The 7 th FEBRUARY 2014 - PERINATAL MENTAL HEALTH DISCUSSION DAY OXFORD HEALTH GERRY BYRNE (Clinical Lead, FASS, IPPS, ReConnect) Consultant Nurse & Consultant Psychotherapist JUDITH RICHARDSON (Clinician, IPPS) Community Psychiatric Nurse
The P E R I N A T A L M E N T A L H E A L T H C O N F E R E N C E 1 0 t h J U L Y 2 0 1 4 What does excellence in Perinatal Mental Health look like? GERRY BYRNE (Clinical Lead, FASS, IPPS, ReConnect) Consultant Nurse & Consultant Psychotherapist JUDITH RICHARDSON (Clinician, IPPS) Community Psychiatric Nurse
Service Rationale: Medium-Long term N e w H o r i z o n s ( D H 2 0 1 0 ) Maternal health during pregnancy and the child parent relationship during the first few years of life have a very significant influence on brain architecture, lifelong habits and patterns for dealing with life and adversity, and future mental health and well-being. Confident Communities, Brighter Futures: A framework for developing well-being (New Horizons, DH 2010)
Service Rationale: Immediate-short term K e y S t a t i s t i c s Approximately 1 in 5 women will experience a diagnosable mental illness at some point during pregnancy and in the first year after birth Approximately 1 in 7 women will experience antenatal depression/anxiety Approximately 1 in 10 women will experience postnatal depression/anxiety Approximately 1 in 500-1000 women will experience puerperal psychosis
Service Rationale: Child outcomes K e y F a c t s Parental perinatal mental illness is associated with an increased risk of: Low birth weight, obstetric complications and still birth Poorer quality of bonding and more insecure attachment Poorer socio-cognitive development ADHD, conduct disorder and behavioural difficulties 4 fold increase in risk of mental illness for the infant in the future
All cases of adolescent depression at 16 years were associated with depression in the mother during early life (Pawlby et al 2009)
Time Magazine October 2010
The Guardian October 2011
Service Development O x f o r d C a r e P a t h w a y S t e e r i n g G r o u p Oxford Radcliffe NHS Trust Maternity Services invited representatives from Mental Health services, Health Visiting, GP services, voluntary organisations, commissioners and lay representatives 2007 No existing specialist perinatal mental health service (or single dedicated perinatal mental health clinician) Oxford Care Pathway Steering Group established 2007 - Consultant Midwife - Consultant Psychiatric Nurse (CAMHS) - GP Lead - Health Visitor Lead - Oxford Health Operational Manager - Oxfordshire Commissioner
Service Development D r i v e r s f o r C h a n g e Saving Mothers Lives 2003-2005 (CEMACH 2007) Antenatal & Postnatal Mental Health Care (NICE 2007) Maternity Matters (DH 2007) Towards Better Births (HCC 2008) Standards for Maternity Care (Royal Colleges 2008) High Quality Care for All: NHS next stage review final report (Darzi 2008) And more recently: Safeguarding Children; Healthy Child Programme, New Horizons, and others
Service Development I n t e g r a t e d S e r v i c e M o d e l The recommended model of care is for women and their babies to be managed at home, by primary care and maternity teams with specialist perinatal mental health support within managed care networks Cathy Freese National Perinatal Mental Health Project Lead
Service Development P l a n n i n g & I m p l e m e n t a t i o n Sep 2007 Nov 2008 Dec 2008: IPPS launched Steering group meet regularly Scoped existing services Identified service gaps Identified training needs Agreed service design Planned training programme Recruited staff
The S E R V I C E D E L I V E R Y
1 Assessment & treatment of moderate perinatal mental illness Assessment & treatment of parent-infant relationship difficulties 2 3 4 Training & Supervision in perinatal mental health (identification & treatment) to midwives, health visitors & other professionals. Incl. delivery of groups. Specialist Consultation in perinatal mental health to any health or social care professional in the county Strategic Responsibility for perinatal mental health across the county
Service Delivery P r e v a l e n c e o f P e r i n a t a l M e n t a l H e a l t h 3% 17% 80% SEVERE MENTAL ILLNESS Puerperal psychosis Suicidal intent Acute and debilitating illness, eg. PTSD, OCD, eating, etc. MILD - MODERATE MENTAL HEALTH DIFFICULTIES Post/Antenatal depression Anxiety PTSD, etc. Symptoms moderately limiting one s ability to function MILD - NO MENTAL HEALTH DIFFICULTIES Stress & tearfulness Shock of birth Sense of inadequacy Shattered expectations Struggle with change of identity / role Etc.
