An audit of obstetric liaison psychiatry in 1984

An audit of pregnant women with severe mental illness referred during the first 2 years of a new perinatal mental health service

The importance of identifying pregnant women at high risk of postpartum psychotic illness has been highlighted by recent enquiries and guidelines. It has been recommended that these women are referred to perinatal mental health services, and that individualised care plans are made prior to delivery. This audit describes a cohort of 45 women, referred to a new perinatal mental health service, with a history of psychotic illness or at risk of developing a postpartum psychotic episode. It describes the characteristics of this group, and the outcomes in terms of relapse and whether their children remained in their care. Thirty-nine women (87%) were seen for assessment. Sixty-seven per cent were under the care of a community mental health team. Twenty-one (53.8%) were well at the time of referral. Planned pregnancies were uncommon (15%). All women seen antenatally had care plans written to address the high risk of postpartum relapse. Ten (26%) women had psychiatric admissions during pregnancy. Fifteen (38%) relapsed or had admissions during the first postpartum year. At 1 year postpartum, 74% women had care of their children; 18% children had been adopted or were in foster care; and the outcome was unknown for 8%.

Consultation-liaison psychiatry in an obstetric service

OBJECTIVE

The aim of this paper is to provide an overview of the work of a consultation-liaison (C-L) psychiatry service to an obstetric inpatient unit in a university affiliated teaching hospital, with the aid of a comprehensive clinical database.

METHOD

The MICRO-CARES clinical database system was used for prospective recording of data on all obstetric inpatients referred to the C-L psychiatry service and the hospital clinical database was used to compare referred inpatients with all obstetric inpatients.

RESULTS

Ninety patients were referred in 3 years, a referral rate of 1.2% of obstetric admissions. There was no bias in referral on age, but there were significantly more unmarried patients in the referred group (p < 0.001). Referred patients had a significantly prolonged length of stay: a mean of 9 days for referred patients, with 6 days for all obstetric patients (p < 0.001). The most frequent reasons for referral were: coping problems, depression, anxiety/fear and past history of major psychiatric illness. The most common DMS-III-R psychiatric diagnoses were: Personality Disorders (19%), Mood Disorders (17%), Schizophrenic Disorders (15%) and Adjustment Disorders (13%). At least one confirmed diagnosis was made in 77% of patients, but 42% of diagnoses remained differential. There were significantly more patients with diseases of the nervous system, endocrine and circulatory disorders in the referred group (p < 0.001). Recommendations of psychosocial interventions predominated over psychopharmacological interventions, and concordance with these was 97% and 98%, respectively. Issues in the relationship of obstetrics and psychiatric C-L services are discussed and future directions indicated.

CONCLUSIONS

The referral rate was low compared with other specialty units. This is probably due to factors inherent in obstetric practice. A wide spectrum of psychiatric disorders was referred, including a higher than expected number of women with postpartum psychotic disorders, the majority of whom were managed successfully in the obstetric ward. There is a need for increased liaison with obstetric and community services and for collaborative research, with a particular emphasis on the prevention of psychiatric morbidity associated with pregnancy.

The psychiatrist in an obstetric/gynaecology hospital: establishing a consultation-liaison service

The establishment and first six months of a psychiatric consultation-liaison service to an Australian obstetric and gynaecology hospital is described. Referrals, diagnoses and follow-up of patients are discussed, with case reports used to illustrate the types of patients seen. Evaluation of the findings and possible future directions for the service are discussed.

Psychological strategies in the prevention and treatment of postnatal depression

Prevention or treatment of most postnatal psychological disorders currently demands the manipulation of psychosocial not biological variables. How we treat women matters in terms of the emotional outcome of pregnancy and ultimately the family outcome. This is confirmed by two types of studies. Firstly, there are the controlled trials of psychological strategies aimed at the prevention or treatment of postnatal mood disturbance. Secondly, there are the studies of the relationship between the type of obstetric and midwifery care and emotional well-being following the birth. There have been far too few of either type of study. Since the rapid advances in medicine which relate to physical outcome have peaked, with mortality rates at an all-time low, the 1990s should see more clinical and research effort devoted to psychological outcomes. Perhaps some progress can now be made in reducing postnatal psychiatric and psychological morbidity.

The psychiatrist in the obstetric unit. Establishing a liaison service

The establishment and first 18 months of a psychiatric liaison service to a general hospital obstetric unit are described. The service was initially intended to predict antenatally those at risk of post-natal depression and to offer follow-up throughout pregnancy and in the post-natal period. However, a large proportion of referrals were of women currently unwell. Furthermore, post-natal follow-up in the community proved difficult. Referrals, diagnoses and disposal are analysed, leading to conclusions about the effectiveness and problem of such a service. The components of a comprehensive obstetric liaison provision are proposed, emphasising the need for strong community links built around a CPN service, allowing adequate postnatal psychiatric care.