Perinatal Mental Health Seminar · • Introduction into perinatal mental health • Signs,...

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@sssftnhs sssft.nhs.uk @sssftnhs

in partnership with Health Education NHS England

Perinatal Mental Health

Seminar

Beckett’s Farm, Birmingham

Monday 18th September 2018

Programme Director: Dr Marie Wardle, South Staffs & Shropshire Healthcare Foundation Trust

@sssftnhs sssft.nhs.uk

Maternal Mental Health

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Housekeeping

Silent

please


Key speakers today: • Dr Marie Wardle – Programme Director for Interpersonal Psychotherapy, (IPT) SSSFT

[email protected] and [email protected]

• Jane Fisher - Action on Postpartum Psychosis (APP)

• Wendy Hallows – Service Manager of the Mother and Baby Inpatient Unit St Georges, Stafford, SSSFT [email protected]

• Mark Cox Perinatal Mental Health Service Manager, Solihull & Birmingham Children’s Hospital

• Dr Laura Stevenson - NICE Guidelines on Medication in the perinatal period

• Rob Ewers – Operational Director for Acacia Family Support

• Cathy Coombs – Birmingham Women’s & Children’s NHS Foundation Trust – Baby Buddy App

mailto:[email protected]



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Schedule for the day Morning 9.30 – 12.45

• Introduction into perinatal mental health

• Signs, symptoms and causes of perinatal mental health

• Potential impact on infant, partner and the family. 1001 Critical Days

• High Risk perinatal problems, postpartum psychosis APP

• 5 year forward and working together in the West Midlands - Clinical Networks, Local Perinatal Networks and MBU

• Perinatal Mental Health Team Services, pathways in secondary care

• Lunch Break 12.45

Afternoon 1.30 – 4.00

• NICE Guidelines on Medication

• Accessing Psychological Therapies and NICE Evidence Based Practice

• Acacia Family Support, helping families

• Baby Buddy App

• Final discussions

• Handouts and collecting information on services.

• End 4.00 pm.


What is perinatal mental health? Let’s recap

The Perinatal period extends from when pregnancy begins to the first year after the baby is born

Mental health is determined by many factors including hormonal, social and psychological…. Perinatal mental health is about the emotional well-being of pregnant women, and their child, partner and families

Suicide – is a leading cause of death for women during the perinatal period, the majority due to postpartum psychosis (PP)

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During pregnancy and in the year after birth women can be affected by a range of mental health problems, including:

• Anxiety • Depression • Postnatal psychotic disorders

These are collectively called perinatal mental illness.

• Perinatal mortality refers to the number of stillbirths and deaths in the first week of life (early neonatal mortality).

• The number of stillbirths varies across the country. The rates are higher than the rates seen in many other high income countries.

MBRRACE-UK Maternal, Newborn and Infant Clinical Outcome Review Programme www.npeu.ox.ac.uk/mbrrace-uk


The Patients Voice is a Powerful Voice …..

” Advocates Promoting Disclosure,

Discussion and Education

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The known costs of perinatal mental health problems per year’s births in the UK defined as the period during pregnancy and the first year after childbirth

£8.1 billion • Public/wider sector, NHS and Social Services - per year’s births in

the UK

• Maternal health affects the older children as well as partners and other family members and contributes to monies going downstream.

• Perinatal Mental Health is an NHS priority area after being highlighted in the National Maternity Review ‘Better Births’ document as an area requiring further funding and improvement.


of these costs ……….

only 28% relates to the mother and

72% relates to the adverse impact on the infant and family

• Approximately 20% of women develop a mental health

problem during pregnancy or within a year of giving birth.

• Women in the UK – half have NO access to specialist

perinatal mental health services

•

www.centreformentalhealth.org.uk/perinatal

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Costs v improvement

• The cost to the public sector of perinatal mental

health problems is 5 times the cost of improving

services

• It will cost the NHS around another £280 million

to bring the whole pathway of perinatal mental

health care up to the level and standards

recommended in national guidance. Long-term

this will prevent some of the money that goes

downstream an relates to the child and family


1001 critical days

.

The importance of the conception to age two period is now of the utmost concern and hence we are now looking at the 1001 critical days, a cross-party manifesto that highlights the importance of acting early to enhance the outcomes for children. Too many children and young people do not have the start in life they need leading to high costs for society, and too many affected lives.

