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Prevention and recovery: perinatal mental illness

Prevention and recovery: perinatal mental illness

 - Issues relating to perinatal mental illness including the life limiting symptoms women experience and the impact of these on bonding and attachment

 - The bio-psycho-social causes of perinatal mental illness

- Interventions used to prevent and treat perinatal mental illness when working within a proportionate universal service

Perinatal mental illnesses affect more than one in 10 women in the UK.1 It has been claimed that 144,000 babies under the age of one year live with a parent who has a mental health problem.2 Conditions including depression, anxiety disorders and postnatal psychotic illnesses can occur at any time during the antenatal period and for up to one year in the postnatal period.3 These conditions are now referred to as ‘perinatal mental illnesses’, as the term ‘postnatal depression’ is often used inappropriately as a general term for any perinatal mental disorder. Mental illnesses are the primary cause of maternal death in the UK4 and in the rest of the developed world; suicide is one of the most common causes of maternal death in the first postnatal year.5
Many mental health disorders affecting women in the perinatal period have the same incidence rates as in the general population1 but severe perinatal mental health conditions, such as postpartum psychosis, have higher incidence rates during this period. Women may be diagnosed with one condition in isolation or may experience features of several conditions (see Table 1). These symptoms are life-limiting and can have a drastic impact on mothers, babies and the wider family. These conditions are not to be confused with ‘baby blues’ which may feature symptoms such as tearfulness, anxiety and low mood, but are short lived and normal in the first days after delivery.6
Sensitive parenting and attachment
It is clear to see that these symptoms can make sensitive and responsive parenting extremely difficult. Reduced capacity for sensitive parenting can result in children experiencing behavioural, social or learning difficulties, possibly resulting in them failing to fulfil their potential.2 Research shows that children’s cognition, language development and intelligence can all be affected.14 The societal problems stemming from perinatal mental illness have been well documented.15 These include; higher rates of depression in partners, divorce, social isolation and increased psychological disorders in children. 
Secure attachment16 is considered to be the basis for ‘normal’ development in children and is formed between and infant and their care-giver in the first few months of life. Perinatal mental illness is thought to influence the development of insecure attachments in infants17 due to ‘unavailable’ care-giving.18 Children with unreliable or unavailable care-givers may develop negative behavioural strategies in order to regulate their emotions. This can impact on developing behaviours and abilities in forming social relationships in the future.19 These children may have difficulty in expressing emotion and in seeking proximity with others.20 However, it is also important to remember that children have a certain amount of resilience and not all children will experience the same effects.21 
Although any woman in the perinatal period may be vulnerable to developing a mental disorder, there are thought to be a number of bio-psycho-social factors which increase risk.
The Marmot Review22 identifies a clear correlation between socioeconomic status and poor maternal mental health, pointing to factors such as unemployment, low income and debt as predisposing factors in mental illness. Homelessness and poor housing are major contributory factors leading to poor mental health in all members of the family. It is estimated that more than one million children in the UK are living in inadequate housing conditions.23 Social isolation is also discussed as a risk factor in the perinatal period3 and people living in economically-deprived communities may, due to fewer resources, face higher levels of isolation and decreased social capital.22 
Young maternal age (18-24) has been found to be a key predictor of perinatal mental illness.24 Young single mothers are three times more likely to develop perinatal mental illness compared to older women. This may be due to poor social support and economic instability. However, it is important to note that a report by Centre for Maternal and Child Enquiries in 2011 found that over half of all perinatal suicides (2006-2008) were committed by married white women aged 30 years and over.4
Life Stressors
The stress-vulnerability model25 may help us to understand how stressful life events such as traumatic childbirth, adjusting to life with a baby, relationship issues, loss of income and other major life stressors impact upon wellbeing during the perinatal period. People with more vulnerability factors such as personal or family history of mental illness3, exposure to domestic violence  or previous abuse26, sleep deprivation27 or drug and alcohol use will be more susceptible to stress, which can trigger an episode of mental illness. Therefore, a woman experiencing a high proportion of vulnerability factors will require significantly lower amounts of stress before becoming mentally unwell. Conversely, women with fewer vulnerability factors may be more resilient to stressful life situations, as illustrated in Figure 1.
Prevention and Early Interventions to Aid Recovery and Promote Attachment.
There are a number of interventions which support the recovery process, encourage bonding and attachment and improve overall outcomes for children. In cases of severe mental illness, mothers may require specialist inpatient treatment but in most other cases, a variety of bio-psycho-social interventions can be delivered in the community.
