NICE Antenatal and
postnatal mental health:
Maternity and mental
health ; Making a
difference 2nd Oct 07
Welcome and introduction to
the guideline
Dave Tomson and Stephen
Pilling
Aims for today



Focussing on the challenges of implementation
and making it work for mothers, children and
families
Draw not just on expertise of workshop leaders
but on YOUR knowledge and skills
Share good practice and draw out energy and
ideas to support implementation
Conference design



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‘Proper’ workshops of 90 minutes – led and
facilitated
Interspersed with keynote presentations
Summary of key ideas
Feedback of main learning to all participants
after the conference
The Scope




Mental healthcare for women who are
considering pregnancy, pregnant or in the
first postnatal year
Covers a broad range of disorders
Balances risk and benefits
Develops more effective care pathways and
services
Particular features of this
guideline
Caveats
 Limited evidence base
 Draws on other guidance – problems same,
context different

Says little (not enough) about families
Providing andof
using
information
Principles
care
effectively as always but
A trusting relationship – challenge for some
mums
Supporting family and carers – affects not
just mum
Discussing risks – not just mum but fetus
Key recommendation
- prediction and detection
ALL staff need to be aware of the importance of mental well being
and the impact of all mental disorder (not just depression) in
pregnancy and postnatal period.
IDENTIFY significant MH history and ACT on information
Routine attempts to identify CURRENT depression using
Whooley and Arroll Help questions both antenatally and
twice postnatally
As part of subsequent assessment or for routine monitoring
of outcomes consider using self report measures such as
EPDS, HADs or PHQ9
Key recommendation
- referral and initial care
If you identify either current or past mental illness then do
something.
Acknowledge and take seriously
Refer including to specialists if necessary
If a woman has history of severe disorder or current mental illness,
then ask about mental health at every contact ( just as you would
measure BP)
Clearly specified pathways, training and supervision for staff at all
levels – effective timely and patient centred pathways
Key recommendation –
preventing mental disorders
Detect current disorder ( including sub-threshold illness) rather than
focus on predictors of future illness
Treat sub threshold symptoms –
Psychosocial interventions designed to reduce likelihood of
developing illness should not be used
Do not offer single session formal debriefing
Do not routinely encourage mothers of infants who are stillborn or
die soon after birth to hold the dead infant – ( but don’t dissuade
either if this is what the woman wants)
Key recommendationtreatment
Access to psychological
treatments
Normally within a month
And definitely within 3months
Key Recommendation Treatment
For a woman who develops mild or moderate depression
during pregnancy or the postnatal period
Self help strategies
Non directive counselling delivered at home ( listening visits)
Brief CBT
AND medication if depression persistent/ declines offer of
psychological intervention and understands risks
For a woman with severe/ psychotic illness:
Increased contact with specialist services
Early development of a Care plan
Key recommendation - risk
and prescribing
-More
sophisticated alternative, comprehensive, understandable
and patient centred risk discussions are required
-
Using absolute risk and acknowledge uncertainty about risk
Explain background level of malformations
Checking understanding
Negotiating involvement of carers/ family
Use of risk discussion aids
Use of written or audiotaped recording of discussions
-Advice
about prescribing and stopping prescribing
-Particularly around taking medications and already pregnant
and around breastfeeding
Specific guidance – detailed
On psychotropic medication
On the management of specific disorders where this differs from
existing guidelines
 Has to be read in conjunction with the guidance on risk and
informed consent where possible
Key points:
The threshold for recommending psychological treatments is lower
Don’t always stop drugs because you are thinking of, or have
become, pregnant – there is a risk stopping as well as continuing
medication
Key Recommendation
Clinical networks for the delivery of perinatal mental health services
should be established throughout England and Wales, comprising a
Coordinating board, and able to develop, coordinate and support the delivery
of
Specialist perinatal services in each locality – in areas of high
morbidity these may be separate specialist teams
Access to specialist expertise
Clear referral and management protocols in a stepped framework
Clearly defined pathways of care and clearly defined roles and competencies
for all professional groups involved in the pathway
Each network should have designated MBU service ( 6-12 beds and cover
population of 25-50 000 live births a year
Key
Coordinating centre
Coordinate associated inpatient unit(s)
Coordinating board
Network manager
Local specialist service provision
Protocol development
Patient flow
Information and
education flow
Specialist perinatal services
Local specialist provision
Managing admissions
Consultancy and training to
primary and secondary care
May be separate service or
part of specialist MH service
Primary care services
Local service provision
Assessment and referral
Specialist mental health services
Local service provision
Assessment and referral
Consultancy and advice
Maternity services
Local service provision
Assessment and referral
Current Situation - challenges





Mechanisms at a national level
Unequal distribution of resources ( MBU, community
teams and psychiatrists)
Finance/ Resources
Networks – size, coordination
Complexity – children/ primary care/ maternity/
mental health
Current Situation - challenges




GPs and midwives ever farther apart, with GPs
marginalised in maternity
Health visitors as part of children’s centres, with
GPs marginalised in children’s health
But GPs central in primary care mental health and
prescribing
Maternity Matters –choice and equality partic. focus
on disadvantaged – MH cuts across all
Opportunities and levers




There IS a NICE Guideline!
IAPT – increasing access to psychological
services
Higher profile of mental health in primary and
community settings
Existing networks/ good practice to learn from
The key tasks – clinical

Skills and knowledge and systems





Detection – use of brief questions and tools
Sub-syndromal patients
Discussion of risk and benefit
Records and referral – communication
Effective use of medication
The key tasks – organisational/
commissioning



Development of clinical networks
Identify existing psychological therapies
resource and supplementing this as
appropriate
Strategic decisions about nature of specialist
provision – community teams, Perinatal
psychiatrists, MBUs etc
Implementation – the components
Core business in maternity and primary care
 Specialist and generalist psychiatry – using
the drugs and getting the pathways right
 Psychological therapies
 Networks and beds
These will all be the focus of the workshops

The first steps in implementation –
clinical 1


Helping GPs stay involved in maternity/family
care
Ensuring partnerships between various
stakeholders in primary care – Implementation
team/ project plan


Development of agreed clinical pathway
Excellent communication systems – minimum
data in letters, feedback on performance
The first steps in implementation –
clinical 2



