Advocacy for mothers with psychiatric illness: a clinical perspective

Maternity in women with schizophrenia and schizoaffective disorder

PURPOSE

Maternity rates in women with schizophrenia have tripled in the past decades, with a current percentage similar to the general population (50-60%). However, mothers with schizophrenia present higher rates of single marital status, and social dysfunction than the general population. In addition, the incidence of unplanned pregnancy, abortions, miscarriages and obstetric complications is higher. This study aimed to describe variables related to maternity in this population.

METHODS

One-hundred and ninety-two outpatient women diagnosed with schizophrenia and schizoaffective disorders were included (DSM-IV-TR criteria) in a two-site study. Psychosocial risk factors, demographic variables and clinical features were recorded in the same visit. Non-parametric tests were used in order to describe variables for likelihood offspring in psychotic women.

RESULTS

One-hundred and forty-seven (76.6%) women suffered from schizophrenia and 45 (23.4%) schizoaffective disorder. Psychotic mothers used to be married/having a partner and presented a later onset of the illness (over 36 years old) compared to non-mothers. In addition, mothers generally presented pregnancy before the onset of illness. Regarding obstetric complications, around the 80% of the sample presented at least one obstetric complication. Although desire or wish of pregnancy was reported in 66.3% of the mothers, rates of planned pregnancy were 25% and only the 47.9% were currently taking care of their children with their husband/partner.

CONCLUSION

Maternity rate is high in this population. This study highlights the need to promote reproductive health care for women with mental disorders and to consider their reproductive life plan. Later onset of disease and being married are potential predictors of maternity in our sample of women with a schizophrenia and schizoaffective disorders while only the half were caring their children at the moment of the evaluation.

Detection and Prevention of Postpartum Posttraumatic Stress Disorder: A Call to Action

The rising maternal mortality rate has drawn increased focus to postpartum depression. However, other mental health conditions, such as birth-related postpartum traumatic stress disorder, have not garnered the same level of attention. The majority of research about postpartum posttraumatic stress disorder (PTSD) is published in journals focused on psychiatry, psychology, and nursing, where this phenomenon is well recognized. In contrast, there is a lack of awareness among most obstetricians. Consequently, few recommendations are available to guide clinical practice. This commentary will present a clinical vignette, provide background that is key to the detection of PTSD, explore available data on postpartum PTSD, and provide recommendations for recognition and prevention of this disorder.

Perspectives of partners of mothers who experience mental distress in the postnatal period: A systematic review and qualitative evidence synthesis

OBJECTIVE

To offer insight and understanding on the perspectives of the partners of mothers who experience postnatal mental distress.

BACKGROUND

Partners have an important role in identifying postnatal mental distress, supporting the mother, and encouraging help-seeking behaviours that may help reduce the associated long-term consequences on the mother and baby.

DESIGN

A qualitative evidence synthesis.

DATA SOURCES

Medline, CINAHL, EMBASE, Maternity and Infant Care, PsycINFO and Scopus were searched from their foundation to May 2017 and updated again in April 2019.

REVIEW METHODS

A total of 2928 studies were retrieved. Studies were screened for inclusion and included studies were assessed for methodological quality using the Critical Appraisal Skills Programme quality assessment tool. Study characteristics and findings were extracted and analysed using thematic synthesis methods.

RESULTS

Twenty-five studies between 1998 and 2018, involving 270 partners from seven countries were included. Four main themes and nine associated subthemes were identified. These main themes were Knowledge, Relationships, Personal Impact and Disclosure.

CONCLUSIONS

This qualitative evidence synthesis provides clear, nonbiased findings on the perceptions of partners of mothers who experience postnatal mental distress. Partners lacked knowledge on how to identify postnatal mental distress and how to access help. The distress impacted on their relationship with the mother and baby, their health and raised questions about disclosure.

RELEVANCE

The findings from this synthesis will contribute to the development of responsive care for families when a mother experiences postnatal mental distress.