1001 days is calling for a re-focusing of support during pregnancy and until the infant reaches age 2.

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Good perinatal mental health services

Because of the costs of perinatal mental health problems, the potential

benefits of early intervention and better services would be sufficient to justify

the additional spending on value for money grounds:

• Promoting prevention, early detection and diagnosis

• a standardised measurement scale across the board

• Effective, evidence based treatment – psychological therapies

• Seamless, integrated pathway giving comprehensive care across organisations

and professional boundaries

• Training and supervision from specialist teams

• Sharing information

• Improvement in referral process and new referral form

West Midlands Clinical Networks www.wmscnsenate.nhs.uk

Perinatal Mental Health Transformation – NHS England


Diagnosis of Disorders frequently seen

• Primary presentation of Depression

• Mixed Anxiety and Depression

• Generalized anxiety disorder and/or combining panic disorder and OCD

• Who will notice and who will diagnose?

• 6 week check by GP following birth may be too soon to diagnose illness

• About half of all cases of perinatal depression and anxiety go undetected and many of those which are detected fail to receive evidence based forms of treatment

http://www.wmscnsenate.nhs.uk/

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Signs and symptoms of illness variation before and after the birth

• Low mood and irritability

• Tearful

• Sad

• Not enjoying things/baby

• Problems with sleep/not sleeping when baby sleeps

• Low sex drive

• Feeling worthless

• Poor appetite or overeating

• Feeling lonely and isolated

• Poor motivation

• Panic attacks

• Suicidal thoughts

• Not bonding with baby

• Hard to leave the house

• Not wanting to see others

• Worrying more than usual

• Blaming self unnecessarily

• Feeling numb and disconnected from others

• Anxiety

• Lost interest in appearance

• Anger

• Not able to concentrate


Communication

• Its not always what they say and what they tell you that will detect any signs of illness

• It is often what they don’t tell you and what is hidden

• Look for mismatch between their body language, voice tone, non verbal communication to detect

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What do women tell us?

• 70% said their relationship with their partner had been affected by their illness

• 36% said their relationship worries had an impact on the way they felt

• 59% cited low sex drive as one of the key ways they were affected

• 40% had suffered a traumatic birth

• 14% considered that a history of mental health problems was the primary cause of their perinatal illness

• 28% of mothers admit to have trouble bonding with their child

• 30% are reluctant to discuss the type and depth of their feelings and never tell a professional

• 34% who admitted they had hidden their feelings said they had done so because they were concerned their baby might be taken away.

Joint Commissioning Panel for Mental Health


Causes of perinatal mental health problems

• Stressful life events

• Psychological issues with transition into motherhood

• Genetic factors

• Stress hormones

• Economic, social, environment,

• Relationship and family difficulties

• Lack of support from family and friends

• No partner, intimate partner violence

• Poverty

• Social isolation

• Illicit Drugs and alcohol misuse

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Stress

• The nervous system is compromised with high levels of stress in pregnancy, and this can be passed onto the infant

• Stress regulation is a problem for the infant, as they cannot regulate stress and unregulated stress injures the brain

• This will lead to difficulties as they develop through life


What determines an Individuals ability to cope in adversity ?

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Not forgetting Dads…….. Silent Sadness

• Feel included and excited during the pregnancy.

• The best predictor of a man’s risk of depression is whether his wife is also depressed. PPPD may be more prevalent now largely because this generation of fathers is feeling the same psychological, social and economic stressors that mothers have long experienced.

• PPD = postpartum depression PPPD = postpartum paternal depression

• www.acacia.org.uk


Why is depression on the increase for dads?

• This generation of fathers is feeling the same psychological, social and economic stressors that some mothers have long experienced. 80% of people who lost their job during the recession were men.

• With more mums working, dads are shouldering child care and household tasks that traditionally fell to women.

• PPPD goes up sharply during the three to six months after birth, just around the time many women end their maternity leave and head back to work.

• Problems that may have been simmering on the back burner, or that simply were never discussed, can boil over when the question of who-does-what when becomes more complicated.

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Could the partner and father be depressed? How will you know?

• Has he become uncharacteristically irritable or agitated

• Is he distancing himself from mum and the baby

• Does he have a personal or family history of depression

• Is he sad, tearful, or uninterested in doing things that he used to enjoy? Has he lost interest in sex?

