Perinatal Mental Health Guideline

Transcription

1 Perinatal Mental Health Guideline N.B. Staff should be discouraged from printing this document. This is to avoid the risk of out of date printed versions of the document. The Intranet should be referred to for the current version of the document. Owner: Maternity Services/Health Visiting/Mental Health

2 Contents: 1 Executive Summary Scope of guideline Quick guide Aims Purpose Guideline Statement Responsibilities Skills and training Security Monitoring and Effectiveness References Appendices...16 Page 1

3 1 Executive Summary There is breadth of need identified in Aneurin Bevan Health Board regarding the early identification, assessment and treatment of women who are at risk from serious mental health issues during the perinatal period. The Health Board currently has no specialist services and so it is imperative that maternity, child health and mental health services work closely together to ensure clear communication and efficient, effective treatment and support for women who experience mental illness in relation to childbirth or for those women identified as being at high risk of serious post-partum mental disorders. 1.1 Scope of guideline This guideline addresses the issues of mental health for women during the antenatal, intrapartum and postnatal periods. It serves to guide midwives, obstetricians, general practitioners, health visitors and mental health nurses and psychiatrists in the care, support and referral for women and their families during this important time of their lives. 1.2 Quick guide Staff should work to develop a trusting relationship with the woman, and where appropriate and acceptable to the woman, her partner and family members and carers. In particular, they should: o explore the woman s ideas, concerns and expectations and regularly check her understanding of the issues. o discuss the level of involvement of the woman s partner, family members and carers, and their role in supporting the woman. o be sensitive to the issues of stigma and shame in relation to mental illness Ask the questions in the new All Wales hand-held antenatal record regarding personal and family history of mental illness and record answers accurately Refer appropriately according to the Aneurin Bevan Health Board Pathway in this guideline Any concerns / difficulties, speak to manager who will contact manager in mental health services Guidelines for the management of women who are at risk of a relapse or recurrence of a serious mental illness following delivery should be in place in every Health Board providing maternity services Women who have a past history of serious psychiatric disorder, postpartum or non-postpartum, should be assessed by a psychiatrist in the antenatal period. Page 2

4 2 Aims A management plan regarding the high risk of recurrence following birth should be agreed with the woman, her maternity team and GP, the mental health team, and placed in her handheld records. To provide a guideline for practice that is evidence based and streamlines services in order to promote positive mental health of pregnant and postnatal mothers and their families. 2.1 Purpose To ensure clear co-ordination between services, so that each Health Professional is aware of their responsibility and that of their colleagues. Communication pathways must be in place so that management plans or significant concerns are communicated between general practice, obstetric, child health and mental health services. Care pathways should be in place to reduce confusion and uncertainty and to avoid duplication. 3. Introduction & Background Perinatal mental health problems are common, many are serious and they can have long-lasting effects on maternal health and child development. Attention frequently focuses on the more common disorder of postnatal depression, but other perinatal issues are equally important. Clinical and public health importance The death of Dr Daksha Emson and her daughter illustrate the potentially serious consequences of not recognising and monitoring women at risk. On the 9 th of October 2000, she stabbed her 3-month-old daughter, stabbed herself, and finally covered herself and her baby in accelerant and set it alight. This tragedy took place during a psychotic episode triggered by childbirth and was a consequence of her history of bipolar affective disorder. Sadly, her experience is far from unique. The death of a mother from suicide and a tragic case of the homicide of a baby in the Health Board has also highlighted the need to ensure collaborative working and communication across professional groups and agencies. The development of mental disorders in pregnancy and in the postnatal period may be associated with or aggravated by a number of factors, such as: Page 3

