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Perinatal Mental Health in
General Practice
Hillingdon Sessional GP Group 1st May 2019
GP SPOTLIGHT 2 PROJECT
Dr Lizzie Davison - NWL GP Champion PNMH
#GPspotlight2
Lizzie Davison @Mayonasian
Perinatal Mental Health: QUIZ
“To look after others,
we need to look after ourselves” – Dr Jenny Rattray,
Wessex Spotlight GP Champion
Perinatal Mental Health discussions can
be distressing
Given the prevalence of PMH, some of
you may well be affected personally
Talk to me after the session for support
If you need to slip out the room for a
break, please do
CL 01/19
Perinatal Mental Health UK Maternal Mental Health Awareness Week -5th May
@PMHPUK #maternalmhmatters
& World Maternal Mental Health Day today
What is Perinatal Mental Health?
Effective screening: Prediction & detection
Opportunities to improve care
Principles of Treatment
Resources
Cases
Questions-feel free to ask as we go along
What is Perinatal Mental Health / Illness?
What?
What conditions are we talking about?
When?
Define ‘Perinatal’
Why?
Why do GP’s need to know about it?
Who?
Who is affected?
CL
08/17
What conditions are we talking about?
All Mental Health problems
Up to 1 in 5 (20%) women
Up to 1 in 10 (10%) men Depressive illness:
The most common major complication of pregnancy
What conditions are we talking about?
All Mental illness
Known ‘at risk’ groups: SMI /PMHx /FHx
BUT it can affect anyone
Any age / profession / gender / socioeconomic group.
General psychiatric conditions & specifically:
Postpartum Psychosis (0.2%)
Tokophobia (6%+)
Perinatal PTSD (3%)
CL
08/17
Voluntary disclosure by a woman
represents a‘red-flag moment’
Barriers to detection Barriers for women to disclose
symptoms of PNMI to GP
Barriers for GP to diagnose PNMI
Falling through the gaps, Centre for Mental Health, 2015 https://www.centreformentalhealth.org.uk/publications/falling-through-the-gaps
Barriers to detection
Barriers for women to disclose
symptoms of PNMI to GP
Barriers for GP to diagnose PNMI
Poor awareness of maternal mental
health significance/symptoms
Lack of continuity of HCP/GP throughout
perinatal journey
Stigma
Assumption other people have asked the
questions
Fear of judgement
Lack of contact between MDT members
Fear of baby taken away/social
services
Lack of time & competing priorities
Sense of failure Lack of training & competencies
Pressure to be a perfect parent
Subconscious bias HCPs/internal
prejudice
Dismissing or normalising symptoms
https://www.centreformentalhealth.org.uk/publications/falling-through-the-gaps
What is PNMH/illness
Quick case
Elka 24yrs
Reason for appt: To discuss periods
PMHx: Bipolar Affective Disorder
Currently well
Not under Mental Health team
No medication
Thoughts? What do we want to know?
Perinatal Care Pathway
EN
HA
NC
ED
CA
RE
SP
EC
IALIS
T C
AR
E
Primary care
management
Depression
Anxiety
Baby Blues
Complex
management
Mod-severe
Depression
Tokophobia
PTSD
OCD
Co-morbidity
Personality
Disorder
Bipolar Affective
Disorder
Schizophrenia
Schizoaffective
Disorder
Severe
depression +/-
psychotic
symptoms
Postpartum
Psychosis
L Nunn 2017
JS
08/17
https://www.npeu.ox.ac.uk/mbrrace-uk/reports
“Women who died by suicide were, in the main,
clear about the intended outcome of their act”
“Violent methods formed the greater proportion of
all suicides in all time periods in pregnancy and
the postnatal period”
Roch Cantwell, Marian Knight, Margaret Oates and Judy Shakespeare on
behalf of the MBRRACE-UK mental health chapter writing group
Effective Screening
Perinatal depression: 40-50% is recognised
Only 50% of those identified receive adequate
treatment
50-70% of untreated women with
antenatal or postnatal depression will
still have depression 6 months later
NICE 2016 CG 192: All women should be asked about
their emotional wellbeing at each routine antenatal &
postnatal contact
http://www.nice.org.uk/guidance/cg192
Case History : 22yr old Jane
Discuss with your neighbour
10 weeks pregnant
PMHx Anorexia
?Depression
Management: ?Antenatally ?Post-natally
Case History : Depression
Presentation:
• Symptoms lasting at least every day for 2 weeks
• Feelings/mood – low mood, tearfulness, anxious, lack of
enjoyment usual activities
• Thoughts/beliefs – negative outlook on self/situation/future –
distress, inadequacy as a mum, failure, guilt, shame, feeling
overwhelmed by motherhood
• Behaviour – slow, inactive, withdrawn, loss appetite, poor sleep
pattern, fatigue, irritable
• NOT the “Baby Blues”
(physiological state 3-5d postnatal, affects <50%, resolves <day10)
Importance of Communication
How are you finding being a mum(again)?