• Does he make comments that he feels worthless or share suicidal thoughts.

• Doe he spend more time than usual at work

• Is he gambling, drinking, taking drugs,

• Who will notice, how will dad get diagnosed and how will he access treatment?

• Check out www.saddaddy.com


Video World Mental Health Day: These Mothers share their experiences of

Postnatal Depression

HuffPost UK

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Jane Fisher

Action on Postpartum Psychosis

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My Story

•


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Leaflets & web resource for women, their families & health professionals

We field requests for specialist advice

to our panel of experts & offer signposting to

appropriate resources/ sources of support.

Regional Reps, “Experts by Experience”

We campaign for improvements

in perinatal mental health care.

What APP Offers


What APP Offers: PP Community

We offer a one-to-one peer email

service supporting women and partners

who have experienced Postpartum

Psychosis

PPTalk online forum,

manned by trained peer

support volunteers,

where women & their

families can talk to

others who have

experienced PP

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What is happening in the West Midlands

Wendy Hallows

Service Manager Mother and Baby Unit,

The Brockington Suite, St Georges, Stafford


What is happening in the West Midlands

• Mother and baby units in the West Midlands

• Pathway into treatment – who and how?

• What are Clinical Networks (CN’s)

• West Midlands Clinical Networks – designing a better future: steps and priorities

• Improving services and referrals

• What can a dedicated PMH Network do for you?

• Next Steps

• Improve training and increase the current workforce across the West Midlands

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Mother & Baby Units


UK Specialist community perinatal mental health teams (current provision)

Red areas

no specialist team exists.

Pink areas

Some extremely basic level of

provision exists but currently falls

short of national standards and

needs expanding.

Amber areas

Some basic level of provision

exists but currently falls short of

national standards and needs

expanding.

Green areas

Women and families can access

treatment that meets nationally

agreed standards.

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Designing a better future: Steps and Priorities

Perinatal mental health identified as key national priority:

Five Year Forward View for Mental Health – Feb 16

Better Births independent report- Feb 16

Priorities: Support the implementation of perinatal mental health networks locally and across the country

See the inclusion of parent-infant mental health services within the perinatal setting

Work closely with developing perinatal services such as new perinatal mental health teams and perinatal IAPT.

Commissioning Local Groups (CLG’s) – on-going role and goals: Strategic development: perinatal accreditation and development of unique referral forms.


What are Clinical Networks (CNs)?

Hosted by NHS England

Each network has a clinical director, a network lead and a network project team. The network is driven by a strategic clinical leadership group chaired by the clinical director.

West Midlands Clinical Networks

• Gap analysis of current and required service provision across the region completed in PMH.

• creating a new infrastructure.

• Clinical Commissioning Groups (CCG’s) across the region

• The National Programme is anticipated to last 5 years and is focused on both acute and community settings with much focus on workforce, capacity and demand, pathways of care and the creation of regional networks.

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What can a dedicated PMH Network do for you?

• Provide easy access for everyone – improving pathways

• Support to develop services

• Sharing of best practice and quality standards

• Training

• Peer support

• Enhanced workforce

• Enhanced working relationships and networking

• Research

• Access to patient voice

• Working together - strengthen voice to commissioners

Perinatal Mental Health Transformation NHS England


Next Steps:

• Innovative leadership and Cross-Trust working.

• Improve current inconsistent care pathways – some areas have no care pathway in place at all. Referral and MDS needs to be consistent across all services.

• Get everyone talking to each other.

• More specialist knowledge and training.

• Continue to engage and collaborate with Clinical Commissioning Groups (CCG’s) and GP’s.

• Increase number of dedicated PMH services across the West Midlands (currently 4 out of 8 Trusts have these – Coventry & Warwickshire, Worcestershire, SSSFT and Birmingham and Solihull.

• SSSFT and Birmingham and Solihull have dedicated Mother and Baby Units. More units needed so women do not have to travel so far.

• Without a perinatal mental health service we struggle to identify those women suffering from moderate mental health disorders.

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Improve training and increase the current workforce across the West Midlands

Consultant Psychiatrist

Psychologist

Psychotherapist/Counsellor

Community Psychiatric Nurses

Junior Doctor

Occupational Therapist

Administrative Support

Huge variation across services and some having no services at all.

