Perinatal

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Perinatal Infant Mental Health

• GP NSW Mental Health State Update Meeting 30 June
  2009

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Perinatal Mental Health

• Umbrella colloquial term PND
• From the birth of every 100 babies, 10 -15
  mothers experience PND
• There is no sound evidence that the rate of PND
  is increasing in the Australian/NSW community
• Use and misuse of the term PND is widespread

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Perinatal Mental Health

• Birth rate in NSW is steadily increasing
  predicted to reach 97,000 in 2009
• Some changes in mental state and functioning are
  a normal part of the antenatal and postnatal
  experience and caution should be taken about
  basing any diagnosis or label such as PND on such
  features without careful consideration of the
  context

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Perinatal Mental Health

• The World Health Organisation (WHO) predicts that
  depression will be the second greatest cause of
  premature death and disability worldwide by the
  year 2020.
• Depression and anxiety are high prevalence
  disorders.
• PND is the same as depression (and anxiety)
  occurring in the general population at other
  times yet it is particularly important because it
  is so common and because it occurs at such a
  critical time in the lives of the mother, her
  baby and her family.

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Perinatal Mental Health

• There are problems with definition of PND given
  the range of mental disorders that occur during
  the perinatal period.
• Depression during pregnancy is of considerable
  importance.
• Focus on only PND can lead policy and service
  development that excludes the full range of
  mental disorders occurring during the antenatal
  and postnatal period.

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Perinatal Mental Health

• Common false beliefs
• That its all just hormonal and will go away
• Symptoms and effects less severe than depression
  or other mental illness for others, at other life
  stages
• Around breastfeeding and interaction with baby

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Perinatal Mental Health

• Methodological issues in reported studies
• Variety of perinatal illness
• Time points
• Caution should be applied when interpreting and
  PND/perinatal mental health data

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Perinatal Mental Health

• Although suicide is the most common cause of
  death in the perinatal period and women with
  severe mental illnesses have high rates of
  suicide postnatally, the rates of suicide for
  women in the antenatal and postnatal periods are
  lower than that for the whole female population
  (although there is some suggestion that rates are
  higher in younger women who have recently
  experienced a termination)

9
References for PMH slides

• Centre for Epidemiology and Research. NSW
  Department of Health. New South Wales
• Mothers and Babies 2004. N S W Public Health Bull
  2005 16(S-4).
• Primary Health Community Partnerships Branch,
  NSW Department of Health

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References for PMH slides

• Scottish Intercollegiate Guidelines Network
  (SIGN)
• Publication No. 60 Postnatal Depression and
  Puerperal Psychosis ISBN 1899893 18 0 Published
  June 2002
• http//www.sign.ac.uk/guidelines/fulltext/60/index
  .html
• National Institute for Health and Clinical
  Excellence (NICE) Guideline 45 Antenatal and
  postnatal mental health guidance - Date issued
  February 2007 Reference  CG45
• http//www.nice.org.uk/Guidance/CG45

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PMH Information 1

• Common mental health problems during the
  antenatal and postnatal period include depression
  and anxiety disorders, such as panic disorder,
  obsessive compulsive disorder (OCD) and post
  traumatic stress disorder (PTSD). An estimated
  10 to 15 of women suffer from depression after
  the birth of an infant. For the vast majority of
  these women, professional help will be provided
  solely by primary health care services in
  community settings (National Collaborating Centre
  for MentalHealth, 2007).

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PMH Information 2

• Around 3 to 5 of women giving birth have
  moderate or severe depression, with about 1.7 of
  these women being referred to specialist mental
  health services (Cox, Murray Chapman, 1993).

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PMH Information 3

• First presentations of severe mental illness,
  primarily schizophrenia and bipolar disorder, in
  the perinatal period are rare, with a rate in the
  region of two per thousand resulting in hospital
  admissions (Kendell, Chalmers Platz, 1987).

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PMH Information 4

• More common, particularly with bipolar disorder,
  is the exacerbation of an existing disorder, with
  some studies reporting relapse rates for bipolar
  disorder approaching 50 in the antenatal period
  and 70 in the postnatal period (Viguera, Nonacs,
  Cohen, et al., 2000).

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PMH Information 5

• These women, along with others suffering from
  severe depression and other severe disorders such
  as severe anxiety disorders or personality
  disorders will benefit from integrated specialist
  mental health care (National Collaborating Centre
  for Mental Health, 2007).

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PMH Information 6

• In Australia it has been estimated that between
  25-50 of children and young people with parents
  with mental illness experience psychological
  disorder (Barnett, Schaafsma, Guzman Parker,
  1991).

