Mental health in London the perinatal perspective

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• Mental health in London the perinatal
  perspective
• Dr Geraldine Strathdee, Clinical Lead, Mental
  health project
• Dr Anna Burnside, Research Associate, Mental
  health project
• Dr Lucinda Green, Consultant Psychiatrist in
  perinatal mental health

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This talk

• Mental health In London How common are mental
  health problems
• How can Healthcare for London improve mental
  health services in London
• The 4 workstreams and the care pathway to improve
  outcomes
• Introduction to the mental health needs in
  maternity care
• The specialist perinatal evidence
• Summary what can WE ALL do to improve care for
  women their families across all of London

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How common are mental health problems
Impact statement
Acute physical care services
Senior Citizens
The workforce
Our children
1 in 5 under the age of 15 Only 25 can access
care 50 bullied, leading to Depression Low
self-esteem Suicide 1 10 have unrecognised
dyslexia or dyspraxia
1 in 6 adults at any time 1 10 have depression
Suicide is the greatest cause of male deaths lt
35 yrs Work related stress affects 1.5 million
5.6 million work days lost a year
Dementia effects 5 over 65s 10-20 over
80 1 in 6 over 65 suffer from depression Major
factors Social isolation Physical ill- health
30 of gt65s in Acute Trust beds have dementia
50 of people in some long term acute clinics
have medically unexplained symptoms 50 people
with irritable bowel syndrome have unrecognised
abuse histories In A/E the prevalence of
alcohol-related injury is approx 24
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Why is mental health a major issue for London?
because of the very large scale of the problem

• London has a greater burden of mental ill health
  than in any other English region
• More socio-economic risk factors than other
  regions e.g. significant asylum and refugee
  population higher levels of homelessness higher
  rates of unemployment
• 1 million Londoners in any one time experience a
  common mental health problem e.g. depression
• London has the highest rate of compulsory
  psychiatric admissions in England
• 1 in every 5 people at some time will have a
  mental health problem
• People with physical illnesses improve more if
  they have good mental health

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4 Mental health care pathway workstreams
outcomes

• How to improve outcomes in the care pathway
• Prevention/ promoting health
• Identification
• Assessment
• Evidence based interventions, access, quality,
  safety
• Recovery social inclusion

• 4 Mental health pathways
• Complex needs/ Co-occurring disorders
• Dementia
• Medically unexplained Symptoms
• The psychological impact of physical illness
  surgery
• Stroke
• Polyclinics
• Unplanned care
• Diabetes
• Children
• Maternity

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Maternity care and depression

• 1 in 10 women will suffer an episode of
  depression after giving birth and
• one-third to a half will have a severe episode.
• 1 in 1000 women will suffer an episode of severe
  psychosis after giving birth
• More than 1 in 10 women use drugs or alcohol
  during pregnancy.
• Suicide is the second leading cause of maternal
  death in the UK after cardiac disease.

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How can we identify women who may have problems?

• 2007 Saving Mothers Lives report recommended
  that midwives should check on the continuing
  mental health of all their clients at least twice
  during pregnancy and following delivery
• At a womans first contact with primary care, at
  her booking visit and postnatally healthcare
  professionals (midwives, obstetricians, health
  visitors, GPs) should ASK TWO questions to
  identify depression
• During the past month, have you often been
  bothered by feeling down,
• depressed or hopeless?
• 2. 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.
• 3. Is this something you feel you need or want
  help with? (2)

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Substance misuse

• 11 of all the women who died in the last three
  years, of any cause, had problems with drugs or
  alcohol
• Substance misuse was associated with the deaths
  of nearly two thirds of the mothers who died due
  to psychiatric conditions  
• One fifth of the women were alcohol dependent and
  four fifths were drug dependent
• Many of these women were socially excluded and
  most were homeless or living in very poor
  circumstances
•  The majority (80) were late bookers and poor
  attendees for antenatal care. Most had previous
  children in the care of the local authority and
  were subject to child protection conferences in
  their current pregnancy
• These women are being missed
• Nearly a third of women received no treatment for
  their psychiatric disorder during pregnancy  
• Less than half of women with substance misuse
  problems had been in contact with drug or alcohol
  services during their pregnancy

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Perinatal mental health services

• Dr Lucinda Green
• Consultant Perinatal Psychiatrist
• St Thomas Hospital

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Pregnant women with mental illness why be
concerned?