Social Worker

Specialist Nursery Nurse

Specialist Midwife

Specialist Health Visitor

Infant Mental Health Therapist

Service/Team Manager

Let’s talk together

Perinatal services in

Birmingham and Solihull – now

and next

Mark Cox, Team Manager

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• Inpatient unit – Chamomile Suite

• Antenatal Liaison clinic – Admission vulnerable women

– Severely unwell women

– Some moderately unwell women with complexity

– With specialist midwives

– Consultant only at BWH service.

– Joint consultant and CPN at City, Solihull, Heartlands and Good Hope

• Outreach service and Therapeutic group programme for Admission

Vulnerable

Services in B’ham/Solihull prior to CDF

• Minimal access to CPN and psychology (inpatient only)

• Antenatal mental health liaison clinics (funded by maternity hospitals)

receive referrals from midwives

• Not funded/or have capacity to respond to urgent community referrals

• Emergency referrals for admission screened by inpatient service

• Emergencies/urgent - referred to Single Point of Access – (SPOA) on 0121

301 4000)– over 25s

• Under 25s Forward Thinking Birmingham (FTB) - Access Centre team a call

on 0300 300 0099.

• SPOA/FTB refers to HTT/CMHTs and perinatal team receive referrals for

co-working from CMHTs

Services in B’ham/Solihull prior to CDF

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• Women booked at BWH with Birmingham GP

• Women 18 or over

• Full team to provide NICE-concordant care to severely

unwell women (410/year = 5%)

• Can take referral directly for assessment (work with

HTT/Crisis if needed)

CDF – new team at BWH

• Pre-conception assessments

• Shorter waiting times for assessment from 12/40

– 50% in 2 weeks, 95% within 6 weeks

– 4 hours for emergencies

• Care coordination of all those at high risk of

perinatal relapse

– Jointly with other teams if indicated

• Choice in where women are seen

What we will offer

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What we will offer

• NICE-concordant psychological interventions

– Assessment within two weeks of referral

– Intervention within six weeks

• Parent-infant interventions – early intervention

• Nursery nurse support in community

• Telephone consultation for professionals

• Consultation to & training of other professionals

• Development of all pathways as part of BUMP

(STP)

• Consultant Psychiatrist and SAS doctor

• Team manager (50% clinical)

• 4.4 WTE CPN/OT

• 2 WTE Clinical Psychologists

• 2 WTE Nursery Nurses

• 1 WTE Assistant Psychologist

• 1 WTE Admin assistant

• 0.6 WTE Project manager

Perinatal Community Team for Birmingham

Women’s Hospital

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• Inpatient unit – Chamomile Suite

• Antenatal Liaison clinic – Admission vulnerable women

– Severely unwell women

– Some moderately unwell women with complexity

– With specialist midwives

– Joint consultant and CPN at City, Solihull, Heartlands and Good Hope

• Outreach service and Therapeutic group programme for Admission

Vulnerable

BUT…………… remainder of Birmingham

and Solihull:

• Minimal access to CPN and psychology (inpatient only)

• Antenatal mental health liaison clinics (funded by maternity hospitals)

receive referrals from midwives

• Not funded/or have capacity to respond to urgent community referrals

• Emergency referrals for admission screened by inpatient service

• Emergencies/urgent - referred to Single Point of Access – (SPOA) on 0121

301 4000)– over 25s

• Under 25s Forward Thinking Birmingham (FTB) - Access Centre team a call

on 0300 300 0099.

• SPOA/FTB refers to HTT/CMHTs and perinatal team receive referrals for

co-working from CMHTs

Which means:

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• Current or past history of severe mental illness

(psychosis, depression, anxiety)

