Perinatal mental health

Perinatal mental illnesses (PMI) are the most common complications of pregnancy, affecting around 15-20% of all pregnancies. Not all PMI is postnatal depression or even a single diagnosis, for example depression and anxiety are often co-morbid. Table 1 illustrates the rate and diversity of diagnoses⁴.

Childbirth and new motherhood carries an expectation of happiness, but it is also a time of emotional upheaval and adjustment to changes in lifestyle and relationships. Mental illness at this time causes enormous distress and can seriously interfere with the adjustment to motherhood and the care of the newborn baby as well as the existing children and a woman’s partner.

Perinatal psychiatric disorder has been a leading cause of maternal mortality for the last two decades contributing to 15% of all maternal deaths in pregnancy and the first six months postpartum⁵. Over half of women who tragically die during this time have a previous history of severe mental illness and over half of the deaths are caused by suicide.

Table 1. Rates of perinatal psychiatric disorder per thousand maternities

JCC-MH: Guidance for commissioners of perinatal mental health services. RCPsych 2012⁴

Postnatal depression, anxiety and psychosis together carry an estimated total long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK (6). Nearly three-quarters (72%) of this cost relates to adverse impacts on the child rather than the mother. Over a fifth of total costs (£1.7 billion) are borne by the public sector, with the bulk of these falling on the NHS and social services (£1.2 billion). The average cost to society of one case of perinatal depression is around £74,000, of which £23,000 relates to the mother and £51,000 relates to impacts on the child.

Mental illness is as common during pregnancy as following birth^{7, 8} and covers the same range of psychiatric conditions and severity as after birth. The risk factors for antenatal depression are broadly social vulnerability, childhood abuse, domestic abuse, and a previous history of depression (9). The impact of poor mental health can be greater at this time, particularly if left untreated because of the impact on the cognitive, emotional, social, educational, behavioural and physical development of infants⁹. Disturbances in the infants are not inevitable; they are increased from 5 to 10%. When disorders occur in the absence of social adversity and if they are of short duration, the risks to the child are generally low, and despite adversity many children in such situations develop normally and remain healthy¹⁰.

Risk factors for postnatal depression are antenatal depression or previous depression⁹. Bereavement by miscarriage, stillbirth or neonatal death are also more likely to lead to mental health problems in both parents¹¹. Bipolar disorder is significantly associated with postnatal psychosis, although 50% of women who develop postnatal psychosis have no history of previous mental illness¹².

GPs are the only health professionals who hold chronological medical records for women, and they need to ensure that midwives at booking have access to full records of any psychiatric illness, as this is the most important predictor of future illness. In some Pathfinder areas, such as Lambeth and Tower Hamlets, there are already shared electronic records across primary, secondary, and social care and this is facilitating information sharing.

There are a range of effective interventions for mothers affected by PMI^1,2, so GPs can offer women hope about recovery. On the other hand, a recent international paper suggests that few women receive optimum treatment (13). About 90% of women with perinatal mental health illness will have subthreshold, mild, or moderate illness and should be cared for in primary care with input from other universal services, such as health visiting, midwifery or IAPT. Women with severe mental illness should be able to access specialist perinatal psychiatric care.

However, only about 50% of CCGs in the UK have commissioned a specialist perinatal mental health service¹⁴, producing huge disparities in the availability of care for women and families with severe illness. The English Department of Health.

(DH) has recognised this as a clinical priority and has made £365 million available to increase the numbers of mother and baby units and specialist perinatal community teams. In the UK access to psychological therapies is currently limited and untimely, but the DH have pledged that 30,000 more women will have access to IAPT services throughout England by 2020/21¹⁵.

For those mothers experiencing impairment of their relationship with their infant, there is also promising evidence that interventions promoting parent/infant relationships can generate improvements in the quality of attachment.^1,2,6

In a meta-analysis of adult patients with depression in primary care 47.3% were identified correctly as depressed, although there were more false positive diagnoses than missed diagnoses¹⁶. There is no UK study of the detection of perinatal depression by GPs, but it is probably similar.

The reasons that these illnesses are poorly recognised and treated are complex and include maternal and GP factors. One qualitative paper, conducted in areas of the country where there was poor access to specialist perinatal services, suggested that women with postnatal depression had made a conscious decision about whether or not to disclose their feelings to their GP or health visitor¹⁷. In this paper GPs described a reluctance to label women with a diagnosis of postnatal depression, as they had few personal resources to manage women with postnatal depression themselves, and no specialist perinatal services to refer to for further treatment.

In April 2014 the RCGP recognised the importance of perinatal mental health for GPs and made it a clinical priority for a duration of three years. Dr Judy Shakespeare is in post, assisted by Dr Carrie Ladd, Clinical Fellow.

