Gloucestershire’s€¦ · mental health of the partner and the potential impact on the baby. Concerns Concerns Concerns Concerns Women’s Journey – initial screening pathway

Gloucestershire’s Perinatal Mental Health Pathway

May 2017

First antenatal contact ask MH questions and consider the mental health of the partner. Provide culturally relevant information on

mental health problems in pregnancy. Follow NICE Guidelines(115 alcohol, 51 drugs) if drug or alcohol misuse is suspected.

6-8 week postnatal ask MH questions and consider mental health and wellbeing of infant, partner and siblings

Observations outside of formal assessment leading to additional MH questions

At every visit for at risk groups repeat MH questions and consider the mental health of the partner and the potential impact on the

baby

First postnatal contact ask MH questions and consider mental health of infant and partner

Notify GP of concerns regarding mother, partner or infant and follow referral pathway. Consider referral to GPMHT (follow referral pathway on

p2), specialist midwife and TACS team

First targeted antenatal contact ask MH questions and consider mental health of the partner and the potential impact on the baby

8 week check. Consider postnatal mental health of mother, infant, partner and siblings

2 year check. Ask postnatal MH questions and consider mental health of infant, partner and siblings.

Woman and family remains well – discharge

9 month check. Ask postnatal MH questions and consider mental health of infant, partner and siblings

At 36 weeks repeat MH questions for all women and consider the mental health of the partner and the potential impact on the baby.

Concerns

Concerns

Concerns

Concerns

Women’s Journey – initial screening pathway

Concerns

Concerns

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Refer to safe guarding procedures if there are any concerns including domestic violence, call 01452 426565

0800 0151 499 (9am-5pm)

Monday - Friday

2gether Contact Centre

Postnatal

If mother is under 18 please call CYPS Practitioner advice line on 01452 894272, 9am-5pm, Monday to Friday

Version XX, Date of issue: May 2017, Date of Review: June 2020

Concerns

The Perinatal Mental Health Team are available to give advice and guidance on 01453 xxxxtbc

Concerns

Have you any past or present history of severe mental health illness, including

schizophrenia, bipolar disorder, psychosis in the postnatal period or sever

depression?

Have you ever had any treatment by a psychiatrist or specialist mental health

team including any inpatient care?

Do you have a family history of mental ill health around the time of childbirth or

bipolar disorder?

Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?

Completed positive screening tools will be reviewed weekly by the GPMH team and specialist midwives.

All women will get a response from this process

0800 0151 499 (9am-5pm),

Monday - Friday


For anyone who answers positively to these questions midwives should complete Early

Detection and Screening Tool. Once completed please send to specialist midwives at the

Women’s Centre, GRH. For high risk women consider referral to obstetrician.

Issue letter with advice and guidance

Referral to Mental Health Primary Integrated Care

Team

Appointment offered for

specialist GPMH team

Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?

If yes to both questions 4 & 5, is this something you feel you need help with?

Midwife Screening


Symptom threshold for referral to secondary mental health should be lower than usual as this group is at increased risk of a severe post natal episode. Risk increases during pregnancy and immediately after birth.

Midwife Antenatal Mental Health Screening

Page 2 of 7

A Plan should be in placeby 32 weeks gestation

Women in the perinatal period are given priority access to the Let’s Talk service

If mother is under 18 please call CYPS Practitioner advice line on 01452 894272, 9am-5pm, Monday to Friday

Screening questions for pregnant women



Assess level of urgency using red flags and direct

referral to appropriate team

Book screening assessment by telephone/face to face within 2/4 weeks

(50% to be seen within 2 weeks,

remaining 50% within 4 weeks)

Follow standard referral process

Complete urgent face to face assessment, in liaison with GPMH team within 4-24 hours

and feedback to GP/midwife/HV

Complete assessment and communicate to all professionals

involved

Discharge to Midwife/HV/GP offering advice on management

and warning signs

If MDT meeting is needed this should be arranged prior to 32 weeks.Develop multi disciplinary / agency management plan with all professionals involved and Woman (seek advice if necessary from Mental Health Service) including: Identify mental health care coordinator/perinatal worker Agree level of information / confidentiality and communication Crisis Relapse & Contingency plan ensuring lower thresholds

due to high risk Risk/Benefits of medication dosages/ side effects Impact of mother’s mental health on baby/ child and partner

(consider referral to infant MH Team) Consider implications of medication post deliver and liaison

with neotologists Any safeguarding issues Agreed frequency & format of ongoing review and monitoring Potential for follow up (up to 1 year if indicated) Follow NICE Guidelines(115 alcohol, 51 drugs) if drug or alcohol misuse is suspected.

