A brief, valid mental health screen for mothers living in adversity

The PMHP identified a major obstacle to providing mental health care: the relevant mental health screening tool validated for our setting

The high prevalence of maternal depression in South Africa requires that maternal mental health screening, performed routinely and on-site, be logistically feasible and responsive to the local risk factors which may influence mental distress. To address this gap, we have developed a brief 5-question screening tool to identify symptoms of depression, anxiety and suicidal ideation.  

The study was based at our Hanover Park site. Women attending the maternity service were screened, offered counselling if required and referred to social support services where appropriate. Screening included the PMHP’s risk factor assessment, as well as several other risk and mood screens which are being assessed against a diagnostic gold standard. The most robust screening items were identified for inclusion in a valid, responsive and pragmatic new tool which may be used in limited-resource settings.

Overview of the Hanover Park maternal mental health screening study

Looking beyond depression

Call for greater global focus on improving quality of mental health care for women in the perinatal phase

Researchers and healthcare services have focused on depression, particularly postnatal depression, but a growing evidence base has accrued on the importance of other primary and comorbid disorders, particularly bipolar disorder, anxiety disorders (post-trauma stress, obsessive-compulsive, panic and generalized anxiety disorders), psychosis, eating disorders and personality disorder in both the antenatal and postnatal period.

The World Psychiatric Association urges all health care professionals and policy makers to improve pregnancy outcomes, reduce maternal and infant morbidity and mortality, improve care of the infant and enhance the mother infant relationship.

The WPA calls for all health professionals and other care providers to look beyond depression and also focus on other symptoms of anxiety, PTSD, somatic symptoms (as potential indicators for depression) and psychotic disorders. Women with severe mental illnesses need to be recognised as a high risk group requiring co-ordinated obstetric, paediatric and mental health care.

Read the full statement by the World Psychiatric Association (WPA)

Perinatal depression and anxiety: Let’s talk about moms and dads in Africa

In low- and middle-income countries (LMICs), competing health priorities, civil conflict, and a lack of political will mean that expenditure on mental health is a fraction of that needed to meet the mental health care needs of the population.

For mothers, this treatment gap is most notable in regions where health agendas focus on maternal mortality indicators.

Source: Essentials of Global Mental Health

Who is at risk of perinatal mental health disorder?

Common mental disorders during pregnancy and in the first year after birth are associated with certain risk factors. These include poverty, migration, extreme stress, exposure to violence (domestic, sexual and gender-based), previous history of mental disorders, alcohol and other drug use as well as low social support.

– Migration
– Violence and abuse
– Alcohol and drug use

In South Africa, there is a very high prevalence of adolescent pregnancies with 39% of 15- to 19-year old girls being pregnant at least once. When adolescent mothers suffer from depression, the likelihood of a subsequent teenage pregnancy nearly doubles.

SAsouthAfrica

– Teenage pregnancy
– HIV/AIDS

How to address maternal mental illness among economically disadvantaged parents? 

Integration of services!

Mothers in many settings are using maternal and child health services as well as social services. Thus, detection and access will increase if maternal health screening and services are integrated into these public care platforms.

How to implement a maternal mental health intervention in low-resource settings?

We are sharing our lessons learned in this learning brief. 

We have also developed a Service Development Guidelines which demonstrates how to develop a mental health intervention at your facility, even with limited resources.

Find more free & open access resources for professionals on our website

And what about dads?

Postnatal depression can affect dads too. Find out about common concerns for new dads and discover helpful tips on how they can become more involved. We compiled a leaflet with information that could help you be better prepared for what is happening. The leaflets are available in

EnglishisiXhosa • Afrikaans • French

Women’s voices report on maternal mental health

Women’s Voices – Maternal Mental Health

The Royal College of Obstetricians and Gynaecologists (RCOG), supported by the Maternal Mental Health Alliance (MMHA), have published a survey Women’s Voices – Maternal Mental Health which highlights the urgent need to improve maternal mental health-care.

The survey of over 2,300 women who had given birth in the last five years in the UK, explores their experiences of perinatal mental health problems, engagement with healthcare professionals and the quality of care they received.  It reveals the impact of low rates of specialist referral, long waits, as well as lack of consensus over medication and little support for their partners.

The results present a stark picture of how services are letting down some of the most vulnerable women in our society, and provides key recommendations for healthcare professionals, managers, providers, commissioners and policy-makers.

Key findings

– Women reported experiencing low rates of referral, long waits, regional variation of care, a lack of continuity of care, misunderstanding and stigma

– The mental health of women’s partners is also often neglected by healthcare professionals and services

Source: RCOG survey women’s voices

Download the RCOG survey

Download the RCOG infographic

Maternal Depression: A Hidden Burden in Developing Countries

The most common mental health condition to affect perinatal women and mothers worldwide are depression and anxiety.

These illnesses impact thoughts, feelings and behaviours.

Routine antenatal and postpartum health services provide an opportunity for heightened and psychologically informed mental health care. Even in the poorest countries, there is some provision for antenatal, perinatal, postpartum, and infant health care and other primary health care services.

