Antenatal and Postnatal Mental Health Services in Lewisham: A Health Care Needs Assessment
Maternal mental health problems pose a huge human, social and economic burden to women, their infants, their families and society, and constitute a major public health challenge. This needs assessment explores the mental health needs of women during pregnancy and postnatally, and the services that are currently available to help them in Lewisham. Throughout the document related services will be referred to as perinatal mental health services as used by NICE.
Purpose of the Needs Assessment
· To provide an overview of the epidemiology of perinatal mental illness in Lewisham and nationally.
· To review the evidence and recommendations for effective management of perinatal mental illness and quality care services.
· To identify current service provision.
· To identify gaps in current service and make recommendations for local planning and strategy formulation
What do we know?
Facts and Figures
Lewisham is home to over 266,500 residents from a range of diverse communities, neighborhoods and localities and the local population is forecast to rise to over 290,000 over the next twenty years1.
Children and young people (0-19 years) make up 25% of the population, whilst elderly residents (over 75) make up just 5%, with the average age of the population in Lewisham being 34.7 years, young compared to other London boroughs1.
The most widely adopted measure of deprivation in England is the Index of Multiple Deprivation (IMD). Using this measure, Lewisham is the 31st most deprived Local Authority in England and relative to the rest of the country Lewisham’s deprivation is increasing. The highest deprivation is particularly found in Evelyn ward in the North and Downham in the South and along the A2 corridor. The map below shows how uneven the distribution of deprivation is across Lewisham.
Figure 1 The distribution of IMD 2010 in Lewisham by national quintile.
Source: http://www.lewishamjsna.org.uk/health-inequalities/index-of-multiple-deprivation (accessed 04/05/2012)
Perinatal mental illness covers a wide range of disorders, and affects one in six mothers during the antenatal and postnatal period2. The chronic illnesses that occur pre-pregnancy such as chronic depression, bipolar disorder and schizoaffective disorders can be exacerbated by pregnancy. There are also those disorders more specific to the antenatal and postnatal period such as antenatal depression and anxiety, postnatal depression and puerperal psychosis.
The epidemiology quoted in this document comes from the NICE guidelines and the referenced studies from there. Further detail can be found by going directly to the NICE guidelines. Depression and anxiety are approximately twice as prevalent globally in women as in men, and are at their highest rates in the lifecycle during the childbearing years from puberty to menopause. Of the perinatal mental illnesses, postnatal depression is the most common, with over 11% of mothers experiencing it during the postnatal period3. Depression and anxiety often occur together, making it difficult to find an accurate prevalence for anxiety, although studies have shown that up to 20% of women in the perinatal period can suffer from a combination of anxiety and depressive symptoms. Puerperal psychosis, the most severe of the perinatal disorders is relatively rare and occurs in 0.1-0.2% of postnatal women and approximately 4 women per 10,000 births will require admission to a specialist unit pre or postnatally for severe mental illness3.
It has been estimated that 50% of people with depression, not just those in the perinatal period are not identified4. This means that only around half of the pregnant or postnatal women who develop depression may present to primary care mental health services each year. A similar or lower figure might reasonably be expected for anxiety disorders, with fewer disorders being identified than for depression.
For the vast majority of these women, professional help will be provided solely by primary healthcare services. However, this is not always the case with around 3% to 5% of women giving birth having moderate or severe depression, and about 1.7% being referred to specialist mental health services5,6. Thus, around 17 women per 1,000 live births would be referred to specialist mental health services with depression postnatally. Again, it is reasonable to expect the figures for anxiety disorders to follow the national trend, with a lower rate of referral through to specialist services.