L O C A L E P I D E M I O L O G Y 10,000 live births p.a
Severe Perinatal MH Difficulties: 300 mothers 300 mothers (3%) with severe perinatal mental health difficulties
Moderate Perinatal MH Difficulties: 1700 mothers 1700 mothers (17%) with moderate perinatal mental health difficulties 300 mothers (3%) with severe perinatal mental health difficulties
Mild / no Perinatal MH Difficulties: 8000 mothers Approx. 8,000 mothers (80%) with mild or no perinatal mental health difficulties 1,700 mothers (17%) with moderate perinatal mental health difficulties 300 mothers (3%) with severe perinatal mental health difficulties
Severe Perinatal Mental Health Difficulties EXISTING SERVICES Already receiving specialist mental health treatment (although not specialist perinatal treatment) via existing tertiary mental health services, e.g. - Community Mental Health Teams - Outpatient services - Inpatient services - Out-of-area MBUs (3%) 300 mothers
Severe Perinatal Mental Health Difficulties IDENTIFIED SERVICE NEEDS 1 Improved access to tertiary mental health services for maternity and health visiting services 2 Specialist perinatal mental health consultation service available to tertiary mental health services (3%) 300 mothers
Severe Perinatal Mental Health Difficulties IDENTIFIED SERVICE NEEDS CLINICAL DELIVERY Improved access to acute mental health services for maternity and health visiting services 1 Care pathway developed jointly by maternity services, GPs, health visiting / universal services, and OHFT Specialist perinatal mental health consultation service available to tertiary mental health services 2 Newly formed Infant-Parent Perinatal Service (IPPS) to provide consultation to tertiary mental health services
Moderate Perinatal Perinatal MH Mental Difficulties: Health Existing Difficulties Services EXISTING SERVICES Receiving either no mental health treatment or mental health treatment from very limited statutory and non-statutory services e.g. - MIND - OXPIP (Oxford Parent Infant Project) - GP counsellors Held / supported by primary health care often reporting to be working beyond their remit and skills (17%) 1,700 mothers
Moderate Perinatal Mental Health Difficulties IDENTIFIED SERVICE NEEDS 1 2 Community based access to specialist perinatal mental health assessment and treatment for mothers Community based access to parentinfant assessment and treatment (17%) 1,700 mothers
Moderate Perinatal Mental Health Difficulties IDENTIFIED SERVICE NEEDS Community based access to specialist perinatal mental health assessment and treatment for mothers Community based access to parentinfant assessment and treatment 1 2 3 CLINICAL DELIVERY IPPS provides community based assessment and treatment of the mother s mental health difficulties IPPS provides community based assessment and treatment of the parent-infant relationship IPPS provides advice, care co-ordination and care planning with health care and social care professionals
Moderate Mild / No Perinatal MH Mental Difficulties: Health Existing Difficulties Services EXISTING SERVICES Receiving non-specialist support for mental health difficulties (if required) from primary health care services, e.g. - Health visitors - Midwives - GPs - etc. (80%) 8,000 mothers
Mild / No Perinatal Mental Health Difficulties IDENTIFIED SERVICE NEEDS 1 Training to primary health care services in the identification and prevention of perinatal mental health difficulties 2 Consultation to primary health care services in providing support to mothers (80%) 8,000 mothers
Mild / No Perinatal Mental Health Difficulties IDENTIFIED SERVICE NEEDS Training to primary health care services in the identification and prevention of perinatal mental health difficulties Consultation to primary health care services in providing support to mothers 1 2 CLINICAL DELIVERY IPPS trains over 350 midwives p.a., 265 health visiting staff p.a, Oxford Brookes student nurses/midwives, obstetric SHOs, Social Workers & Children s Centre workers in identification of perinatal mental health symptoms including the use of the Whooley Questions and the Care Pathway IPPS provides consultation and supervision to any health or social care professionals involved in the care of women with mild perinatal mental health difficulties
IPPS: Service Delivery T R A I N I N G ( 1 ) Delivered more than 30 half day workshops in Introduction to Perinatal Mental Health (identification & intervention) and Introduction to Whooley Questions to midwives and health visitors (including several other professional groups) (Since March 2011) Delivering 8 Advanced level ½ day training in Clinical Microskills to Health Visitors per year: (1) Cognitive microskills x 2 (2) Systemic microskills x 2 (3) Microskills in parent-infant interventions x 2 (4) Microskills for complex families x 2