• Those with pre-existing illness and family history

of bipolar disorder or PP

Who we will see - Antenatal

Mild depression / anxiety disorders

Moderate depression /

anxiety disorders

Past history of: • Bipolar

disorder • Severe

recurrent depression

• Severe perinatal anxiety

Current: • Bipolar

disorder • Schizoaffectiv

e disorder • Severe

depression / anxiety

• Tokophobia / birth related PTSD

Any moderate illness + FH of PP

/ Bipolar

Birmingham and Solihull / FTB

IAPT providers / other agencies

GP ± IAPT (NICE guidance)

treatment

Persists or concerns

Specialised perinatal mental health team

Antenatal

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• Psychosis

• Severe depression with postnatal onset or

relapse

• Severe anxiety disorders

• Birth-related trauma

• Any severity with red flags

• Discharges from ward

Who we will see - Postnatal

Mild depression / anxiety disorders

Moderate depression /

anxiety disorders

• Severe depression / anxiety disorders

• Any illness + red flags

• Significant concerns bonding

• Psychotic symptoms

• Significant suicidal thoughts

Birmingham and Solihull / FTB

IAPT providers / other agencies

GP ± IAPT (NICE guidance)

treatment

Persists or concerns

Specialised perinatal mental health team

Postnatal

Urgent referral OOH = GP urgent

pathway

MBU

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Red Flags from the Confidential

Enquiry into Maternal Deaths

• 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

Risk and severity are not static

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Useful contacts • Inpatient admission – Chamomile Suite 0121 301 2190

• Booked or delivered at BWH – 0121 301 2199 (in hours)

• All other referrals (including BWH out-of-hours):

– Over 25 – SPOA – 0121 301 4000

– Under 25 – FTB - 0300 300 0099

• NB. SPOA accept referral from GPs so need to use out-of-hours GP

• Life threatening emergencies – 999/A&E

Questions?

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Lunch-break 12.45 – 1.30 pm


Medication Use in the Perinatal Period

Dr Laura Stevenson

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Objectives

• Summarise physiological changes during pregnancy

• Summarise basic foetal development

• Consider the impact of non-prescribed substances

• Summarise current evidence for prescribing of psychotropic medications

• Questions


Physiological changes in pregnancy

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Basic foetal development


How do medications have an

effect on the foetus?

• May act directly if cross placenta

• Indirectly if affects placental function

• Effect depends on specific mechanism of action, concentration, frequency of exposure, stage of pregnancy…..

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Effects of non-prescribed substances

• Substance misuse disorders commonly co-morbid with major mental disorder

• Risk increased and multifactorial

• Management is complex


Foetal alcohol syndrome

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Summary of effects


Effects of stress of mental ill-health on pregnancy

• Increased risk of major complications including spontaneous abortion, placental insufficiency, premature birth, postpartum bleeding….

• Mechanism not entirely clear but linked to increase seen in maternal catecholamines, cortisol and pro-inflammatory cytokines

• Cortisol crosses placenta and can re-set foetal HPA axis

• Catecholamines cause placental vasoconstriction

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Effects of mental ill-health on baby

• Clear evidence that maternal stress can negatively impact on baby both in utero and following birth

• Increased risk of:

• Poor foetal growth, small for dates, low birth weight

• Developmental/ language/ cognitive delay

• Behavioural and emotional problems

• Poor bonding/ emotional difficulties


Pre-pregnancy

• Contraception, contraception, contraception

• Recommended that women of child bearing age not prescribed certain psychotropics due to potential risks to foetus

• Ideally discuss prior to trying to conceive so that appropriate steps can be taken and woman adequately supported

• If medicated pre-pregnancy may be appropriate to discontinue and monitor depending on circumstances

• Confirm pregnancy as soon as possible

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Pre-pregnancy cont…

• Need to consider if medication dose will likely need to alter to compensate for maternal physiological changes

• If plan is to remain on current medication need to consider whether dose will require tapering down towards end of pregnancy to reduce effects on newborn

• Consider whether woman plans to breastfeed as this may influence decisions


General considerations in perinatal period

• Consider if alternatives to medication may be an option

• Consider whether use of medication could be delayed (after first trimester, not breastfeeding)

• Explain all the options including benefits and risks of using medication and allow woman where possible to make informed choice

• Use the lowest effective dose and avoid polypharmacy but remember that mental disorder itself can have consequences so aim should be to treat symptoms adequately

• Bear in mind past treatment and illness severity

• Reduce any modifiable risk factors- smoking, obesity, alcohol

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Treatment of depression

• May be that psychological therapy suitable option

• If depression severe may need combination

• NICE recommends SSRI/ TCA/ SNRI

• SSRIs used most commonly/ first line

• Risks thought to be small

• SSRIs- spontaneous abortion, congenital cardiac defects, persistent pulmonary hypertension in the newborn

