Fundamentals of Midwifery: A Textbook for Students (120 page)

Past or present severe mental illness, including schizophrenia, bipolar disorder, psychosis in the postnatal period and severe depression

Previous treatment by a psychiatrist/specialist mental health team, including inpatient care

Family history of perinatal mental illness.284
Do not use other specific predictors, such as poor relationships with her partner, routinely to predict development of a mental disorder.
Detection questions (Whooley questions)
At the woman’s first contact with primary care, at her booking visit and postnatally (usually at 4 to 6 weeks and 3 to 4 months), healthcare professionals (including midwives, obstetricians, health visitors and GPs) should ask two questions to identify possible depression.

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?If the woman answers ‘yes’ to either of the initial questions, also ask:

Is this something you feel you need or want help with?As part of a subsequent assessment or for routine monitoring of outcomes, consider using self- report measures such as the Edinburgh Postnatal Depression Scale (EPDS), Hospital Anxiety and Depression Scale (HADS) or Patient Health Questionnaire 9 (PHQ9).of CEMD, giving it the highest priority. MBRRACE-UK’s programme of work will also include a series of themed topic-based confidential clinical reviews of serious maternal morbidity, with near-misses and cases of serious morbidity being more numerous than deaths. Women who are at high risk of major postpartum mental illness in pregnancy and who subsequently develop a postpartum psychosis requiring psychiatric admission is a topic selected to be carried out in 2014 and 2015.
Policy context
Since 2004 there has been an increasing focus on PMI in UK maternity policy (DH 2004) and national maternity guidelines (NICE 2003; 2006) which ultimately culminated in the publication in the UK of the NICE guidelines for antenatal and postnatal mental health (NICE 2007). These guidelines set out key priorities for PMH, emphasising that women with PMI must be recognisedearly, have access to effective treatment and be supported by services to promote optimal recovery. These guidelines gave all healthcare professionals working with pregnant and post- natal women, a clearly defined remit for prediction of the current disorder, detection of risk factors, familiarity with the signs and symptoms of mental health disorders and referral through clearly identified pathways and involvement in a multidisciplinary approach to care.‌
Identification and assessment
Through early identification and the provision of professional care and treatment options, theonset of such illnesses can often be prevented or the severity significantly lessened. As such, it has been identified that effective prevention, detection, and treatment of PMI could have posi- tive impact on those suffering from these conditions, and improve the health and wellbeing of children and families across the UK (NSPCC 2013). The need for specialist psychiatric services where pregnant and postpartum women can be referred, via rapid access pathways is empha- sised in all the confidential enquiry reports and is indeed clearly mandated in the NICE guidance (NICE 2007).Worthy of consideration for practitioners, however, is that whilst short self-report measures are undoubtedly attractive for use in clinical practice due to their ease of use (as in the Whooley questions) and potential cut-off scores (as for the EPDS) which help facilitate practitioner judge- ments (Alderdice et al. 2013); measures are not without their problems. They are not diagnostic in nature and a score on a screening tool only serves to highlight possible or probable PMI. Issues have been raised in relation to both embedded anxiety items within the EPDS with impli- cations for threshold scores (Jomeen and Martin 2005) and the validity of the Hospital Anxiety Depression Scale (HADS) in a childbearing population (Jomeen and Martin 2004). Authors have also recommended differing thresholds for antenatal and postnatal use of measures such as the EPDS (Matthey et al. 2006), which have not necessarily translated into practice. A good screen- ing test should reflect both reliability and validity, and the National Screening Committee have expressed concerns about the widespread implementation of the EPDS in particular as a screen- ing tool (Raynor and England 2010). Indeed while tools might be useful in underpinning mood assessment, they should not be considered a replacement for clinical skills and expertise, but as part of a broader assessment and decision-making process (Jomeen 2012).
285
Further reading activityFor further short reading on the issues related to measures and assessment see the followingeditorial:Jomeen, J. (2013) Women’s psychological status in pregnancy and childbirth – measuring or understanding?
Journal of Reproductive and Infant Psychology
30 (4), pp. 337–340.
Identifying risk factors
The successive confidential enquiry reports all highlight the difficulties with identifying the risk,as well as managing the risk appropriately. Risk factors are best described as vulnerability or adverse factors or characteristics that are present in a person’s life and hence put them at greater risk of developing PMI (Raynor and England 2010; see Box 13.2).286
Chapter 13 Perinatal mental health
Box 13.2 Potential risk factors for PMI (WHO 2004; CEMACH 2004, 2007; CMACE 2011)

Previous psychiatric disorder

Family history of serious mental ill-health

Social disadvantage and isolation

Poverty

Minority ethnic group

Asylum seekers and refugees

Late bookers and those who repeatedly miss appointments

Domestic violence

Substance misuse

Known to child protection services

Employment status

Physical ill health

Life events

Lack of support
Box 13.3 Predictors of PND (Beck 2001)

Antenatal depression
_•
Self-esteem
_•
Childcare stress

Antenatal anxiety
_•
Life stress
_•
Social support

Marital relationship
_•
History of depression
_•
Infant temperament

Maternity blues
_•
Marital status
_•
Socio-economic status

Unplanned pregnancy

Other authors have identified risk factors as significant in the development of PND in particu- lar (for examples see O’Hara and Swain 1996; Beck 2001). No consistently reliable risk factors have emerged for predicting the onset of mental disorders during pregnancy and the postnatal period. Hence, risk factors, as independent causal variables, cannot be recommended to predict AND or PND (NICE 2007). This is because risk factors are not necessarily causal, that is, their presence will not necessarily result in PMI. Presence of risk factors may well, however, increase an individual’s vulnerability, particularly if the individual is subject to ‘a cluster of these adverse factors’(Raynor and England 2010, p.55). The presence of risk factors may also support midwives and healthcare professionals in sketching out profiles of vulnerable women; profiles which can be considered when assessing a woman’s needs across the perinatal period (see Box 13.3 for predictors of postnatal depression).