Guidance for commissioners of perinatal mental health services
Guidance for commissioners of perinatal mental health services 1VolumeTwo:Practicalmental healthcommissioningGuidance for commissioners ofperinatal mentalhealth servicesJoint Commissioning Panelfor Mental Healthwww.jcpmh.info
2 Practical Mental Health CommissioningContentsTen key messagesfor commissionersIntroduction04What areperinatal mentalhealth services?Why are perinatalmental healthservices importantto commissioners?05 06What do weknow aboutcurrent perinatalmental healthservices?09What would agood perinatalmental healthservice look like?14Supportingthe deliveryof the mentalhealth strategy18References20
Guidance for commissioners of perinatal mental health services 3Ten key messages for commissioners1 Ensure that a regional perinatal mentalhealth strategy is present and that allproviders of care for perinatal mentalhealth problems are participating.2 Ensure that there is a perinatal mentalhealth integrated care pathway inplace which covers all levels of serviceprovision and severities of disorder.All service providers should becompliant with this so that there isequitable access to the right treatmentat the right time by the right service.3 Mother and baby units should beaccredited by the Royal College ofPsychiatrists’ quality network forperinatal services, and have formalestablished links with a number ofspecialised community perinatal mentalhealth teams in their region.4 Specialised perinatal communitymental health teams should bemembers of the Royal College ofPsychiatrists’ quality network forperinatal services and should casemanage serious mental illness. Theyshould have a formal link with amother and baby unit.5 Parent-infant services provided bychild and adolescent mental healthservices (CAMHS) and maternal mentalhealth teams provided in primary careand by non-health organisations arean addition to, not a substitute for,services provided for women withserious mental illness. They should workcollaboratively with specialist services.6 When commissioning adult mentalhealth services there is a need toensure that:• these either provide a mother andbaby unit, or have formal links toensure access to one• all women requiring admission inlate pregnancy or after deliveryare admitted with their infant to amother and baby unit not an adultadmission ward.7 Ensure that adult mental healthservices:• counsel women with seriousaffective disorder about the effectsof pregnancy on their condition• provide information and adviceabout possible effects of theirmedication on pregnancy• provide additional training topsychiatric teams about perinatalmental health• routinely collect data on whichfemale patients are pregnantor in the postpartum (followingchildbirth) year.8 Ensure that when commissioningmaternity services the needs ofpregnant and postpartum patients aremet. This includes:• midwives receiving additionaltraining in perinatal mental healthand the detection of at-risk patients• maternity services asking all womenat early pregnancy assessmentabout previous psychiatric history,and referring on those with a pasthistory of serious mental illness• maternity services shouldroutinely inform the GP about thepregnancy, and ask for furtherinformation• maternity services should haveaccess to perinatal mental healthteams• maternity services should haveaccess to designated specialistclinical psychologists• maternity service midwivesshould routinely enquire aboutwomen’s current mental healthduring pregnancy and the earlypostpartum period.9 Ensure that when commissioningIAPT services (Improving Access toPsychological Therapies) that the needsof pregnant and postpartum patientsare met. This includes:• routinely collecting data onwhether referrals are pregnant orin the postpartum year• receiving additional training inperinatal mental health• ensuring that pregnant andpostpartum women are assessedand treated within three months.10 Ensure that when commissioningprimary care services that the needsof pregnant and postpartum patientsare met. This includes:• General Practitioners (GPs) andother primary care staff receivingadditional training in perinatalmental health• GPs and other primary care staffbeing made familiar with theperinatal mental health integratedcare pathway• Health Visitors receiving additionaltraining in perinatal mental health.
The Joint Commissioning Panelfor Mental Health (JCP-MH)(www.jcpmh.info) is a newcollaboration co-chaired bythe Royal College of GeneralPractitioners and the RoyalCollege of Psychiatrists,which brings together leadingorganisations and individualswith an interest in commissioningfor mental health and learningdisabilities. These include:• Service users and carers• Department of Health• Association of Directorsof Adult Social Services• NHS Confederation• Mind• Rethink Mental Illness• National Survivor User Network• National Involvement Partnership• Royal College of Nursing• Afiya Trust• British Psychological Society• Representatives of the EnglishStrategic Health Authorities• Mental Health Providers Forum• New Savoy Partnership• Representation fromSpecialised Commissioning• Healthcare FinancialManagement Association.IntroductionThe JCP-MH is part of the implementationarm of the government mental healthstrategy No Health without Mental Health1.The JCP-MH has two primary aims:• to bring together service users, carers,clinicians, commissioners, managers andothers to work towards values-basedcommissioning• to integrate scientific evidence,service user and carer experience andviewpoints, and innovative serviceevaluations in order to produce the bestpossible advice on commissioning thedesign and delivery of high quality mentalhealth, learning disabilities, and publicmental health and wellbeing services.The JCP-MH:• has published Practical Mental HealthCommissioning2, a briefing on the keyvalues and principles for effective mentalhealth commissioning• has so far published six other practicalguides on the commissioning of primarymental health care services3, dementiaservices4, liaison mental health servicesto acute hospitals5, transition services6,perinatal mental health services7, andpublic mental health services8• provides practical guidance and adeveloping framework for mental health• supports commissioners to deliver thebest possible outcomes for communityhealth and wellbeing.Who is this guide for?This guide is about thecommissioning of good qualityperinatal mental health services.It has been written to assistspecialised commissioners, aswell as Clinical CommissioningGroups and Health andWellbeing Boards. It will also beof use to provider organisations,service users, patients, carers,and the voluntary sector.WHAT THIS GUIDE DOES NOT COVERThis guide does not coverthe provision of care ofpostpartum women and theirinfants by drug and alcoholservices or learning disabilityservices.4 Practical Mental Health Commissioning
Guidance for commissioners of perinatal mental health services 5What are perinatal mental health services?Perinatal mental healthservices are concerned withthe prevention, detection andmanagement of perinatalmental health problems thatcomplicate pregnancy andthe postpartum year. Theseproblems include both newonset problems, recurrences ofprevious problems in womenwho have been well for sometime, and those with mentalhealth problems before theybecame pregnant.Promoting emotional and physicalwellbeing and development of the infant iscentral to perinatal mental health services.Perinatal mental health problems includea range of disorders and severities whichpresent in a variety of health settings andare currently managed by many differentservices. Some of these services arespecifically designed to meet the needsof pregnant and postpartum women andtheir infants. Others care for them as partof a general service. These include:• specialised inpatient mother andbaby units• specialised perinatal communitymental health teams• general adult mental health servicesincluding admission wards, community,crisis, early intervention in psychosisand assertive outreach teams• drug and alcohol services• learning disability services• child and adolescent mental healthservices• parenting and infant mental healthservices• clinical psychology services linkedto maternity services• maternity services• IAPT services• health and social care organisations• children’s centres• General Practitioners, Health Visitorsand the extended primary care team• voluntary and self-help organisations.Specialised perinatal mental healthservices which include mother and babyunits and their linked specialised perinatalcommunity mental health (outreach) teamsare provided by Mental Health Trustsand will be commissioned by the NHSCommissioning Board under specialisedcommissioning arrangements. Otherservices that provide care for pregnant andpostpartum women, including some ofthe care provided by specialised perinatalcommunity teams, will be commissionedby Clinical Commissioning Groups.A comprehensive perinatal mentalhealth strategy should encompass alllevels of service provision no matter ifthose services are commissioned by theNHS Commissioning Board or ClinicalCommissioning Groups. Robust carepathways, education, training andresourcing of non-specialists is essentialto ensure that “the right patient reachesthe right service where they are seen bythe right professional at the right time.”MANAGEMENTIn this guidance, the term “management”is used to encompass medical,psychological and social treatments,interventions and care.