Tell me about the delivery?
Formal screening (Whooley / GAD 2)
How are things at home/ Afraid of anyone?
Feel Safe?
RCGP PMH Special Interest Group Top Tips, July 2016
Anticipate & assess risk
Explore expectations
Be aware of your own prejudice.
Beware of stigma
Acknowledge
Listen don’t just hear
Open the door to disclosure
Reassure
Encourage discussion without judgement
Promote self-care
Offer hope – there is effective, evidence-based treatment for PNMH
- women can and do get better
Opportunities to improve care
Pre-conception/contraception
Maternity Leaflet/Information
Check notes if pregnancy notification
Don’t Stop Medication
Wellbeing plan
Case History :Louise
Discuss with your neighbour
33yr old Hairdresser with 5m old viral URTI
4th presentation in one month
?Mental health issues?
Case History :Perinatal OCD
Prevalence Anxiety disorders 12% -similar to nonPerinatal prevelence
OCD more likely during perinatal time up to 2-2.5%
• Risk factors – previous psychiatric issues
• Can affect men too
https://maternalocd.org/
Charity set up by two women with lived experience of Perinatal PCD
Offers lots of information, support and further details for patients and HCPs
RCPsych have an excellent leaflet they have produced on this condition:
https://www.rcpsych.ac.uk/healthadvice/problemsdisorders/perinatalocd.aspx
Case History :Perinatal OCD
Presentation
Often not picked up or misdiagnosed – may have one or both of the following:
Intrusive thoughts - recurrent and unwelcome, often violent, abhorrent,
upsetting images of catastrophic situations – no intent to make these things
happen but recurrent images of “what If” scenarios of the baby or child being
accidentally or deliberately harmed -These thoughts stop normal functioning
Compulsive (neutralising) acts - these help to suppress those intrusive
thoughts such as excessive cleaning – other habits may be difficult to identify –
these affect ACTIVITIES OF DAILY LIVING
NB: Delusional thoughts are very different and they suggest a psychotic
disorder needing immediate psychiatric referral and assessment.
Most parents think they might accidentally harm their babies,
50% think they might do it deliberately, 2% have frequent and repeated
OCD thoughts. But NOT an indicator of actual risk
Opportunities to improve care
6-8 week check
Avoid ‘normalising’
Look behind the smile
Consider partner
Postnatal Issues
Interaction with caregivers is vital to infant
social and emotional development
Parental mental illness can impact on:
The developing parent-infant relationship
Parent’s ability to care for their baby and
parenting styles
Infant mental health
Still-Face Paradigm, Dr Edward Tronick et al
Dr L Santhanam 2019
Treatment Biopsychosocial model
Self care
Support: GP: more frequent review
PNMH Specialist Midwife
Health visitor
Social worker
Community & 3rd sector
Talking therapy: http://cnwltalkingtherapies.org.uk/
Medication?
Risk of taking vs. risk of not taking
Don’t stop medication: get advice
Consider specialist Drug & Alcohol services:ARCH
Consider Specialist PNMH team
+/- Mother & Baby Unit if admission
eg: Coombe Wood
Specialist PNMH Team CNWL Riverside Centre, Hillingdon Hospital
https://www.cnwl.nhs.uk/service/hillingdon-hospital-perinatal-
mental-health-service/
Tel: 01895 485187
Dr Chrishanthy Jayarajah, Consultant in Perinatal Psychiatry
Mon-Fri 9-5, not emergency service. Crisis no: 0800 0234 650
Specialist provision for
London is now Green!
Quick case
Savannah 35yrs
Reason for appt:Newly pregnant
PMHx:Recurrent Depression
DHx: Sertraline 50mg once daily
Thoughts? What do we want to know?
