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Theme: ARC - Mental Health
Perinatal mental health (PMH) problems (mental disorders occurring in pregnancy or the year after childbirth) are a serious public health issue, associated with distressing symptoms and poor functioning, and a leading cause of maternal deaths (Howard et al 2014; Jones et al 2014). In addition to the impact on the mother, PMH disorders are also associated with pregnancy complications (low birthweight, preterm birth), and long-term negative effects on child cognitive, social and emotional development (Howard et al 2014; Stein et al 2014; Netsi et al 2018, Pearson et al 2018). These effects are thought to be mediated prenatally by the effects of cortisol on the developing fetus leading to alterations in infant stress reactivity, and postnatally through problems in the quality of the mother-infant interaction (Stein et al 2014). Although there are contradictory findings, recent research suggests that the children of most women who are effectively treated for their maternal depression will not have developmental problems at age two (few studies have examined impact of treatment of other disorders on child outcome) (Stein et al 2018). Effective services could therefore reduce the costs of PMH disorders, which are estimated to cost the UK economy £8.1 billion for each one-year cohort of births in the UK (28% due to direct costs, 72% to the effect on the infant) (Bauer et al 2014).
The perinatal period is therefore a critical period for maternal and infant mental health (and long-term health of both), and the mother-infant bond (Howard et al 2018). Women see health providers through pregnancy and after birth (including midwives, health visitors, GPs), so there are many opportunities to identify mental health difficulties and engage women needing help in appropriate mental health interventions. However, until recently there was a lack of integrated care across the care pathway that effectively identified women with PMH needs. The recent perinatal transformation investment (£365 million) by NHSE seeks to redress this imbalance, and includes expansion of comprehensive specialist community perinatal mental health teams (CPMHTs) to deliver NHSE evidence based perinatal care pathways (NHS England 2018; NHS England 2014). The currently recommended workforce composition of CPMHTs was outlined in the Royal College of Psychiatrists’ report CR197 (Royal College of Psychiatrists 2015), but there is little evidence about which CPMHT service models provide optimal access and better outcomes for women and their infants. Team composition can affect the range and types of interventions offered to women and there remains considerable variability in the way teams are configured and the services they provide. With the increased number of CPMHTs since the initial investment there has been a 49% increase in the number of women seen by CPMHTs over a 2-year period (2015-2017), and further increases are expected (NHS England, 2019). Despite anticipated increases it is still unclear as to whether women most in need of CPMHTs are accessing them, the extent of inequity of access across primary and secondary mental health care for specific groups, and whether access to CPMHTs improves maternal and infant outcomes (NHS England, 2019). It is theorised that the variations in configurations and components of CPMHTs will affect the communication between CPMHT and other health and social care professionals, and women’s willingness and ability to access care, thus it is critical to understand which models and components will provide identification and better outcomes for women and their infants.
Due to the current situation of COVID-19 there will be significant effects of uncertainty and isolation on women and children’s well-being. Services have had to rapidly adapt how they delivery support to women and infants, with little guidance for understanding what works best. A realist evaluation approach will enable learning that may be transferable to any future public health emergencies. It is likely that many of the service changes enacted during COVID-19 may persist beyond the acute pandemic period (i.e., remote delivery). It is critical to know what changes work best during difficult periods such as this, and which changes to keep, and for whom.
The overarching research question is: Which CPMHT components and configurations work most effectively for whom, in what circumstances, how and why (i.e. what are the underlying mechanisms, when are they triggered, for whom and what outcomes results). More specifically the study will focus on and answer the following aspects of the overarching research question:
A mixed-method approach that will use a multi-informant, mixed qualitative and quantitative, prospective approach will be taken. The study design for this workpackage is a realistic evaluation and will investigate whether, how, why and for whom the CPMHT service configurations and components are effective at delivering greater acceptability, willingness to access and engagement with care and better outcomes.
Up to 10 services have been purposefully selected that vary on different components and configurations. A purposive sampling approach (with maximum variation in characteristics) has been taken to identify up to 10 women and 10 of their significant sources of support to help us refine and test aspects of our initial programme theory. Where possible, women will be purposively sampled with different types of mental health problems (i.e., personality disorder, SMI, Anxiety Disorder, Trauma/PTSD, Severe Depression) and across diverse sociodemographic groups.
The findings of the research will be disseminated to relevant audiences (including service user groups and charities) using a range of media, e.g. twitter, websites and blogs. We will publish academic papers in high-quality scientific journals. High quality executive summaries, scientific summaries and user-focused research summaries will be prepared and disseminated through national and international academic conferences, and the relevant research networks and local clinical networks.
Howard LM, Molyneaux E, Dennis C-L, Rochat T, Stein A, Milgrom J. Non-psychotic mental disorders in the perinatal period. The Lancet 2014; 384(9956): 1775-88.
Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum.Lancet 2014; 384(9956):1789-99.
Stein A, Pearson RM, Goodman SH, et al. Effects of perinatal mental disorders on the fetus and child. The Lancet 2014; 384(9956): 1800-19.
Netsi E, Pearson RM, Murray L et al. Association of persistent and severe postnatal depression with child outcomes. JAMA Psychiatry 2018; 75(3): 247-53.
Pearson R, Campbell A, Howard L, et al. Impact of dysfunctional maternal personality traits on risk of offspring depression, anxiety and self-harm at age 18 years: a population-based longitudinal study. Psychological Medicine 2018; 48(1): 50-60.
Stein A, Netsi E, Lawrence PJ, et al. Mitigating the effect of persistent postnatal depression on child outcomes through an intervention to treat depression and improve parenting: a randomised controlled trial. The Lancet Psychiatry 2018; 5(2): 134-44.
Bauer A, Parsonage M, Knapp M et al. Costs of perinatal mental health problems, 2014. https://www.centreformentalhealth.org.uk/Handlers/Download.ashx?IDMF=07afd94b- 92cb-4e47-8439-94cbf43548d8
Howard LM, Ryan EG, Trevillion K, et al. Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and othermental disorders in early pregnancy. British Journal of Psychiatry 2018; 212(1): 50-6.
Royal College of Psychiatrists. Perinatal mental health services: Recommendations for the provision of services for childbearing women. College Report CR197 2015.
NHS England. Five Year Forward View. https://www.england.nhs.uk/wp- content/uploads/2014/10/5yfv-web.pdf2.
NHS England. The NHS Long Term Plan. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan.pdf
NHS England. https://www.england.nhs.uk/wp-content/uploads/2018/05/perinatal- mental-health-care-pathway.pdf2018.