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Training programmes linked to necessary changes
in systems
Review of current tools ( EPDS etc) and
development of new PDAs ( patient discussion aids)
Formularies, pharmacists and up to date Drug
treatment information
Use of correct questions/ subsequent actions at
each stage of pathway
The possible solutions in
implementation - organisational/
commissioning


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Identification/ Audit of existing services and
pathways
Commissioning plan – in partnership with other
commissioners
Identification of leaders and stakeholders including
LA and children’s services
Development of clinical networks
Development of local implementation teams
Summary :First and second
steps in implementation


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Identify leaders/ champions
Allies in psychiatry and Specialist trust
Try and stay engaged with interested GPs
Engage the Childrens Centres/ SURE START etc
Find the commissioner(s)
Multidisciplinary stakeholder group – project team
Start with the vanguard
Develop new care pathways
Find ways of joint learning
Maternity and Mental Health: making a
difference
Tuesday 2nd October 2007
The voice of women and
families
1. Context
2. Some general concerns
3. The APMH Guideline
4. The families
5. Concluding thoughts
1.
Context

My background

Experience of postnatal mental ill
health
2. Some concerns
Woman not considered as an individual in a social
context;
‘One-size-fits-all’ model;
‘Management’ rather than ‘care’.
3. The APMH Guideline
 Patient-centred care
 Organisation of care
Patient-centred care
Listen
Explain
Consult
Listen
Fiona:
I think the most important message I would have for an audience
would be that they listen to women. That women know better than
anybody else does what is important for them and how they are
feeling. And that health practitioners making time, however they can
do it, and not ticking the woman into a box, but listening to her - her
fears, her wishes, her terrors, etc - is one of the most important
things they can do. And the thing that, again and again, they don't
do.
Jane suffered severe anxiety during pregnancy:
I had the assessment while I was still pregnant; it was horrible. Two
men asked me all sorts of questions that were not related to how I was
feeling. I felt very tense and uncomfortable and like a fake who was
wasting their time. Then after 45 minutes they said that there was
nothing wrong with me, that it was just in my personality and that I
would have to live with it. I was devastated because I knew that
something wasn’t right but no one listened. I tried to ignore my
feelings because after all they were professionals, had studied for years
and had to be right........ Now whenever I go to the doctor no matter who
I see I am very honest and keep telling them till they listen.
Elizabeth, who was severely depressed after a
traumatic birth:
The consultant did not seem to understand my feelings at all and
discarded many of the factors that my CPN and I feel are the major
causes of my illness. He decided to change my medication ........ I did
not feel listened to or understood at all, especially when I told him that
it was impossible for me to go out or speak to anyone without my
husband or mum present, yet he told me that it would be a good idea
for me to return to work in 2 weeks’ time.
In contrast, Sue:
A sympathetic GP was very important as were regular
visits from my health visitor and community psychiatric
nurse. The latter spent hours listening to me and
finally I was convinced that I had been ill and was not a
failure.
Explain
Louise:
All I wanted was a hug, sympathy, someone to listen and not
judge me for the way I was feeling, and someone to explain
what was happening to me. Telling someone to pull
themselves together and get on with it is wrong; it is not that
simple and it makes you feel worse.
My perspective:
Needed explanation of physical condition
And explanation of side effects of drugs
Consult
My experience – no consultation with regard to
administration of drugs (general hospital)
I woke on two successive nights having wet the bed,
something which raised my anxiety levels still further. A
lovely night nurse told me that I had been given
largactil, and this had caused me to wet the bed – I
had no idea.
Transportation from a general to a psychiatric
hospital:
I can’t remember what led to the next stage, but I can
remember being in a drugged stupor, and being
transported, with Gareth, by ambulance to the local
psychiatric hospital (different from the first). I didn’t
know I was going there; I thought I was going home.
On arrival I became very confused and distressed.
Please remember:
Listen
Explain
Consult
Organisation of care
Continuity
Anne:
I feel that people with mental health problems need to have continuity of
care throughout the illness. In my opinion it is extremely important to have
a 24-hour emergency contact number for professionals who have
knowledge of your case. I have been advised to go to the local A&E
department if I feel I cannot cope, but this isn’t practical for me as a main
trigger of my symptoms is hospitals! Also it is difficult having to explain
myself over and over again to yet another complete stranger who knows
nothing about my situation.
Gill:
I was told I had a named midwife who would see me
regularly; in the first 5 months I never saw the same
person twice....
Sue:
I saw several psychiatrists and I felt huge decisions
were made about me based on a few scribbled notes.
My care did not feel continuously managed.
Hospital care
General hospital care
Plays important part in mental health
Anne:
Some midwives on the ward expect you to ‘know it all’ and
do not offer advice concerning the new skills of being a
mother. You feel like just ‘another one on the conveyor
belt’ –it could be so much better if you are made to feel
special.
Pauline:
Left alone in a side ward for much of the day, I sought
comfort in my thoughts. I am not, and was not then, in
any way religious, but my maternal grandmother had
been a great believer in a spiritual world, a belief she
tried to instil in her children and grandchildren. I began
to think about her and how her belief helped her cope
with bereavement (husband and children). I began to
think of my mother. It was comforting to imagine that I
could hear her talking to me. And the imagined
gradually became ‘real’.
General psychiatric hospital
Sue:
In hospital it was initially suggested that I changed my
medication and ‘had a rest’, but the new medication made
me twitch and led to me sleeping even less. A member of
staff severely reprimanded me for knocking over a vase
when I was confused. The following night I was found
curled up between the bed and bedside table gouging
holes in my hands with my nails – I was too afraid to ask
for help
Pauline:
Life on the ward was very regimented. I had to line
up to go to OT, I had my mouth checked to make
sure I had swallowed the drugs, and I even had to
have an internal examination because I complained
of being constipated, and they wanted to check that I
was. The other patients just sat around miserably,
unable to make coherent conversation.
Mother and baby unit
Jenny:
I was admitted to the mother and baby unit of a psychiatric hospital,
where I stayed for over 6 weeks. My son was by my side the whole
time.........Having people around really helped, especially meeting other
sufferers. I had been beginning to think I was going insane and I was
the only one who had ever felt like this so it was good to know I wasn’t
the only one. The nurses were very sympathetic and helpful; they
explained what was happening to me and ways to cope without selfharming.
There needs to be:
 Joined-up care;
 Specialist perinatal mental health
service;
 More specialist mother and baby units;
 Inclusivity.
The families
Partners
Sue:
My husband coped amazingly well during my illness. He
experienced the traumatic birth of his son and no one
asked if he was okay. Similarly the events he witnessed
when I became psychotic must have haunted him yet no
one asked if he was fine. No one ever consulted him
about my moods and behaviour.
Helen:
When my son was about 3 months old his father left; he
could no longer cope with me constantly crying. He said
some awful things about how I had made him miserable
and that I was failing as a mother, which just fed into my
guilt and finally tipped me over the edge.
Other adults
and
the children
Concluding
thoughts
The Context