• Fluoxetine only SSRI licenced in pregnancy but found in breastmilk


Treatment of psychosis

• May well require hospitalisation due to associated risks

• Depending on diagnosis may require treatment with

• Antipsychotics (also first line for mania)

• Antidepressants

• Anxiolytics

• Mood stabilisers

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Antipsychotics • Little NICE guidance as to which

• If patient well, likely best to continue treatment (even clozapine) to avoid relapse and associated risks, but avoid depots

• Recent evidence that 2nd generation (risperidone, quetiapine, olanzapine) do not significantly increase risk of gestational diabetes, hypertension/ pre-eclampsia, VTE, premature birth or low birth weight

• 1st generation- haloperidol, chlorpromazine, trifluoperazine

• Potential that when used in 3rd trimester may cause EPSs and withdrawal symptoms in newborn (changes in muscle tone, agitation, sleepiness, difficulty breathing)

• Difficult as few RCTs in pregnant women and those done small scale


Anxiolytics

• NICE recommends low dose chlorpromazine or amitriptyline

• Lorazepam probably the safest benzodiazepine- short half life and limited penetration into breastmilk

• Clonazepam appears to be least teratogenic but evidence of others increasing risk of congenital cleft defects is variable

• Potential to cause neonatal withdrawal, sedation and hypotonicity

• CBT and good sleep hygiene encouraged

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Mood stabilisers

• Lithium

• If planning pregnancy may be safer to slowly withdraw and consider switch to antipsychotic instead

• Fully crosses placenta

• Relative risk of Ebstein’s anomaly (tricuspid valve) increased up to 20 times if exposed in 1st trimester (but still only low)

• Potential for foetal thyroid dysfunction

• If treatment continues, pregnanacy will need close US monitoring

• Thought to be safer during 2nd and 3rd trimesters but dose may be reduced to prevent “floppy baby syndrome”- due to toxicity

• Dose increase usually needed during 3rd trimester but reduction on delivery

• Found in breastmilk but not absolutely CI


Mood stabilisers cont…

• Anticonvulsants

• 1st trimester exposure carries greater risk of birth defects (neural tube, cleft deformities), growth restriction, cognitive impairment (with valproate and carbamazepine especially)

• Likely dose related

• Need for folate supplementation

• Risk greatest with valproate so not used in women of child bearing age unless all other treatment failed

• Important to supplement with folate

• For severe manic/ depression consider ECT

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Summary

• Few RCTs in pregnant women therefore evidence regarding medication choice is limited

• When considering prescribing pre, during or post pregnancy important to take into account severity of mental disorder and previous treatment success as well as patient choice- importance of good support from services cannot be underestimated

• 1st trimester most critical in terms of foetal development

• Need to take into account maternal physiological changes for some medications


Summary cont…

• NICE guidance helpful

• Antenatal and postnatal mental health: clinical management and service guideline 2015

• Questions/ comments???

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Secondary Care Services for service users requiring psychological interventions

• Psychologists - CMH

• Early Intervention Team – Psychosis

• Complex Care

• Eating Disorders Service


Primary Care

Psychological Therapies and evidence based interventions

• The IAPT programme

• NICE approved

• Referral process – Improved Access to Psychological Therapies

• MDS - PHQ-9 and GAD-7 are used

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Referrals entering treatment by provisional diagnosis IAPT and other psychological services Depressive episode

Generalised Anxiety Disorder

Recurrent depressive disorder

Panic disorders

Post traumatic stress disorder

Obsessive compulsive disorder

Social phobias

Bereavement related depression/complicated grief

Specific (isolated) phobias

Agoraphobia

Eating disorders

Mental & behavioural disorders due to use of drug and alcohol misuse

Bipolar affective disorder

Borderline Personality Disorders

(frequently seen in perinatal referrals)


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IAPT Improving Access to Psychological Therapies

Primary Care Trust • Self referral system in place

• GP’s and other professionals can also still refer

• Referral times will vary depending on treatment

• All perinatal and postnatal referrals will be prioritised

• Step 1 and 2 proceeds quickly. Self referral, (just pick up the phone and dial).

• Brief telephone intervention offered around two weeks after initial telephone call made

• No IAPT Service in your area? refer to your GP

• Some GP Services have their own therapists who are independent to IAPT.

