The Specialist Perinatal Mental Health Service

1. The Specialist Perinatal Mental Health Service • Dr Michael Harris • Consultant Psychiatrist, North West Sussex and East Surrey Specialist Perinatal Mental Health Team

2. Traditional service • Incorporated within usual Primary, Secondary and Tertiary level care • Admissions to hospital with detrimental effects on mother and child.

3. Perinatal Team • The NHS Five Year Forward View implementation plan includes the objective that there will be increased specialist mental health support in all areas by 2020 to 2021 • Increasing access to specialist perinatal community teams • Five-year transformation programme, backed by £365m in funding, is underway to build capacity and capability in specialist perinatal mental health services

4. What is a specialist perinatal service? • Concerned with prevention, detection and management of perinatal mental health problems that complicate pregnancy and the postpartum year. • Include • New onset problems • Recurrences of previous problems in women who have been well for some time, • Those with mental health problems before they became pregnant.

5. North West Sussex and East Surrey Perinatal Mental Health Team • Consultant Psychiatrist • 4 Specialist Practitioners • Part time psychologist • Team Leader • https://www.youtube.com/watch?v=Ny_G3Y4Yl_Y&feature=youtu.be

6. Who do we see? • Women with severe mental health problems: • Past or present Bipolar, Schizophrenia, Severe Depression • Previous puerperal psychosis (or family history of PP) • Primary tokophobia • Pre-conception counselling for women with SMI • Previous severe depression/PND/hospital admissions to MBU

7. Red Flag Symptoms Presentations which should prompt urgent senior psychiatric assessment • Recent significant change in mental state or emergence of new symptoms • New thoughts or acts of violent self-harm • New and persistent expressions of incompetency as a mother or estrangement from the infant

8. Referrals from any practitioner • Advice in 1 – 3 days • Urgent referrals seen < 5 days • Routine referrals seen < 28 days • Initial assessment in antenatal clinics, local children centre, person’s home or by telephone (not in mental health clinics) • Usually a medication review by doctor early in the pregnancy • Joint working with obstetrics team (if booked to deliver at ESH) • Psychological treatments or work alongside IAPT • Signposting to community resources/social services • Joint working with obstetrics teams and community teams • 32 week birth planning meeting

9. Perinatal Team and YOU • GP can manage mild-moderate PND (Sertraline & CBT) • We co-work with community mental health teams where a patient has a severe and enduring mental illness not cause by/significantly worsened by pregnancy. • Preconception advice where pregnancy is likely to post an increased risk • Preferential status with IAPT during the perinatal period • BUMPS leaflets – updated regularly • We are happy to give advice and share Sussex Partnership Pregnancy Medication leaflets https://www.choiceandmedication.org/generate.php?sid=65&fname=handyfactsheetperinatalsertraline.pdf

10. Medication prescribing – general points • Better outcomes when depression and anxiety is treated • Explore other treatment options • Prescribe the least amount of medication at the lowest effective dose • First trimester is when baby’s organs and body are formed • Third trimester serum levels may decrease • Withdrawal affects post-partum • Abrupt withdrawal may be associated with risks • Off-licence prescribing • Lack of robust evidence (empiric evidence and animal studies mainly)

11. NICE • Sertraline is safest in pregnancy and breastfeeding. • Fluoxetine as safe in pregnancy and not a contraindication to breastfeeding • Venlafaxine: high BP, higher toxicity in OD & withdrawal issues – but usually on it because other antidepressants have been ineffective • Quetiapine safe in pregnancy and breast feeding, can be used for a variety of issues including: anxiety/intrusive thoughts/mood stabiliser/psychosis • Promethazine for agitation and insomnia

12. Medications to avoid • Paroxetine • Sodium Valproate • Regular use of benzodiazepines • Lithium in first trimester

13. THE FACTS Affects 10% to 15% of women postnatally during the first year following childbirth. Postnatal depression is a treatable illness, the length and type of treatment depends on the severity and how early it is detected with more emphasis being placed on early detection of potential risk factors in the ante natal period. SYMPTOMS Constantly feeling tired, no energy. Sleep problems/ appetite problems Poor attachment and connection with baby Over anxious with baby Feels rejected by baby/ family Poor motivation/ concentration Intrusive thoughts/ guilt Suicidal thoughts/ thoughts of harming self/ baby Physical manifestations Postnatal Depression

