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Antenatal and postnatal mental health

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Interpersonal psychotherapy. Explaining risks. Absolute and relative risk. Decision aids ... interpersonal psychotherapy. cognitive behavioural therapy ... – PowerPoint PPT presentation

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Title: Antenatal and postnatal mental health


1
Antenatal and postnatal mental health
February 2007
NICE clinical guideline 45
2
What this presentation covers
  • Context
  • The guideline recommendations
  • Key areas for implementation
  • Costs and savings
  • Further information and support

3
Changing clinical practice
  • NICE guidelines are based on the best available
    evidence
  • The Department of Health asks NHS organisations
    to work towards implementing guidelines
  • Compliance with developmental standards will be
    monitored by the Healthcare Commission

4
Need for this guideline
  • Risk of women with an existing disorder
    stopping medication abruptly
  • Increased risk of relapse and first
    presentation of bipolar disorder
  • More urgent intervention may be required
  • More rapid onset of postnatal psychotic
    disorders

5
Need for this guideline
  • Psychological health is as important as physical
    health
  • Effects on the extended family
  • Appropriate use of psychotropic drugs in this
    context
  • Need for prompt and effective psychological
    interventions

6
What the guideline covers
  • Prediction and detection
  • Management
  • psychological treatments
  • psychotropic medication
  • risk discussion
  • Organisation of care and service delivery

7
Mental disorders during pregnancy and the
postnatal period
  • Severe mental illness
  • Schizophrenia
  • Bipolar disorder
  • Depression
  • Mild, moderate or severe
  • Anxiety disorders
  • Panic disorder
  • Generalised anxiety disorder
  • Obsessivecompulsive disorder (OCD)
  • Post-traumatic stress disorder (PTSD)
  • Eating disorders

8
Prediction
  • At first contact with maternity services, ask
    specific questions about
  • Past or present severe mental illness
  • Previous treatment by psychiatrist/specialist
    mental health team
  • Family history of perinatal mental illness

9
Detection
  • Use the Whooley questions at first contact with
    primary care, at the booking visit, and
    postnatally
  • Other self-report measures can be used as part of
    subsequent assessment
  • Identify possible depression

10
The Whooley questions
  • During the past month, have you often been
    bothered by feeling down, depressed or hopeless?
  • During the past month, have you often been
    bothered by having little interest or pleasure in
    doing things?
  • Consider a third question
  • Is this something you feel you need or want help
    with?

11
Psychosocial treatments
  • provide treatment within 1 month of initial
    assessment
  • Subthreshold symptoms
  • Previous depression or anxiety
  • 46 sessions of brief psychological treatment
    such as interpersonal therapy (IPT) or cognitive
    behavioural therapy (CBT)
  • No previous depression or anxiety
  • Social support such as regular informal
    individual or group-based support

12
Management of depression
  • Mild or moderate depression
  • Self-help strategies
  • Counselling (listening visits)
  • Brief cognitive behavioural therapy
  • Interpersonal psychotherapy

13
Explaining risks
  • Absolute and relative risk
  • Decision aids
  • Personalised view of risk
  • Written material
  • Needs of adolescents

14
Prescribing antidepressant medication
Tricyclics (TCAs) have lower known risks during
pregnancy than other antidepressants. May be
more dangerous if taken in overdose
SSRIs taken after 20 weeks gestation may be
associated with an increased risk of persistent
pulmonary hypertension in the neonate
Venlafaxine may be associated with increased risk
of high blood pressure at high doses, toxicity
in overdose compared with other drugs and
increased difficulty in withdrawal
Fluoxetine has fewer known risks during
pregnancy than other SSRIs Paroxetine taken in
the first trimester may be associated with fetal
heart defects
All antidepressants carry the risk of withdrawal
or toxicity symptoms in neonates
Most antidepressants pass into the breast milk.
15
Organisation of care
  • Effective detection
  • Effective assessment and referral to appropriate
    services
  • Timely, appropriate management and treatment
  • Accurate information about the disorder and the
    benefits and risks associated with interventions
  • Provision of care in the most appropriate setting
  • Appropriate communication about care with other
    services as required, taking into account
    confidentiality
  • Choice