• See handout with list of IAPT Services across the West Midlands


Treatments and Therapies you might expect to be offered within an IAPT Service

• Cognitive Behavioural Therapy (CBT)

• Cognitive Analytical Therapy (CAT)

• Eye Movement De-sensitisation Reprocessing (EMDR)

• Counselling for Depression

• Interpersonal Psychotherapy (IPT)

• Psychological well-being practitioners – low intensity treatment (step 2)

Group Therapy

• Anger Management

• Anxiety and Stress Management

• Assertive Training and Confidence Building Courses

• Women’s groups

• Acceptance Commitment Therapy – known as ACT

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Cognitive Behavioural Therapy (CBT) • Depression and anxiety disorders including social anxiety, generalised anxiety

obsessive compulsive disorder, PTSD, health anxiety, low self esteem, panic

disorder and phobias

• Evidenced based treatment protocol, homework activities, formulation

• How can we access it? - Guided self help, telephone sessions, face to face and group

• High intensity for moderate to severe symptoms of anxiety and/or depression

and low intensity for mild to moderate

• CBT-e (available within an Eating Disorders Service – Secondary Care)

• CBT-p (available in secondary care for psychosis – Secondary Care)


I can’t be bothered

sad

lethargic

Reduce activity

© Think CBT Ltd [email protected] 01732 808 626 www.thinkcbt.com

Cognitive Behaviour Therapy (CBT) is a

talking therapy that examines:

• How you think about yourself, the world and other people

• How what you do affects your feelings and thoughts

• How the way you think and feel affects the way you act

We can break this vicious cycle by changing the way we think and act.

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What is IPT? • IPT is an evidenced based treatment for moderate to severe

depression with or without comorbidity, with or without medication

• Initially developed as a brief, time-limited psychotherapy for the

treatment of non-bipolar, non-psychotic, depressed adult out-

patients

• It maintains a here and now perspective on what might be recent or

recurrent

• The typical therapeutic dose of 16 treatments is increased for more

complex and higher patient cluster groups (i.e. eating disorders, bi-

polar, B.P.D.)


How was IPT-A developed? • 1968 – a clinical trial looking at ways of reducing relapse rates for adults

following anti-depressant treatment of depression.

• The trial, for the first time, brought together what was considered best clinical practice for depression, in a standardised manual.

• Numerous studies throughout the 70’s and 80’s demonstrated the effectiveness of this new treatment approach

• Over time IPT has been developed to offer treatment to the adolescent population and now known as IPT-A.

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Interpersonal Psychotherapy

the antidepressant model for treating depression

• Based on premise that, regardless of the cause of depression, the depression is inextricably intertwined with the patient’s interpersonal relationships.

• It does assume a relationship between depression and social and interpersonal functioning and that depression develops in, and is maintained by, the social context.

• IPT treatment will target the depressive symptoms and the interpersonal difficulties following life events.


Social Model of Depression

• Many studies demonstrate an association between depression and social impairment

• Intimacy and social support shown to protect against depression in the face of adverse life events

• A lack of intimacy, or a confiding relationship shown to be a vulnerability factor in depression

• Depressed people engage their environment in a manner which reduces support and prolongs depression

• Early exposure to relational stress and trauma shown to increase vulnerability to depression

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Genetic Studies in support of IPT

• Myrna Weissman, Professor in Psychiatry and Epidemiology has researched extensively on the subject of depression. Some of her studies involved 3 generations of families at high and low risk of depression, including MRI and genetic studies.

• Outcome Depression occurs following life events (at exit) rather than entry into life events. Whilst depression is a biological disorder, it needs an interpersonal event to trigger it.


Depression in the interpersonal context that is associated with..........

Interpersonal Role Transition

• Role change, subjectively experienced as a loss

Interpersonal Role Disputes

• Current overt or covert dispute with a significant other

Grief - complicated • Bereavement related depression associated with

withdrawal from current relationships

Interpersonal Sensitivity/Deficits

• Long standing difficulty establishing and/or maintaining relationships

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Evidence and Research for IPT and perinatal

• Individual and group therapy

• Effective treatment for depression may still not be sufficient to improve the developing mother-child relationship

• Benefits of combining massage therapy with group IPT

• Partner-Assisted IPT

• How to reduce depression in low-income mothers of infants and toddlers

• Postnatal depression and child development

• Perinatal, postnatal depression and loss


Interpersonal Psychotherapy Therapy (IPT)

Group Treatment

for mums and babies

see separate handout

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IPT Training:

• SSSFT – Stafford, St Georges

• One day workshops or practitioner training courses

• Funded places available – Health Education England

[email protected] or ipt-uk.org.uk

• Working together and partnership training through IPT West Midlands Training Centre

Other training available:

• Attachment and Bonding

• Communication Skills

• Counselling Skills and the Therapeutic Relationship

• Supervisor Training

• IPT practitioner and supervisor training

crossing over services to deliver training


Who else can help in the West Midlands?

