Perinatal Mental Health - One size does not fill all A Pathway approach to service design Margaret Oates Clinical Director East Midlands Strategic Clinical Networks Mental Health, Dementia & Neurological Conditions

Perinatal mental health

Pathway

Perinatal Mental Health Range of disorders of severities of risk Require different treatments resources professionals & skills Infant is at the centre of all we do

At conception- those currently/recently seriously ill or maintained on medication (psychoses/BPD) high rates of relapse during pregnancy and following delivery Those on antidepressants who stop - high rates of relapse during pregnancy

Weeks at Risk Off Lithium % Remaining Stable Pregnancy (Weeks 1–40) Nonpregnant Postpartum Nonpregnant Pregnant (n=42) (n=59) (n=20) (n=25) Viguera AC. Am J Psychiatry. 2000;157: Postpartum (Weeks 41–64)

Effects of stopping medication Viguera et al. Am J Psychiatry. 2007

Most new onset conditions in pregnancy anxiety/depression 10%-15% may continue after delivery Beware moderate/severe last trimester

Women with PH severe depression BPD & psychoses Even if well for some time are at 50% risk of recurrence after delivery

Postnatal disorders Psychoses new onset 2/1000 births pre-existing 2/1000 births Severe depressive illness 30/1000 births Moderate depressive illness Mild depression/anxiety Distress/adjustment ? Between 15 & 20% mental health problems 100/1000

In General The most serious illnesses present early after birth Distinctive features Deteriorate rapidly Require specialist care

Is childbirth associated with increased risk? Onset of major functional disorders in the puerperium Number of admissions Weeks prior to deliveryWeeks following delivery Kendell et al 1987

In General Psychological treatments (expert) are effective for mild/moderate conditions Some but not all mothers require additional or primary mother-infant therapeutic interventions Don’t forget (services & professionals for substance misuse

Pathway – one word many uses Patient journey o Steps/decision points along way o Time taken o Ask patient(s) o Reflects what does happen

Road map o Start and finish o Steps/professionals/services o Decision aids o Designed by professionals o Protocol o Ideal

But often Final destination missing Too many side roads Too slow Suits majority & “typical” not unusual No fast tracking Practitioners rarely trained to use them

Additional words Referral pathways Care pathways Integrated care pathways +treatment algorithms Stepped care pathways Access pathways (inclusion/exclusion criteria) Priority pathways

All valid But need to know purpose & which type you mean May need more than 1 Pathways are central to :  Service mapping & gap analysis  Understanding patient experience  Identifying barriers  Planning education & training workforce development Patient care

Care Pathway Right person Right treatment/intervention Right time Right place Right professional

Simple to follow Brief One Direction Shelf life Consultation/sense checked Seamless transition

Snakes and Ladders

What do they need? How can that best be provided? How do they get there?

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High risk women – BPD psychosis, serious depressive illness Pre-conception counselling Early pregnancy advice Risk benefit assessment Ongoing care Maternity liaison Need service development - specialised community service

Psychological intervention Pregnancy loss, anxieties, HEG Phobias, PTSD etc etc. Need service development - Perinatal Psychologist

Emergency Adult Psychiatric Services Crisis, Home treatment, Liaison teams Need education, training & awareness distinctive features perinatal illness distinctive risk different necessary service response

IAPT Need PWP and High Intensity Workers skills and competencies perinatal conditions education and training & workforce increase Perinatal lead in each service Red flags

Need for all women emotionally literate maternity Workforce, education spot unusual & serious & protocols & procedures that do not increase anxiety and guilt.

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