“One of the reasons we need a psychological perspective is because individual women differ enormously in how they experience and feel about pregnancy,” says Dr Helen Sharp. “Some feel completed: others feel invaded. There is an enormous, complex plethora of reactions to pregnancy and early parenthood. We need to use the resources of our psychological training to bring to these.”
Sharp is a consultant clinical psychologist and the reader in clinical psychology and research lead for perinatal, infant and child mental health at the University of Liverpool. She is also chairs the British Psychological Society’s Faculty of Perinatal Psychology and is the one of the authors of a research briefing published this February, which draws on a range of policy recommendations to argue for expert specialist support for the mental health needs of pregnant women and new mothers.
According to the Independent Mental Health Taskforce, fewer than 15 per cent of localities in England provide effective specialist community perinatal services for women with severe or complex conditions at the moment (more than 40 per cent have no specialist support at all). The £8.1bn annual cost of perinatal mental ill health in the UK equates to almost £10,000 per birth, and untreated maternal mental health problems can have long-term effects on children’s emotional, social and cognitive development. “The Independent Mental Health Taskforce identified the need for an extra £1bn of spending by 2020-2021. This new briefing paper shows that poor perinatal mental health is a widespread and expensive problem and that perinatal psychologists have the specialist skills to help in ways new mothers appreciate, transforming lives at this very important time for families,” says BPS president Professor Peter Kinderman.
But in an increasingly cash-strapped NHS, are perinatal services the best use of resources to tackle this? Sharp and her colleagues make their case both strongly and coherently – not simply calling for these services but identifying ways in which they should be positioned within broader teams, and the number of specialists which should be available within a wider hospital population.
Clinical psychologists, the researchers argue, can provide a better option than medicalised interventions (which usually means drugs). For one thing, there is the whole issue of taking medication in pregnancy (though see inset box for women who are already receiving treatment). Even when the treatment is approved for pregnant women, Sharp points out: “A large group of people – let alone mothers in pregnancy – aren’t willing to take pharmacological treatments. Often people want to attribute meaning to the experience they are having, and have sense of resolving these issues.”
Clinical psychologists are the people who have the training and track record in delivering evidenced-based psychological therapies – and importantly, training in a range of therapies, so that they can select the most appropriate one for the circumstances. They are also used to working with other health professionals, which is particularly important for women who are already linked into maternity services. That is not to rule out pharmacological options altogether (and many women, especially postnatally, want them as a ‘quick fix’ while they also undertake the longer-term work); but another argument for psychological therapy is that it builds the strategies which should help in the future. “There’s evidence that cognitive behavioural therapy for depression, for instance, is better at preventing future relapse than medication alone,” says Sharp. “A number of psychological difficulties are chronic and relapsing.” That is particularly relevant at a period when most women – including women who have never had any undue psychological problems before - are having their lives turned completely upside-down by their new baby. They are struggling with a whole new identity as ‘mother’; they are sleep deprived; their bodies have changed – and they may be in considerable physical discomfort; they are out of the workplace and the structures that they are used to; and they are responsible for a completely dependent infant.
Why perinatal psychologists?
On top of the usual training (which takes up a minimum of six years), specialist clinical perinatal psychologists undertake post-doctoral training in perinatal service provision, under the supervision of a clinical consultant. They’re trained in the specific issues that pregnant and postnatal women face both physically and mentally, and in applying psychological theory and practice to these. That training also covers assessing, identifying and intervening in situations where the mother’s health is likely to affect the baby’s.
“Each individual makes the transition to parenthood in different ways,” Sharp points out. Indeed for some, parenthood may be a protective factor for their mental health, because it gives them a new focus and makes them very happy. “The challenge for professionals is to assess each person, especially if they have a history of mental difficulties. I think the key thing is that the perinatal specialism tackles a number of key challenges: understanding how mental health problems can evolve very quickly in the perinatal period; the physical adaptations and the psychological adaptations, and judging how much of this is healthy (some degree of adjustment and upset is quite normal, but we need to be able to assess when this is disproportionate).” Investing in this expertise should be cost-effective because, among other things, it reduces unnecessary admissions and shortens hospital stays as well as some requests for elective caesarean sections; and further down the line it should reduce the costs of addressing the longer-term effects on mothers, children and the wider family (two-thirds of the original £8.1bn annual cost is in fact associated with later costs for the child).
Working within a team
Over the next few years the Faculty of Perinatal Psychology hope to support Health Education England in a planned program of specialist training aimed at improving perinatal psychology knowledge amongst all professionals involved with the care of women and babies at all points of prenatal and postnatal care.
The report sets out several different options for ways in which this expertise could be embedded within a setting (see box). The important thing, however, is that these psychologists should be working closely with midwives and health visitors as well as with GPs and with other mental health professionals. “At the moment some perinatal psychologists are in multidisciplinary mental health teams, and some are within separate psychological therapy services. We feel very strongly we need to work in multi-disciplinary specialist perinatal teams to address the mix of medical and psychological healthcare needs that present in the perinatal period in an integrated way,” says Sharp.