Charities and organisations – can you suggest any more?

• ACACIA Family Support - pre and post natal depression support services for mothers, fathers and other family members to overcome the symptoms associated with pre and postnatal depression. acacia.org.uk or tele 0121 301 5990

• One Fit Mama Charitable Trust – different locations across the West Midlands - Alverchurch, Birmingham, Bromsgrove and Droitwich, East Staffs, Sutton Coldfield, Solihull & Warwick, Tamworth & North Sutton, Worcester. onefitmama.co.uk

• NSPCC, Help for adults concerned about a child. Information Service that provides quick and easy access to the latest child protection research, policy and practice. nspcc.org.uk 0808 800 5000 and helpline for children and young people 0800 1111

• Maternal Mental Health Alliance. A Christian charity working across Birmingham to provide , free of charge, a wide range of support and therapies to help you recover from the symptoms associated with pre and postnatal depression. (promotes the support and help of dads with depression). and survival for dads. maternalmentalhealthalliance.org.uk/

• MIND www.mind.org.uk (services vary across the country)

• Home-start UK www.homestart.org.uk


http://www.mind.org.uk/

http://www.homestart.org.uk/

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Useful Networks and resources

• West Midlands Clinical – Networks www.wmscnsenate.nhs.uk

• The 1001 Critical Days – www.1001criticaldays.co.uk

• MBRRACE-UK - www.npeu.ox.ac.uk/mbrrace-uk

• The Maternal Mental Health Network (a website for health professionals working in perinatal

mental health www.maternalmentalhealth.org.uk/

• Supporting couple relationships - www.oneplusone.org.uk/

• From Best Practise to Breakthrough Impacts www.twoinmind.org.uk/

• Ante-natal support and research www.beginbeforebirth.org.uk & www.bestbeginnings.org.uk/

• Cry-sis www.cry.sis.org.uk/ Helpline 08451 228 669 Offers support for families with

excessively crying, sleepless and demanding babies.

• MAMA – The ‘Meet a Mum Association’ www.mama.co.uk/ helpline 0845 120 3746

• Pandas Foundation – Helpline, advice and much more apni.org helpline no. 020 7386 0868

• The Association for Infant Mental Health. On-line Training at aimh.org.uk

• APP Action on Postpartum Psychosis www.app-network.org

•


Handouts

• Mind: Understanding postnatal depression

• Home-Start UK

• Acacia (Birmingham based)

• APP – Action on Postpartum Psychosis

• Recovery College - South Staffs & Shropshire Service

• Improving Access to Psychological Therapies (IAPT) services in the West Midlands – referral process and contact nos.

• 1001 Critical Days – A cross-party manifesto

• Information on Evidence Based Treatments (CAT and IPT)

• Postnatal Depression, Anxiety and coping strategies

• Attachment and Bonding

• One Fit Mama

• Personal Social Services Research Unit (PSSRU)

• Health Education Funded Places for IAPT IPT Training in Depression – information on how to apply

http://www.1001criticaldays.co.uk/

http://www.npeu.ox.ac.uk/mbrrace-uk



http://www.maternalmentalhealth.org.uk/

http://www.beginbeforebirth.org.uk/

http://www.bestbeginnings.org.uk/

http://www.cry.sis.org.uk/

http://www.mama.co.uk/

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What Is The Trigger For Postpartum Depression?


Finally,

Psychological wellbeing for mums, dads, infants, siblings, other family members is everyone’s business. It has a ripple effect and hence affects everyone in our society.

A healthy mum has the best chance to have a healthy infant who has the best chance of becoming an emotionally and psychologically healthy adult.

Thank you.

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Perinatal Mental Health Seminar · • Introduction into perinatal mental health • Signs,...

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