Common mental health problems during the antenatal and postnatal period include depression and anxiety disorders, such as panic disorder, OCD and PTSD. An estimated 10% to 15% of women suffer from depression after the birth of an infant; in England and Wales this is between 64,000 and 94,000 women a year and is equivalent to between two and three women per year on the average GP list and 100 to 150 per 1,000 live births7,8. Prevalence data for anxiety disorders during the perinatal period are not as reliable. The Office for National Statistics estimates that the prevalence of anxiety is around 4% of men and 5% of women9. This would mean that around 30,000 women giving birth per year in England and Wales are also likely to be suffering from anxiety, with two or three women per year on the average GP list; 50 per 1,000 live births.
First presentations of severe mental illness, primarily schizophrenia and bipolar disorder, in the perinatal period are rare, with a rate in the region of two per thousand resulting in hospital admissions10. These episodes are associated with a clustering of admissions in the first month after the birth; 1 per 2,000 live births. More common, particularly with bipolar disorder, is the exacerbation of an existing disorder, with some studies reporting relapse rates for bipolar disorder approaching 50% in the antenatal period and 70% in the postnatal period11, 19. These women, along with others suffering from severe depression and other severe disorders such as severe anxiety disorders or personality disorders, will benefit from referral to specialist mental health services.
Risk factors for perinatal mental illness include3, 17, 25:
· Recent migration
· Exposure to violence (domestic, sexual and gender-based)
· Emergency and conflict situations such as war and natural disasters
· Poor social support and being a single mother
· Past history of mood and anxiety disorders including postnatal depression (30% relapse rate with subsequent births)
· Family history of perinatal illness
· Childhood abuse
· Low income
· Unplanned pregnancy
· Large number of existing children
· Young age of the mother
· Traumatic delivery
· Perinatal death
Live births in Lewisham residents have risen annually in the last few years, and the majority of the deliveries occur at University Hospital Lewisham. In 2010 there were 723,165 live births in the UK, and 4,982 to Lewisham women. Using the prevalence figures above, it can be estimated that in 2010 approximately 1000 mothers would have been affected by a perinatal mental illness, with 600 of these having symptoms diagnostic of postnatal depression. 85 women would have required referral to the Perinatal Mental Health team and approximately two women would have required admission to the mother and baby unit for treatment. Many of the risk factors listed above, including recent migration, poor social support, being a single mother, low income, young age of the mother and perinatal death, are more common in Lewisham than in England and Wales, therefore greater numbers of women may require care in Lewisham. This is particularly evident in that seven Lewisham women were admitted to a mother and baby unit between 2011 and 2012 as apposed to the predicted two, and between 2010 and 2011 there were 193 women from Lewisham referred to the specialist Perinatal Mental Health service as apposed to the predicted 85.
Figure 2 A chart to show the number of referrals to the Lewisham Perinatal Mental Health Team, and from where the referrals originated.
Consequences of Maternal Mental Illness
The overall prevalence of mental disorders is similar in men and women. However, women’s mental health requires special consideration in view of women’s greater likelihood of suffering from depression and anxiety disorders and the impact of the mental health problems on childbearing and childrearing12.
Many women with chronic mental illness stop taking their psychotropic medication when they become pregnant due to concerns about potential harm to the developing foetus, and this underlies the high rates of relapse in pregnancy.
Women suffering from mental illness who become pregnant are at a high risk of obstetric complications with poorer outcomes for themselves and their babies13. It is therefore clear that women with mental health problems have specific obstetric treatment needs in addition to psychiatric treatment needs during the perinatal period, and this care should be delivered in a structured and cohesive manner.
During pregnancy, women with mental illness may be less likely to eat and sleep well, gain adequate weight, not attend antenatal care, fail to seek help for the birth, use harmful substances such as alcohol, cigarettes and drugs, and self harm or commit suicide12.
In developed countries suicide causes 10% of maternal deaths in the year following delivery12. The Confidential Enquiry into Maternal Deaths (2001, 2004) showed that over half of the women who commit suicide after childbirth had a previous psychiatric history, but this risk factor was neither identified nor acted upon by involved health professionals14.