Medication: Factors to consider
Previous illness, choice of treatment, response &
side effects
Severity of this illness
Risk of sudden cessation or withdrawal symptoms
Risk of worsening mental health without
medication
Stage in pregnancy / postnatal
Breastfeeding intentions/habits
Patient preferences
Risks to baby from
medication e.g. :
• Cardiac
malformations
• PPHN
• Neonatal Adaptation
Syndrome
• Limited evidence re
long term
outcomes
Risks likely small
Impact of untreated
illness:
• Preterm delivery
• Low birth weight
• Long term impact of
untreated PND
• Poor self care
• Poor nutrition
• Lack of antenatal
care
• ↑ smoking, alcohol
and drugs
• Psychiatric
admission
Dr Lucinda Green 2017
Medication: Factors to consider
Prescribing in Pregnancy and breastfeeding
DO Individualised approach
Shared decision making
Lowest effective dose
Increase dose if needed
Avoid poly-pharmacy
Inform maternity service
DON’T Stop or switch medication
without review and discussion with woman & considering history
Use a sub-therapeutic dose
Prescribe sodium valproate to women of childbearing age
Dr Lucinda Green 2017
Treatment
ALWAYS REFER TO SPECIALIST PERINATAL SERVICES IF
Severely depressed /risk of self harm or suicide.
Severe self-neglect.
Psychotic features
(eg: confusion, hallucinations, or delusions) or manic or
extravagant or uncharacteristic behaviours
(eg: increased activity, talking, or spending).
Definite, or possible, diagnosis of bipolar disorder
History of severe mental illness,
incl. PND, puerperal psychosis, or bipolar disorder.
Family history of severe depression, puerperal
psychosis, suicide, or bipolar illness.
Quick case Sanjita, 6week postnatal check
Planned unremarkable pregnancy spontaneous labour but prolonged labour & poor CTG trace led to emergency C-section
You start the consultation with an open question
“How are you finding parenthood?
Sharon says fine and starts asking about her baby’s nappy rash
Partner interrupts and says he a bit worried about Sharon as she doesn’t quite seem herself; “Could she have the Baby blues Dr?”
Thoughts? Baby blues? What do we want to know?
Differential?
Sharon 6weeks post partum Partner reports she seems emotional and tells you although baby sleeps
quite well she doesn’t. It transpires she is having vivid nightmares about
giving birth.
She asks you if every new mum feels like this?
Further discussion reveals her deep sense of deep disappointment about
what happened – it all seemed so “chaotic”, terrifying (she thought she
was going to die). She didn’t know what was happening when the
“alarms were going off everywhere”. There was little information given
to them and her partner was even asked to leave the room at various
times which they both found very upsetting. She didn’t have a photo of
her holding her baby soon after delivery. The whole thing felt like a
“bad dream”.
Perinatal PTSD
Prevalence:
• Up to 3% - often misdiagnosed as PND and doesn’t
respond to antidepressants
• Many present much later
Risk factors:
• Traumatic delivery – note may be different perception
from patient to doctor
• Lack of information from HCPs
Protective factors:
• Information
Perinatal PTSD
Presentation/ Identification:
Flashbacks – as though back in the room – sights/smells/tastes
Avoidance of triggering situations i.e. attending medical appts,
looking after baby, intimacy with partner
Hypervigilance – constantly “on the look-out for danger”
Increased anxiety
Management
• Debriefing – if compulsory- leads to worse outcomes
NICE advises offer to meet and discuss the birth with appropriate
person, such as lead midwife or consultant, care with terminology
• Medication if co-morbid
• IAPT – EMDR
• Referral/Communication with MDT colleagues
Resources:
Practical implications for primary care of the NICE
guideline CG192 Antenatal and postnatal mental health
10 questions a GP should ask themselves (and their
team)
http://www.rcgp.org.uk/clinical-and-research/clinical-
resources/~/media/Files/CIRC/Perinatal-Mental-
Health/RCGP-Ten-Top-Tips-Nice-Guidance-June-2015.ashx
Maternal Mental Health Alliance
http://maternalmentalhealthalliance.org.uk/
MBRRACE Reports https://www.npeu.ox.ac.uk/mbrrace-uk/reports
JS
08/17
https://www.rcgp.org.uk/cli
nical-and-
research/resources/toolkits/
perinatal-mental-health-
toolkit.aspx
Free, open access, >400
resources.