16
Service deliveryperinatal mental health networks
  • Coordinating board
  • Specialist perinatal services in each locality
    providing direct services, consultation and
    advice
  • Access to specialist expert advice on
    psychotropic medication
  • Clear referral and management protocols
  • Clearly defined roles and competencies for all
    professional groups
  • Clearly defined pathways of care for service
    users

17
Organisation of carethe stepped/tiered care
model
Personnel
Service
Core functions
Specialist perinatal mental health services
Psychiatrists, nurses, nursery nurses,
psychologists
Prevention, management treatment of
moderate/severe illness specialist advice and
consultation to primary care
CMHT (psychiatrists, psychologists, nurses
social workers)
Specialist mental health services
Assessment treatment referral to specialist
services inpatient care
GPs, obstetricians, psychological therapists,
PCMHWs
Primary care mental health services
Assessment and referral treatment of mild to
moderate illness
GPs, obstetricians, midwives, health visitors,
practice nurses
General healthcare services (maternity and
primary care)
Detection of history of and current mental
illness referral
18
Perinatal clinical network
  • Coordinating centre
  • Coordinate associated inpatient
  • units
  • Coordinating board
  • Network manager
  • Local specialist service provision
  • Protocol development and
  • monitoring
  • Specialist perinatal services
  • Local specialist provision
  • Managing admissions
  • Consultancy, training to 10 and 20 care
  • May be separate or part of specialist
  • mental health service
  • Specialist mental health services
  • Local service provision
  • Assessment and referral
  • Consultancy and advice
  • Primary care services
  • Local service provision
  • Assessment and referral
  • Maternity services
  • Local service provision
  • Assessment and referral

19
Specialist perinatal inpatient services
  • Typically provide for a population of between
    25,000 and 50,000 live births with 612 beds
  • Designed specifically for mothers and infants
  • Staffing appropriate to care for infants
  • Effective liaison with general medical and mental
    health services
  • Full range of therapeutic services
  • Closely integrated with community mental health
    services

20
Key areas for implementation
  • Coordination of service delivery
  • The competencies of the multidisciplinary team
  • Promoting prediction and detection
  • Effective communication
  • Appropriate use of medication

21
Coordination of service delivery
  • Engage with local commissioning partners to
    commission and develop a managed clinical network
    for perinatal mental health provision
  • Develop clear pathways and protocols for referral
    and management to ensure effective care for women
    who need to access this service
  • Develop clearly defined roles and competencies
    for all professional groups involved in the care
    pathway
  • Review local provision of psychological therapies

22
Competencies of the multidisciplinary team
  • Ensure effective risk discussion and use of
    screening questions by providing appropriate
    training
  • Ensure thorough knowledge of perinatal mental
    health issues and develop competencies
  • Invest in training to ensure sufficient local
    provision of CBT and IPT

23
Promoting prediction and detection
  • Review use of tools used to detect depression
  • Review use of the Edinburgh Postnatal Depression
    Scale with practitioners
  • Incorporate key predictor questions (Whooley
    questions) into clinical practice

24
Effective communication
  • Review communication processes across settings as
    part of developing perinatal network activity
  • Develop and agree communication pathways between
    service providers in line with developing
    perinatal network activity
  • Review competence in issues of consent and
    capacity in relation to adolescents

25
Appropriate use of medication
  • Review local formularies in line with guideline
    recommendations related to antidepressant
    medication
  • Review local formularies in line with guideline
    recommendations related to other psychotropic
    medication
  • Work with local prescribers to raise awareness
    and promote effective prescribing practices

26
Costs and savings
  • Use NICE costing tools to identify
    recommendations with the greatest impact on
    resources
  • interpersonal psychotherapy
  • cognitive behavioural therapy
  • managed clinical networks for the delivery of
    perinatal mental health services

27
Access tools online
  • Costing tools
  • costing report
  • costing template
  • Audit criteria
  • Implementation advice
  • Available from www.nice.org.uk/CG045

28
Access the guideline online
  • Quick reference guide a summary
    www.nice.org.uk/CG045quickrefguide
  • NICE guideline all of the recommendations
    www.nice.org.uk/CG045niceguideline
  • Full guideline all of the evidence and
    rationale www.nice.org.uk/CG045fullguideline
  • Understanding NICE guidance a plain English
    version www.nice.org.uk/CG045publicinfo
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