Use of primary health care prior to a postpartum psychiatric episode

Clinicians' experiences in signposting an online mental health resource to expectant mothers: a qualitative study

BACKGROUND

Poor maternal mental well-being and a lack of secure parent-infant attachment, have been identified as important factors associated with adverse mental health outcomes later in a child's life. Interventions designed to care for maternal mental well-being during pregnancy and early parenthood, are therefore likely to support healthy child development. Mentalization is a skill parents can practice, improving the emotional bond to the child, offering insights into their own and the child's mental states and potentially improving parental mental well-being. Most pregnant women in Denmark schedule antenatal consultations in general practice, potentially offering a solid platform to promote web-based interventions aiming to enhance mentalization skills. Signposting towards online resources has several advantages including high accessibility, ease of distribution and cost-effectiveness. We aimed to explore the attitudes and experiences of clinicians in general practice in signposting women towards a web-intervention to increase parental mentalization skills.

METHODS

The intervention was offered to pregnant women at their primary preventive antenatal consultation in Danish general practice around week eight of pregnancy, and was designed to be incorporated into the following antenatal- and pediatric consultations until the child's second birthday. Semi-structured interviews about clinicians' experiences with signposting the intervention were conducted with 11 general practitioners (GP), three practice midwives (MW) and one practice nurse (NR).

RESULTS

Clinicians wanted to enhance the focus on mental well-being in pregnancy and early childhood during preventive consultations. The main barriers to signposting the web-program were decreasing motivation over time, lack of financial viability and time limitations. Utilizing a psychoeducational web-intervention was generally accepted by clinicians, but ideally not carried out solely in general practice.

CONCLUSION

Signposting web-programs to improve parental mentalization skills can be welcomed by clinicians in general practice but need to be more tailored to suit the everyday workflow of the clinics. Addressing parental mentalization remains largely unchartered territory for pregnant women and clinicians alike, therefore training clinicians on the subject and its presentation should be offered.

TRIAL REGISTRATION

The study is part of a larger project that has been approved by the Research Ethics Committee at the University of Copenhagen, Nov. 2019 (reference number 504-0111/19-5000).

Perinatal mental health: how nordic data sources have contributed to existing evidence and future avenues to explore

PURPOSE

Perinatal mental health disorders affect a significant number of women with debilitating and potentially life-threatening consequences. Researchers in Nordic countries have access to high quality, population-based data sources and the possibility to link data, and are thus uniquely positioned to fill current evidence gaps. We aimed to review how Nordic studies have contributed to existing evidence on perinatal mental health.

METHODS

We summarized examples of published evidence on perinatal mental health derived from large population-based longitudinal and register-based data from Denmark, Finland, Iceland, Norway and Sweden.

RESULTS

Nordic datasets, such as the Danish National Birth Cohort, the FinnBrain Birth Cohort Study, the Icelandic SAGA cohort, the Norwegian MoBa and ABC studies, as well as the Swedish BASIC and Mom2B studies facilitate the study of prevalence of perinatal mental disorders, and further provide opportunity to prospectively test etiological hypotheses, yielding comprehensive suggestions about the underlying causal mechanisms. The large sample size, extensive follow-up, multiple measurement points, large geographic coverage, biological sampling and the possibility to link data to national registries renders them unique. The use of novel approaches, such as the digital phenotyping data in the novel application-based Mom2B cohort recording even voice qualities and digital phenotyping, or the Danish study design paralleling a natural experiment are considered strengths of such research.

CONCLUSIONS

Nordic data sources have contributed substantially to the existing evidence, and can guide future work focused on the study of background, genetic and environmental factors to ultimately define vulnerable groups at risk for psychiatric disorders following childbirth.

Reproductive planning, vitamin knowledge and use, and lifestyle risks of women attending pregnancy care with a severe mental illness

OBJECTIVE

Women with severe mental illnesses are a vulnerable population and little is known about their reproductive planning needs. The aim of our study was to describe rates of unintended pregnancies, postpartum contraception, identify use and knowledge of prenatal/pregnancy vitamins and identify modifiable lifestyle risks.

DESIGN

Mixed methods study incorporating a cross-sectional survey and prospective pregnancy data collection.

SETTING

A multidisciplinary antenatal clinic in Australia.

METHOD

Thirty-eight pregnant women with severe mental illnesses: schizophrenia, schizoaffective, bipolar and severe post-traumatic stress disorder.