Launched July 2016
BAP prescribing guidance
https://www.bap.org.uk/pdf
s/BAP_Guidelines-
Perinatal.pdf
CL
08/17
Resources:
Resources
Specialist PNMH team for advice: Referral form
Patient leaflets: www.rcpsych.ac.uk www.mind.org.uk www.patient.co.uk
Best Use of Medicines in Pregnancy
UK Tetralogy Information Service http://www.medicinesinpregnancy.org
LACT MED a Toxnet database http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm
UKDILAS: UK Drugs in Lactation Advisory Service (NHS)
https://www.sps.nhs.uk/articles/ukdilas/
UKDILAS enquiry answering service is available from 09:00 – 17.00, M-F 0116
258 6491 (Trent Medicines Information Centre)
0121 424 7298 (West Midlands Medicines Information Centre)
Resources:
eLfH open access sessions
http://www.e-
lfh.org.uk/programmes/perinatal-
mental-health/open-access-sessions/
• commissioned by HEE
• Five sessions of 20-30 mins
• 2 core &antenatal
• /puerpurium/postnatal
• Authors: GP, Perinatal
psychiatrist, Midwife,
Obstetrician, Health Visitor
• 4 sessions launched 25/2/16
CL
08/17
RCGP #PMHTIPS
Power of Social
Media
Twitter Chats
#PNDHour
#Maternalmhmatters CL
08/17
Perinatal Mental Health Awareness Video NHS England
You Tube https://www.youtube.com/watch?v=Unid96ezWwI&feature=youtu.be&fbclid=IwAR1lV2UCul
Wp2ttCtTKlo63kw9rW_znnSM1HBpJpieYkdfada6Ro81osoSE
PNMH CEPN You Tube videos: Out of Step and
My story of Mental Health & Wellbeing in Pregnancy https://www.youtube.com/playlist?list=UUHQqwZSeDNr5hpW1Kz9g5Aw&fbclid=IwAR0BxmRu
zfvct9UassMKhVFnqHRxVlDqGXwMJrjVhdJQmHfPRZBWKYNLN9Y
PND and me website & Twitter
Rosey @PNDandMe Wed 8-9pm
http://pndandme.co.uk/
Resources & Information: For women
Https://www.tommys.org/pregnancy-information/health-professionals/free-
pregnancy-resources/pregnancy-and-post-birth-wellbeing-plan
The Pregnancy and Post-birth
Wellbeing Plan
It’s 2-page plan,
endorsed by NICE,
that helps you start
thinking about how you feel
emotionally and what
support you might need
in your pregnancy
and after the birth.
Boots Family Trust
Resources & Information: Apps for parents
Mum & Baby free app
Best beginnings & Baby Buddy free app
http://www.bestbeginnings.org.uk/baby-buddy
https://thedadpad.co.uk/
Resources & Information
• Healthy London leaflets IAPT & Specialist PNMH services
https://www.healthylondon.org/resource/perinatal-patient-leaflet-london-
iapt-services/
https://www.healthylondon.org/resource/london-specialist-perinatal-
mental-health-services/
• GP infant feeding network
https://gpifn.org.uk/
RCOG Women’s Voices 2016
https://www.rcog.org.uk/en/patients
/maternal-mental-health
---womens-voices/
PERINATAL MENTAL HEALTH EXPERIENCES
OF WOMEN AND HEALTH PROFESSIONALS
October 2013
https://www.tommys.org/sites/default/files/Perinatal_Mental_Health_Experienc
es%20of%20women.pdf
Resources & Information
https://www.homestart-hillingdon.org.uk/
Giving Children the Best Start in Life
All Saints Church Hall, 306 Long Lane,
HILLINGDONLondon UB10 9PE
Tel: 01895 252 804 Fax: 01895 251979
Drop in -No appointment needed
Office Hours: Mon – Fri: 9.00am – 5.00pm
/
Perinatal Mental Health
What is Perinatal Mental Health?
Effective screening: Prediction & detection
Opportunities to improve care
Principles of Treatment
Resources
Cases / Questions
Thank you & Questions QUIZ by Dr Alain Gregoire (Consultant Perinatal Psychiatrist)
Please complete Feedback Forms
Q1) How helpful did you find today’s session?
1-10 where 10/10 = very helpful
Q2) How likely are you to change your clinical practice
after today’s teaching?
1-10 where 10/10 = very likely
Any other comments welcome, or if you would like further
sessions/would like to expand your interest in PNMH please
get in touch
[email protected] @Mayonasian
