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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/

cnw-tr.Hillingdonperinatal@nhs.net

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)

ukdilas.enquiries@nhs.net

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

e.davison@nhs.net @Mayonasian