www.england.nhs.uk

Bryony Gibson

Perinatal Lead

TVSCN

26 September 2018

Thames Valley SCN

Perinatal Mental Health

www.england.nhs.uk

www.england.nhs.uk 3

www.england.nhs.uk 4

www.england.nhs.uk

Pre-conceptual advice

• Women who have personal history of serious or significant mental health

issues including those during a previous pregnancy i.e. post natal

psychosis

• Women who have a close female relative who has a psychotic disorder or

who experienced post partum psychosis

• Women who have a diagnosis of Bi-Polar 1 are at significantly increased

risk

• Guidance indicates that such women should be referred to specialist

services for:

• Assessment of risk and risk management planning

• Medication advice-addressing the risk of both taking or not taking

medication

• Maternity planning-completion of document shared with all those involved

in her care to help mitigate risk

• Close monitoring during pregnancy and in the post partum period

5

www.england.nhs.uk

Specialist Assessment:

Perinatal Mental Health

6

• Whole range of disorder seen at other times however with the perinatal

frame of mind need to consider the impact on treating or not treating MH

• The range of presentations will be similar to those occurring outside of the

perinatal period.

• Approx 20% of women experience a MH issue during the perinatal period-

4% will require the specialist perinatal mental health services

• Increase in OCD-sometimes with thoughts of harm to the baby

• Evidence that low mood and anxiety in pregnancy is an increased risk

factor for post natal illness and impact on the child

• Women presenting with serious or significant mental health presentations

during pregnancy and in the first year post partum

• Previous significant personal history of MH, close family history of

psychosis requiring pre-conceptual advice or pregnant but planning

required for support during perinatal period

• Birth Trauma assessment-birth trauma pilot in BHFT

www.england.nhs.uk

Emergency Assessment:

Psychosis an urgent response • Risk of 1-2 per 1000 live births with no previous history (increased risk if bi-

polar diagnosis)

• Onset is usually within the 14 days of birth with 80% presenting by 28 days

post partum

• Most mums will report subsequently report symptoms starting on day 1.

• Onset is the most acute, most rapid, most florid of all mental health

presentations and onset can take place over hours rather than days

• Presentation is most often of mania but can initially present with perplexity,

confusion and anxiety often leading to misdiagnosis (Saving Lives 2011)

• Mania poses increased risk to the baby due to the dangerous situation the

mum may put herself in as a consequence of her psychotic phenomena

• Hallucinations or delusions relating to the baby will increase the risk to that

child.

7

www.england.nhs.uk

Psychosis an urgent response

• Bi-Polar Disorder carries the highest known risk of all mental health

disorders

• Episodes of postpartum psychosis occur after approximately 25% or 1 in 4

births to women with bipolar disorder.

• This is many hundred times higher than for women who have not had

previous psychiatric illness. (1-2 per 1000 live births)

• Postnatal depression follows a further 25% or 1in 4 births.

• Therefore, about 50% of women with bipolar disorder stay well after

• having a baby and about 50% are likely to have an episode of illness.

**********************

• If you suspect a psychosis do not wait to see if it settles - take urgent

action immediately.

• Refer to your local mental health services requesting an assessment

for suspected psychosis.

• NICE recommend that this assessment commences within 4 hours.

8

www.england.nhs.uk

Psychological Interventions Provided both within IAPT services and specialist perinatal MH service

Perinatal frame of mind

Delivered in timely manner-to mitigate impact of the mothers mental health on the

child and with prescribing limitations

IAPT:

Developing silver cloud for perinatal (part of GDE)

Delivering CBT, counselling

phone, face to face

Specialist Team:

CBT, birth trauma, IPT

Home assessment and interventions-all assessment are face to face

Support from nursery nurses to support CBT interventions

Specialist birth trauma service following assessment from perinatal service

9

www.england.nhs.uk

Urgent Admission to MBU • Specialist Mother and Baby Unit provision-admission can be to any unit in

England

• Nationally funded beds -Increased number of MBU beds being built (4 new

MBUs commissioned) but no intention for MBU in Thames Valley

• Admission to MBU during final stages of pregnancy and up to one year post

partum-any woman who requires admission to an adult mental health unit

should be considered for admission to MBU. Thresholds are lower.

• If you feel a woman may be requiring admission to MBU please make an

urgent referral to MH service

• Minimal exclusion criteria for admission to MBU:

• If baby is not/will not be with the mother

• Where the risk is sufficiently high for MBU to be unable to manage risk to self

or to infant/others

• MBU do not routinely provide court reported parenting assessment

• Following assessment by MH services (including MHA) and where care

is not manageable within the community provision available - admission

can be directly to MBU with the infant

10

www.england.nhs.uk

MBBRACE – Red Flags SUICIDE REMAINS ONE OF THE LEADING CAUSES OF MATERNAL

DEATH UP TO ONE YEAR POST PARTUM

• Presenting in the first four weeks post-partum (highest risk period

for presenting psychosis)

• Sudden deterioration of mental health presentation

• Thoughts of violent method of suicide (even if fleeting)-women use

violent methods more than at other times

• Estrangement/feeling estranged from infant bonding

• Thoughts of absconsion

• Previous history of suicide or self-harm

• Last trimester of pregnancy and first 12 weeks post birth

• Any thoughts of harm to child or psychotic thoughts relating to

child increases risk – if the woman says she would never leave her

child ask if she has thoughts of taking her child with her

• Be wary of the ‘gated community’ of high achieving, well educated,

financially stable women.