Aims of the Clinical Champion Programme 2014-7

Stakeholders

The major umbrella stakeholder is the Maternal Mental Health Alliance (MMHA), a coalition of over 80 UK organisations, including Royal Colleges, committed to improving the mental health and wellbeing of women and their children in pregnancy and the first postnatal year. The MMHA is currently running an “Everyone’s business campaign” in which the RCGP is an active member of the campaign working group. This has just been awarded a second grant of £750k by Comic Relief to continue from 2016-2108.

• Awareness raising
  To pro-actively increase the profile and awareness of the impact of perinatal mental ill-health on the mother, her infant and her family among general practitioners, the wider primary health care community, and patient-related organisations and groups.
• Education
  To promote best clinical practice by developing a range and quality of educational and information resources in perinatal mental health for GPs.
• Collaborative working
  To spearhead collaborative and partnership working with midwives, health visitors and specialist perinatal psychiatry teams in addition to other stakeholders.

Falling through the gaps: perinatal mental health and general practice.

A report by the Centre for Mental Health, working with the RCGP¹⁸ has shown that the greatest barriers to providing better support to women is the low level of disclosure and identification. This report was based on a survey of 1547 women who had responded to a questionnaire run by NetMums¹⁹. A number of barriers to identification were identified, including:

Barriers to identification for women

• Poor awareness of perinatal mental illness among women, their partners and families
• Considerable stigma and a fear among women that their baby might be taken away if they admit their difficulties
• Women feeling dismissed or overly reassured when discussing their problems with GPs

Barriers to identification for GPs

• Time pressures on GP consultations
• Lack of training and confidence among GPs in managing PMI
• Reduced contact between GPs and women during pregnancy and fragmented primary health care team working between GP practices and midwives and health visitors

Potential opportunities

There were potential opportunities to increase the chances of identification, including:

• The six-week maternal postnatal health check by GPs offered a crucial safety net for women disclosing later
• Improving the quality of GP responses when women raise concerns about their wellbeing. It is so difficult for women to be honest about their feelings that if they do disclose to a GP they may well have a problem. This should be regarded as a “red flag” and should prompt a clinical assessment. Having their feelings dismissed as “normal” or being given false reassurance was distressing for women and made them less likely to present their symptoms again.
• GPs need longer consultations times if they are to manage women with PMI effectively. Providing compassionate human care for these women is the very essence of quality general practice.

NICE Guidance on improving the identification of PMI

NICE guidance suggests that health professionals should consider asking the Woolley questions (for possible depression) and GAD-2 questions (for possible anxiety disorders) at every contact with a pregnant or perinatal women¹. If either of these are “positive” the recommendation is a full clinical assessment, usually by the GP. A GP is in the position of being a trusted professional, responsible for women across the life-course and able to offer continuity and compassionate care. Other non-judgemental ways of opening the conversation about feelings could be considered, such as asking “Has motherhood been what you expected?” The Edinburgh Postnatal Depression Score is not recommended for screening women in the UK.^{1, 2, 20}

Recommendations and actions for the RCGP champion (from Falling through the gaps)

1. The 6-8 week maternal postnatal check is an opportunity for GPs to detect mental health problems. The evidence base for this check is poor, needs to be developed and should recognise the parity of esteem between mental and physical health. Action: JS has lobbied DH and spoken to Dame Julia Cumberlege during the NHS England maternity review consultation process. This document contains a possible framework for the maternal postnatal check, based on JS advice²¹.
2. GPs need training to develop the knowledge, skills and attitudes needed for this work. Perinatal mental health is now included in the GP curriculum, but established GPs need opportunities to maintain and develop their skills in this area through their CPD. Action: Five sessions of eLearning are available on the eLfH website, with open access. JS was the editor for this programme and was involved in developing all the sessions with the authors.
3. GPs and their patients need easy access to appropriate resources. Action: A perinatal mental health toolkit, written by Clinical Fellow, Dr Carrie Ladd and Dr Louise Santhanam was launched on July 22^nd 2016
4. Produce an accessible guide to recent NICE guideline on antenatal and postnatal mental health. Action: “NICE guideline antenatal and postnatal mental health: CG 192”. This was launched in June 2015 to make NICE guidance more accessible for GPs.

Recommendations for NHS England

5. NHS England should invite RCGP to be represented at the Perinatal Mental Health Transformation Board.

Recommendations for RCGP

6. The “Put patients first: Back general practice” campaign should continue to lobby for longer consultation times within general practice, using PMI as an example of an important part of a GP’s work that cannot be done adequately within a 10-minute consultation.

