Gloucestershire Maternal Mental Health Conference November 2005 Maternal Depression In Primary Care:

1
GloucestershireMaternal Mental Health
ConferenceNovember 2005Maternal Depression
In Primary Care Gloucestershires Vision

• Sue Moos
• Maternal Mental Health Lead CT PCT

2
Why was a Strategy for Maternal Depression needed?

• Maternal mental health public and individual
  health problem with significant mortality and
  morbidity issues
• Maternal deaths

3
BBC
NEWS

• Railway mother depressed
• A mother who jumped to her death from a railway
  platform with her two children was thought to be
  depressed ..
• February 2005

4
Why was a Strategy for Maternal Depression
needed? ? Maternal mental health public and
individual health problem with significant
mortality and morbidity issues? Maternal
deaths

• Deaths just the tip of the iceberg
• Many have predictable risk factors
• Pregnancy is the only trigger for mental illness
  that comes with a nine month warning!
• Evidence and recommendations
• Build on current skills, expertise and enthusiasm

5
Strategy for Maternal Depression

• Based on the Stepped Care Approach

6
Stepped Care Approach
Specialist Mental Health Care secondary care MD
community teams, MBU facility, Specialist
Perinatal Mental Health Service

Structured Interventions Primary Care Gateway
Nurses, GMHWs, MMHL, Infant Mental Health
Teams Assessment,intervention, Guided Self Help,
CBT, counselling
Assisted Self Help Primary Care PHCT better
equipped and with specialist roles PND Support
Groups, non-directive counselling, SFBT, MH
Toolkit, Baby massage
Self Help - Community Mother Baby Groups,
Family Centres, Organisations NCT, APNI, BTA,
Fathers Direct, NHS Direct, Relate, DV Helpline
7
Strategy for Maternal Depression? Based on the
Stepped Care Approach

• Drivers
• Why Mothers Die 2000 - 2002 (2004)
• NSF for Children (2004)
• NICE Guideline for Depression (2004)
• NICE Guideline for Antenatal Care (2003)
• SIGN Guideline for Postnatal Depression
  Puerperal Psychosis (2002)
• Womens Mental Health into the mainstream (2002)
• NSF for Mental Health (1999)
• Recommendations from the CPHVA and National
  Screening Committee
• Sure Start Agenda and Social Inclusion Policy

8
Strategy for Maternal Depression The process

• Mapping of services/resources in Gloucestershire
• Current maternal mental health assessment and
  identification
• Applied epidemiological data

9
APPLIED EPIDEMIOLOGICAL DATA (1)
10
APPLIED EPIDEMIOLOGICAL DATA (2)
11
Strategy for Maternal DepressionImplementation

• Care Pathway for Maternal Depression
• PMHS developments
• Specialist Perinatal Mental Health Service

12
Strategy for Maternal Depression

• Care Pathway for Maternal Depression

13
Strategy for Maternal Depression Care Pathway
Policy Perspective (1)

• All women should be routinely assessed during
  the antenatal period for a history of
• depression
• puerperal psychosis
• other psychopathology esp. affective psychosis
• and a family history of affective psychosis
• SIGN 2002

14
Strategy for Maternal Depression Care Pathway
Policy Perspective (2)

• All women should be
• asked about previous psychiatric history and
  family history of serious mental illness
• provided with information on pregnancy and mental
  health which helps them to disclose and discuss
  mental health issues
• NSF for Children 2004

15
Strategy for Maternal Depression Care Pathway
Policy Perspective (3)

• Systematic enquires about previous psychiatric
  history, its severity, care received and clinical
  presentation should be routinely made at the
  antenatal booking
• CEMACH 2004

16
Strategy for Maternal Depression Care Pathway
Policy Perspective (4)

• Women who have a past history of serious
  psychiatric disorder, postpartum or
  non-postpartum, should be referred for an
  assessment by a psychiatrist in the antenatal
  period
• CEMACH 2004

17
Strategy for Maternal Depression Care Pathway

• Aims to improve care, experiences, outcomes and
  access to high standard, evidence based,
  equitable services for women
• Based on the patient journey or womans
  journey
• Compares planned care with actual care Care
  Pathway Variance Tracking

18
Strategy for Maternal Depression Care Pathway

• Baseline questionnaires
• Women
• Staff
• Mapping the womans journey
• 3 groups of women
• Multi-disciplinary group