5 Psychological Social Family Biological Personal History Health The demands and expectations of being a mother in addition to the possible psychological effects following a traumatic birth. Social isolation, economic status, ethnicity, cultural issues and housing. The relationship with the child s father and the support received from family and friends. Genetic factors and the hormonal changes that occur during pregnancy, childbirth and following childbirth. Inc drug & alcohol use, domestic violence, childhood sexual and physical abuse, family history, past psychiatric history and previous maternal history. The mother and infant s general health. Mental disorders in the antenatal and postnatal period may have a significant impact on the mother infant relationship and as a result, there may be longer-term consequences for all areas of the infant s development. In addition, the mother father (partner) relationship may be affected. There are many current frameworks and strategies highlighting the need for a more robust, coordinated and interdisciplinary approach to perinatal mental health services. Also the requirement for specific training for those involved in the treatment and care of women with perinatal issues. (i) NICE Guideline: Antenatal and postnatal mental health: clinical management and service guidance (2007) This report recommends that healthcare professionals should routinely ask women about their mental well-being in pregnancy and the postnatal period using specific structured questions. There is also a recommendation for managed clinical networks for the delivery of perinatal mental health services across England and Wales, with clearly defined Pathways of care for service users and clearly defined roles and competencies for all professionals involved in the pathways. (ii) National Service Framework for Children, Young People and Maternity Services (WAG, 2006) The NSF standard 3.18 states: Women are offered an assessment for depression in the antenatal and postnatal period by appropriately trained health professionals, and there is access to specialised follow-up support services if needed. Page 4

6 (iii) Royal College of Psychiatrists, Council Report CR88, April 2000 This report recommends that every health authority should: Have a perinatal mental health strategy that aims to ensure that the knowledge, skills and resources necessary for detection and prompt and effective treatment are in place at all levels of health care provision. Identify a consultant with a special interest in perinatal psychiatry. This consultant should take a lead role in promoting these aims and in establishing a specialist multi-disciplinary team. Have access to a consultant and other mental health professionals with a special interest in their condition. Mother and baby units to serve the needs of a number of health authorities should be established. (iv) NICE Guidelines - Development of Perinatal Mental Health Services (2005) Clinical management and service guidelines for the management of puerperal/perinatal mental health (v) Developments in Perinatal Mental Health Assessments (British Journal of Midwifery) This report states that: There is substantial evidence that perinatal mood disorders are present at significant rates in the population. Despite this there are no systematic evidence-based processes in place to ensure women who suffer receive appropriate care. There is also significant evidence that early detection is critical to outcome. (vi) Confidential Enquiry - Maternal & Child Health Why Mothers Die This report emphasises that routine enquiry should be made about previous psychiatric history during pregnancy and that management psychiatric plans should be put in place for those at risk of recurrence of their condition following delivery. There were 60 deaths (out of 391) in Page 5

7 this enquiry which had psychiatric aspects and suicide was found to be the leading cause of maternal death. A specialist perinatal mental health team with the knowledge, skills and experience to care for women at risk of, or suffering from, serious postpartum mental illness should be available to every woman. Women who require psychiatric admission following childbirth should be admitted to a specialist mother and baby unit, together with their infant. It is important to note from the confidential enquires that: The profile of maternal suicides is different Most died violently - hanging or jumping Relative social advantage / education All early suicides were living in comfortable social circumstances Majority Puerperal Psychosis - abrupt-onset psychotic illness usually within days of childbirth 46% had previous contact with psychiatric services - half with a previous admission following childbirth Although half in contact with psychiatric services - none had detailed management plans / close surveillance (vii) Under Pressure: Report of the Risk & Quality Review of the NHS Mental Health Services Recommendation 10 states: By April 2006, mental health commissioners should ensure that effective liaison services are established for each general hospital and A& E department. The special needs of expectant / nursing mothers should be addressed with support and advice from skilled mental health nurses. (viii) The Out of the Blue? Motherhood and Depression (MIND, 2006) Highlights the importance of developing perinatal services within every Health Trust: It is essential that the mental health and well-being of new mothers is the responsibility of all involved professional groups and services, and not just psychiatry. As the report shows, the wide range of perinatal disorders which affect women during pregnancy and after childbirth should be managed at all levels of healthcare by primary, secondary and tertiary services. An important step is to make sure adequate services are in place to improve the skills, knowledge and confidence of all health and professionals who promote the mental health and well being of Page 6