11

www.england.nhs.uk

PERINATAL PRESCRIBING CONSIDERATIONS

Pre-Conception, Pregnancy and Breastfeeding

• The possibility of pregnancy should be discussed with all women of child-

bearing potential before any medication is prescribed. Advice and

contraception should be made available if necessary.

• Valproate is of particular risk to an unborn child; women of child-bearing

potential should be on the Pregnancy Prevention Programme (PPP) and

regularly reviewed by a Consultant Psychiatrist / Neurologist if prescribed.

• Women may wish to exclude pregnancy if they deem the risks associated with

undergoing treatment whilst being pregnant as unacceptable. Once excluded, it

would be prudent to discuss contraception or signpost woman to appropriate

services to explore contraceptive options.

• All prescribing in pregnancy and breastfeeding is off-label.

• Women should be informed that whilst it is not possible to guarantee the safety

of any medication prescribed during pregnancy or breastfeeding, an individual

assessment of potential risks and benefits may help to guide treatment

decisions.

12 Slide provided by Beki Inglis Berkshire Perinatal Pharmacist

www.england.nhs.uk

PERINATAL PRESCRIBING CONSIDERATIONS

Pre-Conception, Pregnancy and Breastfeeding

• Risks associated with untreated or deteriorating maternal mental illness should

be weighed against the risks associated with exposing a foetus / baby to

medication. The mother (and if the mother agrees, the partner / significant

carer) must always be involved in the decision-making process where

possible.

• Prescribing during the first trimester is generally considered the time of

greatest risk to the foetus as major organ development will be taking place.

Based on an assessment of potential risks and perceived benefits, it may be

preferable to temporarily discontinue or delay medication until the second

trimester.

• Consider the potential effects of medication on the foetus during labour and

immediately following the birth. Delivery within a hospital setting and additional

monitoring of the newborn may be required.

13 Slide provided by Beki Inglis Berkshire Perinatal Pharmacist

www.england.nhs.uk

PERINATAL PRESCRIBING CONSIDERATIONS

Pre-Conception, Pregnancy and Breastfeeding

• Switching medication during the perinatal period carries a risk of relapse or

deterioration in mental state but also exposes the foetus / baby to more

drugs. Careful consideration of potential risks should be undertaken before a

change in treatment is commenced.

• Where possible, monotherapy should be prescribed in order to limit foetal /

infant exposure to medication.

• Unless a women is already open to a CMHT (or has been discharged from a

CMHT in the last 6 months), all women with a diagnosis of bipolar affective

disorder, history of psychosis or a history of severe perinatal mental ill-

health should be referred to the Perinatal Mental Health Team for pre-

conceptual counselling and / or assessment.

• Prescribing slides provided by Beki Inglis Berkshire Perinatal Pharmacist

Please contact the Berkshire Perinatal Mental Health Team on

0300 365 0300 if you require further advice.

www.england.nhs.uk

Takeaway messages

Treat MH disorders across the whole spectrum: Consider a referral to SHaRON for peer support from others who have a shared

experience-no open MH referral needed(media based peer support-referral

made via referral point at CPE)

Refer on to services sooner rather than later i.e. Talking Therapies for

psychological intervention (where presentation is mild to moderate, low risk etc)

– late referrals may mean intervention is not completed or effective prior to

delivery

If the presenting situation is causing concern seek advice from or refer to your

local specialist perinatal mental health service

For women at high risk please offer a referral to the specialist perinatal mental

health service for pre-conceptual counselling/maternity planning

15

www.england.nhs.uk

Takeaway messages

16

Consider the risks of not prescribing or not treating MH – the impact/risks

could be higher for the child if the mother becomes unwell. Avoid poly

pharmacy.

If the woman says she is FINE but doesn’t look it just ask again-about 70-

80% of women wont say how they feel or how much they are struggling

Do not wait to see if a suspected psychosis settles-make an urgent referral

to your local (perinatal) MH services 24 hours a day.

Don’t forget the dads – they can experience MH during this time too and

possibly PTSD following traumatic events during pregnancy and birth.

www.england.nhs.uk 17

www.england.nhs.uk

Referral Options in Berkshire

Mild – moderate MH conditions,

low risk, CBT / Counselling.

Variety of CBT based

interventions

0300 3652000

Perinatal Service

Admission-vulnerable

women, moderate to severe

MH conditions, complex,

higher risk

0300 3650300

Urgent/emergency out of

hours – CRHTT

0300 3659999

www.england.nhs.uk

Further opportunities

• If you have a specific interest in the field of perinatal mental health and

wish to be kept informed of any future opportunities that arise to support

training for GPs

• If there are any specific subjects or areas that you would wish to be

covered in training-webinars etc re prescribing/sim training

• Any ideas as to how we can make training opportunities more accessible

for GPs

• Please contact me at:

• bryony.gibson@berkshire.nhs.uk

• Thames Valley Perinatal Lead and Co-Chair of the TVSCN Regional

Perinatal Network

19