6 Practical Mental Health CommissioningWhy are perinatal mental health servicesimportant to commissioners?PERINATAL MENTAL HEALTHPROBLEMS: AN OVERVIEWPerinatal mental healthproblems are those whichcomplicate pregnancy andthe postpartum year.They include both mental healthproblems that arise at this time and thosethat were present before the pregnancy.Childbirth is associated with a substantialpsychiatric morbidity. It has long beenknown to increase the risk to women’smental health, particularly of developinga serious mental illness (postpartumpsychosis and severe depressive illness)9,10.It is also known to be associated with anincreased risk of recurrence particularlyof serious affective disorder (bipolarillness and severe depressive illness)11.Women with chronic longstanding seriousmental illnesses such as schizophreniabecome pregnant and their condition maydeteriorate or recur during pregnancyand the postpartum period12.Non-psychotic conditions, particularlydepressive illness and anxiety are commonduring pregnancy and following delivery13.The incidence (new onset) of seriousmental illness is not elevated duringpregnancy in contrast to the markedelevation of risk in the early weeksfollowing delivery9. However, recurrencesand relapses of serious affective disorder(bipolar illness and severe depressiveillness) do occur during pregnancyparticularly if medication has beenstopped. The majority of acute onsetserious perinatal disorders present as apsychiatric emergency in the days andweeks following childbirth14,15.In contrast, the incidence and prevalenceof mild to moderate depression andanxiety are broadly similar duringpregnancy and the postpartum period.However, there is evidence of an increasedincidence of severe non-psychoticdepressive illness in the early weeksfollowing delivery. These conditions mayinitially present as anxiety and depressionin the first two to six weeks followingchildbirth and can deteriorate rapidly10,16,17.Post traumatic stress disorder is estimatedto occur in approximately three percentof maternities and six percent of womenfollowing emergency caesarean section.Women admitted to high dependency orintensive care units and those sufferingobstetric loss are at increased risk18. Otherobstetrically relevant states of distressinclude women previously abused, thosewith sick infants in neonatal units andthose with very serious medical disorders.The epidemiology of perinatal psychiatricdisorders is well established9,10,13. Using thebirth rate of their area, commissioners willbe able to estimate the perinatal mentalhealth morbidity and the necessary serviceuptake for their population.IMPACT OF PERINATALPSYCHIATRIC DISORDER• Childbirth and new motherhood carriesan expectation of happiness and isa time of emotional upheaval andadjustment to changes in lifestyle andrelationships. Significant mental healthproblems at this time cause enormousdistress and can seriously interfere withthe adjustment to motherhood andthe care of the newborn baby as wellas existing children. Poorly managed,perinatal mental health problems canhave lasting effects on maternal self-esteem, partner and family relationshipsas well as the mental health and socialadjustment of the child.• Acute serious perinatal illness usuallypresents as an emergency and oftenrequires inpatient care. Separationof mother and infant prevents theearly development of mother-infantattachment and relationship. Thismay be difficult to reverse and havelongstanding effects on both childand mother. Separation causes greatmaternal distress and interferes withtreatment of the mother as well aspreventing breastfeeding.Rates of perinatal psychiatric disorder per thousand maternitiesPostpartum psychosis 2/1000Chronic serious mental illness 2/1000Severe depressive illness 30/1000Mild-moderate depressive illness and anxiety states 100-150/1000Post traumatic stress disorder 30/1000Adjustment disorders and distress 150-300/1000Figure 1Notes: this table is based on information contained in references 9-18.
