Transcript A priority for primary care, Dr Judy Shakespeare

MATERNAL MENTAL HEALTH –A PRIORITY FOR
PRIMARY CARE
Dr Judy Shakespeare, RCGP Clinical
Champion in perinatal mental health
[email protected]
What I’m going to talk about
• My background
• Being a GP at the moment
• RCGP Clinical priority and champion programme
• The role of the GP in perinatal mental health
• The potential of lived experience and social media
The Oxford City Postnatal Depression Strategy: A qualitative
interview study of postnatal women’s views of screening for
postnatal depression by health visitors with the Edinburgh
Postnatal Depression Scale (EPDS). 2000
Evaluation of screening for postnatal depression against the
NSC handbook criteria 2001 (revised 2011)
A screening programme for postnatal depression is not
recommended
antenatal and
NICE GUIDELINE
postnatal
mental health U 2014
I
THE NICE DELINE ON CLINICAL MANAGEM
AND SERVICE GUIDANCE
UPDATED EDITION
General practice deals with 90% of patient contacts.
Despite this, general practice receives just 8.4% of the
NHS budget across the UK
81% of GPs now say general practice does not have
sufficient resources to deliver high quality care
Source: ComRes UK-wide RCGP Poll, Aug 2013
Impact on patients?
Almost half of GPs say their practices have had to cut back on
services for patients and 39% have cut back on practice staff
Source: ComRes UK-wide RCGP Poll, Aug 2013
Aims and objectives of the clinical priority and
champion programme 2014-2017
•Awareness raising
•Education
•Collaborative working
Practical implications for primary care of the NICE guideline
CG192 Antenatal and postnatal mental health –
10 questions a GP should ask themselves (and their team)
http://www.rcgp.org.uk/clinical-and-research/clinicalresources/~/media/Files/CIRC/Perinatal-Mental-Health/RCGPTen-Top-Tips-Nice-Guidance-June-2015.ashx
Q1 Why is perinatal mental health important?
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Common, can be very serious
90% in primary/community/universal care
Intergenerational effects
Huge cost to NHS, society
Extreme distress for woman and family
Effective, evidence based treatment.
NICE Dec 2014
But
• Fragmentation of care
• Current lack of services
Where are we now? Cradle to grave?
to
minus
Maternity services should ensure smooth transition between midwife,
obstetric and neonatal care, and ongoing care in the community from
their GP and health visitor
National Maternity Review 2016
Fragmentation of primary care services
Planned care
GP practices, GPs and Practice Nurses
Health visitors
Midwives and assistants
Children’s centres
IAPT
Unplanned care
GP practices
OOH centres
Walk-in centres
Maternity day assessment units
A&E departments
The six week appointment by GPs
“a particularly crucial element of post-natal care”
Women need to be clear what the appointment will cover and it should
happen at a different time from the baby’s check.
The check should include:
• The transition to motherhood, including her mental health;
• Recovery from the birth, using direct questions about common
morbidities;
• Longer term health risks for any morbidity identified;
• Any further help whether or not connected with the birth;
• Advice about future family planning.
National maternity review 2106
Specialist
Perinatal
Community
Care
The costs of perinatal mental health
problems
• Perinatal depression,
anxiety and psychosis
together carry a total longterm cost to society of
about £8.1 billion for each
one-year cohort of births in
the UK.
• Nearly three-quarters (72%)
of this cost relates to
adverse impacts on the child
rather than the mother.
Published October 2014
Perinatal Mental Health Curricular Framework
October 2006
Getting It Right for Mothers and
Babies
Community Perinatal Mental Health Services across
Scotland
SIGN 127 • Management of perinatal mood disorders
A national clinical guideline March 2012
Evidence
How is it in Scotland?
Perinatal mental health – burden
of care on primary care
Average practice: 10k patients
120 deliveries/year
15-20 postnatal depression
4-5 receive anti-depressants
1-2 referrals to psychiatry
One case perinatal psychosis/10 years
All referred
3 cases in my experience (30 years)
Q2 In my work how could I improve detection?
Detection and treatment gap (PND is only an example)
• 40-50% of perinatal depression is recognised clinically and only half
of these women receive any treatment
• 50% - 70% of untreated women with antenatal or postnatal
depression will still have depression 6 months later
Recognising mental health problems in
pregnancy and the postnatal period NICE 2014
Whooley questions for depression
At a woman's first contact with primary care, and during the early postnatal period, consider asking the
following depression identification questions as part of a general discussion about a woman's mental
health and wellbeing:
• 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?
Also consider asking about anxiety using the 2-item Generalized Anxiety Disorder scale (GAD-2):
• During the past month, have you been feeling nervous, anxious or on edge?
• During the past month have you not been able to stop or control worrying?
If positive refer for assessment and diagnosis, usually to a GP
Barriers to detection for Women
Put significant effort into hiding their distress
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Stigma
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Wanting to be a good mother
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Fear the child might be taken away
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Don’t recognise that they are ill; it takes time
Were put off disclosing to health practitioners due to:
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Feeling dismissed or told that what they were feeling was ‘normal’.
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Feeling rushed, judged or processed
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Lack of continuity/fragmentation of care: different GPs, midwives, health visitors
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Experiencing inconsistent responses
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Lack of hope
By the time they saw a GP they were on a knife edge
Barriers to identification for GPs
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Lack of time: workload and workforce issues
Competing priorities
Assumption that someone else has dealt with it
No specialist service
Lack of training and confidence
Lack of hope
Fragmentation of care with MW and HVs
Red flag for detection
If a woman consults a GP saying she thinks she has a
perinatal mental health problem, she is almost
certainly right.