Increased demand for psychological interventions
Established evidence base – NICE
Limited number of specialist therapists
DH Improving Access to Psychological Therapies
Requires increased number of people delivering
treatment in a range of settings
The Challenge



Limited implementation – possible retrenchment
But even when implemented outcomes in routine
practice may be poorer than in clinical trials
(Shadish et al, 2000)
Why –



Trial populations – comorbidities
Setting – specialist, highly resourced clinics
Therapists – curiously absent from discussions
The Therapist Problem 1

Considerable variation in outcome


Brown et al (2005)
 10,000 + patients, 281 therapists
 71 (25%) identified as highly effective
 53% greater improvement
 Not explained by diagnosis, age, sex, severity, prior
treatment history, length of treatment, or therapist
training/experience.
Okiishi et al (2006)
 7,500 + patients, 149 therapists
 Most effective 22.40% recovered 5.20% deteriorated
 Least effective 10.61% recovered 10.56% deteriorated
The Therapist Problem 2




Manual and guidelines – some benefits but overall
10% improvement (Grimshaw et al, 2004)
Increased training – but effects modest (Stein and
Lambert, 1995)
Emphasise supervision – limited evidence (Cape
and Barkham, 2002)
Focus on outcomes – emerging evidence (Lambert
et al, 2001)
The Therapist Problem 3

Focus on what we know to be effective in bringing
about change/good outcomes


The alliance - 0.25 corr. (6% of variance) (Martin et al,
2000)
Lessons from CBT (Roth and Pilling, 2007) – specific
actions (often the ‘concrete’ ones such as session agenda
or homework setting tasks, or helping clients identify and
modify negative automatic thoughts associated with
positive outcomes
Developing a Competence Framework




Assumes that competences associated with
effective delivery of CBT are those found in research
trials which demonstrate efficacy
Yields information about likely “best practice
Identified ‘exemplar’ trials of CBT for people with
depression and with anxiety
Development of the CBT framework is intended as a
prototype for other therapies
Generic Competences in psychological therapy
competences needed to relate to people and
to carry out
any form of psychological intervention
Basic behavioural and cognitive competences
CBT competences used in most CBT interventions
Specific behavioural
and
cognitive techniques
specific techniques
employed in most CBT
interventions
Problem specific CBT skills
Problem A – specific competences needed
to deliver a treatment package for specific
problem presentation A
Problem B – specific competences needed
to deliver a treatment package for specific
problem presentation B
Metacompetences
Competencies used by therapists to work across all these
levels and to adapt CBT to the needs of each individual patient
Ability to implement CBT using a collaborative
approach
Generic therapeutic
competences
knowledge and understanding
of mental health problems
knowledge of, and ability to
operate within, professional
and ethical guidelines
knowledge of a model of
therapy, and the ability to
understand and employ the
model in practice
Basic CBT competences
Specific behavioural and
cognitive therapy
techniques
Problem specific competences
exposure techniques
Specific phobias
applied relaxation & applied
tension
Social Phobia – Heimberg
Social Phobia - Clark
activity monitoring & scheduling
Panic Disorder (with or without
agoraphobia ) - Clark
Panic Disorder (with or without
agoraphobia ) - Barlow
knowledge of basic principles of
CBT and rationale for treatment
knowledge of common cognitive
biases relevant to CBT
knowledge of the role of safetyseeking behaviours
ability to explain and demonstrate
rationale for CBT to client
Guided discovery & Socratic
questioning
using thought records
OCD – Steketee
OCD – Kozac
Metacompetences
Generic metacompetencies
capacity to use clinical
judgment when implementing
treatment models
capacity to adapt interventions
in response to client feedback
capacity to use and respond to
humour
ability to engage client
ability to agree goals for the intervention
ability to foster and maintain a
good therapeutic alliance, and
to grasp the client’s perspective
and ‘world view’
ability to deal with emotional
content of sessions
ability to manage endings
ability to undertake generic
assessment (relevant history
and identifying suitability for
intervention)
ability to make use of
supervision
identifying and working with
safety behaviours
Ability to structure sessions
Sharing responsibility for session
structure & content
ability to adhere to an agreed agenda
ability to plan and to review practice
assignments (‘homework’)
ability to detect, examine and help
client reality test automatic
thoughts/images
ability to elicit key
cognitions/images
ability to identify and help client
modify assumptions, attitudes and
rules
using summaries and feedback to
structure the session
ability to devise a maintenance
cycle and use this to set targets
PTSD - Foa & Rothbaum
PTSD - Resick
PTSD – Ehlers
Depression – High
intensity interventions
Cognitive Therapy – Beck
ability to identify and help client
modify core beliefs
ability to use measures and self
monitoring to guide therapy and to
monitor outcome
GAD – Borkovec
GAD – Dugas/ Ladouceur
GAD – Zinbarg/Craske/Barlow
ability to employ imagery
techniques
ability to plan and conduct
behavioural experiments
Behavioural Activation Jacobson
Depression – Low
intensity interventions
Behavioural Activation
problem solving
ability to end therapy in a planned
manner, and to plan for long-term
maintenance of gains after treatment
ends
ability to develop formulation and
use this to develop treatment plan
/case conceptualisation
1
ability to understand client’s inner
world and response to therapy
Guided CBT self help
CBT specific metacompentencies
capacity to implement
CBT in a manner
consonant with its
underlying philosophy
capacity to formulate and
to apply CBT models to
the individual client
capacity to select and
apply most appropriate
BT & CBT method
capacity to structure
sessions and maintain
appropriate pacing
capacity to manage
obstacles to CBT therapy
Examples of Generic competences
• knowledge and understanding of mental health
problems
• knowledge of, and ability to operate within,
professional and ethical guidelines
• knowledge of a model of therapy, and the ability to
understand and employ the model in practice
• ability to engage client
• ability to foster and maintain a good therapeutic
alliance, and to grasp the client’s perspective and
‘world view’
• ability to deal with emotional content of sessions
Basic CBT competences
ability to structure sessions
ability to share
responsibility for session
structure and content
ability to adhere to an agreed agenda
ability to plan and review practice
assignments
using summaries and feedback to
structure the session
Specific BT and CBT techniques
guided discovery and Socratic questioning
using thought records
identifying & working with safety
behaviours
ability to detect, examine and help
client reality test negative thoughts
/images
etc
Examples of Metacompetences
Generic metacompetences
• capacity to use clinical judgment when implementing
treatment
• capacity to adapt sessions in response to client feedback
CBT specific metacompetences
• capacity to implement CBT in a manner consonant with its
underlying philosophy
• capacity to formulate and apply CBT models to individual
client
• capacity to select and apply most appropriate BT & CBT
method
• capacity to manage obstacles to CBT therapy
Using the Competence Framework