• Non-psychotic depressive illnessesand anxiety states, particularly ifuntreated or chronic and associatedwith social adversity, have been shownto affect the infant’s mental healthand have longstanding effects on thechild’s emotional, social and cognitivedevelopment19.• Serious perinatal psychiatric disorderis associated with an increased risk ofsuicide. Suicide has been shown to bea leading cause of overall maternalmortality in the last two decades andthe suicide rate in pregnancy and thefirst six months postpartum is notdecreasing in contrast to the suicide ratein women in general17.• Serious perinatal psychiatric disorder isalso associated with an increased risk toboth mortality and morbidity in motherand child. Over the last two decadespsychiatric disorder has been a leadingcause of maternal mortality contributingto 15% of all maternal deaths inpregnancy and six months postpartum.Serious mental illness and its treatmentscan complicate the management ofpregnancy. Psychotic illness in pregnancyis known to be associated with poorerpregnancy outcomes and an increasedrisk of preterm delivery, stillbirth,perinatal death and neurodevelopmentaldisorder20.Perinatal mental health problems aretherefore a major public health concern.They have wide ranging impacts on bothmaternal and infant mental and physicalhealth and make a significant contributionto both maternal and infant morbidityand mortality.THE NEED FOR SPECIALISED SERVICES• Women with serious mental illnesscomplicating childbirth need specialisedknowledge and skills on the part of theprofessionals who care for them. Theseinclude specialist knowledge of the risksand benefits of medication in pregnancy,the skills to manage and nurse seriouslymentally ill women, at the same time asenabling them to meet the emotionaland physical needs of their infants. Inaddition they need an understandingof the emotional and physical changesassociated with childbirth and thedifferent organisation of maternityservices.• Services for seriously mentally ill womenneed to be organised differently fromgeneral adult mental health servicesand need to respond to the maternitycontext, the timeframes of pregnancy,the differing thresholds and responsetimes to presenting problems, andbe able to relate to different healthprofessionals (particularly to maternityservices and children’s social services).• Perinatal mental health servicesrequire different resources to those ofgeneral adult mental health services.Women who are admitted in latepregnancy in the postpartum periodrequire inpatient mother and baby unitswhich are designed and resourced tosafely meet the physical and emotionalneeds of both mother and infant whilstresolving the usually severe mentalhealth problems.• Women with non-psychotic conditionsof moderate intensity may not meet thecriteria for access to adult mental healthservices. The potential risk to the motherof the subsequent development of amore serious condition and additionalrisks to the infant determine a loweredthreshold for referral and intervention.• Adult mental health services are notorganised to respond to the occasionalperinatal mental health crisis withintheir sectors. The organisation of adultmental health services into differingfunctional mental health teams does notfit easily with the rapid developmentand deterioration of an early postpartumillness which can move very quicklywithin days from early concerns aboutanxiety to a profound psychotic illness.• Adult mental health services arenot accustomed to the proactivemanagement of a well woman inpregnancy, who is nonetheless at a veryhigh risk because of her previous historyof becoming profoundly ill within daysof delivery.• Clinicians within adult mental healthservices are not experienced in thedetection of difficulties within an infant-parent relationship which can seriouslyimpact on the infant’s mental health andlong term development.• A critical mass of patients is essentialto maintain experience and skill inmanaging complex and difficultconditions. No individual Mental HealthTrust or functional psychiatric team willhave sufficient experience of managingpostpartum psychosis or severe postnataldepressive illness. The epidemiologyof these conditions suggest that thiscritical mass can only be achieved byproviding specialised mother and babyunits on a regional basis, and at the levelof an individual Mental Health Trustby providing a specialised communitymental health team. These teams canthen work very closely with colleagues inadult mental health to ensure the propercare of women who become pregnantwhilst in the care of adult mental healthservices.Guidance for commissioners of perinatal mental health services 7
8 Practical Mental Health CommissioningWhy are perinatal mental health services important to commissioners? (continued)OPPORTUNITIES FOR EFFECTIVEINTERVENTION AND MANAGEMENTPregnancy and early motherhood aretimes of unparalleled contact withhealth services. This should provide theframework to relatively easily:• identify those at increased risk ofdeveloping perinatal conditions• develop a personalised care plan foreach woman at increased risk• ensure the prompt and early detectionof any illness• ensure early intervention and prompttreatment.Effective treatments and psychologicalinterventions exist, and timely andappropriate treatment can improvematernal and infant outcomes.Women with acute serious perinatal illnesswill have better outcomes and betterrelationships with their infants if cared forin mother and baby units21. If they receivespecialised aftercare they will have shorteradmissions and fewer readmissions22.Women with a history of serious illnesscan be prepared for pregnancy and receivepreventative management when pregnantwith regard to their high risk of recurrencefollowing delivery.Health Visitors with additional training inactive listening and cognitive counsellinghave been shown to be effective inboth preventing and treating postnataldepression23.Parent and infant mental health services,and services with a focus on parenting,can significantly improve both infantmental health and maternal wellbeing inthose women who have problems withtheir relationship with their child.Psychosocial interventions by health andsocial care agencies and voluntary agenciescan improve both maternal wellbeing andinfant outcomes in those with less seriousproblems or as an adjunct to managementby specialist services24.
Guidance for commissioners of perinatal mental health services 9What do we know about currentperinatal mental health servicesThe policies and guidelinesin Figure 2 make consistentrecommendations about aspectsof care that a pregnant andpostpartum woman shouldreceive and the provision ofspecialised care for perinatalpsychiatric disorder shouldit be necessary. Theserecommendations effect:n the provision of specialisedservicesn adult mental health servicesn maternity servicesn General Practitioner,Health Visitor and extendedprimary care teamn clinical networks.• All those involved in the care of pregnantor postpartum women should havetraining in the normal emotional changesassociated with pregnancy and thepostpartum period, the maternity context,psychological distress, perinatal disordersand early parent-child relationship issues.• All women with serious psychiatricdisorder should have access to specialistadvice before becoming pregnant.This should cover the possible impactof pregnancy and childbirth on theircondition, and of their condition andits treatment on the outcome of thepregnancy.• All women should be asked aboutprevious mental health problems atearly pregnancy assessment. Those whohave had a serious mental illness shouldbe referred to a psychiatrist (preferablya perinatal psychiatrist) for proactivemanagement during pregnancy.• All women should be regularly askedabout their current mental health duringpregnancy and the postpartum periodand if they have problems whether theywould like help.• All women requiring admission to apsychiatric unit in late pregnancy or thepostpartum period should be admittedtogether with their infant to a specialisedmother and baby unit unless there arespecific reasons not to do so.• Women with perinatal conditions whorequire the care of secondary mentalhealth services should receive specialisedperinatal community care.• Women should have access topsychological and psychosocial treatmentsincluding prompt treatment by IAPT andother providers of psychosocial treatmentssuch as listening visits and cognitivecounselling by health visitors.• Managed (strategic) clinical networksshould be set up and commissionedcovering populations of patient flowof approximately four to five million(delivered population 50,000) to advisecommissioners, assist in the developmentof strategic plans and commissioningframeworks, advise providerorganisations, assist with workforcedevelopment and training, developintegrated care pathways and developand maintain a network of involvedclinicians and other stakeholders includingpatient organisations.The Royal College of Psychiatrists CR88 200025The Women’s Mental Health Strategy 200226The Scottish Maternity Framework 200227The Children and Young People’s NSF Maternity Standard 11 200428NICE Guidelines on Antenatal and Postnatal Mental Health Care 200729The Confidential Enquiries into Maternal Deaths 201117NICE Guidelines Caesarean Section 201118The SIGN Guidelines 201230The Royal College of Obstetricians and Gynaecologists’ Guidelines onManagement of Women with Mental Health Issues during Pregnancyand the Postnatal Period (Good Practice No 14) 201131NATIONAL DRIVERS POLICIES AND GUIDELINESFigure 2Guidance for commissioners of perinatal mental health services 9