Copies sent to patient, GP, Community Midwife, Obstetrician, Health visitor, MH Specialist Midwife based at

the Women’s Centre – GRH, and any other professional involved

0800 0151 499 (9am-5pm),

Monday - Friday


A comprehensive care plan will be devised and communicated and should include:

Impact of mother’s mental health on baby/child and partner (consider referral to infant MH Team

Crisis and relapse contingency plan Consideration of psychological support Consideration of support for partner and significant other Safeguarding issues

Copies sent to patient, GP, Health visitor, any other professional involved

Referrals into Specialist Mental Health Services

Woman in the community requires referral to MH Service

Urgent - 24 hour urgent response or inpatient admission sought

If accepted antenatally

Not accepted

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Refer to safe guarding Procedures if there are any concerns includingdomestic violence, call 01452 426565

Symptom threshold for referral should be lower than usual as this group can deteriorate quickly

If mother is under 18 please call CYPS Practitioner advice lineon 01452 894272, 9am-5pm, Monday to Friday

Mild to moderate

Specialist Response

If accepted postnatally



Recent significant changes in mental state or emergence of new symptoms.

New thoughts or acts of violent self-harm.

New and persistent expressions of incompetency as a mother or estrangement from the infant.

Perinatal risk indicators (Antenatal and postnatally period )

Women with a history of bipolar disorder, schizophrenia, severe depression, other psychotic disorder, or previous inpatient/crisis care should be referred to the perinatal team; this group is at increased risk of severe postpartum episodes.

Women with a family history of a first degree relative with bipolar disorder or puerperal psychosis should be referred even if presenting with mild symptoms of mental disorder.

Antenatal presentation can be a predictor for post-natal episode of mental ill health; discuss all antenatal referrals with perinatal team.

High risk period for is 1- 10 days post-natal but the threshold should be lower for women up to 10 weeks postnatally.

Women who are presenting with uncharacteristic symptoms and marked changes to normal functioning. This can include symptoms of confusion and general perplexity.

If partner, family , friends report significant change in presentation and acting out of character.

Older professional women with depression who appear to be functioning at high level.

Women who present with anxiety/panic attacks or unusual or overvalued ideas (ideas that seem out of context or extreme).

Perinatal Red Flags and Risk Indicators


Provide culturally relevant information on mental health problems in pregnancy and the

postnatal period.

Refer to 2gether Contact Centre 0800 0151 499. Consider referral to obstetrician.

Assess situation and give advice including continuing with medication or psychological

therapies and warning signs how to respond to these, liaise with GP

Complete full assessment and give advice. If identified as high risk women will be offered as

fast track option into the Gloucestershire PNMH team once pregnancy.

0800 0151 499 (9am-5pm),

Monday - Friday


Communicate outcome of assessment to patient, GP and any other professionals

involved

Well women with a history of mental health difficulties considering pregnancy

Well woman with history of mental health difficulties presents considering pregnancy

If history is mild to moderate

Sodium valproate is contraindicated in women of child bearing age,

further information see the Maternal Mental Health section of

RiO help link

Women on medication should be asked at their annual review if they are considering pregnancy

If history is severe


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Symptom threshold for referral should be lower than usual as this group is at increased risk of a severe post natal episode. Risk increases during pregnancy and immediately after birth.



Provide woman with culturally relevant information on mental health problems in

pregnancy and the postnatal period.

Liaise with GP, community midwife and other professionals involved in their care to ensure they

know they are pregnant and the care they are receiving

Multi Disciplinary Team Meeting by 32 weeks carried out in conjunction with the Gloucestershire PMH Team

Develop multi disciplinary / agency management plan with all professionals involved and Woman (seek advice if necessary from Mental Health Service) including:

Identify mental health care coordinator Agree level of information / confidentiality and communication Crisis Relapse & Contingency plan ensuring lower thresholds due to high risk Risk/Benefits Medication dosages/ side effects Impact of mental health on baby/ child and partner (consider referral to infant

MH Team) Any safeguarding issues Agreed frequency & format of ongoing review and monitoring Potential for follow up (up to 1 year if indicated) by Gloucestershire PMH team Agreed outcomes

Follow NICE Guidelines(115 alcohol, 51 drugs) if drug or alcohol misuse is suspected.