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Some definitions

• Perinatal
• Perinatal Mental Health
• Infant Mental Health
• Mental Health Promotion, Prevention and Early
  Intervention
• Specialist Mental Health Services Treatment
• Initiatives, Models, Programs Partnerships

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Background 1

• 2000 National Action Plan for Promotion,
  Prevention and Early Intervention for Mental
  Health
• Perinatal Infants 0 2 years
• Develop initiatives to implement and coordinate
  screening programs for infant health and parental
  mental health problems (particularly maternal
  depression)

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Background 2

• 1999 NSW Health Integrated Perinatal and infant
  Care (IPC)
• Psychosocial assessment and depression screening
  for all women expecting or caring for a baby
• Integrated care pathways for perinatal families
  requiring extra support or health interventions
• Education and training for health professionals

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Background 3

• 2007 IPC re-named SAFE START
• Same model, just a new badge
• Families NSW ( Families First new badge)
• FNSW is the NSW Governments whole-of-government
  prevention and early intervention strategy for
  families with children up to 8 years
• 2007 FNSW funding of 3.5M to NSW Health for SAFE
  START to screen pregnant postnatal women for
  depression

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Background 4

• NSW Healths Mental Health and Drug Alcohol
  Office (MHDAO) and Primary Health and Community
  Partnerships Branch (PHCPB) have collaborated to
  develop NSW Healths Families NSW Supporting
  Families Early Package
• Also known as the SFE Package

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SFE Package

• Promotes integrated approach to the care of
  women, their infants and families in the
  perinatal period and comprises 3 documents
• Maternal and Child Health Primary Health Care
  Policy
• SAFE START Strategic Policy
• SAFE START Guidelines Improving mental health
  outcomes for parents and infants

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SAFE START Psychosocial Assessment

• I. Lack of support
• 1. Will you be able to get practical support with
  your baby?
• 2. Do you have someone you are able to talk to
  about your feelings or worries?

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SAFE START Psychosocial Assessment

• II. Recent major stressors in the last 12 months.
• 3. Have you had any major stressors, changes or
  losses recently (i.e., in the last 12 months)
  such as, financial problems, someone close to you
  dying, or any other serious worries?

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SAFE START Psychosocial Assessment

• III. Low self- esteem (including lack of self-
  confidence, high anxiety and perfectionistic
  traits)
• 4. Generally, do you consider yourself a
  confident person?
• 5. Does it worry you a lot if things get messy
  or out of place?

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SAFE START Psychosocial Assessment

• IV. History of anxiety, depression or other
  mental health problems
• 6a. Have you ever felt anxious, miserable,
  worried or depressed for more than a couple of
  weeks?
• 6b. If so, did it seriously interfere with your
  work and your relationships with friends and
  family?
• 7. Are you currently receiving, or have you in
  the past received, treatment for any emotional
  problems?

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SAFE START Psychosocial Assessment

• V. Couples Relationship Problems or dysfunction
  (if applicable)
• 8. How would you describe your relationship with
  your partner?
• 9 a). Antenatal What do you think your
  relationship will be like after the birth OR
  
• 9 b). Postnatal Has your relationship changed
  since having the baby?

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SAFE START Psychosocial Assessment

• VI. Adverse childhood experiences
• 10. Now that you are having a child of your own,
  you may think more about your own childhood and
  what it was like. As a child were you hurt or
  abused in any way (physically, emotionally,
  sexually)?

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SAFE START Psychosocial Assessment

• VII. Domestic violence
• Questions must be asked only when the woman can
  be interviewed away from partner or family member
  over the age of 3 years. Staff must undergo
  training in screening for domestic violence
  before administering questions

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SAFE START Psychosocial Assessment

• VII. Domestic violence
• 11. Within the last year have you been hit,
  slapped, or hurt in other ways by your partner or
  ex-partner?
• 12. Are you frightened of your partner or
  ex-partner?
• (If the response to questions 11 12 is No
  then offer the DV information card and omit
  questions 13-18)

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SAFE START Psychosocial Assessment

• VII. Domestic violence
• 13. Are you safe here at home? /to go home when
  you leave here?
• 14. Has your child/children been hurt or
  witnessed violence?
• 15. Who is/are your children with now?
• 16. Are they safe?
• 17. Are you worried about your child/childrens
  safety?
• 18. Would you like assistance with this ?

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SAFE START Psychosocial Assessment

• Opportunity to disclose further
• Are there any other issues or worries you would
  like to mention?

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SAFE START Depression Screen

• Edinburgh Postnatal Depression Scale (EPDS)
• Also known as EDS when use outside immediate
  perinatal period and with fathers
• Simple, reliable, valid and user-friendly tool
  used to check if a woman has been experiencing
  some emotional distress in the past seven days

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SAFE START Depression Screen

• EPDS/EDS
• Self-rating questionnaire available in several
  languages including Arabic, Chinese, Vietnamese
  and others.
• Can be administered relatively quickly in a
  multiplicity of settings.

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SAFE START Depression Screen

• EPDS/EDS for English speaking women the score for
  probable depressive symptoms is
• Antenatal 15 or more
• Postnatal 13 or more
• For any score above 0 (zero) on Question 10 it is
  imperative that the clinician undertakes further
  sensitive questioning.
• AHS Policy for assessment and response to clients
  with possible suicidal behaviour (based on NSW
  Healths PD2005_121

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On formulating strategy (for pathways)

• If he prepares to the front, his rear will be
  weak if he defends the rear, his front will be
  fragile. If he strengthens his left he will
  weaken his right if he strengthens his right, he
  will weaken his left. If he tries to prepare
  everywhere, he will be weak everywhere (Sun Tzu,
  The Art of War).
• Consider Practice Development or Action
  Research Methodology

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Questions

• ?
• Good Luck
• Karen Raine, MH-Kids
• Telephone [phone]
• Karen.Raine_at_doh.health.nsw.gov.au