10 Practical Mental Health Commissioningwhat do we know aboutSPECIALISED PERINATAL MENTALHEALTH SERVICES?There are 19 inpatient mother and babyunits in England, two in Scotland and one inWales32. There are none in Northern Ireland.The overwhelming majority of these motherand baby units belong to the Royal Collegeof Psychiatrists’ Quality Care Network andadhere to their national standards. Theyall admit seriously mentally ill women inlate pregnancy and the postpartum periodtogether with their infants. They all aim toadmit women directly to the mother andbaby unit in the early postpartum periodwithout the need for prior admission to ageneral adult psychiatric ward.All mother and baby units will continuouslyassess mother-infant care and attachmentdetermining the level of supervision, supportand guidance the mother needs to meet theemotional and developmental needs of herinfant. The staff will have skills in promotingattachment and parenting interventions.Many units also have psychologists who willprovide additional expertise in psychologicaltreatments and parenting interventions.Eleven mother and baby units are alsointegrated with specialised communityperinatal mental health teams32. Theseteams in addition to their other functionscan promote early discharge, provideaftercare and manage women with seriousillness in the community and decrease therisks to both mother and infant.There are still large areas of the countrywhich have no specialised facilities. Womenare either admitted without their babies togeneral adult wards, or have to travellong distances to an out of area motherand baby unit.There are approximately 168 mother andbaby beds in England33. There is a nationalshortfall in the number of inpatient motherand baby beds of approximately 50beds (between five and eight unitsdepending on size).There are at least 19 specialised perinatalcommunity mental health teams in England,11 of which are integrated within a motherand baby unit33. All have at least a corestaff of a consultant perinatal psychiatristand community psychiatric nurse. Theseteams provide a maternity liaison service,manage new onset conditions and high riskpatients in the community, pre-conceptioncounselling and will arrange admissions to amother and baby unit when necessary.Fewer than half of all mental health trusts inGreat Britain provide a specialised perinatalmental health team that is staffed by atleast a consultant perinatal psychiatrist andspecialised community perinatal mentalhealth nurses33.In addition, there is a variable and patchyprovision of services often involving asingle or small number of professionalswho provide partial care or “signpostingservices” to women. However noneof these will be able to providecomprehensive services, particularly forwomen with serious mental illness.To summarise, the provision of specialisedperinatal psychiatric care in England ispatchy and inequitable34. Women with acutesevere mental illness needing inpatient careor needing specialised community care arenot able to access the appropriate type andstandard of care as recommended by NICEguidelines and other national guidance29.what do we know about GENERALADULT MENTAL HEALTH SERVICES?Even those areas which do providespecialised perinatal services will need touse crisis and home treatment teams onoccasion when capacity is exceeded andout of working hours.Some Mental Health Trusts do not accessor provide mother and baby units norprovide specialised perinatal communityteams. In these services, women whorequire admission will be on a generaladmission ward without their babies. Theadmission of a mother and infant togetherto a non-specialised adult psychiatric wardis no longer acceptable nor should it takeplace in the UK.Other Mental Health Trusts that do not havespecialised perinatal services of their ownmay refer to out of area mother and babyunits. However, this is rarely done proactivelyor in an emergency. Women thereforeusually spend some time on a general adultadmission ward without their babies before areferral is made and funding agreed.Pregnant and postpartum women inthese areas will be cared for by the usualadult mental health, community, crisis,early intervention, assertive outreach andliaison psychiatric team. In these areas, nospecialised advice and input into their carewill be available to women. In addition itis unlikely that in these areas, women willhave access to specialised advice on themanagement of their pre-existing conditionsin pregnancy, advice on medication inpregnancy and breastfeeding, nor theproactive management of their conditionsduring pregnancy and their risk of apostpartum recurrence.General adult mental health services in areaswithout specialised teams do not usuallyadapt their thresholds for accepting referralsof perinatal patients for intervention orfor admission. This is of great concernbecause of the additional risks posed tothe mother and the infant by perinatalpsychiatric disorder and because disorderspresenting early in the postpartum periodcan deteriorate very rapidly.The provision of care for women with lesssevere conditions in the community is evenmore variable and inequitable.What do we know about current perinatal mental health services (continued)
Guidance for commissioners of perinatal mental health services 11what do we know aboutMATERNITY SERVICES?Midwives are responsible for earlypregnancy risk assessment determiningwhich women will need additional obstetricinput and/or other services. It is part oftheir role to explicitly enquire about awoman’s previous psychiatric history and toappropriately refer on those women whoare at risk of serious perinatal psychiatricproblems. It is also part of their role to askabout a woman’s current mental healthand to know who and how to refer. Theywill need to work collaboratively withprimary care and mental health services.Obstetricians deal with high risk andcomplex pregnancies, including womenwith serious mental illness. They will also seewomen with a range of other psychiatricdisorders in pregnancy and the earlypostpartum period.Some maternity services will have accessto a specialised perinatal communitymental health team, provided by a localMental Health Trust. This service will seeemergencies, provide advice and care aswell as work collaboratively in themanagement of high risk patients.Other maternity services will have torely upon adult mental health servicesincluding liaison services.Some maternity services will have adesignated clinical psychologist.The NICE caesarean guidelines recommendthat women with traumatic stress responsesto childbirth whether in pregnancyor postnatally should have access topsychological interventions at both sub-threshold and threshold levels of posttraumatic stress disorder. However, thisremains poorly implemented18.PARENT-INFANT MENTALHEALTH SERVICESPresent variably throughout England area variety of services, some called perinatalservices, others called parent-infant mentalhealth services. Whilst the focus is on theinfant’s current and future mental health,they treat mothers together with theirinfants who either have parenting difficultiesor are thought to be at risk of them. Someof these services are funded by PrimaryCare Trusts or community health services,some are provided by maternity or children’shospitals, some by adult mental health, andsome by child and adolescent mental healthservices. Some are led by psychologists,working alone or with other psychologists;others include health visitors and midwives.Some services are multidisciplinary. All focuson psychological therapies and parentinginterventions, some include child and familypsychotherapists. They access additionalcare from adult mental health services forserious mental illness. Some have a focus onworking with a particular vulnerable groupsuch as mothers who have been in care orare referred by social services.The provision and function of thesespecialist services is variable and inequitable.There is little available data to estimatethe unmet need but it is likely to beconsiderable. Services with a parentingfocus can substantially improve maternaland infant mental health and improve theemotional social and cognitive developmentof the child. They can offer additionalexpertise, advice and supervision to adultmental health services who care for parentsof young children. They can also provideguidance and training for workers in primarycare and childcare social services. They donot provide comprehensive psychiatric carefor women with serious disorders. They arean important part of an overall perinatalmental health strategy, and a necessarybut not sufficient component of a perinatalmental health service.IMPROVED ACCESS TOPSYCHOLOGICAL THERAPY TEAMS (IAPT)IAPT services are now in place throughoutEngland. Patients may self-refer or bereferred by their general practitioneror health worker. They are triaged bytelephone and offered help using a stepped-care model ranging from guided self-helpthrough to cognitive behavioural therapy(CBT) by specialist workers. Most IAPTservices are also linked to a single-point ofaccess scheme for mental health services.Within the perinatal context they will bemanaging women with mild to moderateconditions, depression and anxiety disorders.It has been acknowledged that a substantialproportion of their clients will be pregnantand postpartum women. A pathfindersite estimated this to be 27% and specificguidance (the IAPT Perinatal PositivePractice Guide) was published by theDepartment of Health 200735.There are concerns about the current IAPTsystem within the perinatal context. Noneof the training schemes for IAPT workersof any grade include training on thenormal emotional changes associated withmotherhood, the change in relationshipsand family dynamics, clinical featuresof perinatal psychiatric disorder and theadditional risks to both mother and infantof perinatal mental health problems.None of the treatment modalities includeany focus on parenting or mother-infantinteraction. It is of concern that womenpresenting initially with depression andanxiety in the early postpartum periodwho subsequently develop a more seriousillness may have access to the appropriatelevel of care delayed.
