Guideline No 60: Postnatal Depression and Puerperal Psychosis

Postnatal depression and puerperal psychosis
Section 5: Implementation and audit

5.1 Introduction

Implementation of national clinical guidelines is the responsibility of each NHS Trust and is an essential part of clinical governance. It is acknowledged that every Trust cannot implement every guideline immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor compliance. This may be done by a variety of means including patient-specific reminders, continuing education and training, and clinical audit.

Local implementation groups, consisting of representatives from the Health Board, acute and Primary Care Trusts, professionals, partner agencies (e.g. social services), the voluntary sector, and service users should be drawn together to consider the many strands which make up an effective, implementable service.^65,169,170

5.2 integrated care pathways

Integrated care pathways (ICPs) are structured multidisciplinary careplans which detail essential steps in the care of patients witha specific clinical problem.¹⁷¹ ICPs have been in use in NHSScotland since the mid 1990s. Although initially used almost exclusively in hospital settings, they have become increasingly popular across a range of care contexts and for many different conditions, including rehabilitation medicine and mental health. ICPs are based on the premise that, while respect for individuals must dominate the approach to care planning and delivery, there are nonetheless a series of steps that must be followed in relation to every individual with a particular illness or condition if the best possible outcome is to be secured. This includes actions and timetables for assessment, diagnosis, referrals and treatment. Standards for detecting and acting upon symptoms can and must be agreed and adhered to by all professionals involved. The pathway will ideally be held by the patient. ICPs offer service users and the people who care for them a clear idea of what to expect and from whom and they offer an opportunity for audit, in particular, of omissions of care.

There is no evaluative evidence available for the effectiveness of ICPs for perinatal disorders at present. However, ICPs have been demonstrated to increase patient satisfaction, and reduce documentation and duration of care in other conditions.¹⁷¹ ICPs for perinatal disorders have been developed in several Health Board areas throughout Scotland following a recent Health Department letter.⁶⁵

5.2.1 ICP DEVELOPMENTS IN SCOTLAND

The guideline development group contacted all Primary Care Trusts (PCTs) and Health Boards in Scotland for details of current or planned integrated care pathways for postnatal disorders. A 93% response rate was achieved, providing a 'snap shot' view of ICP development in NHSScotland in Spring 2001. Five Health Board/PCT areas had an ICP either already in use or being piloted, two of which were approaching the initial evaluation stage. Three areas were working towards an ICP. Training programmes had been developed either in-house or through modular further education provision (e.g. from Napier and Paisley Universities).

The ICPs currently in use in Scotland all have flowcharts as their core. These have a comprehensive and easy-to-follow format that illustrates the care components, options, roles, lines of consultation and referral for all health professionals involved. They also include specific documentation reflecting the care pathway and, to a greater or lesser extent, have provision to detail variances from this and make comments related to a particular case. The other features identified as common to the ICPs in use in Scotland are outlined overleaf:

Antenatal period

explanation of the ICP to the expectant mother
screening of risk factors with timing and methodology detailed
available options dependent on presence of risk factors
provision of information and education to expectant mothers (and fathers).

Postnatal period

details of screening through use of EPDS
available options related to clinical judgement and the EPDS results
criteria for consultation within primary care
criteria for consultation with and / or referral to secondary care and other support services (statutory or voluntary).

Additional features present in some ICPs

the optional use of the EPDS during the antenatal period
use of locally developed evidence-based checklists for risk factor assessment
midwifery interventions during early postnatal stage e.g. labour debriefing
attempts to provide access to records for all professionals involved, e.g. the use of patient-held records.

ICPs were commonly incorporated within broader information packs which included all or some of the following:

a list of predisposing factors for PND
a copy of the EPDS and information on its appropriate use and interpretation
notes for the prescribing of psychotropic medication to expectant and breast feeding mothers
ethnic and cultural issues relating to pregnancy, baby care, family and mental health
recommended references and sources of information for professionals and mothers
useful contact addresses, statutory and voluntary, local and national
provision of a locally developed information booklet.

The development of an integrated care pathway should involve representatives of all
health professions engaged in the provision of ante- and postnatal care and service user representatives. The ICP should relate to local needs and circumstances.

The ICP should be presented in a user-friendly and succinct format.

The ICP should include specific documentation reflecting the pathway and facilitate
recording of any variance from this to aid evaluation and audit.

Mechanisms should be in place to ensure the orientation of all staff (current and newly appointed) to the ICP. Adequate training and on-going supervision should be available for staff with identified knowledge or skill deficits related to the ICP.