8 pregnant and postnatal mothers. This includes the wide range of common mental health problems and mild disorders that are more often seen by health professionals, which should be dealt with both sympathetically and sensitively. Audits of mental health service provision should take account of their accessibility and responsiveness to the needs of mothers with dependant children. There should be funding for mental health advocacy that specifically addresses the needs and concerns of parents with mental health problems. It is also essential that skilled specialist teams and mother and baby units are available to all those with serious mental health problems regardless of where they live. (ix) Other relevant papers\reports that support the need for service development in this area Delivering Race Equality - a Framework for Action [2003]. National Domestic Violence Strategy. Inside Outside New ways of Working for Psychiatrists in a Multi-Disciplinary and Multi-Agency Context [2004]. National Women s Mental Health Strategy [2002] and Implementation Guidance [2004]. The SIGN guidelines for the management of Postnatal Depression and Puerperal Psychosis (June 2002). The National Institute of Clinical Excellence (NICE) guidelines for Antenatal Care (October 2003). Perinatal Maternal Mental Health Services. Council Report CR88. The report of the independent inquiry into the care and treatment of Daksha Emson and her daughter Freya (October 2003). National Perinatal Mental Health Project Briefing Paper Perinatal Mental Health Paper: Sue Waterhouse and Cathy Freese, January The project aims to assist helping to set up managed care networks within each region and work across government departments to establish ways to encourage different agencies to work together better. The National Institute for Health and Clinical Excellence (NICE) published guidance on the clinical management of antenatal and postnatal mental health: The British Psychological Society & The Royal College of Psychiatrists, 2007 Consultation on Maternity Services and Support for Post-Natal Depression: A report prepared by Professor Gargi Page 7

9 Bhattacharyya and Ajmal Hussain, InterLanD, Aston University. Report prepared for the Amina Project 2010 Saving Mothers` Lives : The Seventh Report on Confidential Enquiry into Maternal Death in the United Kingdom. London: CEMACH. Lewis, G., (Ed) (2007): The aim of this recommendation is to improve the health of mothers, babies and children by carrying out confidential enquiries on a nationwide basis and by widely disseminating our findings and recommendations. Informed gender Practice: Mental health acute care that works for women: Jennie Williams and Jenifer Paul 2008: This best practice guidance is intended to support improvements in acute inpatient care for women. It progresses implementation of the women's mental strategy. 3 Guideline Statement MANAGEMENT (i) Predictors of risk are known (Jones & Craddock, 2005). Research from Cardiff has demonstrated clear-cut predictors of risk. Women with Bipolar Disorder (lifetime incidence of 1%) suffer episodes of Puerperal Psychosis following % of births. This very high rate of illness represents an enormous increase from the base rate of 1 in births in the population generally. In addition to a history of bipolar disorder, other important risk factors include having experienced a previous episode of puerperal psychosis, a first-degree relative who has experienced an episode of puerperal psychosis or a first-degree relative with bipolar disorder. Women can therefore be identified who are at a vastly increased risk of developing Puerperal Psychosis. However, because of the relapsing and remitting nature of Bipolar Disorder women at very high risk are often currently well, are not in contact with mental health services and will not themselves recognize the seriousness of the situation. It is clear that in order to ensure women at risk are identified, all women should be screened antenatally for the important risk factors and protocols should be in place to ensure that for women at risk, pregnancy and the postpartum period are managed appropriately (ii) General Statistics (extracted from NICE Guidance - antenatal & postnatal mental health) At least half of women, who give birth, experience low mood either at Page 8

10 some point in their pregnancy and/or in the initial days or weeks following the birth. This is commonly known as baby blues. Symptoms include feeling tearful, overwhelmed and irritable, but these may pass with rest, support and reassurance. If low mood persists during pregnancy a diagnosis of antenatal depression may be applicable. Low mood is thought to affect up to 15% of pregnant women and although prevalence is similar to that of postnatal depression, antenatal depression is often a neglected aspect of pregnancy. Diagnostic features include - a loss of interest in oneself, anxiety, loss of appetite and feeling tearful, lonely, irritable and irrational. If following the birth of the child, low mood persists for a prolonged period of time, the mother may be diagnosed with postnatal depression (affects 15 20% of new mothers within 12 months of their child s birth). Diagnostic features include Irritability, fatigue, sleeplessness, lack of appetite, anxiety, poor mother infant interaction (e.g. lack of interest in the child), anxieties about the child (possibly including thoughts of harming the child), lack of motivation, panic attacks, feelings of isolation. Also a sense of being overwhelmed, physical signs of tension such as headaches or gastrointestinal symptoms and thoughts of self-harm and suicide may also be present, which may or may not lead to self-harming behaviour. A more severe illness, with acute onset, is puerperal psychosis; a relatively rare disorder characterised by psychotic depression, mania or atypical psychosis. This affects between 1 in 500 and 1 in 1000 women who have given birth. Characteristic features in those with mania include excitability, disinhibition and intense over-activity. More commonly, pregnancy, childbirth and the postnatal period can be associated with the re-emergence or exacerbation of a pre-existing psychotic illness such as schizophrenia or bipolar disorder. For some women, there may be an increased risk of danger to themselves or others. The UK Confidential Enquiry into Maternal Deaths (CEMD) reports that psychiatric disorders contributed to 12% of all maternal deaths (10% of which were due to suicide). Mental disorders may go untreated, although response to treatment in the case of antenatal and postnatal depression tends to be good. If untreated, women may remain depressed, sometimes for many years, with consequent negative impact not only for the mother but also for other family members. The rate of recurrence of postnatal depression after a subsequent birth is about 30%. Page 9