12 Practical Mental Health CommissioningGENERAL PRACTITIONER,HEALTH VISITOR AND EXTENDEDPRIMARY CARE SERVICESThe majority of women with perinatalmental health problems will be seen bythese services. Frequently, GPs are nolonger involved in the routine care ofpregnant and postpartum women andvaluable information on a woman’s pastmental health may not be accessed bymidwives or Health Visitors. Midwivesmust ensure that GPs know that theirpatient is pregnant and seek to obtain fromthem information about significant aspectsof a patient’s medical and psychiatric history.GPs will see women who refer themselvesor who have been identified by themidwife or health visitor. They can treatuncomplicated non-psychotic depressionand anxiety themselves, refer to IAPT,or for complex or serious disorders, referto perinatal mental health services (or intheir absence adult services).The effectiveness of health visitorintervention in the prevention and treatmentof mild to moderate postnatal depressionis now well established23. Health Visitorswith additional training in listening visitsand cognitive counselling can significantlyimprove the outcome of women withpostnatal depression compared tostandard health visitor care. Interventionsby additionally trained health visitors areclinically and cost effective23.CLINICAL NETWORKSNICE recommends establishing regionalperinatal mental health clinical networks34of perinatal clinicians and resources, andother stakeholders including service users.These networks will advise commissioners,maintain the integration of providers acrossthe care pathway and promote clinicalexcellence. They should be funded and haveformal status and governance.The NHS Commissioning Board has releaseddetails of 12 strategic clinical networks tobe set up in England36. Each of these willconsist of four umbrella networks into whichexisting networks will be placed. One ofthe umbrella networks is for mental health.Perinatal mental health clinical networksshould be further developed across Englandand fit into this structure as “enclave”networks under the mental health strategicclinical network “umbrella”.This will not only promote equity of access,regional integration and clinical excellencebut also provide a conduit for advice to bothspecialised and local Commissioners.The Royal College of Psychiatrists’ Centrefor Quality Improvement (CCQI) hasa quality network for both mother andbaby units and specialised perinatalcommunity mental health teams. Theoverwhelming majority of such teamsare members of the CCQI Network.They have developed consensusstandards of care to which all membersadhere and are subject to annual peerappraisal visits. See www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/qualityandaccreditation/perinatal/perinatalqualitynetwork.aspxWhat do we know about current perinatal mental health services (continued)
Miss Smith, in her late 20shad been under the care ofpsychiatric services since herlate teens for the treatmentof a bipolar illness.She had had a number of admissionsto a psychiatric unit for the treatmentof episodes of mania. She waseventually successfully stabilised onSodium Valproate and had been wellfor at least the last three years. Duringthis time, she had a baby. She didnot have a recurrence of her bipolarillness but there are concerns aboutthe baby’s delayed development. Shesubsequently stopped her SodiumValproate and was discharged frompsychiatric care early in the pregnancyof her second child.During this second pregnancy, hermidwife did not obtain a previouspsychiatric history nor did her generalpractitioner alert the midwife. She wasnot referred back to her psychiatricteam. She remained well during herpregnancy but a few days after deliverythe hospital midwife was concernedabout her “odd” behaviour. She wasseen by a duty psychiatrist who didnot feel that she was mentally ill, didnot note her risk of a recurrence ofher condition and no active steps weretaken for her management.Two weeks after the birth of baby, shewent to see her general practitionercomplaining of feeling depressed. Hedid not think she was ill and attributedher difficulties to her recent separationfrom her partner. She continued todeteriorate and became preoccupiedwith the idea that she might bepregnant again. Six weeks after thebirth of her baby, her family becameconcerned about her mental health andtelephoned the health visitor.On the next day when the healthvisitor had planned to visit, Miss Smithcommitted suicide on a local railway line.What might have made a difference?The psychiatric team managing herbipolar illness should have counselledher about the effects of the pregnancyand childbirth on her bipolar illness,the high risk of recurrence followingdelivery even though she had been wellfor some time and the risks to the babyof taking Sodium Valproate duringpregnancy.The midwife should have asked herabout her previous psychiatric history.She should have obtained furtherdetails from the general practitionerand Miss Smith should have beenreferred back to her psychiatric team.She should have had a peripartummanagement plan. Both she and herfamily should have been aware ofthe high risk of recurrence followingdelivery, known what to do if theybecame concerned and at the veryleast, she should have had closesupport and monitoring in the earlypostpartum weeks by a communitypsychiatric nurse.Both the psychiatrist who saw her afterdelivery and the GP should have beenaware of her high risk of recurrencefollowing delivery and the significanceof these early symptoms.Improved knowledge about perinatalmental health problems in general andthe impact of childbirth on bipolarillness in particular, would undoubtedlyhave improved Miss Smith’s outcome.However, this case also demonstratesthe need for standards of care andsystems of service delivery to be putinto place so that there is a seamlesscontinuity from pre-conception topostpartum care. If a specialisedperinatal community perinatal mentalhealth team had been available in thatarea then perhaps the outcome wouldhave been different.THE NEED FOR CHANGE: A CASE VIGNETTEGuidance for commissioners of perinatal mental health services 13
What would a good perinatalmental health service look like?key principles• A good service requires a perinatalmental health strategy which includes acommissioning framework and servicedesign for populations large enough toprovide a critical mass for all the servicesrequired across a clinical pathway. This willrequire collaboration with providers andother commissioners.• Services should be provided on the basisof the known epidemiology of perinatalconditions taking into account any specialgeographical or socio-economic featuresof the area to be covered.• The delivered population should be thedenominator for service planning andprovision.• Good perinatal mental health serviceswill use an integrated care pathwaydrawn up and agreed by all stakeholdersto ensure the timely access of womento the most appropriate treatment andservice for their condition.• All women should have equal accessto the best treatment for the conditionirrespective or where they live, their socio-economic status, their ethnicity.• Good perinatal mental health servicesshould promote prevention, earlydetection and diagnosis and effectivetreatment.