Interventions to improve maternal mental health and related child survival, health and development can be integrated into these existing services.

Source: Maternal Depression: A Hidden Burden in Developing Countries

At the PMHP service delivery sites, we provide routine screening for pregnant women and girls for depression and anxiety at the first antenatal visit. If they show signs or are at risk of depression or anxiety, free on-site psychosocial counselling, follow-up and case management is provided by our trained counsellors for up to one-year post delivery.

The PMHP model is based on a stepped care approach, which means that referrals are made to psychiatric services when necessary

Learn more about our integrated, stepped-care, collaborative service model, implemented through task sharing.

[#WMMHday Blog Series #2] Postpartum Bipolar Disorder: The Invisible Postpartum Mood Disorder

Guest blog post by Dyane Harwood – originally submitted to WMMHday Blog

Bipolar disorder, postpartum depression, and postpartum psychosis have made media headlines over the past couple years. Katie Holmes stars as a lovestruck poet with bipolar disorder in the film “Touched With Fire.” The British hit television show “EastEnders” featured a postpartum psychosis storyline that gained national attention. In a landmark decision, the U.S. Preventative Task Force called for screening for depression during and after pregnancy.

While the greater awareness of postpartum mood disorders is promising, postpartum bipolar disorder, the mood disorder I was diagnosed with, is virtually unheard of. Postpartum bipolar is also known as bipolar, peripartum onset, and it’s arguably the least known of the six postpartum mood and anxiety disorders. It might seem unimportant to publicize an obscure mood disorder, but every mom’s postpartum experience counts. Many medical professionals are unaware that postpartum bipolar exists. Some postpartum and bipolar organizations are unfamiliar with postpartum bipolar or they’re unclear about its definition. When I was pregnant, my obstetrician didn’t question me about my mental health or my family’s mental health history. My father had bipolar disorder, but before and during my pregnancy I didn’t show any signs of mental illness.

When I went into labor, my life changed overnight. We went to the hospital and I stayed up all night in pain. When my daughter Marilla was born the next day, I became hypomanic. I was exuberant and talkative (both signs of hypomania), but I appeared relatively normal. My baby attracted most of the attention, and no one noticed that I was in trouble. Exhausted, I sensed something was off, but I kept my fearful feelings inside. Within forty-eight hours I had hypergraphia, a rare condition in which one compulsively writes. I wrote at every opportunity, even during breastfeeding, when I should’ve been resting and focusing on my baby. I could barely sleep as my mania escalated, and poor Marilla didn’t gain enough weight because I didn’t breastfeed her sufficiently. A month postpartum, I knew I was manic; after all, I had witnessed mania in my father. I frantically searched the internet about postpartum mania, but my search only yielded postpartum psychosis statistics. During Marilla’s six-week checkup, her observant pediatrician heard my racing voice and pressurized speech (both behaviors are symptoms of bipolar disorder) and blurted out “Dyane, I think you’re manic!” I burst into tears. While I felt ashamed, I was relieved that he realized what was happening. It was clear I needed hospitalization, but leaving my newborn was agonizing. I admitted myself into a hospital’s psychiatric unit where I was diagnosed with postpartum bipolar disorder. After years of hospitalizations, medication trials, and electroconvulsive (ECT) therapy, I’m stable and doing well. While bipolar disorder ravages many relationships, my husband and I have stayed together, in part, thanks to the guidance of counselors and psychiatrists. Life will always be a challenge, but my two daughters inspire me to take care of myself.

While chances of postpartum bipolar are low, it can affect any mother. Obstetrician and Perinatal Mental Health Lead Dr. Raja Gangopadhyay of West Hertfordshire Hospitals NHS Trust, UK, explains, “The risk of developing new-onset severe mental illness is higher in early post-childbirth period than any other time in women’s life. Family history, pre-existing mental health conditions, traumatic birth experience and sleep deprivation could be potential risk factors. Bipolar illness can present for the first time during this period. Accurate diagnosis is the key to the recovery.” Confusion abounds regarding postpartum bipolar and postpartum psychosis. While the two conditions can present together, postpartum bipolar isn’t always accompanied by postpartum psychosis. Perinatal psychologist Shoshana Bennett Ph.D., co-author of the bestselling classic “Beyond the Blues: A Guide to Understanding and Treating Prenatal and Postpartum Depression and Anxiety\” says, “Many women I’ve worked with had been previously misdiagnosed with postpartum depression. I always make a point of discussing this during my presentations. In addition, postpartum bipolar disorder deserves its own category separate from postpartum psychosis.” Mental health screening during pregnancy would be of immense value to every mom. Women with a family history of bipolar disorder could be observed postpartum, and if symptoms manifested they’d be treated immediately. It’s imperative that doctors and other caregivers assess women not only for postpartum depression but also bipolar symptoms. Everyone who lives with a stigmatized illness deserves a chance to find support and empathy from others who understand her experience. Through connecting with those who can relate to our mood disorder, we may not find a magic cure, but virtual support can be profoundly helpful.

