Perinatal depression is gaining a higher profile, with. a drive to increase awareness and provide wider access. to specialist provision. Emma Dent reports
The arrival of a new baby is usually an event to be heralded with joy. But for some women, pregnancy can cause debilitating and life-threatening depression and even psychosis, or a recurrence of an existing illness that can turn lives upside down.
The area of perinatal mental health for women before and after they give birth has been gaining a higher profile. Screening for mental health issues is now standard in care for pregnant women.
The tragic death of psychiatrist Daksha Emson, who killed herself and her daughter after a catalogue of errors surrounding the treatment of her bipolar condition during and after pregnancy, drove the Royal College of Psychiatrists to establish perinatal care as a section of the college and to improve training for members.
Official estimates for post-natal depression have for some time been estimated at 10 per cent of women having babies, of which a third to a half will be severely depressed.
But a survey released in April by the Royal College of Midwives found that 20 per cent of women reported that they had needed medication, group counselling or therapy for depressive symptoms after having their baby.
The most severe form of post-natal first episode mental illness, puerperal psychosis, is rare, occurring in about one in 1,000 births, although the rate is growing for the first time in over a decade.
Meanwhile there are no statistics on how many women with a severe and enduring mental illness either become pregnant or have children, the levels of likely incidence are not known.
But pregnancy can increase the risk of a crisis in women with bipolar disorder by as much as 50 per cent and the numbers are thought to be increasing, partly because of modern drugs. First-generation antipsychotic medications often had a side effect of suppressing ovulation, leaving women taking them unable to become pregnant.
If they did become pregnant it was often assumed that the baby would be looked after by someone else or would be given up for adoption. The first mother and baby units did not emerge until the 1960s.
And access to specialist care, both in the community and in inpatient settings, remains woefully inadequate.
Experts argue that those with the most severe conditions who are in need of extra help require specialist care and should not be taken on in general psychiatric services.
National Institute for Health and Clinical Excellence guidelines released in February say that women in need of specialist inpatient care within a year of childbirth should usually be admitted to a specialist mother and baby unit. It recommended doubling current provision.
Disturbingly, fewer than half of all mental health trusts have any kind of perinatal service. There are currently only 12 mother and baby units. As well as catering specifically for women with babies, some help those who have not delivered yet but are experiencing severe mental illness. There are also 17 community-based teams, although not all current mother and baby units work with a community service and not all community services are backed up by inpatient provision.
A 2006 report by mental health charity Mind, Out of the Blue?, found that of the women surveyed who had to be admitted to an inpatient unit with a post-natal mental illness, 63 per cent were placed on an adult psychiatric ward, usually without their baby. This comes despite fears that such a separation could cause more harm than good, with lasting effects on the mother and baby's ability to bond.
'Such scarcity of provision is outrageous, it is not justifiable,' says Hampshire Partnership trust consultant perinatal psychiatrist Dr Alain Gregoire. 'The complacency around the lack of access is shocking. Women have to travel hundreds of miles for treatment and become separated from their families. They could end up being admitted to a unit at the other end of the country or be forcibly removed from their kids and admitted to a general inpatient unit.'
Astonishingly, a scoping review carried out in preparation for the NICE guidelines found that three trusts were prepared to allow a woman to be admitted to an inpatient unit - as opposed to a specialist perinatal unit - with a baby.
'If something were to go wrong, it would be very difficult for such actions to be justified,' says Nottinghamshire Healthcare trust consultant perinatal psychiatrist Dr Margaret Oates, who has helped to found several mother and baby units. 'We are talking about severe mental illness with substantial risks to life and the quality of life.'
Suicide is the leading cause of maternal mortality, with psychiatric causes attributed to 10 per cent of all deaths of new mothers. Although the numbers are small, as is England's maternal mortality rate overall, experts argue that most are avoidable. Occasionally, a woman will also take the life of her child, though this is rare.
Dr Gregoire says that to provide a full service, a mother and baby unit must work alongside a community-based service.
'We believe that having a community team in place can reduce the need for inpatient beds. An area with both a community team and an inpatient service needs about 2.3 beds per 1,000 deliveries, but without a community team 2.6 beds are needed per 1,000 deliveries. But we need twice what is currently provided across the country,' he says.
'To the west and east of our unit no other perinatal beds are provided in the South West, Surrey and Sussex and Kent,' adds Dr Gregoire.
Although some areas, such as London, are reasonably well provided for, there remain areas, such as the whole of East Anglia, south Wales, between York and London and most of the North East, with no specialist provision at all. Provision also remains largely stagnant - of the 12 units, only two have been built in recent years.
Clinicians say the location of mother and baby units can be traced to there being local champions of such services working in the areas. Where there is no such champion, there is no such service. Lack of services can lead to some units operating waiting lists, although some severe conditions, such as puerperal psychosis, develop quickly.
The amount of support a woman has at home affects her chances of becoming ill and of being admitted. Vulnerable women, such as those with unstable home lives, refugees and asylum seekers are at particular risk.
'The need to admit depends on the severity of the illness,' says clinical nurse specialist Caroline Carr, who is service manager of South Staffordshire Healthcare foundation trust's six-bed mother and baby unit, the Brockington.
'If someone has a lot of family support, then they can stay at home for longer and the trust's crisis resolution team can support people out of hours. But if they do need to be admitted, it is homelier than a general ward and the environment is geared towards children and babies. There is a lot of support for families - we have a fortnightly fathers' group and a carers' group - and the people working here have specialist knowledge of perinatal mental health needs,' she says.