• The right treatment should be evidencebased, effective, personalised andcompassionate. It should meet the needsof both mother and infant, respect thewishes of the mother wherever possibleand compatible with the safety of theinfant and promote optimal care andoutcome for the infant.• A good service should accommodate thecultural and religious practices for a newlydelivered woman compatible with thehealth and safety of mother and infant.• Good perinatal mental health servicespromote seamless, integrated,comprehensive care across the wholeclinical pathway and across organisationaland professional boundaries. Thisrequires close working relationships andcollaborative commissioning betweenmental health services and maternityservices, children’s services and social care,primary care and voluntary organisations.• Good perinatal mental health serviceswill ensure that no woman is needlesslyseparated from her infant and that shereceives the appropriate support, careand guidance to safely care for her infantif she is mentally unwell. If she requiresadmission to a psychiatric unit, she mustbe admitted to a specialised mother andbaby unit unless there are compellingreasons not to do so.• Good perinatal mental health servicesshould include an education and trainingprogramme which should be providedfor non-specialists involved in the careof pregnant and postpartum womenincluding general psychiatric teams,GPs, midwives, Health Visitors and IAPTworkers to ensure the early identificationof those at high risk:s early diagnosiss an understanding of the maternitycontexts the additional clinical featuresand risk factors associated withperinatal disorderss the developmental needs of infants.• Good perinatal services should be partof a clinical network. With so manydifferent agencies and services,providers and differing commissioningarrangements in the pathway of carefrom early pregnancy through to thepostpartum period, it is essential thatsystems are in place to maintain theintegration and collaboration of theseagencies. Part of the perinatal mentalhealth strategy should includea managed (strategic) network madeup of all stakeholders, including patients’representatives, to ensure the functioningof the whole service pathway and toallow for development and innovationas new evidence arises. A clinicalnetwork also has the important functionof advising both commissioners andproviders.• Good perinatal mental health services willinclude a range of services including:s specialised inpatient motherand baby unitss specialised community perinatalmental health teamss parenting and infant mentalhealth servicess clinical psychology services linkedto maternity hospitalss specialist skills and capacity within:z maternity servicesz general adult servicesz IAPTz general practice and the extendedprimary care teamz health visiting. SPECIALISED SERVICES14 Practical Mental Health Commissioning
Guidance for commissioners of perinatal mental health services 15A good specialised perinatal serviceshould be organised on a hub-and-spokebasis so that inpatient mother and babyunits to serve the needs of large populationsare closely integrated with specialisedcommunity perinatal mental healthteams provided by Mental Health Trustsin each locality.Mother and baby unitsA good mother and baby unit shouldbe accredited by the Royal College ofPsychiatrists’ quality network and meettheir standards. It should:• provide care for seriously mentally illwomen or those with complex needswho cannot be managed in thecommunity in late pregnancy and inthe postpartum months• provide expert psychiatric care forseriously ill women whilst at the sametime admitting their infants, avoidingunnecessary separation of motherand infant• offer advice, support and assistancein the care of the infant whilst themother is ill, meeting the emotional anddevelopmental needs of the infant• provide a safe and secure environmentfor both mother and infant• offer timely and equitable access suchthat mothers are not admitted to generaladult wards without their baby prior toadmission• be closely integrated with specialisedcommunity teams to promote earlydischarge and seamless continuity of care.Specialised community perinatalmental health teamA good specialised community perinatalmental health team will be a member ofthe Royal College of Psychiatrists’ qualitynetwork. It will assess and manage womenwith serious mental illness or complexdisorders in the community who cannotbe appropriately managed by primary careservices. It should:• respond in a timely manner and havethe capacity to deal with crises andemergencies and assess the patients in avariety of settings including their homes,maternity hospitals and outpatient clinics• have close working links with adesignated mother and baby unit• manage women discharged from in-patient mother and baby units• work collaboratively with colleaguesin maternity services (including providinga maternity liaison service) and in adultmental health services with women withprior or longstanding mental healthproblems.A good community perinatal mentalhealth service will offer pre-conceptioncounselling to women with pre-existingmental health problems and those whoare well but at high risk of a postpartumcondition.PARENT-INFANT MENTALHEALTH SERVICEA good parent Infant mental healthservice will assess and provide care formothers with complex perinatal mentalhealth problems who have or are at riskof parenting difficulties. These include lesssevere depression, anxiety and personalitydifficulties. They will also work with motherswith more serious problems who haveparenting difficulties. They provide a varietyof psychotherapeutic, psychological andpsychosocial treatments and parentinginterventions. They are able to see mothersand their infants at home as well as in theclinic setting. The service is staffed by amultidisciplinary team whose skill mix andcompetencies reflect their ability to dealwith both maternal mental health problemsand infant mental health issues and theinteraction between the two. At least oneclinician should have the clinical skills andexperience to identify and if necessary referon more serious perinatal problems. Theseservices should work collaboratively withother psychiatric services, both specialisedperinatal services and mother and babyunits, adult psychiatric services and children’ssocial services. These services should provideadvice and training to enhance the skills ofIAPT workers and health visitors.GENERAL ADULT MENTALHEALTH SERVICEA good general adult mental healthservice should:• regard women of reproductive ageas having the potential for childbearing.They should ensure that patientswith serious mental illness receivepre-conception counselling and areaware of the risks to their mental healthof becoming pregnant. They should alsotake into account the possible adverseeffects of psychotropic medication inpregnancy when prescribing to womenof reproductive potential and providewomen with this information.• wherever possible, redirect referrals ofpregnant and postpartum women tospecialised perinatal psychiatric services.Where these do not exist, they should beaware of a differing threshold of responseto all interventions including admissionand the capacity of perinatal conditionsdeteriorating rapidly and being associatedwith substantial morbidity and mortality.