Copies sent to Patient GP Midwife Obstetrician Health visitor Specialist Midwives based in the

Women’s Centre, GRH Any other professional involved

0800 0151 499 (9am-5pm),

Monday – Friday


Women Currently Receiving Treatment Whilst in Mental Health Care Who Becomes Pregnant


Sodium valproate is contraindicated in

women of child bearing age further information see the

Maternal Mental Health section of RiO

help link

Service user in treatment with 2gether trust secondary care becomes pregnant

Page 5 of 7



Woman identified with a deteriorating mental state. Complete GHT Mental health Risk Assessment (A1089).

Contact mental health liaison on 0300 422 5490 (24 hour service)

Arrange for joint management on ward and

specialist support

Specialist assessment and risk assessment completed. Integrated care plan developed and shared with all

professionals involved

Transfer to Mother and Baby unit

Transfer Mother to Wotton Lawn Hospital, arrangements

made for care of baby

Woman identified with a deteriorating mental state. Ensure case is discussed with

GP if not already involved

Contact 2gether Crisis Team via the contact centre on 0800 0151 499

Mental health assessment to be undertaken, liaise

with MW/HV/GP as appropriate. Consider hospital admission to mother and baby unit.

Crisis Team to manage at home with support of PNMH Team

Develop an Integrated Care Plan and share it with all professionals involved

Assess for admission if possible liaise with

Gloucestershire PNMH Team

0800 0151 499 (9am-5pm),

Monday - Friday


Women Presenting as Acutely Unwell

Can be managed on the ward with support

Not safe to manage at GRH

Bed not available at a Mother and Baby Unit

Bed available at a Mother and Baby Unit

Appropriate for home treatment

Woman inpatient at GHNHSFT presents

as acutely unwell

Woman in the community presents as

acutely unwell

If condition deteriorates

Not appropriate for home treatment

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During the postnatal period a woman’s mental health can fluctuate widely, therefore symptom threshold for treatment should be lower. Important to listen to views of

significant others

If mother is under 18 please call CYPS Practitioner advice lineon 01452 894272, 9am-5pm, Monday to Friday



Over the last 2 weeks, how often have you been bothered by the following problems?

Not at all

Several days

Over half the days

Nearly every day

1. Feeling nervous, anxious, or on edge

0 1 2 3

2. Not being able to stop or control worrying

0 1 2 3

3. Worrying too much about different things

0 1 2 3

4. Trouble relaxing

0 1 2 3

5. Being so restless that it's hard to sit still

0 1 2 3

6. Becoming easily annoyed or irritable

0 1 2 3

7. Feeling afraid as if something awful might happen

0 1 2 3

Generalised Anxiety Disorder Assessment (GAD7)

Add the score for each column. Total Score (add the column scores) =

Scores represent anxiety severity: 0-5 mild, 6-10 moderate, 11-15 moderately severe, 15-21 severe.

GAD7 – Generalised Anxiety Disorder Assessment/ PHQ9 – Depression Assessment

Over the last 2 weeks, on how many days have you been bothered by any of the following problems?

Not at all Several days

More than half the days

Nearly every day

1 Little interest or pleasure in doing things 0 1 2 3

2 Feeling down, depressed or hopeless 0 1 2 3

3 Trouble falling or staying asleep, or sleeping too much

0 1 2 3

4 Feeling tired or having little energy 0 1 2 3

5 Poor appetite or overeating

0 1 2 3

6 Feeling bad about yourself – or that you are a failure or have let yourself or your family down

0 1 2 3

7 Trouble concentrating on things, such as reading the newspaper or watching television

0 1 2 3

8 Moving or speaking so slowly that other people could have noticed, or the opposite – being so fidgety or restless that you have been moving around a lot more than usual

0 1 2 3

9 Thoughts that you would be better off dead or of hurting yourself in some way

0 1 2 3

PHQ9

GAD7

Page 7 of 7

Depression Severity Assessment (PHQ9)

Add the score for each column, Total Score (add the column scores) =

Scores represent depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe.


Documents

Gloucestershire’s€¦ · mental health of the partner and the potential impact on the baby. Concerns Concerns Concerns Concerns Women’s Journey – initial screening pathway