Curriculum for training
Procedure for identifying competent
practice
Developing supervision
Assuring service quality
Commissioning services
High and Low Intensity Interventions

Low intensity interventions



Guided self-help, CCBT, Brief behavioural activation
Self-contained, protocol driven, para-professionals
High intensity interventions


Set in stepped care system
Based on competence framework – again linked to
manuals
Using the Competence Framework

2 DH publications

Competence List and Service User Guide
The competences
required to deliver
effective cognitive and
behavioural therapy for
people with depression
and with anxiety
disorders

Competence map at
www.ucl.ac.uk/CORE/
What can
midwives do?
Yana Richens
What midwives should do?
CEMD 2001 and CEMACH 2004
Maternity standards NSF 2004
NICE Antenatal care 2004
CNST 2002, 2005
All say midwives need to screen.
To plan care, mother and family need:
Why
screen?
-
-
Understandable and consistent information
Support and treatment
Access to specialist care
Embed ‘screening tool’ in booking in process
What
Midwives
can
do?
 Detect those at risk of developing serious
psychiatric illness post-delivery
 Detect those at risk of developing other nonpsychotic conditions post-delivery

Prediction definitely possible for severe
Is mental
prediction
possible?
illness


More difficult in less severe depressive
illnesses
Assist in management of common mental
What
can do?
healthMidwives
problems in pregnancy
 Midwives must refer directly to psychiatric
service
 Management plans/pre-birth planning

 Questions not easy
Problems




Apprehension re. stigma and intrusion
Unable to answer woman’s questions
Lack of understanding of organisation of
psychiatric services
Risk assessment at booking already taking a
long time
Training


Training before using questions
Screening useless without management
plans, referral process and services
Questions
Have you ever had depression before?
Are you feeling low or depressed now?
Questions
Are you feeling worried, panicky or anxious
now?
Have you felt like that in the past?
Questions
Have you ever had bipolar affective disorder
(manic depression)?
Have you ever had any other serious
mental health problems e.g. hearing voices,
psychosis, schizophrenia?
Are you in contact with psychiatric
services?
Questions
Did you have any problems with anxiety or
depression in an earlier pregnancy or after
the baby was born?
Have you ever had puerperal psychosis?
What can midwives do to make
a difference



Always ask women about previous history so
risk can be identified
Management Plan
Liaise with general practitioners to ensure
that all relevant information concerning a
woman’s current or previous psychiatric
history is included in referral letters to the
booking clinic.
Role of the Midwife




Predicting perinatal mental illness
Detecting current mental illness esp.
depression
Referral
Discussion about risks of psychotropic
medication
Is prediction possible?

Prediction definitely possible for severe mental
illness

Ask about: previous or current serious mental illness, previous
treatment in secondary care, family history of severe or perinatal
mental illness

Other factors such as poor relationship with partner
not to be used as tools for prediction.

More difficult in less severe depressive illnesses
Detection





At initial contact and postnatally (4-6 weeks and 3-4
months) ask:
During the past month have you 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 or want help
with?
Referral




Referral to GP if significant concerns
Refer women with severe mental illness to mental
health services. Discuss with woman and her GP.
If current mental disorder or history of severe mental
illness, ask about M.H. at each contact.
Multi-agency/ multi-disciplinary care planning to
include mother and family/carer
Problems




“Postnatal depression”
Serious versus mild
Illness versus social distress
Illness versus substance misuse
High risk women




Postnatal visits
Interpersonal therapy/CBT
Educational programmes for preparation for
parenthood
Do not discharge at 6 hours
Conclusions

Clear risks associated with mental illness in
pregnancy and postnatally

Screening needs to be embedded in routine
practice

Risks can be reduced by early intervention and
planning
 Midwives require training and clinical support
Conclusions

Formal procedures need to be defined.
Antenatal &
Postnatal
Mental Health
Implementing the Guideline
in Primary Care
Claire Hesketh
Why Implement the Guideline?

Mental disorders in pregnancy & postnatal period can have serious
consequences

CEMACH indicates that suicide is the leading cause of maternal death
and is often not appropriately identified or managed

It makes specific recommendations on the identification, treatment and
management of all mental health disorders in these women

It makes specific recommendations about services required to support
effective detection and treatment

Standards for Better Health-C5,D2
How to Implement the Guideline in
Primary Care

Identify a clinical lead

Promote the guideline

Carry out a baseline assessment :compare current activity with the
recommendations to clarify what has to change & who should be
involved

Assess cost

Build an Action Plan

Clinical networks
 Prediction
& detection
-who and how?
Key
Priorities
for Implementation

Treatment options - what & why ?