IPPS: Service Delivery T R A I N I N G ( 2 ) (since September 2010) Introductory training in perinatal mental health, attachment and parent-infant interventions to Children Centre staff Course on Mindfulness-Based Cognitive Therapy with Professor Mark Williams for lead midwives and health visitors Intensive two day training packages to Health Visitors in facilitating postnatal depression groups (followed up with regular supervision)
IPPS: Service Delivery T R A I N I N G ( 3 ) Training Children s Centre & Crèche workers in Attachment, Perinatal Mental Health and PND Group process Holding Infants in Mind in September 2013 with Professor Michael Zilibowitz, and Dr Sian Warriner IPPS presented nationally in Conferences (Excellence in Perinatal Mental Health April and Nov 2013 with Dr Rosie Shepperd) and Internationally (World Association of Infant Mental Health June 2014)
IPPS: Service Delivery C O N S U L T A T I O N & S U P E R V I S I O N IPPS Consultation Telephone Line - For any professional to have direct access to specialist advice, information, or to discuss a possible referral Specialist face-to-face consultation for midwives and health visitors Clinical supervision for the Family Nurse Partnership Programme Oxfordshire Monthly joint mental health outpatient clinic run in partnership with the John Radcliffe Obstetric Team
IPPS: Service Delivery R E S O U R C E D E V E L O P M E N T Patient leaflet: Antenatal & Postnatal Depression and other emotional difficulties during pregnancy and after birth - 50,000 now printed - Given to every newly pregnant woman in Oxfordshire - Also available in GP surgeries, Children s Centres and Health Visiting Teams Well-Being Mood Journal Professional Leaflet: Working with Parents with Complex Emotional Needs
IPPS: Service Delivery S T R A T E G I C R O L E Dedicated service to lead and further develop the Oxfordshire Care Pathway Designated point of contact for all services within Oxfordshire providing or seeking perinatal mental health care for mothers Antenatal & Postnatal Mental Health Clinical Advisory Group Oxfordshire Perinatal Clinical Network Oxfordshire Health Visitor s Special Interest Group in Maternal Mental Health
IPPS: Service Delivery S U M M A R Y This year from April 2013 to January 2014 IPPS has: - Received over 280 referrals - Successfully treated over 100 mothers/families - Provided over 200 specialist telephone consultations to health or social care professionals - Provided specialist training in perinatal mental health and attachment to over 665 health or social care professionals - Trained and supervised Health Visitors to run rolling Postnatal Depression Groups in over 6 localities
IPPS: Service Delivery C L I N I C A L T E A M ( 2. 6 F T E ) 0.1 FTE Child Psychotherapist (Clinical Lead) 1.0 FTE Community Psychiatric Nurse (Clinical Coordinator) 0.6 FTE Community Psychiatric Nurse (Care Coordinator) 0.6 FTE Infant-Parent Support Worker 0.1 FTE Child Psychotherapist (FNP supervision) 0.2 FTE Trainee Child Psychotherapist Regular under-the-radar pilfering from FASS
Referral Data: Referral Source (49%) Midwives (38%) Health Visitors (6%) GPs (4%) Obstetrics (2%) Social Services (1%) Mental Health
Referral Data: Primary Presentation 59% (32%) Postnatal depression (27%) Antenatal depression (25%) Anxiety (10%) Birth Trauma (4%) Attachment difficulties (1%) Eating difficulties (1%) OCD
Referral Data: Secondary Presentation 31% (23%) Postnatal depression (8%) Antenatal depression (21%) Anxiety (13%) Attachment difficulties (4%) Birth Trauma (2%) Eating difficulties (2%) OCD (27%) None identified
Treatment Data: Treatment Duration (20%) Less than 4 weeks (27%) 4-13 weeks (38%) 13-26 weeks (15%) 26+ weeks
Treatment Data: Treatment Model (12%) Assessed then signposted (5%) Assessed then discharged (30%) Low intensity / monitoring (34%) Medium intensity (19%) High intensity / transition
IPPS: Future Plans Postnatal Depression Group Development - 300+ mothers in PND group treatment by end of 2012 Antenatal Depression / Relapse Prevention Group Parent-Infant Interventions Group Mindfulness Based Cognitive Therapy Group Watch, Wait & Wonder parent resource Improved collaboration & partnership with Children s Centre, CYP&F & Adult Mental health
A W A R D S & P U B L I C A T I O N British Journal of Midwifery Awards (2009) Team of the Year Awarded: Second Prize Royal College of Midwifery Awards (2010) Excellence in Partnership Working Awarded: Highly Commended Joint midwifery IPPS paper (2011) Published in the British Journal of Midwifery (Warriner, Byrne, Graham)
IPPS: User Feedback Anne case study (pseudonym)
The TRAINING & SUPERVISION OF POSTNATAL DEPRESSION GROUPS
Postnatal Depression Group Project P R O J E C T O V E R V I E W A 10 week therapeutic intervention based group for moderately depressed mothers and partners Based upon Australian model of Milgrom, Martin & Negri (1999) adaptations include a session on attachment and a session for fathers Incorporated evidence-based interventions (ie. CBT, guided self-help, mindfulness, etc.) Audited using BDI and Culture-Free Self-Esteem Inv.