Recommendations for commissioners

7. Commissioners should urgently address postcode inconsistencies in the availability of community specialist perinatal mental health teams/consultants and good quality integrated care pathways (ICPs) to support women facing or with perinatal mental illness.
8. Consistent with NICE Guidance, commissioners should ensure that local IAPT services fast track mothers with common perinatal mental health difficulties into treatment on the basis of the dual risks to mother and infant mental health.
9. Commissioners should ensure that there is adequate commissioning of parent-infant interventions and that these are well publicised to GP practices and mothers and integrated within ICPs.
10. Commissioners should collate a portfolio of local resources to include currently commissioned services for perinatal mental health and relevant local charities and voluntary led groups.
11. Commissioners should aspire to making shared electronic records between primary, secondary and social care a reality in all areas.

Recommendation for every GP practice

12. Proactively develop positive working relationships with midwives and health visitors attached to the practice for the benefit of women and families.

Recommendations for every GP

13. Maintain/develop knowledge and skills in perinatal mental illness.
14. Ensure attached community midwives can access information about the medical history of all pregnant women, either by direct access to the electronic record or by an established system of communication.
15. Know the local pathway of care and about local service provision.
16. Know that the RCGP perinatal mental health toolkit will be able to answer their general queries about PMI.

RCGP Council

Is asked to consider adopting the views and recommendations in this document as College policy.

1. National Institute for Health and Clinical Excellence (2014) Antenatal and postnatal mental health: The NICE Guideline on clinical management and service guidance.
2. Scottish Intercollegiate Guidelines Network (2012) Sign 127: Management of Perinatal Mood Disorders. A national Clinical Guideline. Edinburgh: Scottish Intercollegiate Guidelines Network.
3. National Institute for Health and Clinical Excellence. Antenatal and postnatal mental health NICE quality standard[QS115]
4. JCC-MH: Guidance for commissioners of perinatal mental health services. RCPsych 2012.
5. Saving mothers lives: Reviewing maternal deaths to make motherhood safer. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom, ed. Lewis G. BJOG, 2011; 118 (Suppl.1), Chapter 11
6. Austin, M. (2004) Antenatal screening and early intervention for perinatal distress depression and anxiety: where to from here? Archives of Women’s Mental Health, Vol 7, pp. 1-6
7. Milgrom, J. et al. (2008) Antenatal risk factors for postnatal depression: a large prospective study. Journal of Affective Disorders, 108(1-2), pp. 147-157
8. Howard l et al. Non-psychotic mental disorders in the perinatal period. Lancet 2014; 384: 1775–88
9. Stein A.et al. Effects of perinatal mental disorders on the fetus and child Lancet 2014; 384: 1800–19
10. Redshaw M, Rowe R, Henderson J. Listening to Parents after stillbirth or the death of their baby after birth. Oxford: National Perinatal Epidemiology Unit 2014.
11. Jones I et al. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet 2014; 384: 1789–99
12. Gavin N et al. Is Population-Based Identification of Perinatal Depression and Anxiety Desirable?: A Public Health Perspective on the Perinatal Depression Care Continuum in Identifying Perinatal Depression and Anxiety: Evidence-based Practice Eds. Milgrom J and Gemmill A. Wiley 2015.
13. Maternal Mental Health Alliance Everyone’s Business campaign website: Specialist perinatal mental health care in the UK 2023  
14. Prime Minister Office January 11th 2016
15. Mitchell et al. Clinical diagnosis of depression in primary care: a meta-analysis: Lancet: pp 609–619,
16. Chew-Graham et al. Disclosure of symptoms of postnatal depression, the perspectives of health professionals and women: a qualitative study. BMC Family Practice 2009, 10:7. doi: 10.1186/1471-2296-10-7  
17. Khan (2015). Falling through the gaps: Perinatal mental health and general practice. London, Centre for Mental Health  
18. Boots family Trust. Perinatal mental health experiences of women and health professionals. 2013  
19. National Screening Committee. The UK NSC recommendation on Postnatal depression screening in pregnancy. December 2011 NHS England. The National Maternity Review Better Births: Improving outcomes of maternity services in England: A Five-Year Forward View for maternity care  
20. Judy Shakespeare Date July 2015, review July 2016, review August 2016

Declaration of interests

Judy Shakespeare is the RCGP Clinical Champion in Perinatal Mental Health. She was on the Guideline development group for NICE 192: Antenatal and postnatal mental health published Dec 2014. In addition, she is a co- collaborator on the MBRRACE-UK collaboration, in particular working with the Maternal Death Enquiry. She has received travel and accommodation expenses for all these pieces of work. She has been paid for training by BMJ Masterclass, BMJ Webinars and RCGP One Day essentials.

This document has been commented on by Carrie Ladd and Margaret McCarthy.