MAIN OUTCOME MEASURES

Unintended pregnancy rates, immediate postpartum contraception, use of prenatal and pregnancy vitamins and knowledge sources, obesity, and use and cessation rates for smoking, and substances, and comorbid medical conditions.

RESULTS

Overall 42% of women had unintended pregnancy, with those with schizophrenia at most risk (56%). A long acting reversible contraception was inserted in 5 women (13%), with 45% having no immediate contraception prescribed prior to postnatal discharge. Women's main source of vitamin supplementation for pregnancy was from general practitioners. Prenatal folic acid use occurred in 37%, with rates differing for those with a diagnosis of bipolar disorder (52%) and schizophrenia (25%). Vitamin deficiencies occurred in pregnancy, with iron deficiency (ferritin <30 ng/mL) (n = 27, 73%) the most frequent. Overall 21% of women smoked cigarettes and 35% were obese.

DISCUSSION

Addressing gaps in use of effective contraception, proactive reproductive planning and lifestyle management may improve outcomes for women with mental illnesses and their babies.Key pointsWomen with severe mental illnesses have complex health needs that require targeted reproductive counselling. This study adds to what is known by highlighting that:•Women with schizophrenia appear more likely to have unintended pregnancy.•Prenatal counselling for women with severe mental disorders should include recognition and optimisation of management for the high rates of pre-existing medical comorbidities, obesity and elevated nicotine and substance use.•Many women with severe mental illness need increased doses (5 mg) of prenatal folic acid due to psychotropic medication risk and obesity, as well as treatment for high rates of iron and vitamin D deficiency in pregnancy.

Effects of Pregnancy Loss on Subsequent Postpartum Mental Health: A Prospective Longitudinal Cohort Study

Pregnancy loss, natural or induced, is linked to higher rates of mental health problems, but little is known about its effects during the postpartum period. This study identifies the percentages of women receiving at least one postpartum psychiatric treatment (PPT), defined as any psychiatric treatment (ICD-9 290-316) within six months of their first live birth, relative to their history of pregnancy loss, history of prior mental health treatments, age, and race. The population consists of young women eligible for Medicaid in states that covered all reproductive services between 1999-2012. Of 1,939,078 Medicaid beneficiaries with a first live birth, 207,654 (10.7%) experienced at least one PPT, and 216,828 (11.2%) had at least one prior pregnancy loss. A history of prior mental health treatments (MHTs) was the strongest predictor of PPT, but a history of pregnancy loss is also another important risk factor. Overall, women with a prior pregnancy loss were 35% more likely to require a PPT. When the interactions of prior mental health and prior pregnancy loss are examined in greater detail, important effects of these combinations were revealed. About 58% of those whose first MHT was after a pregnancy loss required PPT. In addition, over 99% of women with a history of MHT one year prior to their first pregnancy loss required PPT after their first live births. These findings reveal that pregnancy loss (natural or induced) is a risk factor for PPT, and that the timing of events and the time span for considering prior mental health in research on pregnancy loss can significantly change observed effects. Clinicians should screen for a convergence of a history of MHT and prior pregnancy loss when evaluating pregnant women, in order to make appropriate referrals for counseling.

Ações do programa de puerpério na atenção primária: uma revisão integrativa

Resumo O puerpério trata-se de um período de significativa morbimortalidade para as mulheres, e a Atenção Primária à saúde (APS) é importante no desenvolvimento de ações para atender as necessidades de saúde das mulheres. Objetivou-se sistematizar o conhecimento produzido sobre as ações de programas de atenção pós-parto no âmbito da APS, tanto em nível nacional, como internacional. Utilizou-se revisão integrativa de literatura de artigos junto às bases Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde), BDENF (Base de dados em Enfermagem), SciELO (Scientific Electronic Library Online) e PubMed (Biblioteca Nacional de Medicina dos Estados Unidos). A busca ocorreu de abril a maio de 2017. Atenderam aos critérios de seleção 43 artigos. Os resultados apontam que: a APS possui estrutura física para atenção à puérpera, porém com déficit em recursos humanos e materiais; há baixa cobertura de consulta pós-parto e visita domiciliar; boa avaliação do incentivo ao aleitamento materno, porém com foco na criança; rastreamento da Depressão Pós-Parto internacionalmente por meio da “Edimburgh Post-Natal Depression Scale”, e déficit na atenção a esse agravo no Brasil. A atenção pós-parto ainda tem como foco o cuidado ao recém-nascido e são restritos, em sua maioria, ao puerpério imediato e tardio.