Stress hormones are also raised during maternal mental illness and may have physical effects on the mother predisposing her to high blood pressure, pre-eclampsia and an early and difficult labour12. Babies may also be small for age. After the birth mothers may fail to eat, bathe or care for themselves, increasing the risk of infection and anaemia18. Mental illness can hamper the mother-infant attachment, breastfeeding and infant care, and mothers may be less likely to understand their babies cues for hunger, happiness or distress12,15.
Studies have shown that infants of chronically depressed mothers show less sociability with strangers, fewer facial expressions, smile less, cry more and are more irritable than infants of well mothers23. Children do not perform as well on thinking and intelligence tests at 18 months, and they are more distractible, less playful and less social up to the age of 522. Effects on older children have been shown to include neglect, abuse, slower social, emotional and cognitive development and higher rates of school and behaviour problems12,21.
There is also an increase in the disruption of the marriage and/or spousal abuse by either partner16,24.
For women with a mental disorder during pregnancy and postnatally, the clinical context can be complicated by the needs of the foetus and infant, and by the women’s psychological adjustment to pregnancy, motherhood or having an additional child whilst experiencing mental illness. Services also need to take into account the needs of the father/partner, carers and other children in the family.
National Guidelines
The Royal College of Psychiatrists recommends that health professionals should advise women to talk about their feelings, get support with practical tasks from family and friends and to try and catch up on sleep and get time away from the baby26.
However, talking about and confronting the issue of mental illness during pregnancy or the postnatal period still poses challenges for healthcare professionals. Motherhood is loaded with emotive expectations, and not to conform to the idealised image of the ‘blissfully happy, blooming mother-to-be or new mother’ is widely regarded as a taboo. This contributes to a large number of perinatal mental illnesses going undiagnosed.
70-80% of women with perinatal mental disorders can be successfully treated and recover12. To a large extent the identification and management of most of these mental disorders can be done at a primary care level. One challenge faced by those involved in the care of these women is the wide range of services that women use at this time. This requires close communication between all the services. Poor communication has often been identified as the reason for poor quality of care.
Current specialist provision for women with perinatal mental illness is patchy. Only approximately 25% of Primary Care Trusts have a fully developed and implemented policy for perinatal mental health26. Determining the need for specialist services, including perinatal teams and the number of inpatient facilities, their size and location is difficult. Firstly, the incidence of severe mental illness requiring inpatient care varies across the country, with much higher morbidity in the inner city areas compared with suburban or rural areas. Bed usage by Primary Care Trusts reveals a bed use approximately 1.7 times higher in urban than in rural areas, although this may not simply be the result of higher urban morbidity but due to women living in rural areas being reluctant to travel long distances to the nearest inpatient facility. The presence of crisis and home treatment teams may also impact significantly on the use of inpatient services27.
NICE issued clinical guidance in 2007 about the treatment and management of women with perinatal mental illness. It recommends that healthcare professionals ask the Whooley questions at a women’s first contact with primary care, again at her booking visit, and again postnatally, at 4-6 weeks and again at 3-4 months28, 29, 30.
These questions are:
· During the past month have you been bothered by feeling down, depressed or hopeless?
· During the past month, have you been bothered by little interest or pleasure in doing things?
If yes to either question:
· Is this something you feel you need or want help with?
At a women’s first contact with services in both the antenatal and postnatal period, healthcare professionals should also ask questions about past or present severe mental illness, previous treatment by a psychiatrist/specialist mental health team and whether there is a family history of perinatal mental illness. These questions act as a screening tool to try and help identify those women that may be mentally unwell, or may become unwell during or after their pregnancy, which will then allow them to be properly monitored and managed.
Studies have shown that continuity of midwifery care throughout the antenatal and early postnatal periods does not have an effect on depression symptoms, even in women with a history of depression. However, continuity in the postnatal period seemed to result in fewer women with depression at 7 weeks postnatally compared with standard care31, 32.