Do not dismiss her or normalise her symptoms
Red flag: It’s not always depression
• Ask about intrusive thoughts as well
What women want from their health professionals
• Get it right first time
• To be asked (even if they don’t want to answer)
• Time and compassion
• A therapeutic relationship
• Need to be given hope
The importance of the therapeutic relationship
“I mean as much as I needed her to, she would
have been there for me and she, you know, she'd
just sit and listen. She couldn't do much, I know
she couldn't do much but just having someone
that you could sit and cry in front of and you really
get everything off your chest, ‘cos you can”.
Shakespeare J., Blake F. Garcia J. Journal of Reproductive and Infant
Psychology 2006; 24: 149-162
Opening gambits
Good ways of opening
the conversation
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‘How are things going?’
‘How did the birth go?’
‘Has it been how you expected?’
‘Is your baby easy to look after?’
‘We know that one in five women have problems after the birth of their baby.
How has it been for you?’
What not to say
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‘You look great!’
‘How’s Mummy doing?’
‘I expect it’s all been fine because you know what to do the second time around’
‘You can’t be ill – you’re wearing make-up!’
Q3 Do I think involving her partner?
• Make him welcome
• Can help with detection of problems and give support
But, he could also be a problem
• Be aware of relationship problems
• Domestic violence
• Paternal perinatal mental health problems (10% of men have PND)
Q4 How should I care for a pregnant woman with a
history of serious mental illness?
Understand her risk
Refer to specialist service
• Preconception
• Early pregnancy
• Advice about drugs
• Care plan needed
• At sign of any symptoms
• Support alongside specialist team
Red flag – Women with BPD
• Women with bipolar disorder have at least a one in five
risk of suffering from postnatal psychosis (PP)
• They have an even higher risk (approaching one in two)
of experiencing severe postnatal depression
• The risk of PP is one in two for women with a history of
previous postnatal psychosis
• The risk of PP is one in two for women with bipolar
disorder and a family history of postnatal psychosis
• 50% of women who develop PP will have no history of
mental health problems
Q5 How urgent is treatment for symptoms of
possible postnatal psychosis?
•An emergency
•Send to A&E if necessary
•Assess by specialist team within 4 hours
Q6 How is mild-moderate depression and/or
anxiety treated?
• Working together, but a named co-ordinator
• Local support
• According to local pathway
• Self help
• Psychological treatments
• Pharmacological treatments
Q7 What should I consider when caring for women of
childbearing potential who have new or existing mental
illness?
You and she know the risk of her illness if she becomes
pregnant and the risk of her drugs to the baby
Contraception
50% of pregnancies are unplanned
Q8 If a woman taking antidepressants becomes pregnant
should she stop them immediately?
No!
Q9 Do I ever consider how the woman is interacting
with her baby?
• Not my area of expertise
• Simple early intervention can help
• Who can help?
• What local services are there?
Q10 What should I do if there is a bereavement?
• Higher risk of mental illness for both parents
• Difficult to ask for help
• Support as they wish
• Support through another pregnancy
Education
• eLfH (funded by Health Education England)
Five sessions of 20-30 minutes
Two core sessions
One antenatal, one around time of birth, one postnatal
Authors: GP, Perinatal psychiatrist, Midwife, Obstetrician,
Health Visitor
4 launched February 2016
Recommendation for RCGP CC from FTTG
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6-8 week maternal postnatal check is a “safety net” for PMI
More accessible resources for GPs.
A distillation of new NICE guidance for GPs.
GP training and CPD
red-flags
awareness of the important role GPs a safety net
explicit encouragement for partner involvement
emotional wellbeing of significant others
parent-infant relationship
better pre-conception care
coordinated team working at GP practice level.
Actions for every practice
• Consider having a GP lead for maternity and maternal
mental health in every practice
• Ensure community midwives can access information
about the medical history of all pregnant women
• Hold regular meetings with attached midwife and
health visitor to discuss possible mental health issues
for mothers and safeguarding issues
Actions for every GP
Training in perinatal mental illness.
Ask about anxiety and intrusive thoughts as well as depression
Local knowledge of
• local pathways for perinatal mental health
• Access
• Assessment
• Integrated care – a care plan for every woman who may have a problem
• When to refer to secondary specialist care and how to access it
• Details of local support services
• How to get advice about medication queries
Lived experience and social media
#MumTalk Feb 24th 2016
• #MumTalk was the principle topic of conversation for the day on the
RCGP Twitter account
• 65,000 Twitter impressions (average: about 20,000).
Carrie
Ladd
&
Stephanie deGiorgio
A GP only has 10 minutes - tweets
• But what have you possibly got to be sad about? The sun is shining and you
have a beautiful little baby!
JUST ONE CHANCE TO GET IT RIGHT
• An empathetic GP can make a HUGE difference in 10mins! Listen, engage &
know the local pathways
10 MINUTES CAN BE ENOUGH
• Unlike perinatal MWs & HVs the GPs CAN provide this sort of continuity of
care.
CONTINUITY OF CARE
• The therapeutic relationship is based on mutual trust
THERAPEUTIC RELATIONSHIP
Families with lived experience and social media
RCGP has a role in interacting with families
Messages for doctors
• Give hope
• Red flag for detection
• Its not just depression
• Just listen, even if its only for 10 minutes
Messages for families
• Increase self-care and self-efficacy
• Validate feelings
• Not every GP is going to get it right every time. You CAN see someone else
• It’s OK to tell, it’s OK to ask (MBRRACE maternal lay report 2015)
What do I still want to do?
Promote collaborative care across the whole pathway
so it includes infant mental health and families too
Maintain sustainability: Local GP champions in every
SCN who can take the GP agenda forward in their areas
Questions?