This also means that appointments and care are provided in a way that pregnant women and particularly new mothers can actually access (often at home, or in a setting where there is childcare, rather than as a hospital outpatient) and that the professionals can easily get women into the other support networks available – which may be as simple as baby groups where they can meet other women, or specialist groups if one of the things they are struggling with is a child with a disability.
“What’s really important in pregnancy and the post-natal period is the timeliness of the intervention: the right intervention at the right time,” Sharp concludes. “The quality of the assessment of psychological and medical healthcare needs is paramount. Clinical psychologists have had far the longest and most detailed training in applying psychological theory to understanding mental health problems across the lifespan.” [https://www.bps.org.uk/system/files/user-files/Division%20of%20Clinical%20Psychology/public/rep108_perinatal_service_provision.pdf]
Recommended staffing levels
- Maternity hospitals or geographic regions with 3,000 deliveries a year should have access to a minimum of one 0.6 consultant clinical perinatal psychologist and one full-time specialist clinical perinatal psychologist
- Hospitals or regions with more deliveries per year require proportionately more clinical perinatal psychologists (so a hospital with 6,000 deliveries a year should have one 0.6 consultant and two clinical psychologists
- Hospitals or regions with a neonatal intensive care or specialist baby care unit require a further half-time specialist clinical perinatal psychologist
- Services provided as part of a network or across a range of localities may require additional support and/or supervision.
The briefing proposes a range of options for services provided within a specialist perinatal health team, but also recommends that:
Women with pre-existing mental health issues
The most important thing for women who are already taking some form of medication to address a mental health issue is that they should not stop this suddenly when they realise they are pregnant; ideally they should discuss this with their mental health team and/or GP in advance, and discuss their options but in any case they should make an appointment with the professionals. Sharp also recommends asking about access to psychological therapies if these have not been discussed before. “Many antenatal clinics now have a specialist mental health midwife. Every woman needs a holistic assessment to balance out their needs; some medication can go on being taken, but it may also be possible to withdraw gradually and/or have access to therapies. It really depends on each woman’s individual risk.”
Cath Beard, from the west Midlands, has had two experiences of perinatal OCD: one with and one without the help of specialist intervention.
“I was really anxious during my first pregnancy especially since I’d had three previous miscarriages. I had the typical OCD presentation of hand-washing and worries that things would happen if I didn’t do certain things like only wearing the same clothes, not drinking tap water and then stopping eating and drinking at all. I had an emergency C-section and couldn’t sleep for four days; I was very tearful and irrational, and the crisis team was called. The community team prescribed medication to make me sleep and then sent an anxiety specialist out to me and put me on a CBT waiting list. None of this was specialist perinatal so they tackled a couple of things as well as they could – they were a relatively good community team, but they didn’t have any specialist input. I got to a point when I could function, but after my six session of CBT I had very few coping strategies.”
Four years – and four more miscarriages – later, Beard was pregnant again and chose to have her antenatal care at Birmingham Women’s Hospital where there is an antenatal psychiatric liaison clinic. “I had no idea they had this – it was complete luck – but they picked me up at my 12 week scan. They asked about my medical history, picked up I had a history of stress, anxiety and OCD and referred me to the specialist consultant in OCD who also works with a specialist psychiatrist, psychologist, CPN and midwife.”
She started receiving support from the specialist team after her OCD escalated. “The CPN was fantastic. She sat in my house and played with my son and talked me through my symptoms. I was textbook OCD. There was an emergency appointment to see the psychologist. When I first sat down I was so distressed I couldn’t speak; we sat there for an hour and 20 minutes while I wrote the same thing over and over, and then we started talking. She was not fluffy; she told me exactly what we were going to do – learn about my condition and the treatment, and then we’d start the treatment. Suddenly I’d gone from being a risk to being a human being in pain.
“I saw her almost weekly for 18 months. It was one of the best things that have ever happened to me. When I’d had my daughter, there was a crèche and a taxi service that could take me and the children. But there was no molly-coddling – I was facing up to the illness, and it became quite exhilarating to challenge it.
“Before I’d had my daughter there were lots of things I wanted to do, but I couldn’t because of my anxiety. My world was really small. I’m now preparing to give a conference paper at Harvard as part of my PhD on Welsh literature. My daughter is absolutely fearless. My son shares some of my personality traits, but instead of closeting him we try to let him explore and take some risks that I’d never have imagined before. My husband has been able to talk about the trauma he went through when he was coping full-time with my illness. I’d tell any other woman not to be scared of disclosing and don’t be scared to reach out to people who you know have been through the same experience.
“Adult mental health services are terrified of pregnant women. So are GPs. Nobody wants to do a risk assessment or prescribe medication. It should be perinatal specialists who do that, because it’s really important that everything is covered properly in order to keep mothers and babies safe.”