Organisation of Care-what are clinical
networks?
Prediction & Detection

First contacts allow for identification of current or previous illness

Communications with maternity services must include history of
relevant mental disorder

Routine contacts offer early opportunity for detection of illness

Use of the Whooley questions....plus more... left to judgement of health
professionals

Care planning must incorporate details of current or relevant past
illness...... not just limited to self
Clinical Networks - linked services
across the pathway

Managed by a coordinating board of healthcare professionals,
commissioners and managers, users & carers, covering area of 25,00050,000 live births a year.

specialist multidisciplinary service: direct service provision, consultation
& advice for other services

clear referral & management protocols to ensure effective transfer of
information & continuity of care

clear pathways for users with defined roles & competencies for staff

Specialist perinatal inpatient services closely integrated with community
mental health services

Requires significant inter-organisational co-operation led by
commissioners with commitment & enthusiasm

Clearly specified pathways to assessment & treatment are pivotal

Supervision & training of primary care staff to facilitate detection,
delivery of services and referral on where appropriate

The use of targeted psychosocial interventions facilitated or
delivered by health professionals within primary care

Adaptable services meeting local need & delivering integrated care
Delivery: the clinical network
APMH
Antenatal and postnatal
mental health – primary
care challenges,
solutions and early
successes
Debbie
Sharp
University of Bristol
October 2 2007

Very wide ranging
NICE
clinical guideline 45
All mental health problems




Antenatal and postnatal
Primary and secondary care
Very important



High prevalence
Under detected
Impact on baby,family, friends etc
A critique of the guideline – a
primary care perspective on
 Prediction and detection
implementation




Psychological treatments
Explaining risks
Management of depression
Organisation of care
Prediction and detection

Most antenatal care takes place in primary
care




Most women see GP with positive preg test
GP will know the woman/have her medical record
 severe/serious disorders
 psychotropics
Is it appropriate to ‘screen’ for depression in ALL
women at first appointment?
Possibly better for MW to ask formal Qs at booking and
identify high risk women
Prediction and detection

Most postnatal care takes place in primary
care

Screening for PND more acceptable



EPDS?
‘3’ questions?
Why are the ‘blues’ omitted?
Psychological treatments

Is waiting one month reasonable ?





RESPOND
PONDER
Are psychological treatments available within 3
months eg CBT, IPT, counselling
? Role of HVs
? Self help, groups, c-CBT etc
Explaining risks

Mainly relates to drugs – need to keep it in
proportion






Most mental illness is mild/moderate
Rather few women are on drugs when they conceive
Risks of ADs in puerperium are overstated
Fluoxetine – safe in pregnancy but not lactation
Specialist advice often needed
But for some women psychological therapies are
frightening – talking to someone!
Management of depression

Not just depression! so:





Agree diagnosis and severity with patient/family
Consider concordance – engage patient in treatment
decision
Explain stepped care approach
Agree treatment plan – monitoring
Low threshold for shared care with psychiatrist
 Child protection
Organisation of care

Clinical networks


Too much emphasis on the severely ill
woman
Need to bolster the PC team to support
the 98% of women with mild/moderate
disorder


Reaffirm role of HVs (and MWs)
Use of EPDS + clinical assessment



PCTs
Linkage with maternity wards
Self help organisations
Recent research evidence



PONDER – both PCA and CBT reduce EPDS
score at 6 months and 12 months
RESPOND – neither HVs nor GPs feel that PND
is their responsibility
SLCDS - EPDS – has low sensitivity, fails to
predict depression that has long term impact on
children
Conclusions

In order to implement APMH guideline which
aims to offer high quality antenatal and
postnatal care to women with mental health
problems

Strengthen the role of





GP
MW
HV
Increase the availability of psychological therapies
Reduce the stigma of ADs
Getting Started
Implementation of the NICE
APMH Guidelines
Generalists or Specialists?
Institute of Physics
Oct 2nd 2007
The Guidelines begin…
“This guideline offers best practice advice on
the care of women with mental disorders
during pregnancy or up to one year after the
birth of their baby. “
Main Problems

Most women get pregnant; >50% are unplanned

Some women at risk before birth – ill or at risk of
relapse

Women with SMI have complex needs and
coordination of care between agencies is required

Mild/moderate dx has negative effects on the baby and the family
and should be treated ante and postnatally

Treatment with medication in pregnancy involves exposing the
fetus to potential harm
Who is the guidance about?
newly pregnant
 pregnant presenting with symptoms
 pregnant and well but at risk
 post natal with risk and/or symptoms
 risk of relapse
Plus women with existing SMI:
 newly diagnosed, newly medicated: conception and
fertility
 wishing to become pregnant

What treatments?




Psychological – self help, cCBT, IPT, CBT,
listening visits
Social Support – group exercise,
psychoeducation groups
Medication – lowest effective dose; balance
risks of treatment:relapse
Prophylaxis – balance risk of relapse against
negative effects of medication
Organisational responses to the
NICE APMH guidance
What possible configurations should
your organisation consider given:
 The NICE guidance
 The needs of the local population
 The geography
 Local resources
 Key people interested/influential in perinatal
illness
Questions
to
inform
the
process:
What is already going on?













Are there specialist teams/personnel?
What are the existing referral and management protocols?
How do they match up to the guidance?
What needs to be done to meet the implementation standards?
Are these feasible/necessary in this area?
What sort of training is available?
Who gets the training?
Does it need revising/ broadening /updating?
Does it cover the relevant groups?
Where are the specialist resources?
Do we have access to them?
What would make a good service great in this area?
Taking things forward

Raise Awareness

Establish training at all levels

Establish feasible local protocols for management of perinatal
mental health with women

Develop appropriate additional services/pathways

Apply guidelines for specific disorders/therapies

Get access to/appoint a local specialist for advice, care

Establish governance and service audit
Look for research opportunities

Who should be involved?
Who are your stakeholders?
women
their families
mental health workers
social workers
midwives and obstetricians
primary care (GPs, HVs)
commissioners
Specialist or Generalist?

Know key points of the guidance

Consider the reproductive needs of all women under
your care

Decide what you would need a specialist for

Who is your local specialist and what do they offer

Know/contribute to the local protocols for perinatal
mental health
What could the generalist
consider tomorrow?