14. Anxiety and OCD • Anxiety and OCD in pregnancy is common and is being identified much earlier on and recognised as needing treatment ideally before birth. • Anxiety can be debilitating and impact on day to day function with symptoms such as palpitations, dizziness, sweating, shaking and a very real fear that something awful will happen resulting in social isolation and restricted activity. • IAPT service (Time to Talk) prioritise women in the Perinatal period for therapy, usually CBT and women can now also self refer. • www.maternatlocd.org is a useful website focussing on specific OCD for women in the Perinatal period and this can be given to women. • The Headspace app is user friendly and focuses on how to practice mindfulness and meditation in your day to day life through your mobile.

15. Bipolar Affective Disorder • Women with a diagnosis of bipolar need to be referred to the Specialist Perinatal Mental Health Team even if they are stable and have been well for years. • Ideally pre-conception as medication options may impact on baby in first trimester and will need to be considered in the context of breastfeeding. These women have a very high (around 50%) chance of significant relapse on delivery and need close monitoring. • We can predict they will be ill, we can treat them but we need to identify them.

16. The facts: 1 – 2 postnatal women per 1,000 will develop puerperal psychosis (SIGN 60 2002). Puerperal psychosis in almost all cases is a mood disorder accompanied by features such as loss of contact with reality, hallucinations, severe thought disturbance and abnormal behaviour (SIGN 60 2002). Onset is rapid and almost always within the first four postnatal weeks, usually within the first 10 days postnatally and often while Mum is still in hospital or having the community midwifery visits Symptoms Restless, sometimes agitated behaviour, or strange movements. Irrational fearfulness and worrying (often about the baby). Mood swings with inappropriate emotions. Inability to sleep. Behaviour may appear out of touch with reality. Mother may have ideas that are not based in reality or be responding to voices or commands or seeing things that are not there. Often thoughts that people are talking about them or religious ideas can be verbalised. Ideas that the baby is not theirs-high risk. Puerperal Psychosis/Post Partum Psychosis

17. Patient InformationUKTIS: www.uktis.org

19. References • https://www.gov.uk/government/publications/better-mental-health-jsna-toolkit/4-perinatal-mental-health • https://www.choiceandmedication.org/generate.php?sid=65&fname=handyfactsheetperinatalsertraline.pdf • NICE guidelines • *Guideline 127: Perinatal Mood Disorders - SIGN, 2012 • *Getting it Right for Mothers and Babies: Closing the Gaps in Community Perinatal Mental Health Services - NSPCC Scotland, 2015 • UK *Clinical Guideline 192: Antenatal and Postnatal Mental Health - NICE, 2014 • *Guidance for Commissioners of Perinatal Mental Health Services - Joint Commissioning Panel for Mental Health, 2012 • *Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. - Eighth Report of the Confidential Enquiries into Maternal Deaths Centre for Maternal and Child Enquiries, 2011 • *Saving Lives, Improving Mothers’ Care: Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland. Confidential Enquiries into Maternal Deaths and Morbidity 2009-13 - National Perinatal Epidemiology Unit, 2015 • The Cost of Perinatal Mental Health Problems Baeur et al, London School of Ecnomics, 2014 • *Perinatal Mental Health Services: Recommendations for provision of services for childbearing women Royal College of • Psychiatrists, 2015 Good Practice Guidance 14 • Management of Women with Mental Health Issues during Pregnancy and the Postnatal Period Royal College of Obstetricians and Gynaecologists, 2011. • Prevention in Mind. All Babies Count: Spotlight on Perinatal Mental Health - NSPCC, 2013

20. Specialist Perinatal Mental Health Service Film Link: • https://www.youtube.com/watch?v=Ny_G3Y4Yl_Y&feature=youtu.be