The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities

The abortion and mental health controversy is driven by two different perspectives regarding how best to interpret accepted facts. When interpreting the data, abortion and mental health proponents are inclined to emphasize risks associated with abortion, whereas abortion and mental health minimalists emphasize pre-existing risk factors as the primary explanation for the correlations with more negative outcomes. Still, both sides agree that (a) abortion is consistently associated with elevated rates of mental illness compared to women without a history of abortion; (b) the abortion experience directly contributes to mental health problems for at least some women; (c) there are risk factors, such as pre-existing mental illness, that identify women at greatest risk of mental health problems after an abortion; and (d) it is impossible to conduct research in this field in a manner that can definitively identify the extent to which any mental illnesses following abortion can be reliably attributed to abortion in and of itself. The areas of disagreement, which are more nuanced, are addressed at length. Obstacles in the way of research and further consensus include (a) multiple pathways for abortion and mental health risks, (b) concurrent positive and negative reactions, (c) indeterminate time frames and degrees of reactions, (d) poorly defined terms, (e) multiple factors of causation, and (f) inherent preconceptions based on ideology and disproportionate exposure to different types of women. Recommendations for collaboration include (a) mixed research teams, (b) co-design of national longitudinal prospective studies accessible to any researcher, (c) better adherence to data sharing and re-analysis standards, and (d) attention to a broader list of research questions.

Help-seeking patterns in women with postpartum severe mental illness: a report from southern India

Postpartum severe mental illness (SMI) often presents with risks to mother-infant dyad and requires early assessment and interventions. The access to psychiatric care in low and middle income countries is complex. Help-seeking patterns in women with postpartum SMI has not been studied adequately. Hence, the present study was undertaken to examine the help-seeking pattern and reasons for delay in seeking psychiatry services among postpartum women with SMI. Successive patients with a diagnosis of postpartum SMI were recruited over a period of 2 years. Clinical variables including the risk evaluation, perceived delay in seeking care along with the reasons were assessed through clinical interviews using a proforma. Severity of illness was assessed using BPRS and "encounter" form was used to assess the help-seeking pattern. One hundred twenty-three women with postpartum SMI participated in the study. Acute polymorphic psychotic disorder was the most common clinical presentation. Psychiatrists were the most commonly (52.8%) sought care providers followed by faith healers (26%) and general medical practitioners (GMP) (21.1%) at the first level of help seeking. A past history of psychiatric illness was significantly higher among those who first contacted a psychiatrist, and BPRS scores were significantly high among those who contacted a GMP. Forty-four percent of subjects perceived a delay in seeking care from psychiatry services and the most common reason was lack of resources. There is a need to enhance awareness about postpartum SMI in the community. Faith healers need to be sensitized about the associated risks and the need for early referrals. Addressing the barriers to psychiatric care would help in early detection and treatment of postpartum SMI.

Perinatal psychiatric episodes: a population-based study on treatment incidence and prevalence

Perinatal psychiatric episodes comprise various disorders and symptom severity, which are diagnosed and treated in multiple treatment settings. To date, no studies have quantified the incidence and prevalence of perinatal psychiatric episodes treated in primary and secondary care, which we aimed to do in the present study. We designed a descriptive prospective study and included information from Danish population registers to study first-time ever and recurrent psychiatric episodes during the perinatal period, including treatment at psychiatric facilities and general practitioners (GPs). This was done for all women who had records of one or more singleton births from 1998 until 2012. In total, we had information on 822 439 children born to 491 242 unique mothers. Results showed first-time psychiatric episodes treated at inpatient facilities were rare during pregnancy, but increased significantly shortly following childbirth (0.02 vs 0.25 per 1000 births). In comparison, first-time psychiatric episodes treated at outpatient facilities were more common, and showed little variation across pregnancy and postpartum. For every single birth resulting in postpartum episodes treated at inpatient psychiatric facilities, 2.5 births were followed by an episode treated at outpatient psychiatric facility and 12 births by GP-provided pharmacological treatment. We interpret our results the following way: treated severe and moderate psychiatric disorders have different risk patterns in relation to pregnancy and childbirth, which suggests differences in the underlying etiology. We further speculate varying treatment incidence and prevalence in pregnancy vs postpartum may indicate that the current Diagnostic and Statistical Manual of Mental Disorders-5 peripartum specifier not adequately describes at-risk periods across moderate and severe perinatal psychiatric episodes.