Who is under your care?
What are her reproductive and sexual health
needs?
Has she/her team addressed these recently?
What will you do to minimise the impact of
mental illness around birth
How do you manage women planning
pregnancy, who are pregnant or postnatal
Embarking on pregnancy
1. Identify illness/risk
2. Engage appropriate agencies:
 Specialist if you have one – advice, assessment,
care
 Generalist – assessment and planning –short and
long term, the big picture
3. Include family, friends, primary care, mental health,
maternity, social services, non-statutory agencies as
appropriate
4. Plan for recovery, plan for relapse, plan for health
Case 1
Elaine is a 34 year old woman with 2 children
already. She was depressed after her first child.
The father of the child left before the baby was
born. She did not attach to the baby who has
behavioural problems now.
She did well with second child, no depression and
support of new husband. Now unplanned third
child, both Elaine and husband ambivalent.
At booking Elaine is depressed; she improves o
sertraline but objects to a change to lofepramine at
six months. Increasingly anxious at seven months
Case 2
28 year old woman becomes very overactive,
bizarre and pressured in speech 10 days after
baby born.
10 years ago she had a very brief episode of high
mood at college which was followed by depression
associated with losing her boyfriend because she
was unfaithful while high. She has had no
treatment for 8 years. She did not tell her midwife
about her illness and her GP did not pick it up
either.
Case3
A 25 year old woman presents postnatally with low
mood and not coping six weeks postnatally. The
pregnancy was unplanned and she is no longer
with the father of the baby. She was anxious
before the birth but denied depression.
She was depressed 2 years ago and stopped her
medication (citalopram) as soon as she knew she
was pregnant. She is angry with her ex-partner,
feels trapped in her mothering role and is in debt .
Questions to ask yourself
What are the concerns for this patient?
What could you do now?
What might she need?
What might she need to know?
What might you have done differently in an
ideal world?
Organising services in your
area
What have you got?
What would you like ideally?
What can you do now?
Do you have a specialist or specialist team?
What can you need the specialist to do?
(minimum/maximum)
Organisation of care: needs and
capabilities
Admission
Beds with outreach 0.3/1000
Beds without outreach 0.6/1000
Mother & Baby Units
Specialist Perinatal Community
Teams/ outreach Services
“Admission vulnerable”
Severe illnesses 30/1000
Specialist consultation & advice to
other care providers 20/1000
Specialist Perinatal Community
Teams/ outreach services
Improved skills in general adult
mental health services
Mild/Moderate illnesses 10-15%
Specialist MWs & HVs
Improved skills in primary care
Adjustment disorders, distress
15% - 30%
Improved skills in maternity, primary
care and NGOs
Good Psychological care
Knowledge & compassionate
Promoting mother-child mental health understanding for all
Consider your area: estimating
need for specialist APMH services
Births
MBU Beds*
0.3/1000 births
Cons. Psych. PAs #
1/1000 births
APMH Team WTEs #
0.5/1000 births
Psychological therapists
0.1-0.5/1000
births
*Assumes community/outreach teams and 100% occupancy
# Minor adjustment may be required for location of deliveries
Work programme 2006-2008
Area of Work
Network
Development
Service
mapping
Objective/ Outcome to be Achieved
Establish perinatal mental health network across South Central
Establish a patient and family advisory group
Establish agreed work programme priorities
Develop subgroups & project plans
Commission mapping and identify gaps
Care Pathways Develop care pathways for women with
omild/moderate disorders in primary care
ohigh risk of severe mental illness
ocurrent severe mental illness
Service quality Develop quality standards for perinatal mental health care by
standards
ospecialist inpatient units
ospecialist community/outreach teams
oprimary care
omaternity services
oadult mental health services
Work programme 2006-2008
Area of Work
Objective/ Outcome to be Achieved
Stakeholder
conference
Organise stakeholder conference to
inform and involve key stakeholders
across South Central in finalising
pathways and standards
Audit existing
services
Full audit cycles (audit according to
standards, improvement, re-audit) of 3
pathways and 4 services areas
Set service
development
priorities
Identify short, medium and long term
service development prioritiesl to inform
specialist and PCT commissioning
Identify training Based on Scottish Perinatal Mental Health
Curricular Framework
requirements
(www.nes.scot.nhs.uk/publications)
Prescribing Recommendations
and their Implications
The APMH Guideline.
October 2007
Dr. Liz McDonald
Perinatal Psychiatrist
East London and the City Mental Health Trust
Medication: What does the
guideline say?


Prophylaxis and treatment
Switching to medication with lower known risk
within classes of drugs: will it work?, are there other risks
related to the change made?




Use of anti-psychotics instead of anti-manic agents
Depot medication
Rapid tranquillisation
Treatment resistance
What are the dilemmas facing
women and clinicians?




Planning a pregnancy while taking medication for a known
disorder
Unplanned pregnancy while taking medication for known
disorder: confirm pregnancy, scan, discussion of risks
Prophylaxis
New illness episode in pregnancy: how to treat, what to initiate if
unmedicated, what changes to existing medication, addressing potential non-adherence


Onset of illness in pregnancy: how to treat, what medication to initiate
Medication in the intra-partum period: risk of relapse, risks to mother,
risks to fetus, drug interactions


How to re-instate medication post-delivery in woman at high risk
of relapse
Breastfeeding
What do clinicians need to do?


Review indications for treatment, the treatment options and
associated risks
Don’t assume it is always better to stop medication: potential
harm of treatment must continually be balanced against the risks posed to
mother and fetus/infant of non-treatment but know when and how to stop


Need for prompt and effective treatment of mental illness in
pregnancy and postnatal period
Understand, consider and communicate the known risks
(and how these will be managed) of medication: teratogenicity,
neurobehavioural sequelae, withdrawal, over-stimulation, changes in maternal
physiology, interaction with other meds incl. analgesia in labour, preterm
delivery, persistent pulmonary hypertension in neonate, specific risk to mother
with a particular drug, need for a hospital delivery, timing of exposure etc
What do clinicians need to do?


Review indications for treatment, the treatment options and
associated risks
Don’t assume it is always better to stop medication: potential
harm of treatment must continually be balanced against the risks posed to
mother and fetus/infant of non-treatment but know when and how to stop


Need for prompt and effective treatment of mental illness in
pregnancy and postnatal period
Understand, consider and communicate the known risks
(and how these will be managed) of medication: teratogenicity,
neurobehavioural sequelae, withdrawal, over-stimulation, changes in maternal
physiology, interaction with other meds incl. analgesia in labour, preterm
delivery, persistent pulmonary hypertension in neonate, specific risk to mother
with a particular drug, need for a hospital delivery, timing of exposure etc
What do clinicians need to do?