• Range of mental disorders (mild to severe) in
  pregnant and postnatal women
• Pregnancy not protective
• Discontinuing psychotropic medication ? high
  rates of relapse
• Predictable high risk of postpartum psychotic
  relapse for women with certain types of psychotic
  illness

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Pregnant women with mental illness why be
concerned?

• Poor obstetric outcomes e.g. preterm birth, low
  birth weight, stillbirth
• Impact of mental illness on parenting/child
  development/attachment
• Complexity severe mental illness, substance
  misuse, domestic violence, child protection
  concerns, social deprivation, social isolation
  etc.

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Pregnant women with mental illness why be
concerned?

• CEMD Why Mothers Die (2001)
• CEMACH Why Mothers Die (2004)
• CEMACH Saving Mothers Lives (2007)
• NICE Guidelines Antenatal Postnatal Mental
  Health (2007)
• Daksha Emson Inquiry (2003)

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Recommendations clinical care

• Pre-conception advice for women with severe
  mental illness
• Routine questions to identify women with
• Current or previous severe mental illness
• High risk of postpartum psychosis
• Previous treatment by mental health services
• Current depression
• Substance misuse

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Recommendations clinical care

• Women at high risk of serious mental illness
  postpartum to be seen by psychiatrist antenatally
• Written care plan for women with current or
  previous severe mental illness covering
  pregnancy, delivery and postnatal period
• Communication and multi-agency working
• Training

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Recommendations clinical care

• NICE 2007 Care of pregnant / postnatal women
  with range of mental disorders
• psychological treatments - within 1 month
• psychotropic medication
• risk discussion
• Care pathways
• Referral and management protocols

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Recommendations service organisation and delivery

• Specialist multi-disciplinary perinatal mental
  health services
• Mother and Baby Units
• (612 beds 25,000 - 50,000 live births / yr)
• Integrated specialist substance misuse service
  within maternity service
• Perinatal Clinical Network (25,000 -50,000 live
  births/year)

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NICE 2007 Organisation of care the
stepped/tiered care model
Personnel
Service
Core functions
Specialist perinatal mental health services
Psychiatrists, nurses, nursery nurses,
psychologists
Prevention, management treatment of
moderate/severe illness specialist advice and
consultation to primary care
CMHT (psychiatrists, psychologists, nurses
social workers)
Specialist mental health services
Assessment treatment referral to specialist
services inpatient care
GPs, obstetricians, psychological therapists,
PCMHWs
Primary care mental health services
Assessment and referral treatment of mild to
moderate illness
GPs, obstetricians, midwives, health visitors,
practice nurses
General healthcare services (maternity and
primary care)
Detection of history of and current mental
illness referral
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A survey of specialist perinatal mental health
services in England (Oluwatayo
Friedman 2005)

• Inpatient / intensive home treatment    46   
• Community perinatal teams   33
• Obstetric liaison   30   
• Combination of above    23

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Perinatal mental health services in London

• Obstetric liaison / community
• Patchy and variable
• Existence / composition of team
• Maternity service vs borough based
• Referral criteria
• Mother baby units
• Bethlem, Homerton, Springfield, Central
  Middlesex

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What can we ALL DO .

• Stigma reduction depression is very common
• Ask about mental health conditions
• Ask about substance misuse
• For HIGH risk women, alert the right services
• Find out what can help
• Information
• Local services 3rd sector as well as NHS LA
• Commissioners help us develop equitable services
  for women across London
• .

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