Postnatal Depression Group Project D E V E L O P M E N T & P A R T N E R S H I P W O R K I N G Developed in partnership between Health Visiting, IPPS, Carterton Children s Centre & RAF Welfare Services Locally delivered by Health Visitors Training and regular supervision from IPPS Location and creche provided by Children s Centres (with training in attachment given to Children s Centre staff)
Postnatal Depression Group Project 2 0 1 1 2 0 1 2 (2010) Pilot group run by two Health Visitors 2 times = 30 mothers / year (2011) 5 groups 3 times = 150 mothers / yr (2012) 11 groups 3 times = 330 mothers / yr (2011-12) Proposed development of antenatal / relapse prevention groups
Postnatal Depression Group Project P I L O T G R O U P : R E F E R R A L S & S C R E E N I N G 10 moderately depressed mothers were referred by GPs, Health Visitors and IPPS Mothers with babies under 1 who had shown no improvement following standard interventions Screening Tools: - Whooley Questions (NICE 2007) - Edinburgh Postnatal Depression Scale - Past & current mental health & medication
Postnatal Depression Group Project P I L O T G R O U P : P A R T I C I P A N T S & A T T E N D E N C E 10 mothers ranging from 20 to 36 years old (mean: 28 years and 6 months) Children ranging from 8 weeks old to 3 years and 1 month (mean age 9.4 months) 7 of 10 mothers prescribed antidepressant medication before the group started 2 mothers with previous history of mental health difficulties 98% attendance rate
Postnatal Depression Group Project P R O G R A M M E C O N T E N T 1 10 facilitated sessions lasting 90 minutes with crèche (1) Understanding and managing postnatal depression (2) Motherhood and expectations (3) Personal time and relaxation (4) Problem solving strategies (5) Cognitive behavioural therapy & Mindfulness
Postnatal Depression Group Project P R O G R A M M E C O N T E N T 2 cont d (6) Challenging the internal critic (7) Attachment of mother and child ;lkaj(including feedback from the crèche workers on each child) (8) Father s session (9) Transition and goal setting (10) Closing session
Postnatal Depression Group Project E V A L U A T I O N M E T H O D Evaluation included: (1) Pre- and post- Beck Depression Inventory (2) Pre- and post- Culture-Free Self-Esteem Inventory (3) Weekly monitoring of individual patient s mood ratings (4) Interviews with patients using video and audio tape
depression scores Postnatal Depression Group Project E V A L U A T I O N : B E C K D E P R E S S I O N I N V E N T O R Y 45 40 35 30 25 20 pre-group post-group 15 10 5 0 patient 1 patient 2 patient 3 patient 4 patient 5 patient 6 patient 7 patient 8 patient 9
self-esteem raw scores Postnatal Depression Group Project E V A L U A T I O N : C U L T U R E F R E E S E L F E S T E E M 14 General Self-Esteem 12 10 8 6 pre-group post-group 4 2 0 patient 1 patient 2 patient 3 patient 4 patient 6 patient 7 patient 8 patient 9
Postnatal Depression Group Project S H O R T V I D E O P R E S E N T A T I O N
The B E Y O N D 2 0 1 1
New Horizons D E P A R T M E N T O F H E A L T H ( 2 0 1 0 ) Experiences during pregnancy and in the first few years of life lay the foundations for all future learning, behaviour and health. Confident Communities, Brighter Futures: A framework for developing well-being (New Horizons, DH 2010)
Oxfordshire Perinatal MH Services Working Towards Women s Well-being (2010) Nearly half of Trusts in the surveys reported significant developments in perinatal mental health services, including mother and baby units and dedicated multi-disciplinary teams Responses from primary care also indicated service developments, including training for health visitors and midwives. However, there was little evidence of a whole-system approach to perinatal mental health services within Trusts. Improvements seemed often to be championed by a few committed individuals. Working Towards Women s Well-being: Unfinished Business National Mental Health Development Unit (2010)
A W A R D S & P U B L I C A T I O N British Journal of Midwifery Awards (2009) Team of the Year Awarded: Second Prize Royal College of Midwifery Awards (2010) Excellence in Partnership Working Awarded: Highly Commended Joint midwifery IPPS paper (2011) Published in the British Journal of Midwifery (Warriner, Byrne, Graham)