Review indications for treatment, the treatment options and
associated risks
Don’t assume it is always better to stop medication: potential
harm of treatment must continually be balanced against the risks posed to
mother and fetus/infant of non-treatment but know when and how to stop


Need for prompt and effective treatment of mental illness in
pregnancy and postnatal period
Understand, consider and communicate the known risks
(and how these will be managed) of medication: teratogenicity,
neurobehavioural sequelae, withdrawal, over-stimulation, changes in maternal
physiology, interaction with other meds incl. analgesia in labour, preterm
delivery, persistent pulmonary hypertension in neonate, specific risk to mother
with a particular drug, need for a hospital delivery, timing of exposure etc
Discussions about treatment
options should cover








Risk of relapse/ deterioration and ability to cope with this
Severity of previous episodes, response to treatment,
woman’s preference
Stopping drug with known teratogenicity may not remove
risk of malformation
Risks of sudden discontinuation
Need for prompt treatment
Increased risk of harm associated with drug treatment
? Withdraw/ reduce medication before delivery
Treatment options to enable breastfeeding
Medication: What does the
guideline say





Choose drugs with lower risk profile for both
mother and fetus/infant
Start at lowest effective dose, slowly increase
Monotherapy preferable to combination
treatment
Additional precautions for compromised
infants
Risks to fetus/infant during withdrawal
Implications






Timely, appropriate treatment
Accurate information about the disorder, treatment
options, benefits and risks
Care in the most appropriate setting
Accessible, equitable, comprehensive
Least intrusive and disruptive provision
Effective working between professionals that holds
the mother/fetus/infant at the centre of consideration
Implications

Education of professionals including mental health,
midwifery, obstetricians, primary care (epidemiology, course,
potential outcome, risks of treating and not treating, exploring attitudes etc)


Commitment to and taking responsibility for
education by individuals and within organisations
Access to up to date knowledge: perinatal psychiatry,
pharmacy, teratology database etc

Provision of written information for women and their
families
Overarching implication



Thoughtfulness of clinician in prescribing
psychotropic medication to ALL women of
childbearing age
Educating, enquiring about , discussing
sexual health, fertility, planning for
parenthood, contraception throughout contact
with women
Communicating commitment to support the
woman in her plans for pregnancy
Prescribing Recommendations
and their Implications
The APMH Guideline.
October 2007
Dr. Liz McDonald
Perinatal Psychiatrist
East London and the City Mental Health Trust
Barriers to implementation
Use of lithium, carbamazepine and
valproate in women of childbearing
age
Presented by Carol Paton
James et al JPsychopharm (in press)
Audit Method
Part 1 : Psychiatrists knowledge and perceived practice


Psychiatrists known to provide care for women of CBA across Oxleas and SLAM were
approached.
A semi-structured interview was conducted to explore views about the use of Li, CBZ
and VPA (and antipsychotics) in women of CBA, and awareness of foetal
malformations.
Part 2 : Audit of actual clinical practice




Women of CBA (18-45) who had been in contact with Oxleas for >1 year were
identified using PIMS.
Those prescribed lithium, CBZ or VPA were identified as ‘cases’.
All available clinical records of cases were examined for documented evidence that the
patient had been informed about teratogenicity, contraception had been discussed or
was being used and advice was given about folate. Confirmed pregnancies and
outcomes were recorded.
Consultants were provided with a list of ‘cases’ under their care.
Results (Part 1)
52/96 consultants agreed to be interviewed.





96% used lithium, 94% valproate and 79% carbamazepine as a mood
stabliser.
80%, 37% and 51% were aware of the licensed indications of these drugs
with respect to mood stabilisation.
Lithium was used first line by 42%, valproate by 43% and carbamazepine by
2%.
>80% were more cautious about using these drugs in women of CBA
(compared with 55% for risperidone and olanzapine).
28%, 18% and 17% could name specific foetal malformations associated
with these drugs.
Number (%) of cases where lithium, carbamazepine or valproate
were prescribed alone or in combination.
Drug
Number of
cases identified
from PIMS
Total number
of cases
identified
Lithium
54 (7%)
56
Carbamazepine
25 (3%)
26
Valproate
43 (5%)
53
lithium & CBZ
4 (0.5%)
4
VPA & Li/CBZ
2 (0.2%)
5
Total number
128 (16%)
144
•Half had a diagnosis
of bipolar disorder
•A quarter
schizophrenia
•An eighth borderline
personality disorder
Number (%) of cases with documented discussion of potential
teratogenicity of lithium, carbamazepine and valproate and advice
about contraception
Drug
Teratogenic
potential
discussed
(%)
Contraceptiond
iscussed
(%)
Advice given
about folate
(%)
Lithium
10 (19%)
9 (17%)
N/A
Carbamazepine
7 (27%)
6 (23%)
0
Valproate
8 (16%)
15 (29%)
2 (4%)
Li & CBZ
2 (50%)
0
0
VPA & Li/CBZ
2 (40%)
3 (60%)
0
Sub-total (% of total
sample of 138).
29 (21%)
33 (24%)
2 (1.5%)
Sexual vulnerability
Of the 113 cases where there was no documented
evidence that contraception had been discussed or
was being used, entries in clinical notes indicated
that


41 (36%) women were considered to be sexually
vulnerable.
13 (12%) of women were intending to conceive.
Documented pregnancies



34 women had a documented pregnancy test
14 confirmed pregnancies
Complications noted in 8 cases






5 spontaneously aborted
1 electively aborted after prior bleeding
1 currently pregnant and bleeding
1 neonate died (15 hours old) from cardiovascular and respiratory complications.
None of these 8 women had epilepsy.
In the 6 with no documented complications



3 full term
1 elective termination
2 currently pregnant.
Summary of results






The majority of psychiatrists are cautious about the use of Li,
CBZ and VPA in women of childbearing age.
A quarter could name specific foetal malformations associated
with these drugs.
>15% of women of CBA are prescribed lithium, carbamazepine
or valproate.
Documentation about the patient being informed of the
teratogenic potential of these drugs or advised about
contraception was found in less than a quarter of cases.
Advice about folate is rarely given.
The ‘risk’ of pregnancy is real.
Points for discussion

Timing of discussions.


Off label prescribing.


Suicide is the leading cause of maternal death in the UK. Most are in the setting of
postpartum psychosis. Infanticide is also a risk. Complete avoidance of mood
stabilisers is not an option.
Shared care


Safety messages are targeted towards neurologists (licensed indications). Off-label
prescribing increases the responsibilities placed on the prescriber. Documentation
relatively more important.
Balancing risks of illness and treatment.


