6.2.4.1. National guideline documents
The National Institute for Health and Clinical Excellence care guidelines state that clinical networks should be instituted for perinatal mental health services (NICE, 2007). A co-ordinating board of healthcare professionals, commissioners, managers, service users and carers is recommended to manage the service. These groups
should provide a specialist multidisciplinary service for every area, providing direct care and consultation to maternity and community services and other mental health services. It is suggested that in localities with high morbidity, these services could be provided by specific specialist perinatal teams, with clear referral and management criteria to ensure effective transfer of information and continuity of care. It is
recommended that each perinatal mental health network should have designated specialist inpatient services and should provide facilities specifically for mothers and babies. Women who require inpatient care within 12 months of childbirth should be admitted to a specialist mother and baby unit unless there are particular reasons for not doing so. The service should be staffed by an appropriate level of specialist perinatal mental health staff and liaise effectively with general medical and mental health services. Availability of the full range of therapeutic services, such as
psychology, psychiatry, nursing, social work and psychotherapists, is recommended and the facility should be closely linked with community based mental health services to ensure continuity of care and minimum length of stay (NICE, 2007).
Regarding screening, the guidelines state that women should be questioned about past or present severe mental illness including schizophrenia, bipolar disorder, postnatal psychosis and severe depression, and family history of perinatal mental illness, during first contact with antenatal and postnatal services. The guidelines state that women should not be probed about specific prognostic factors, such as
relationship problems in routine predictions of the development of mental illness. However, they should be asked whether they have felt low, depressed or hopeless during the past month or if they have taken little pleasure in daily activities, and if this is the case they should be asked if they need specific help; if psychological therapy is required they should have to wait no longer than 3 months for an appointment. The screening guidelines emphasised that maternity staff required training in order to implement screening sensitively (NICE, 2007).
The National Institute for Health and Clinical Excellence also emphasise the need for access to expert advice about the risks and benefits of psychotropic medication during pregnancy and breastfeeding. The detailed way in which health professionals are instructed to provide information about treatment, with audio recording of the
session, reflects serious concerns, particularly about the safety of anti-psychotic drugs (NICE, 2007).
The Scottish Intercollegiate Guidelines Network developed national clinical guidelines incorporating evidence based recommendations for effective practice in relation to postnatal depression and puerperal psychosis (SIGN, 2002). The guidelines are graded A, B, C, or D to signify the strength of the supporting evidence, with ‘A’ being based on the clearest evidence. The recommendation (graded as A) states that routine screening for a history of depression should be carried out during the antenatal period and all women should be screened (graded as D) for previous episodes of puerperal psychosis, particularly bi-polar disorder, and for a family history of these illnesses. The postnatal recommendations warn that natural
emotional states may mask or be misinterpreted as depression, and that all women should be offered testing, at about 6 weeks and again at 3 months following
childbirth, using the Edinburgh Postnatal Depression Scale, but the use of the Edinburgh Postnatal Depression Scale should not replace a clinical diagnosis of postnatal depression. These recommendations are substantiated by recent work that demonstrates that the Edinburgh Postnatal Depression Scale detects anxiety, but does not adequately distinguish between anxiety disorders and depression in postnatal mothers (Rowe et al, 2008). The guideline further states that the impact of postnatal depression on the whole family should be considered and suggest that high risk mothers may benefit from postnatal visits, psychological therapy and /or
antenatal education, and that women with a high risk of puerperal psychoses should be reviewed by psychiatric specialists (SIGN, 2002).
The Scottish Intercollegiate Network puerperal psychosis guidelines (graded D) state that the disorder should be managed in the same manner as psychosis arising at any other time. The use of appropriate drug treatment during breast feeding and
pregnancy should be considered. Specialist in-patient facilities should be available and mothers and babies should not be admitted to general psychiatric wards. The rest of the guidelines concern recommendations for prescribing anti-depressants. They state that there is no indication for stopping tricyclic or selective serotonin reuptake inhibitor (SSRI) antidepressants during pregnancy and there is no indication
that tricyclic anti-depressants, apart from Doxepin, should be stopped during breast- feeding (SIGN, 2002).
Major findings from the Confidential Enquiry into Maternal Deaths (CEMACH, 2004) underpin many of the clinical risk management guidelines such as those from the National Institute of Clinical Excellence (NICE, 2007). The report recommends that maternity services should follow risk management guidelines and include routine enquiries about previous psychiatric history at the antenatal booking clinic; the term postnatal depression should not be used as an umbrella term for all types of
psychiatric illness and women with a past history of serious mental illness, whether or not associated with childbirth, should be assessed by a psychiatrist during the
antenatal period because of the high risk of relapse after childbirth. The Confidential Enquiry into Maternal Deaths (CEMACH, 2004) supports the development of mother and baby units and suggested that the separation of mothers and babies might have contributed to maternal suicide, given that no deaths occurred in women admitted at any time to a mother and baby unit. The report also recommends that midwives provide active follow up for women at risk, who do not access regular antenatal care. The most recent Confidential Enquiry into Maternal Deaths (CEMACH, 2007) shows a decrease in maternal suicides and comments that if this decrease is maintained through the next triennial reporting period, it may be reasonable to assume that the developments outlined above have resulted in an improvement in the service provided.
6.2.4.2. Guidelines and standards from professional bodies
In 2000, the Royal College of Psychiatrists in England produced recommendations for perinatal mental health services. These recommendations influenced the development of the NICE (2007) and SIGN (2002) guidelines.