11 Antenatal period The most common type of mental health problem that women experience during pregnancy is mixed anxiety and depression. Women who have a pre-existing condition of severe depression, bi-polar disorder and schizophrenia may be at risk of a recurrence during pregnancy; particularly when associated with reducing or discontinuing medication. At Booking Clinic women and their partners should be offered information about potential perinatal mental illness and relevant support services. Each woman should be screened using the agreed risk assessment tool that is contained in the All Wales Hand-held Maternity Records. The appropriate questions are listed on page 6 of the record and must be completed accurately (see Appendix 1). A note should be made in the obstetric record, along with a referral to an Obstetrician, for any woman identified as having serious mental illness or a risk of severe postpartum psychosis. Prospective parents identified as vulnerable or high risk of developing mental illness should be seen by the Obstetrician and the midwife or obstetrician should refer to the Mental Health services as per the guidance in this document. The GP and health visitor should also be informed of the referral. See Appendix 2. On assessment by the mental health team, a management plan of care will be made and all parties should be aware and involved in this plan, including the woman and her family. Women and families with complex social needs may require referral to Social Services. Women misusing drugs and/or alcohol should be referred to specialist agencies. Women with an existing diagnosis of Serious Mental Illness should always be referred back to mental health services. See Appendix 2. Information regarding taking prescribed medication during pregnancy should be available. It is important to encourage women to continue with prescribed medication, and not stop taking it abruptly, until they are assessed by appropriately qualified health professionals. Page 10

12 Intrapartum period Strengthening links of communication between all professionals involved around the time of birth for any woman who has been identified as being at risk will enhance the well-being of the mother. An identified perinatal communication form may be used to inform all professionals involved of the birth. When considering breastfeeding, the benefits of medication to the health and safety of both mother and baby should be discussed and weighed against the risks of using the drug. Postpartum period The risk of Post Natal depression may be reduced by: Promoting of bonding between mother and baby by explanation and initiation of skin to skin contact. Early intervention of infant feeding. Prevention of separation from the family unit. Assessment and appropriate management of pain. Encouragement of appropriate diet and rest. De-briefing following the birth to be offered according to individual needs. Information regarding the availability of self-help groups/voluntary agencies. e.g. NCT, MIND, Surestart, GP Practice Counsellor. PSYCHOSIS A woman presenting with symptoms of a puerperal psychosis may show symptoms soon after delivery. She may not have a previous psychiatric history though will be high risk if she has previous history or family history of bi-polar disorder or schizophrenic illness. Symptoms include: Hallucinations Delusions Restlessness/agitation Uncharacteristic/bizarre behaviour Feeling of elation or deep depression Paranoia/suspicion When a new mother is on the maternity unit If a new mother is displaying any potential psychiatric symptoms the nurse in charge of her care should immediately speak to the liaison psychiatrist. If a Page 11