What would a good perinatal mental health service look like? (continued)16 Practical Mental Health Commissioning• if a woman, already under their care,because of a longstanding serious mentalhealth problem, becomes pregnant,they should work collaborativelywith maternity services to develop aperipartum management plan andwherever possible, seek advice andsupport from a specialised communityperinatal mental health team• if admission is necessary, consideradmission to a mother and baby unit evenif this means an out of area placement• demonstrate that their systems andpractice consider their patients as parentsand the welfare of their children.MATERNITY SERVICEA good maternity service should:• communicate with the GP informing themof the pregnancy, asking for informationabout any mental health problems andalerting them if difficulties arise• ensure that women are asked aboutcurrent mental health problems duringpregnancy and the early postpartumperiod• ensure that women at high risk ofa recurrence of serious psychiatricdisorder are identified at early pregnancyassessment are referred for specialisedcare• equip its midwives with knowledge andskills to deal with the normal emotionalchanges of pregnancy and the earlypostpartum period and common statesof distress• have access to a designated specialisedperinatal mental health team able toprovide collaborative working withwomen at high risk of serious mentalillness and emergency assessments• have access to a designated specialisedclinical psychologist to advise and treat,if necessary, women with psychologicaldistress particularly relating to obstetricloss, post traumatic stress disorder andother obstetrically relevant conditions(e.g. needle phobias, previous rape,abuse etc)• ensure that midwives and obstetriciansshould receive additional education andtraining in perinatal mental health.IAPT serviceA good IAPT service should:• ensure that pregnant and postpartumwomen are “fast tracked”, assessedwithin four weeks and effectively treatedwithin three months of referral in line withNICE guidance29• provide additional training to ensure thatthey understand the maternity contextand the additional clinical features andrisk factors associated with perinatalpsychiatric disorder• be able to refer to perinatal mentalhealth services in cases of concern and topsychological services in cases of highercomplexity.GP AND PRIMARY CARE TEAMA good GP and primary care team should:• ensure that patients with serious mentalillness receive pre-conception counsellingand are aware of the risks to theirmental health of becoming pregnant(they should also take into account thepossible adverse effects of psychotropicmedication in pregnancy when prescribingto women of reproductive potential andprovide women with this information)• ensure that women are asked aboutcurrent mental health problems duringpregnancy and the early postpartumperiod in line with NICE Guidelines29.(instruments such as the EdinburghPostnatal Depression Scale should be usedwith caution and in conjunction with aclinical assessment)• communicate with midwives, with thewoman’s consent, if there is a historyof significant mental illness, even if thewoman is well• be alert to the possibility of postnataldepression and anxiety and to the riskof recurrence of pre-existing conditionsfollowing childbirth• use the integrated care pathway so thatearly onset conditions can be closelymonitored and referred on if necessary.HEALTH VISITOR SERVICEA good Health Visitor service should:• have the education, training and skillsto detect mental health problems inpregnancy and the postpartum period, toknow who to refer and to which serviceusing the integrated care pathway• be able to undertake basic psychologicaltreatments such as listening visits andnon-directive counselling and cognitivecounselling group work and understandwhich women would benefit fromadditional visits and support.Health Visitors undertaking psychologicalinterventions will require clinical supervisionfrom an appropriately trained person.
Guidance for commissioners of perinatal mental health services 17DATA AND OUTCOME MEASURESGood perinatal mental health servicesshould systematically gather data on thepatients they see in such a way that it canbe accessed by clinicians to enable themto understand what they are doing andhow they perform and measure outcomes.Commissioners can request data to supportexpected standards of care and contractualarrangements. For both clinical andcommissioning reasons it would be helpfulif this data was standardised across servicesnationally so that comparisons of clinical andcost effectiveness can be made.The current Mental Health Minimum DataSet does not include data on whether awoman is pregnant or in the postpartumyear. This may well be changed in the futurebut in the meantime, it is imperative thatcommissioners expect providers of adultmental health services to record whetheror not female patients are pregnant orpostpartum. Without this, it is not possibleto measure what proportion of pregnantand postpartum women in the care of adultservices are receiving the appropriate care.This also applies to IAPT services.Information also needs to be recorded byspecialised services specifically designedfor pregnant and postpartum women toprovide data on activity, core standardsof expected care and maternal and infantoutcomes as well as risk assessments. Thesewill be over and above the data required forMental Health Trusts37.Outcome Measures for SpecialisedPerinatal Mental Health ServicesThese, together with CQUINS and“dashboards” are currently being developedby the National Perinatal Mental HealthClinical Reference Group and will beavailable in late 2012.
