Delivering effective psychological therapies and interventions to people in the perinatal period
"For ease and clarity of writing we use the terms woman/women within these documents. Within this we acknowledge that not all birthing people identify as women"
Perinatal mental health difficulties represent a serious public health concern, if women do not receive support it can have considerable impact on their health and wellbeing, and that of their infant, especially where women also face socioeconomic disadvantages- (Tackling Inequalities in the Early Years: Key Messages from Ten Years of the Growing Up in Scotland Study).
Delivery of high quality, evidence-based psychological interventions and therapy improves maternal mental health, infant mental health, and parent-infant relationships.
Good Practice:-
Access
Clinicians should link into the routine clinical network around the woman at this time including midwifery, health visiting, primary care team and specialist perinatal mental health services- (Care Pathways - Perinatal Mental Health Network Scotland).
Women in the perinatal period should be prioritised for treatment. In line with the Scottish PIMH Pathways women should be seen within 6 weeks of referral, or sooner depending on urgency, as better outcomes are achieved if women are seen during pregnancy, and the risk of rapid deterioration post-partum is minimised. Maternal suicide remains the leading cause of direct deaths occurring within a year after the end of pregnancy – (MBRACE-UK).
Clinicians should be aware of how to access the Mother and Baby Unit, Community Perinatal Mental Health Teams, Maternity Neonatal Psychological Intervention Services, Infant Mental Health Services, third sector and peer support- (Care Pathways – Perinatal Mental Health Scotland).
Thresholds for referral to Community Perinatal Mental Health Teams (CPMHTs), or other appropriate acute mental health service in their absence, should be lowered to take into account: the modifying effects of pregnancy and infant care on the course of mental illness, and the importance of rapid intervention to facilitate the mother-infant relationship and infant development. Therefore, disorders which might otherwise be regarded as less severe, may require CPMHT assessment.
Providing childcare during appointments, or clinicians being comfortable working with the baby in the room (or on video call), is vital in helping to facilitate access to therapy for women.
Consideration should be given to individual preferences regarding intervention in terms of modality, location (face to face or remote, e.g. video consultation or computerised CBT), timing, and whether this is a group or individual intervention.
Risk
Clinicians should be familiar with the specific clinical and risk profiles associated with the perinatal period, e.g. the red flags for suicide risk, and amber flags for relapse of existing mental health conditions -(NES Risk Module).
Clinicians should be aware that mental health difficulties can be exacerbated by pregnancy and/or childbirth, or present for the first time during the perinatal period. Recent significant change in mental state or emergence of new symptoms; new or emerging thoughts or acts of violent self-harm; and new and persistent expressions of incompetency as a mother or estrangement from the infant, are all red flags indicating the need for urgent specialist review -(NES Risk Module).
Stigma
Strong cross-cultural stereotypes exist that present childbirth and motherhood as positive and joyful experiences. These stereotypes can act as barriers to women accessing help, for fear of being seen as a bad or inadequate mother, or for fear of having their child removed. Clinicians should be aware that pregnancy and birth experiences that do not conform with these stereotypes can leave women more susceptible to emotional distress and difficulties adjusting, and this will require a compassionate response.
Stereotypes can also lead to clinicians minimising women’s concerns about their mental state and their concerns about their relationship with their infant.
Clinicians should be aware that women from minority ethnic groups and LBGTQ+ people face additional barriers to accessing care. Women from minority ethnic groups are estimated to be 2-5 times more likely to die in the perinatal period, and have an increased risk of developing mental health difficulties - (NES Stigma Module).
Clinicians should be mindful in their assessment that women often experience intimate partner violence for the first time during pregnancy - (5-21% SG 2013). Previous violence in the relationship increases the risk of ante and postnatal anxiety and depression, and previous, coupled with current violence, increases that risk further. Violence, often alongside stigma and disadvantage, acts as an additional barrier to women seeking help.
Assessment
Physical health concerns should be taken seriously in the perinatal period and women should be urgently followed up by midwife/GP/health visitor/obstetrician. Physical health concerns should not simply be attributed to women’s mental health difficulties or pregnancy.
A full assessment in the perinatal period should include an obstetric history including; previous pregnancies, history of mental and physical health, history of previous trauma, baby loss, and fertility difficulties -(NES Assessment Module).
It is important to ascertain if women are having ante and post-natal health checks, and to inquire about the health and development of the infant (ideally to see the infant and other children). Concerns about child welfare, development or protection should be recorded and followed up with relevant professionals – HV, midwife, GP, social work, or specialist children’s services.
Practitioners should be aware fathers, partners and co-parents have similar rates of perinatal depression and anxiety to mothers, and this is associated with prior mental illness, relationship difficulties and socioeconomic adversities (Royal College Psychiatry).
Medication
Discussions about medication in the perinatal period should be person centered and balanced, reflecting both the risks of taking medication and the risks of not treating mental health problems, for mother and baby. Women should be advised to have an informed discussion with their doctor/qualified prescriber before stopping any medication- (NES Pharma Module)