Postpartum Support International created online support groups in English and Spanish led by trained facilitators, while the Postpartum Progress website offers moms a private forum to interact with one another. I’ve never personally met another mom who has postpartum bipolar and I yearn to do so. If you or someone you know is or might be suffering from postpartum bipolar disorder please reach out to me at my blog www.proudlybipolar.wordpress.com — I’d love to hear from you!

Poverty and mental disorders: breaking the cycle in low- and middle-income countries

Mental ill-health and poverty are closely linked and interact in complex negative cycles

“What interventions are needed to break the cycle of poverty and mental ill health?”

Growing international evidence shows that mental ill health and poverty interact in a negative cycle in low-income and middle-income countries. However, little is known about the interventions that are needed to break this cycle.

The vicious cycle of poverty and mental ill-health Social Selection or Social Drift theory: People with mental illnesses are at increased risk of drifting into or remaining in poverty through increased health expenditure, reduced productivity, stigma, loss of employment and associated earnings.

A UN General Assembly Declaration (A/RES/65/L.27 2010) on global health and foreign policy welcomed the WHO report, and recognized that mental health problems have “huge social and economic costs.” There is growing international evidence that mental ill health and poverty interact in a negative cycle in low-income and middle-income countries.

This cycle increases the risk of mental illness among people who live in poverty, and increases the likelihood that those living with mental illness will drift into or remain in poverty.

Mental health interventions can be associated with improved economic outcomes.

 Mental Health interventions can have positive effects on economic status – some poverty alleviation interventions, such as conditional cash transfers and asset promotion programmes, can have mental health benefits.

Read more in this Policy Brief or the full text in The Lancet

Related Publications: Integration of mental health into primary care in low- and middle-income countries (PRIME)

Mental health, Poverty & Development (WHO)

Source: PRIME policy brief #1 

[#WMMHday Blog Series] “When our eyes met”

This post is crossposted By Analía Sierra

When our eyes met

At first everything was new, I did not know what to expect. I got at the end of those nine months without enough information but with all the excitement and expectation that would be the most important moment of my life.

 I had many fears, and they all were reason for my hospitalization- I have always been a healthy woman and have never been in a similar situation- My concern about that was big, I have never liked the idea of going through a surgery and this was the closest I was going to be to a surgery room … In my mind I had the old phrases , which grandmothers and mothers say, “You will forget everything, … it is a special moment and such a joy when you deliver your child all pains stops” … When the moment arrived, everything went slowly. They were long 11 hour of waiting … waiting for something I wasn’t sure what or who, if the anesthetist, the obstetrician or my child deigns to leave …

Analía’s blog is also available Spanish

Make your voice heard!
Tell your story to help raise awareness for maternal mental health issues so that more women will get treatment and fewer will suffer. Submit your blog here

Source: When our eyes met – WMMH Day

Mental health interventions in pregnant women and new mothers

There are clear economic and societal arguments for investing in mental health interventions for women during pregnancy and immediately after birth.

This report examines the economic case for investing in early interventions that reflect best practice in England. Best practices that can and should be transferable to a cost-benefit analysis for perinatal mental health care in Low- and Middle Income Countries.

 

Source: The London School of Economics and Political Science

Reflections from Cape Town, South Africa by Dr Robert Nettleton

The second in a series of blogs by Dr Robert Nettleton, Education Advisor, Institute of Health Visiting, on his travels to Cape Town, South Africa through his Florence Nightingale Foundation Travel Scholarship 2017. He met our director, Simone Honikman, and our clinical team at Mowbray Maternity Hospital:

“The connection between a ‘trauma-informed’ approach and infant and perinatal mental health was obvious from my visit to the Perinatal Mental Health Project team at Mowbray Maternity Hospital, led by Simone Honikman.

There is an ‘epidemic of mental distress among women living in adversity’. Alongside wealth, there are extensive townships or informal settlements that are a legacy of the apartheid era in which, for example, 50% of women are HIV positive and levels of domestic, gender-based and sexual violence are high, as is poverty. Providing for accessible front-line assessment of mental health distress is a priority, through providing training to a range of workers and also within the community through ‘social connectors’ (I’ll learn about this more next week).

A challenge that resonated for me was about promoting quality and consistency in a fragmented system where there is also a heavy reliance on separate NPOs (not-for-profits) as providers of services.

Two key learnings for me were:

  1. The importance of what Simone calls ‘self-care’ – what we might call supervision with a substantial restorative component. I met, briefly, Charlotte who provides counselling out of a cubby-hole of an office in a maternity hospital. Her heart was bigger than her office! Maintaining resilience is something that we know is important, and the ‘Sollihull Approach’, while not rolled out in Cape Town, was something that colleagues recognised as applicable.
  1. The dilemma of seeking to deliver a quality service within a very low-resource environment. This resonated with me as we face resource pressures in the UK. We discussed and reflected on what would be the essential elements of a service (the ‘active ingredients’ or ‘programme mechanisms’) and what could be delegated or substituted without placing effectiveness at risk. The ability to form effective empathic relationships is one of those essential elements common to both South Africa and the UK, as is support and supervision.”

Source: Reflections from Cape Town, South Africa – week 2 – IHV

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