'We educate women about their illnesses and about expectations of being a mum and coping with anxiety. You would not get that on a general acute ward. Even if they are too ill to look after the baby, they still have contact in a setting that secures the safety of the mother and the baby. And if a woman is not sleeping, we can take the baby away for a while and let the mother get a good night's rest.'
Included in the unit is a flat with a double bed, so partners can stay with patients. As in other mother and baby units, its staff includes a nursery nurse and facilities include a milk kitchen and space for each bed to have a cot alongside it.
Before the Brockington opened in 2005, local women needing inpatient care had to be sent to Birmingham. The unit also offers contraceptive advice to women living in the community who take antipsychotic or antidepressant medication, a number of which can affect the development of an unborn baby.
'Discharge planning takes place from the start,' says Ms Carr. 'If they are from out of area we refer them to their own community mental health team if need be, or to a community team if this is their first episode of serious mental illness. We don't send them home with nothing.'
The ratio of women having a first episode of depression or psychosis compared with women who have an enduring mental illness varies from unit to unit, as does the increased rate of incidence that one group may be presenting over the other. Screening to detect women with a history of a severe mental illness is key.
Dr Oates argues that the current lack of services makes little economic sense. Most women who are experiencing first-episode severe depression or even psychosis can be treated successfully and return to full lives, so long as they receive care. Some conditions can also be treated quickly.
'Our average length of stay [for all conditions] is down to 10-12 weeks,' says South London and the Maudsley foundation trust specialist directorate operational service manager Mandy Everett. Close links with local maternity services mean pregnant women can be screened for a history of mental illness and a community service works with women not ill enough for a hospital admission. The trust's mother and baby unit has also started to admit women who are still pregnant if a general acute ward is not considered safe enough.
'The threshold for admission has increased, as crisis resolution teams can now work with a client at home and the unit's patients are now very disturbed women,' says South London and the Maudsley director of specialist services Mark Allen. 'But we would only admit very small numbers of women who have not yet delivered and only in collaboration with obstetric services. We have an excellent service from a local visiting midwife who comes in to do antenatal checks, just like you would get in the community.'
With wards oriented to reducing risk, improving a woman's confidence and helping her bond with her baby, all referrals are considered on the basis of whether an admitted woman is going to keep her baby after delivery.
'If it is considered that the baby is going to be at risk of being taken into care, we will not put women through our service as it would be cruel; every other patient will have a baby,' says Ms Everett. 'But offering the service to women who have not yet delivered is a growth area as it is much needed.'
To improve care delivery, NICE guidelines recommend managed clinical care networks for each population of 25,000-50,000 live births a year, depending on local rates of need.
These should include a specialist multidisciplinary service in each locality, including community services and services linking with maternity care in areas of high need, access to specialist advice on the use of medication, clear referral and management protocols and pathways of care for service users.
There are currently just two networks. The first was set up in the Trent region, founded by Dr Oates, and the second, in Dr Gregoire's patch under NHS South Central, is only now beginning to be formed.
'It is unusual for NICE to set out recommendations on service provision but these are needed because of the inequities in these services. Different areas need different approaches, taking into account local demographics and I do think strategic health authorities are taking this seriously,' says Dr Gregoire. Dr Oates adds that she believes a network should cover an area with a population of around 4 million and build on existing links to be successful.
With the NICE guidelines to arm their cause, Dr Oates hopes perinatal mental health will become a responsibility of specialist commissioning groups, thereby earning it more attention than under general mental health commissioning.
She adds that although pop stars and TV presenters now frequently admit to having post-natal depression, the lack of a high-profile service user who is willing to talk about having post-partum psychosis means that it lacks a high public profile.
Other incentives have been tried elsewhere. Changes to mental health law in Scotland under the Mental Health (Care and Treatment) (Scotland) Act 2003 made it a duty for all Scottish health boards to provide mother and baby units. There are now two units, but before the law was introduced there were none.
Mothers at risk: the east London unit
The mother and baby unit run by East London and the City Mental Health trust has four beds, which are frequently occupied by women who all come from different countries and speak different languages.
'For a lot of the women, it at first appears to be a first episode but when you look at their history they have had a manic or depressive episode, treated or not, in their home country. Most have a lack of family support and are isolated, in poor accommodation with very poor resources. They may be under threat of being deported,' says the unit's consultant perinatal psychiatrist Dr Liz McDonald.
To help patients cope with language difficulties, rooms and equipment such as sterilisers and baby baths are known by colour rather than name or number.
'We do encourage women to speak English as this can help reduce their isolation; learning it is part of discharge planning,' she says.
Dr McDonald says that ideally the trust would also have a community service to increase the breadth of services.
'We also aspire to being able to provide community care to provide a better range of services and because we believe this could also reduce admission,' says Dr McDonald.
There are also plans to redevelop the unit to provide 10 beds and be able to offer beds to the neighbouring North East London Mental Health trust, which has no mother and baby unit.
Find out more
- Report of independent inquiry into care and treatment of Daksha Emson and her daughter Freya, North East London Strategic Health Authority, 2003
- Why Mothers Die, Confidential Enquiry into Maternal and Child Health, 2002.
- Perinatal Mortality 2005, Confidential Enquiry into Maternal and Child Health, 2007
- Guidelines on ante natal and postal mental health, National Institute for Health and Clinical Excellence, 2007