Perinatal Mental Health Great Britain National Institute of Health and Care Excellence NICE guideline: Antenatal and postnatal mental health: Clinical management and service guidance 2007, update 2014 NCCMH 2014 2
Perinatal Mental Health Australia Clinical practice guidelines for depression in the perinatal period. A guideline for primary care health professional (under revision) General practitioners efficaciously treat postnatal depression, particularly when combined with cognitive-behavioural counselling by a mental-health specialist or a trained midwife or nurse Milgrom et al 2011 3
Perinatal mental disorders - definition Perinatal: pregnancy and the first year post partum All mental disorders in this period emerging for the first time, or recurrence of previous mental disorder Howard et al 2014 7
Perinatal mental disorders consequences Leading cause of maternal deaths Knight et al 2014 Increased rate of obstetric complications Bonari et al 2004 Risk of relapse within 5 years postpartum O Hara&Swain 1996 Impair family relationships Chew-Graham et al 2008 Increased financial and social burden for families Lovestone&Kumar 1993 Disturbed bonding and attachment processes Stein et al 2014 If chronic, it can cause cognitive, emotional, social, educational and behavioural problems in children Stein et al 2014 12
Long-term costs of inadequate treatment Estimated 2014 in Great Britain 8.1 billion for each annual cohort of births ~ 10 000 per birth Bauer et al 2014 Costs for adequate care were estimated to be 25-fold lower! 13
Challenges for perinatal mental health care Fetus, breastfed child affected by treatments Schaefer et al 2014 Parenting behaviour Stein et al 2014 Specialised services are rare Dennis&ChungLee 2006, Amiel Castro et al 2015 Stigma related to perinatal mental disorder Health professionals usually are not trained to deal with perinatal mental illness Milgrom&Gemmill 2014 Undertreatment 50-60 % remain undetected Vesga-López et al. 2008, Howard et al. 2014 Of those clinically detected, 10-15% get effective treatment Bauer et al 2014, Gavin et al. 2015 14
Perinatal mental health in Switzerland No prevalence data Perinatal mental health services (2007) Only 1 canton has guideline for perinatal mental Amiel Castro health et al care 2015 9 cantons provide mental health services in obstetric units 65% of Swiss cantons do not provide such specialised services No guidelines from professional associations 15
Study: Perinatal mental disorders in Switzerland- Prevalence estimates and use of mental health care Berger A, Bachmann N, Signorell A, Erdin R et al 2017 We analysed 3 large Swiss health statistics to obtain different estimates of the prevalence of perinatal mental disorders to determine the use of mental health care by perinatal women 17
Question 1: How many perinatal women are treated per year for mental disorders in maternity hospitals? (obstetric inpatient setting) Medical statistics of hospitals Federal Office of Statistics, since 1998 Annual, compulsory full inventory of all inpatients Contains medical diagnoses, International Classification of Diseases ICD10 Year 2012 Sample n = 89 699 all women hospitalised in obstetric units during pregnancy, on occasion of birth or postpartum Federal Office of Statistics 2014 18
Most frequent diagnostic groups (% all mental diagnoses, n=1 174) Neurotic, stress-related & somatoform disorders Mood (affective) disorders 30.7 29.5 disorder due to use of psychoactive substances 22.6 Disorders of adult personality & behaviour 7.6 Behavioural syndromes associated with Schizophrenia, schizotypal & delusional disorders 3.4 4.7 Mental retardation Unspecified mental disorder Behavioural & emotional disorders, onset in Disorders of psychological development 0.7 0.6 0.2 0.2 Berger et al 2017 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 % of all mental diagnoses 20
Question 2: How many women per year are recorded by freelance midwives as having mental disorders? (obstetric outpatient setting) Statistics of the freelance midwives Swiss Confederation of Midwives since 2005 Annual compulsory full inventory of all cases of midwifery care; report of mental-health status is voluntary Year 2014 sample: n= 57 951 cases of freelance midwifery care with mental-health status reported 21
Question 3: How many perinatal women per year use mental health services? Data of the health insurance Helsana 2 nd largest health insurance in Switzerland, covering 1.3 Mio residents with mandatory basic insurance 15% of the Swiss population sample: n= 13 969 (2014) Criteria for «use of mental health care» include all available services for mental health care: medication, psych. consultation with specialist or general practitioner, delegated psychotherapy, inpatient in psychiatric hospital, inpatient in acute hospital with F-diagnose 23
Types of mental health care used 25
Discussion Women with poor mental health are not much identified in obstetric care. Possible reasons: Hospital inpatient setting: women do not disclose problems Midwives might be reluctant to record mental disorders; lack of training Women avoid to inform care providers of mental health problems (fear for stigma, being separated from the child) Women receive mental health care, mainly in outpatient settings The high rate of mental health services use represents women so much impaired by poor mental health that they seek help; real prevalence might be even higher 27
Conclusions It is unclear if the care provided is adequate We need to investigate experiences and needs of women, perspectives of health professionals Guidelines from other countries emphasize the role of midwives in identifying and referring affected women Midwives need training how to deal with perinatal mental illness, e.g. -to raise awareness of the problem and learn -how to reduce the womens fear for stigma -how to sensitively address mental wellbeing as part of a broader conversation on the adjustments to motherhood - the pro s and con s of screening, screening tools -the positive outcomes of adequate treatment 28
Course «Maternal Mental Health» (5 ECTS) as part of the upcoming MSc Midwifery program Epidemiology of mental disorders Psychopathology of mental disorders Detection and treatment Health care for women with perinatal mental disorders Best practice models of care, interdisciplinary care Perinatal mental health care in the canton of Bern Situation analysis of a specialised service Development of advanced practice roles for midwives to maximize maternal mental health
Thank you for your attention! 30