The Healthy Child Programme28 is a public health plan with early intervention and prevention at its core. Its approach of ‘proportionate universalism’ means that health visitors are able to assess families as requiring ‘universal’ (offered to every family), ‘universal plus’ (additional support at times of increased need) or ‘universal partnership plus’ (intensive support co-ordinated with other agencies) services. This enables health visitors to identify vulnerable families (such as those living with perinatal mental illness) and to put in place the right level of support to prevent poor outcomes for children. Perinatal mental illness is the main reason for women accessing universal plus services in the UK.29 As part of universal services, health visitors screen mothers using clinical interviews and validated screening tools at key points during the perinatal period. Early identification of changes in mood or functioning can ensure that timely support is offered.
Table 2 explains the interventions that may be used depending on the progression of the problem.
Perinatal mental illness comes in many forms and effects individuals in very different ways. Its effects can be devastating to families and the wider community. Improving the mental health of women can support effective bonding and attachment and improve outcomes for children who require sensitive and responsive parenting in order to reach their full potential. As leaders of The Healthy Child Programme, health visitors can identify issues and use professional judgement to provide interventions that are proportionate to the nature of the problem. Early detection can lead to early support, which in turn can help to improve outcomes for children and families.
1. Joint Commissioning Panel for Mealth Health. Guidance for commissioners of perinatal mental health services. Joint Commissioning Panel. 2012.
2. Hogg S. All Babies Count: Spotlight on Perinatal Mental Health. NSPCC. 2013.
3. National Institute for Health and Clinical Governance.CG45 Antenatal and Postnatal Mental Health. London: NICE; 2007.
4. Oates M, Cantwell R. Deaths from psychiatric causes. Centre for Maternal and Child Enquiries. BJOG 2011;118(1):132-203.
6. National Institute for Health and Clinical Excellence.CG37 Postnatal care: Routine postnatal care of women and their babies. London: NICE; 2006.
7. National Institute for Health and Clinical Excellence. National Clinical Practice Guideline 90. Depression: the treatment and management of depression in adults. London: NICE; 2009.
9. National Institute for Health and Clinical Excellence. Quick reference guide. Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults. Management in primary, secondary and community care. London: NICE; 2011.
10. National Institute for Health and Clinical Excellence. Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. London: NICE; 2005.
12. Chaudron LH, Nirodi N. The obsessive-compulsive spectrum in the perinatal period: a prospective pilot study. Arch Women Ment Health 2010;13(5):403-410.
13. Timms P. Postpartum Psychosis: Severe mental illness after childbirth. London; The Royal College of Psychiatrists; 2014.
14. Grace SL, Evindar A, Stewart DE. The effect of postpartum depression on child cognitive development and behavior: A review and critical analysis of the literature. Arch Women Ment Health 2003;6(4):263-74.
15. Improving Access to Psychological Therapies. Perinatal Positive Practice Guide. IAPT. London; DH: 2009.
16. Bowlby J. Attachment and loss: Volume 1 Attachment. New York: Basic Books; 1969.
17. Wilkinson R, Mulcahy R. Attachment and interpersonal relationships in postnatal depression. J Reprod Infant Psychol; 2010;28(3):252-65. 
18. Wilson S. Youth in mind. Understanding and promoting attachment. J Psychosoc Nurs Ment Health Serv. 2009;47(8):23-27. 
19. Ein-Dor T, Reizer A, Shaver P, Dotan E. Standoffish perhaps, but successful as well: evidence that avoidant attachment can be beneficial in professional tennis and computer science. J Pers 2012;80(3):749-768. 
20. Tasca GA, Ritchie K, Balfour L. Implications of attachment theory and research for the assessment and treatment of eating disorders. Psychotherapy 2011;48(3):249-59. 
21. Cox J, Barton J, Maternal postnatal mental disorder: how does it affect the young child? In: Tyano S, Keren M, Herrman H, Cox J. Parenthood and mental health: A bridge between infant and adult psychiatry.  West Sussex: Wiley-Blackwell; 2010. 
22. Marmot M. The Marmot review final report: Fair Society, Healthy Lives. London: University College; 2010.
23. Harker L. Chance of a lifetime. The impact of bad housing on children’s lives. Shelter: London; 2006.
25. Zubin J, Spring B. Vulnerability: A New View on Schizophrenia. J Abnorm Psych 1977;86:103-126.
26. Louise M, Howard M, Oram S, Galley H, Trevillion K, Feder G. Domestic Violence and Perinatal Mental Disorders: A Systematic Review and Meta-Analysis; PLOS. DOI: 10.1371/journal.pmed.1001452. 2013.
27. MIND. Understanding postnatal depression. London: MIND; 2013.
28. Department of Health. Healthy Child Programme: pregnancy and the first five years of life. London: DH. 2009.
29. Cowley S, Whittaker K, Grigulis A, Malone M, Donetto S, Wood H, Morrow E, Maben J. Why Health Visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. London: King’s College London; 2013.
30. Gutman LM, Brown J, Akerman R. Nurturing Parenting Capability: The Early Years. Centre for Research on the Wider Benefits of Learning. 2009.
31. Groër MW. Differences Between Exclusive Breastfeeders, formula-feeders, and controls: a study of stress, mood, and endocrine variables. Biol Res Nurs 2005;7:106-117.
32. Strathearn L, Mamun AA, Najman JM. Does breastfeeding protect against substantiated child abuse and neglect? A 15-year cohort study. Pediatrics 2009;123:483-493
33. Onozawa K, Glover V, Adams D. Infant massage improves mother-infant interaction for mothers with postnatal depression; J Affect Disord 2001;63(1-3):201-7.
34. Joint Commissioning Panel for Mental Health. Guidance for commissioners of perinatal mental health services. Volume 2: Practical mental health commissioning. Jcpmh. 2012.

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