Always before treatment is initiated or at what point and with whom?
Should the doctor who prescribes the teratogenic drug take responsibility for advising
about/prescribing contraception (although this may be outside their area of expertise)
or should the GP do this (and how is this communicated between services).
Patient specific feedback regarding prescribing practice

Is this useful?
EMCOM Perinatal Mental Health Managed Care Network
Trent Strategic Health Authority
MANAGED CARE NETWORKS
What are they?
Why do we need them?
What do they do?
Dr Margaret Oates
Lead Chief Executive: Mike Cooke
Lead Clinician: Dr Margaret Oates
Project Manager: Dr Ian Rothera
EMCOM Perinatal Mental Health Managed Care Network
What is a Managed Care Network?
Organisation delivering quality cost effective care for conditions
 Involve different
professions
trusts
organisations
levels of service provision
 Most severe uncommon, critical mass only possible at supra-locality level
 Mildest common-provision locality level
 Requires specialist skills resources (evidence better outcome)
 Suited to “hub & spoke”
 Amendable audit/outcome measures
 Includes at its core a clinical network
Important
M
is for Managed
Organisation with
manager
money
muscle
EMCOM Perinatal Mental Health Managed Care Network
National Drivers
NICE Guidelines ANPNMH
Children young people & Maternity NSF (11) 2004 (06)
Confidential Enquiries into Maternal Deaths 2002 &
2004
CNST
2000 (06)
Scottish Maternity Framework
2002
Women’s Mental Health Strategy
2002
Royal College of Psychiatrists CR88
2000 (06)
All recommend that
EMCOM Perinatal Mental Health Managed Care Network

Specialist MDT with Psychiatrist available to every maternity locality

All women requiring psychiatric admission 9 months following
delivery should be admitted to a specialist Mother & Baby Unit

PH & FH serious mental illness should be elicited at booking

Management plans in place for those at high risk

Managed Care Networks CR88
NSF
Carter Report
NICE
EMCOM Perinatal Mental Health Managed Care Network
Importance Perinatal Psychiatric disorder








Substantial morbidity – wide range disorders
New onset and pre-existing or chronic disorders
Increased mortality
Some predictable and preventable majority treatable
Significant adverse outcome woman and infant
Distinctive clinical presentation and cause
Distinctive needs resources, skills
Service organisation
Sufficient “workload” justify specialist services
EMCOM Perinatal Mental Health Managed Care Network








Patchy and inequitable
Admission without baby
Few outreach specialist services
Inappropriate diagnosis and treatment
Chronically mentally ill become pregnant
Medication issues
Risk recurrence not acknowledged
Avoidable morbidity and mortality
Acute Psychoses 2/1000
Severe/complex 2/1000
“inpatient equivalents”
M
C
N
Mother & Baby Unit
Outreach Service
Consultation & advice
Hub & Spoke integration
Serious illness 30/1000
“admission vulnerable”
Specialist Perinatal Community
Teams
Referral & Management Guidelines
I
C
P
Mild/Moderate 10%
“PND”
Treatment Primary Care
Specialist MW/HV
Adjustment disorders
distress
15% - 30%
Good Psychological care
Promoting Maternal-child
Mental health
Improved skills HV &
Primary Care Teams
EMCOM Perinatal Mental Health Managed Care Network
Based on known
epidemiology of perinatal disorders
None
but
Maternal health communities
sufficient psychiatric morbidity
to justify inpatient unit
together they do
EMCOM Perinatal Mental Health Managed Care Network
all Mental Health Trusts sufficient serious
morbidity to justify locality
perinatal outreach team
+ special interest psychiatrist
EMCOM Perinatal Mental Health Managed Care Network
All maternity localities
Sufficient mild moderate morbidity to justify
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Management and Referral Guidelines
Specific interventions in primary care
Skill Enhancement
EMCOM Perinatal Mental Health Managed Care Network
Joint Commissioning
Standards
Pathways
A NETWORK
East Midlands Perinatal Mental Health Managed Care Network
Cost Effective?
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Acute Inpatient (MH) stay + 0.5
No “generated” morbidity
MCN Mother & Baby Units + Outreach Service
Nos admissions
alternatives
prevention
length of stay
re-admissions
MHA
stay OBS & Paediatrics
opportunity costs
litigation
+ ICP & enhanced
skills
efficiency in Primary Care
EMCOM Perinatal Mental Health Managed Care Network
Lead Clinician
Sponsoring CE
Lead Commissioner
Project Manager
Stakeholders
EMCOM Perinatal Mental Health Managed Care Network
POLICY CONTEXT
- Strategy
- Commissioning
RESEARCH
-Empirical EB
- Good practice
STAKEHOLDERS
VIEWS
NATIONAL DRIVERS
FOR CHANGE
- CEMACH (2004)
- NSF (2004)
- SIGN (2002)
- RCP (2000)
- Professionals
- Experts
PATIENT JOURNEY
- Users
- Maternity
SERVICE MAPPING
- Mental Health
-Specialist
- Mainstream
- Other initiatives
- Good practice
Population
Birth rate
geography
EDUCATION/TRAINING
EVIDENCE BASE
- What there is
- Existing Services
- Perceived need
- Improving Services
EMCOM Perinatal Mental Health Managed Care Network
STANDARDS
-
Evidence based
General principles
Flexible & achievable
Local circumstances
MEASURE
Identify shortfalls
What
Where
Why
RECOMMENDATIONS
- Implementation
- Regional MCN
- Local Perinatal Networks
EMCOM Perinatal Mental Health Managed Care Network
•
Added value
Not “shopping lists”
•
Commissioning - joint beds (SHA)
•
- Standards
local services (Lead PCT)
- Standards Primary Care (PCT)
•
Providing
- Standards
Development resources
•
What can we do for you?
training, advice, access
etc
EMCOM Perinatal Mental Health Managed Care Network
MCN Function
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Development services
Quality control
Commissioning to standards
Bed manage
Advice and information
Maintain and develop skills and knowledge
Maintain integration
Mental Health, Maternity and Primary Care
Why did we establish our
network?
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To get commissioners to invest in developments
& / or increased activity
To get trusts to co-operate with each other
To set standards and audit them
To ensure implementation of national guidance,
policy and targets
To encourage service improvement and staff
development into new roles.