13 referral is to be made out of hours they should speak to the on-call psychiatric SHO (see Appendix 2). If the new mother s symptoms can be managed on the maternity unit the appropriate arrangements should be made with psychiatric services. If the new mother s symptoms are severe and require assessment under the Mental Health Act the psychiatric service may consider detention under the Mental Health Act initially Section 5 (2) if the urgency requires it, this may then later be reviewed and an alternative section under the Act used. At all times risk management around the new mother and the baby need to be our highest priority. It could be that both can be nursed within the maternity unit, that mother and baby are transferred to a specialist mother and baby unit or in the most severe cases the mother and baby are separated and the new mother is nursed within the adult psychiatric service (this will be a last resort). When the new mother is at home. If a new mother presents with acute psychiatric symptoms in the community the GP should be contacted and arrange an urgent visit and a decision should be made whether this requires the intervention of the acute psychiatric service. If the assessment is required under the Mental Health Act the duty approved social worker should be contacted to arrange a Mental Health Act assessment this can be arranged through the hospital switchboard or direct via the duty desks in the Community Mental Health Teams the numbers of which can be found in Appendix 2. Where admission to hospital is necessary every effort should be made to locate a placement in the nearest specialist mother and baby unit. 4 Responsibilities It is the responsibility of each professional to ensure that they have adequate knowledge to use the recommended tool to identify those women who are at high risk of serious mental illness and suicide in the perinatal period. The Pathways into the mental health service must be clear and accessible to all professionals who come into contact with pregnant women. There is a recognised need for a robust perinatal mental health service to be established in Aneurin Bevan Health Board. 5 Skills and training All obstetricians, midwives, health visitors and mental health nurses should have an awareness training regarding the basic issues of perinatal mental health and in the use of the antenatal questions. Page 12

14 The CEMACH report ( ) recommended the following education and training standards be implemented: The Royal Colleges of Psychiatry, Obstetrics & Gynaecology, General Practice and Midwives should ensure that perinatal psychiatry is included in their curricula and requirements for continuing professional development. Local training must be put in place before routine screening for serious mental illness in implemented. This can be achieved with the Consultant Psychiatrist with special interest in perinatal mental health and practice educators / specialist & consultant roles from midwifery and mental health teams. Perinatal mental health should be part of annual mandatory updates. Obstetricians and midwives should be aware of the laws and issues that relate to child protection and where and to whom to refer if concerned. This also applies to other Health Care Professionals involved with this client group mental health nurses and health visitors etc. The University of Glamorgan runs a module on maternal mental health, which complements the in-house educational requirements. The All Wales Perinatal Mental Health Group have developed an on-line training module on the identification and referral of women at high risk of serious post-partum mental illness and this is due to be released late in All midwives should be encouraged to undertake this on-line module which is also suitable for other professional groups and will be accessible. The use of the Annual Supervisory Review by Supervisors of Midwives will help midwives to identify areas in which they feel they require additional training and education. Record Keeping Midwives are required to maintain accurate and detailed records throughout the pregnancy, labour and puerperium Midwifery Rules and Standards (NMC, 2004) and Health Board Record Keeping Guidelines. Records should be available to all health care professionals involved in the woman s care and detailed care plans must be shared, communicated and accessible to all. 6 Security Any staff undertaking home visits must be aware of the Lone Worker Guidelines and should risk assess each situation. Page 13

15 7 Monitoring and Effectiveness This guideline must be audited annually. The number of referrals to each mental health team must be collated and audited on each community midwife s monthly statistics form. The mental health teams must also audit the number of referrals on a monthly basis. Data Collection: There is currently no formal system in place to collect and record data from primary care of women with perinatal mental health problems, who are treated by GP s and who may have benefited from specialist perinatal care. The information available appears inaccurate and that there is also underreporting. It appears that few women had to be admitted outside the Trust Health Board to mother and baby beds. However, many more women are admitted without their babies to acute psychiatric beds, which is inappropriate. There needs to be robust methods of collecting data on women suffering perinatal mental health issues. 8 References Confidential Enquiry into Maternal and Child Health 2007, Saving Mothers Lives : The Seventh Enquiry. London: RCOG Press. Confidential Enquiry into Maternal and Child Health 2004, Why Mothers Die : The Sixth Enquiry. London: RCOG Press. Improving Perinatal Mental Health Care (London South Bank University, London - Currid, T J). Jones I & Craddock N Bipolar disorder and childbirth: the importance of recognising risk. British Journal of Psychiatry (2005) MIND 2006 Out of the Blue? Motherhood and Depression National Institute for Clinical Excellence (NICE) Antenatal and Postnatal Mental Health (2007), Clinical management and service guidance. Nursing and Midwifery Council. Midwives Rules and Standards. London: NMC; 2004 [ Royal College of Psychiatrists, Council Report CR88, April Research and statistics provided by Ian Jones, Consultant Psychiatrist, University of Wales College of Medicine. Page 14