19
Strategy for Maternal DepressionCare Pathway
Mapping the womans journey

I was asked about shoe size and all sorts of
things but not mental health history but I
volunteered information because I would have told
anyone .. to get help and not suffer again
20
Strategy for Maternal DepressionCare Pathway
Mapping the womans journey

I started crying when she was born and stopped
when she was two years old
21
Strategy for Maternal DepressionCare Pathway
Mapping the womans journey

• One to two hours of debriefing would save
  months of postnatal health professional work
• Most people dont understand the benefit of
  debriefing a lot of women dont realise they
  can get it

22
Strategy for Maternal DepressionCare Pathway
The Map

23
Strategy for Maternal DepressionCare Pathway
The Record
CEMACH, NSF for Children, SIGN, MW Standard
Meets legal reqs for record keeping

Risk factors for postnatal depression
Risk factors for puerperal psychosis
Early identification of high risk cases
Other risk factors

• UNMET triggers Variance Record
• Variance
• Cause of Variance
• Action taken

NSF for Children, Fourth Hall Report, RCM,
CPHVA, RCOG, RCGP
24
Strategy for Maternal Depression Care Pathway
the benefits

• Staff
• Improved documentation, quick and easy to
  complete
• Reduced duplication
• Feedback at caseload level
• Practice underpinned by latest research
• Clear referral pathways

• Women
• Early identification
• Early support at appropriate level
• Better access to information
• Improved experience and outcomes

25
Strategy for Maternal Depression

• Primary Mental Health Service Developments

26
Strategy for Maternal Depression PMHS
Developments

• Information
• Booklet
• PMHS webpage
• Mental Health Toolkit
• Additional treatment/management
• Guided Self Help for Maternal Depression

27
Strategy for Maternal Depression PMHS
Developments Information

• Emotions around childbirth and how to deal with
  them
• in conjunction with the care pathway
• includes
• risk factors
• signs and symptoms
• how to stay well
• sources of help, including for fathers
• checklist
• plan

28
Strategy for Maternal Depression PMHS
Developments Treatment

• Workbook for maternal depression
• Advantages
• Specific to women around the time of childbirth
• No side effects
• Additional option for women who
• dont improve with non-directive counselling
• decline non-directive counselling
• do not wanting to attend groups
• live in a rural area
• Could be provided by health professionals

29
Strategy for Maternal Depression

• Specialist Perinatal Mental Health Service

30
Strategy for Maternal Depression Specialist
Perinatal Mental Health ServicePolicy
Perspective (1)
All women with perinatal mental health problems
should, if necessary, have access to a consultant
psychiatrist with a special interest in perinatal
psychiatry, supported by professionals with
experience and skills in this area Royal
College of Psychiatrists (2000)
31
Strategy for Maternal Depression Specialist
Perinatal Mental Health ServicePolicy
Perspective (2)
Local specialist perinatal mental health
services need to be developed with formal
agreements between maternity, primary care
(including health visitors) and specialist mental
health services to ensure that a range of
provision, training and support is
available Womens Mental Health into the
mainstream (2002)
32
Strategy for Maternal Depression Specialist
Perinatal Mental Health ServicePolicy
Perspective (3)
A specialist perinatal mental health team with
the knowledge, skills and experience to provide
care for women at risk of, or suffering from,
serious postpartum mental illness should be
available to every woman CEMACH (2004)
33
Strategy for Maternal Depression Specialist
Perinatal Mental Health ServiceA Vision!

• Integrated, tiered service
• Range of treatments and management strategies
  appropriate to need
• Include
• psychiatric liaison to maternity units
• consultant psychiatrist with a special interest
  in perinatal psychiatry
• alternatives to psychiatric admission
• access to a MBU

• What we already have
• Specialist health visitors/ CPNs
• Maternal Mental Health Lead
• Infant Mental Health Team
• Psychiatrists with an interest in perinatal
  mental health
• Crisis Home Treatment Team
• Access to MBU

34
Maternal Depression In Primary Care Summary One
year on!

• Strategy
• Care pathway
• Booklet
• Information
• Workbook
• RAISED PROFILE!

35
Maternal Depression In Primary Care Summary
Whats next?

• Care pathway - county
• Booklet - county
• Resolution of coding issues
• Increased/continued managerial commitment
• Training programmes
• Perinatal Mental Health Working Group

36
Maternal Depression In Primary Care Conclusion

• Solid foundation
• Experience, skills and enthusiasm
• Ongoing consultation
• Service design
• Service delivery
• Funding

37
Contacts

• Sue.Moos_at_glos.nhs.uk
• Mob [phone]
• www.pmhsglos.org.uk