5.3 Key criteria for clinical audit

The following suggested audit criteria are based on consensus within the guideline development group:

Information

Preparation for parenthood programmes includes information on postnatal depression and puerperal psychosis.

Screening

EPDS offered as part of screening for women in the postnatal period.
Intervals at which the EPDS is used and how often it is used should be recorded per patient.
Results of clinical assessments.

Risk and Prevention

Mental health status assessed on a regular basis throughout pregnancy.
Risk factors for postnatal depression and puerperal psychosis identified antenatally.

Management

All women identified with postnatal depression and puerperal psychosis should be offered treatment and follow-up by appropriate professionals in appropriate settings.
Requirement for mother and baby co-admissions monitored.

Prescribing

Appropriate professional staff involved in the prescribing and monitoring of psychotropic medication in pregnant and lactating women.

5.4 Resource implications

5.4.1 ANTENATAL BOOKING

The inclusion of additional questions on history of psychopathology during the history taking at antenatal booking is, in itself, unlikely to lead to significant resource implications. Education of midwives, general practitioners and obstetric staff to routinely ask such questions may, however, have implications for education and training. Services for closely monitoring women with such a history would also need to be in place.

5.4.2 SCREENING

The guideline recommends the use of the EPDS as a screening tool in the postnatal period. A survey of EPDS screening practice carried out by the guideline development group found that screening is undertaken routinely in all but one Primary Care Trust area in Scotland, where its use is variable. The EPDS is used, with one exception, more than once in all Health Board areas in Scotland. The routine use of EPDS postnatally carries significant implications associated with ongoing training, health visitor time for screening and intervention, and facilities in general practice and secondary care for treatment.

5.4.3 PSYCHOLOGICAL MANAGEMENT

The guideline recommends that psychological interventions should be considered when deciding on treatment options. It has not been possible to estimate the resource implications associated with this recommendation. These are likely to vary between different areas of Scotland, which have different numbers of healthcare professionals with appropriate training in techniques such as counselling, cognitive behavioural therapy or interpersonal therapy. The resulting resource implications will therefore vary according to the availability of staff and their associated training needs.

5.4.4 MOTHER AND BABY UNITS

The guideline endorses the Royal College of Psychiatrists' recommendation that dedicated mother and baby units be provided and that the current ad hoc arrangements for admitting mothers with their babies to general psychiatric wards should stop. The Royal College of Psychiatrists recommends provision of six to nine beds per 1 to 1.5 million population.⁶⁸

This recommendation has significant resource implications for Scotland, with additional resources required across all unified Health Board areas. With the current population of 5.12 million, there would be a requirement for 30 to 45 beds for mothers with their babies in appropriate specialist units with a minimum of four beds per unit. Larger units, which span several Health Board areas are recommended by the Royal College of Psychiatrists' report, and may provide greater cost effectiveness.⁶⁸ Given the current ad hoc arrangements, there are unlikely to be cost savings associated with rationalising existing service provision.

5.5 Research questions

What is the role of antenatal education in the prevention of postnatal depression?
What is the role of antenatal screening for postnatal depression and puerperal psychosis?
Do clinicians treat postnatal depression any differently to the way they treat other forms of depression?
What are the most effective screening and assessment tools for postnatal depression and when should they be administered?
To what extent do general practitioners prescribe antidepressants in the postnatal period?
What are the risks and benefits of antidepressants in the management of postnatal depression?
What is the role of hormonal therapies in postnatal depression?
What is the role of physical activity in preventing and treating postnatal depression?
What are the effects of complementary therapies in postnatal depression?
What are the benefits of psychosocial approaches in the management and prevention of postnatal depression?
What is the role of counselling in the management of postnatal depression within the primary care team?
What psychosocial skills are available in the NHS work force of relevance to the management of postnatal depression?
What are the current management approaches for postnatal depression and puerperal psychoses in the UK?
What is the impact of using the EPDS as part of a screening programme for postnatal depression in the community?
What interventions are effective in the management of puerperal psychosis?
Which interventions for postnatal depression improve outcomes for children and when should they be used?
What are the specific benefits to the mother and family of Mother and Baby units?
What are the specific benefits to the mother and family unit of integrated care pathways?
What is the most effective way of screening for postnatal disorders in ethnic minority groups?
What are the long term consequences of psychotropic drug therapy in pregnancy and lactation on fetal and child development?
What are the effects of postnatal mental illness on partners and existing children?