOG) (2011) Management of women with mental health issues during pregnancy and the postnatal period. Good practice No.14

Royal College of Obstetricians and Gynaecologists. TOG release: Managing teenage pregnancy. Available at http://www.rcog.org.uk/news/tog-release-managing-teenagepregnancy. Accessed July 2013

Whooley MA, Avins AL, Miranda J, Browner WS (1997) Case finding instruments for depression. Two questions are as good as many. J Gen Intern Med 12 (7): 439 -45

Wisner K et al (2013)Onset Timing, Thoughts of Self-harm, and Diagnoses in Postpartum

Women with Screen-Positive Depression Findings, JAMA Psychiatry, p1-9.

Cunningham, J., Harris, G., Vostanis, P., Oyebode, F. & Blissett, J. (2004) Children of mothers with mental illness: attachment, emotional and behavioural problems. Early Child

Development and Care, 174, 639

–650

Park, R.J., Senior, R. & Stein, A. (2003) The offspring of mothers with eating disorders.

European Child & Adolescent Psychiatry, 12, 110 –119.

Maughan, A., Cicchetti, D., Toth, S. & Rogosch, F. (2007) Early-occurring maternal depression and mat ernal negativity in predicting young children’s emotion regulation and socioemotional difficulties. Journal of Abnormal Child Psychology, 35, 685

–703.

Falkov A., (2011) Parents as Patients, Royal College of Psychiatrists, London

Oscouie, F. Zeigham, R. Joolaee, S. (2011) Outcomes of Parental Mental illness on

Children; A qualitative study from Iran. Journal of Psychosocial Nursing, 49: 9, 2011

Rutter, M. & Quinton, D. (1984) Parental psychiatric disorder: effects on children.

Psychological Medicine, 14, 853 –880

Reupert, A.E. & Maybery, D.J. (2007) Families affected by parental mental illness: issues


and intervention points for stakeholders. American Journal of Orthopsychiatry, 77, 362 –

369

Reupert, A. Foster, K. Maybery, D. Eddy, K. Fudge, E (2011) Keeping families and children in mind: an evaluation of a web-based workforce resource, Child and Family

Social Work. Child and Family Social Work, 16, 192 –200


Think Family - Leicestershire Partnership NHS Trust

Perinatal Maternal Mental Health

Guidance to Support Health Visitors and their

Teams

All LPT Policies can be provided in large print or Braille formats, if requested, and an interpreting service is available to individuals of different nationalities who require them.

ₓ

PERINATAL PSYCHIATRY SERVICE REFERRAL FORM

Think Family (Whole Family Approach)

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Think Family - Leicestershire Partnership NHS Trust

Perinatal Maternal Mental Health

Guidance to Support Health Visitors and their

Teams

All LPT Policies can be provided in large print or Braille formats, if requested, and an interpreting service is available to individuals of different nationalities who require them.

ₓ

PERINATAL PSYCHIATRY SERVICE REFERRAL FORM

Think Family (Whole Family Approach)

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