Pregnancy in women with psychotic disorders: risk factors associated with mother-baby separation

Pregnancy in women suffering from psychotic disorders is becoming more common. However, this psychiatric disorder is linked to the highest risk of early mother and child separation. The aim of this study was to evaluate risk factors associated with these separations. In an observational, naturalist, and multicentric study, 320 women suffering from a psychotic disorder and jointly hospitalized with their child in one of the sixteen mother-baby units (MBUs) in France and Belgium between 2001 and 2010 were assessed for risk factors associated with mother-child separation. Eighty-seven (27.2%) mothers were separated from their infant at discharge from MBUs. Early separation was linked to the placement of the mother herself in an institution in childhood (OR 4.44; CI 95% 1.12-18.69), to the mother being single (OR 3.84; CI 95% 1.38-11.44), to early hospitalization of the baby in neonatology (OR 2.88; CI 95% 1.27-6.59), and to maternal psychiatric decompensation during pregnancy (OR 2.60; CI 95% 1.15-6.20), independently from maternal neglectful behaviors. Low family/social support showed a trend towards association with separation (OR 2.17; CI 95% 0.91-5.42). This study shows that separation is mostly linked to mothers' environmental and interactive past and current history, to the child's health, and to maternal mental health decompensation. The identification of these factors is essential to implement antenatal prevention and social programs for these women. Further studies should focus on the long-term development of children of schizophrenic mothers, whether or not they have been placed, in order to help clarifying the impact of the risk factors.

Advancing the knowledge, skills and attitudes of mental health nurses working with families and caregivers: A critical review of the literature

Involving and supporting the family members and caregivers of people with mental illness is essential to high-quality mental health services. However, literature suggests that there is a lack of engagement between family members and mental health nurses (MHNs). Lack of knowledge among MHNs is often cited as one of the main reasons for this lack of engagement. The aim of this review was to explore the knowledge, skills and attitudes that are required by MHNs to enable to them to work more effectively with families affected by mental illness. A literature based critical review was used to access and review 35 papers in order to extract concepts that could inform the design of eLearning materials to assist MHNs advance their knowledge in this area. Two overarching themes were identified; 'Mental health problems and the family' and 'Working with the family'. From these themes, the knowledge, skills and attitudes required to work more effectively with families are described. The findings from this review provide a descriptive account of the knowledge skills and attitudes that are required for effective family work. In addition, the review provides an empirical foundation for education programmes in the area.

Incidence of child and adolescent mental disorders in children aged 0-17 with familial high risk for severe mental illness - A Danish register study

BACKGROUND

Offspring of parents with severe mental illness (SMI: schizophrenia, bipolar disorder or major depressive disorder) have an increased risk of developing mental disorder themselves. In childhood they may have neurodevelopmental delays, cognitive deficits and social adversities. We aimed to investigate if these individuals are more at risk of being diagnosed with a mental disorder during childhood/adolescence in a national sample.

METHODS

By linking Danish registers we established a cohort consisting of all persons born to parents with SMI with those born to parents without SMI serving as a reference group. Incidence rate ratios (IRRs) for offspring diagnosed with a mental disorder by parental mental disorder were calculated.

RESULTS

Offspring of parents with SMI showed increased IRR for all diagnoses of child and adolescent mental disorders compared to the reference group. Offspring of mothers with schizophrenia had IRR of 2.60 (CI: 2.50-2.70, N=2550) of having any diagnoses, for children of fathers with schizophrenia IRR was 2.06 (CI: 1.97-2.16, N=1901) and for offspring of two parents with schizophrenia IRR was 4.57 (CI: 3.94-5.31, N=175). For individuals with a mother with bipolar disorder the IRR was 2.29 (CI: 2.09-2.50, N=502), with a father 1.77 (CI: 1.74-1.87, N=320), whereas the IRR was 2.96 (CI: 2.63-3.34, N=264) if both parents had unipolar depression.

DISCUSSION

Offspring of parents with a SMI have a higher risk of being diagnosed with any child and adolescent mental disorder. The IRRs for all diagnoses during childhood were increased by a factor 2-4. Having two ill parents increased the IRR.

A mixed methods study of collaboration between perinatal and infant mental health clinicians and other service providers: Do they sit in silos?

BACKGROUND

Women at risk of poor perinatal mental health benefit from coordinated approaches to care. Perinatal and infant mental health (PIMH) services have been established to support women with social and emotional needs. This paper examines the nature and extent of collaboration within two PIMH services in Australia.