Supporting the delivery of the mental health strategyGood perinatal mental healthcommissioning as describedin this guide will support thedelivery of the English MentalHealth Strategy.Shared objective 1:More people will havegood mental health.By prevention and the early identification,diagnosis and effective treatment of women with perinatal mental healthproblems, the number of women receiving appropriate care and support will increaseand the numbers of their children with short and longer term problems will bereduced.Shared objective 2:more people with mentalhealth problems will recover.By commissioning a perinatal mentalhealth programme that will enable womento access the right treatment at the righttime, they will recover more quickly,establish good relationships and parentingpractices with their infant and resumetheir normal social functioning.Shared objective 3:more people with mentalhealth problems will havegood physical health.The appropriate care by perinatalmental health services of pregnantand postpartum women contributeto improved health in pregnancy andimproved maternal and infant outcomes.Shared objective 4:more people will have a positiveexperience of care and support.Perinatal mental health services providea special understanding of the issuesof new motherhood and the impact ofmental health problems at this time.Shared objective 5:fewer people will sufferavoidable harm.Perinatal mental health services addressthe additional risks to both mother andinfant associated with mental healthproblems in pregnancy and the postpartumperiod and will reduce both maternal andinfant mortality and morbidity.Shared objective 6:fewer people will experiencestigma and discrimination.Perinatal mental health services willgo some way to reducing the stigmaof suffering from mental health problemsassociated with childbirth because oftheir special understanding of theperinatal context.18 Practical Mental Health Commissioning
Guidance for commissioners of perinatal mental health services 19Expert Reference Group Membership• Margaret Oates (ERG Chair)Consultant PsychiatristEast Midlands Perinatal MentalHealth Clinical Network• Judy ShakespeareGeneral PractitionerRoyal College of General Practitioners• Fiona Seth-SmithClinical PsychologistNWL NHS Foundation Trust• Liz McDonaldConsultant PsychiatristHomerton University HospitalLondon• Alain GregoireClinical Director for MentalHealth and Learning DisabilitySouth CentralStrategic Health Authority• Pauline SladeClinical PsychologistInstitute of PsychologyUniversity of Liverpool• Rosie ShepperdConsultant PsychiatristOxford Health NHS Foundation Trust• Chris FitchResearch and Policy FellowRoyal College of Psychiatrists• Roch CantwellConsultant PsychiatristSouthern General HospitalGlasgow• Jonathan CampionConsultant PsychiatristSouth London and MaudsleyNHS Foundation Trust• Ian HulattMental Health AdvisorRoyal College of Nursing• Hilary OsborneManagerChild and Maternal HealthObservatory• Gerry ByrneClinical lead for FamilyAssessment and Safeguarding Serviceand the Infant-Parent PerinatalService (Oxfordshire)South Central Strategic HealthAuthorityDevelopment processThis guide has been written by a groupof perinatal mental health experts, inconsultation with patients and carers.Each member of the Joint CommissioningPanel for Mental Health received draftsof the guide for review and revision, andadvice was sought from external partnerorganisations and individual experts.This guide was led and revised by theChair of the Expert Reference Group incollaboration with the JCP’s Editorial Board(comprised of the two co-chairs of theJCP-MH, one service user representative,one carer representative, and technical andproject management support staff).
20 Practical Mental Health CommissioningReferences1 Department of Health (2011a)No Health Without Mental Health;a cross government mental healthoutcomes strategy for people of all ages.www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124058.pdf2 Bennett, A., Appleton, S., Jackson,C. (eds) (2011) Practical mental healthcommissioning. London: JCP-MH.www.jcpmh.info3 Joint Commissioning Panel for MentalHealth (2012) Guidance for commissionersof primary mental health services.London: JCP-MH.4 Joint Commissioning Panel for MentalHealth (2012) Guidance for commissionersof dementia services. London: JCP-MH.5 Joint Commissioning Panel for MentalHealth (2012) Guidance for commissionersof liaison mental health services to acutehospitals. London: JCP-MH.6 Joint Commissioning Panel for MentalHealth (2012) Guidance for commissionersof mental health services for youngpeople making the transition from childand adolescent to adult services.London: JCP-MH.7 Joint Commissioning Panel forMental Health (2012) Guidance forcommissioners of rehabilitation servicesfor people with complex mental healthneeds. London: JCP-MH.8 Joint Commissioning Panel for MentalHealth (2012) Guidance for commissionersof public mental health services. London:JCP-MH.9 Kendel RE, Chalmers KC, Platz C.(1987). Epidemiology of puerperalpsychoses. Br J Psychiatry. 150:662-73.10 Cox J, Murray D, Chapman G. (1993).A controlled study of the onset, prevalenceand duration of postnatal depression.Br J Psychiatry. 163:27-41.11 Jones I, Craddock N. (2005. Bipolardisorder and childbirth - the importanceof recognising risk. British Journal ofPsychiatry. 186:453-454.12 Davies A, McIvor RI & KumarR. (1995). Impact of childbirth onschizophrenic mothers. SchizophrenicResearch. 16:25-31.13 O’Hara MW, Swain AM. (1996). Ratesand risk of postpartum depression – ameta-analysis. Int Rev Psychiatry 8:37-54.14 Dean C, Kendell RE. (1981). Thesymptomatology of puerperal illness.Br J Psychiatry. 139:128-3315 Heron J, McGuinness M, BlackmoreER, Craddock N, Jones I. (2008). Earlypostpartum symptoms in puerperalpsychosis. Br J Obstetrics andGynaecology. 115(3):348-5316 Cooper C, Jones L, Dunn E, Forty L,Haque S, Oyebode F, Craddock N, Jones I.(2007). Clinical presentation of postnataland non-postnatal depressive episodes.Psychological Medicine. 37(9):1273-8017 Oates M, Cantwell R. (2011).Chapter 11: Deaths from psychiatriccauses in Saving Mothers’ Lives. Reviewingmaternal deaths to make motherhoodsafer: 2006-2008. The Eighth Report ofthe Confidential Enquiries into MaternalDeaths in the United Kingdom (CMACE)Br J of Obstetrics and Gynaecology, Vol118, Sup 1.18 NICE: Guidelines on Caesarean Section.London: Doh 2011.19 Murray L, Hipwell A, Hooper R,Stein A & Cooper P. (1996). The cognitivedevelopment of 5-year-old children ofpostnatally depressed mothers. Journalof Child Psychology and Psychiatry,37:927-935.20 Howard LM, Goss C, Leese M,Thornicroft G. (2003). Medical outcomeof pregnancy in women with psychoticdisorders and their infants in the first yearafter birth. Br J Psychiatry. 182:63-67.21 Pawlby S, Fernyhough, Meins E,Pariante CM, Seneviratne G, Bentall RP.(2010) Mindmindedness and maternalresponsiveness in infant–motherinteractions in mothers with severemental illness. Psychological Medicine,40:18611869.22 Cantwell R, Sisodia N, Oates M.(2002). A comparison of mother & babyadmission to a specialised inpatient servicewith postnatal admissions to genericservices. Proceedings of the Marcé SocietyBiennial Conference, Sydney.23 Morrell CJ, Slade P, Warner R, Paley G,Dixon S, Walters SJ, Brugha T, BarkhamM, Parry G, Nicholl J. (209). Clinicaleffectiveness of health visitor training inpsychologically informed approaches fordepression in postnatal women: pragmaticcluster randomised trial in primary care.Br Medical Journal 338:a3045.24 Leahy-Warren P. (2007) Social supportfor first time mothers: an Irish studyMCN. Am J Matern Child Nurs Nov-Dec;32(6):368-74.25 The Royal College of PsychiatristsPerinatal Mental Health Services CouncilReport CR88 (2000) www.rcpsych.ac.uk/publications/collegereports/cr/cr88.aspx
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Guidance for commissioners of perinatal mental health services 25A large print version of this document is available fromwww.jcpmh.infoPublished November 2012Produced by Raffertys