16 Welsh Assembly Government 2006 National Service Framework for Children, Young People and Maternity Services (final version). Cardiff: WAG This policy has undergone an equality impact assessment screening process using the toolkit designed by the NHS Centre Equality & Human Rights. Details of the screening process for this policy are available from the policy owner Page 15

17 9 Appendices Appendix 1: Mental Health Questions to be asked at pregnancy booking assessment and recorded in the All Wales Maternity Hand-held Record (page 6): Page 16

18 Aneuri n Bevan Health Board Owne r: Maternity Services/Health Visiting/Mental Health Appendix 2: PERINATAL MENTAL HEALTH REFERRAL GUIDE The contact addresses and telephone numbers are: ROUTINE REFERRALS SHOULD BE ADDRESSED TO THE RELEVANT CMHTs COMMUNITY MENTAL HEALTH TEAMS Newport East CMHT Newport West CMHT Torfaen North & South CMHTs North Monmouthshire 6 Goldtops 6 Goldtops Talygarn Unit Maindiff Court Hospital Newport Newport Griffithstown Abergavenny Lower Monmoutshire Caerphilly Central Referral Caerphilly South Caerphilly North Hywel Dda Ty Cyfannol Ward Ty Siriol Penmaen House, Unit 3, Chepstow Ysbyty Ystrad Fawr Caerphilly Block F, Penmaen Industrial Hengoed Pontllanffraith, Blaenau Gwent CMHTs South Powys South Powys Ebbw Vale & Ebbw Fach Ty Illtyd The Hazels Cwm Coch Brecon Llandrindod Wells Ysbyty Aneurin Bevan Page 17

19 Aneuri n Bevan Health Board Owne r: Maternity Services/Health Visiting/Mental Health EMERGENCY REFERRALS FOR ALL TEAMS SHOULD BE REFERRED TO THE RELEVANT DUTY DESKS MONDAY TO FRIDAY 9.00AM TO 5.00PM The contact numbers are: DUTY DESKS Monmouthshire Torfaen Newport Blaenau Gwent Chepstow Caerphilly Central Referral Point (Fax: ) South Powys Brecon South Powys Llandrindod OUT OF HOURS EMERGENCY REFERRALS CONTACT AND SPEAK TO THE ON-CALL DUTY PSYCHIATRIST. IN-PATIENT REFERRALS FROM DISTRICT GENERAL HOSPITALS (ROYAL GWENT (RGH), NEVILL HALL) CONTACT RELEVANT DUTY DESKS ROYAL GWENT GOLDTOPS , NEVILL HALL MAINDIFF COURT Page 18

20 Aneuri n Bevan Health Board Owne r: Maternity Services/Health Visiting/Mental Health NON URGENT REFERRALS CLIENT KNOWN TO SERVICE CLIENT NOT KNOWN TO SERVICE Midwife/medic referral to CMHT First Access/Assessment clinic and offer of assessment Agree a care plan/contingency plan with either ongoing involvement or fast track back to M.H. services as required. Should mental health deteriorate, care co-ordinator to re-assess patient s mental health needs. CPN CR/HT OPD Admission to local inpt unit without baby Page 19 Admission to Specialist unit UHW with baby.

21 Aneuri n Bevan Health Board Owne r: Maternity Services/Health Visiting/Mental Health URGENT/LIAISON REFERRALS Referral from Midwife/Medic for urgent assessment In hospital: Refer to liaison team 9-5, out of hours refer to on call duty psychiatrist for assessment. At Home: Refer to duty desk 9-5, out of hours refer to on-call duty psychiatrist. CR/HT 9am 9pm (Mon- Sun) or follow up the next working day. CMHT follow up the next working day. Admission to out of area specialist unit. Informal Detained Identification of care co-ordinator to act as liaison with other relevant involved individuals/co-ordinate meetings etc. Page 20