METHODS

A convergent, embedded, mixed methods design was used. Two hundred and forty four medical records were reviewed, 13 professionals (six PIMH clinicians, two PIMH service managers, and five key stakeholders) and 11 women service-users participated in semi-structured interviews.

RESULTS

Three broad themes were drawn from the data, Theme 1: We don't sit in silos … but they do, Theme 2: We need to enhance communication, and Theme 3: Collaboration is hard work. Perinatal and infant mental health clinicians believe they work collaboratively with other service providers. Key stakeholders and documentation in the medical records reveal that collaboration is nominal.

CONCLUSIONS

Professionals believe that collaboration is essential for women with complex needs. Perinatal and infant mental health clinicians are skilled at building relationships with women, however further support is needed to build trusting relationships with other service providers. Women service-users also need to be involved in the collaborative process to become equal partners in their care.

Engaging women at risk for poor perinatal mental health outcomes: a mixed-methods study

Risk factors for poor perinatal mental health are well known. Psychosocial assessment and depression screening during the perinatal period aim to identify women at risk for poor perinatal outcomes. Early intervention programmes are known to improve the mental health outcomes of women and infants. Key to any intervention is initial and ongoing engagement in the therapeutic process. This mixed-methods study reports the proportion of women who engage/do not engage with services and their characteristics, as well as the strategies clinicians use to engage women. Data were collected by reviewing medical records, interviewing perinatal and infant mental health (PIMH) clinicians, their managers, key stakeholders, and women service users. Analyses identified that most (71.3%) women referred engaged with the PIMH service. Themes related to non-engagement are 'time to rethink' and 'stigma'. Themes reflecting the engagement strategies used by PIMH clinicians are initial engagement: 'back to basics' and 'building trust', therapeutic engagement: 'making myself useful', engagement at discharge: 'woman or clinician led', and models that facilitate engagement.

A delicate balance: intervention with mothers with dual diagnosis and their infants

Purpose

– Women with mental illness, substance-dependence or dual diagnosis are at increased risk of losing care of their children which leads to poorer outcomes for mothers. The purpose of this paper is to explore the service response to substance-dependent mothers, many of whom had a dual diagnosis, and reports outcomes for their infants from the perinatal period to the end of each infant's first year.

Design/methodology/approach

– This was a longitudinal case study of 20 women substance-dependent women and their associated care. Semi-structured interviews were held with mothers recruited from a specialist alcohol and other drug obstetric service at infant age six weeks, six and 12 months. Structured interviews were also held with counsellors from the obstetric service at infant age six weeks. Child protection (CP) workers were interviewed at infant age six weeks, six and 12 months regarding mothers involved with the service.

Findings

– By 12-month follow-up, CP services had been involved with 14 mothers and eight had lost the legal care of their infant. Mothers who retained legal care were more likely to have addressed their drug use and less likely to be in a domestically violent relationship. Domestic violence, homelessness and maternal recidivism to crime tipped the scales in favour of protection of the infant through removal from maternal care, essentially leaving mothers with minimal support for reunification and reduced incentive for treatment.

Research limitations/implications

– Reliance on mothers’ self-reports was a limitation of the study. The small sample size restricts generalisability of findings.

Practical implications

– Key workers should engage women (and their partners) during the perinatal period to provide support, advocacy and case-management to enable substance-dependent mothers to safely parent.

Originality/value

– This is one of few studies to report long-term outcomes for mother/infant dyads when substance-dependence and/or mental health are present that allows women to speak for themselves. The prospective design provides a contemporaneous account of events as they unfolded in situ.

A Role for Oxytocin in the Etiology and Treatment of Schizophrenia

Schizophrenia is a chronic debilitating neuropsychiatric disorder estimated to affect 51 million people worldwide. Several symptom domains characterize schizophrenia, including negative symptoms, such as social withdrawal and anhedonia, cognitive impairments, such as disorganized thinking and impaired memory, and positive symptoms, such as hallucinations and delusions. While schizophrenia is a complex neuropsychiatric disorder with no single "cause," there is evidence that the oxytocin (Oxt) system may be dysregulated in some individuals. Further, treatment with intranasal Oxt reduces some of the heterogeneous symptoms associated with schizophrenia. Since Oxt is known for its modulatory effects on a variety of social and non-social behaviors, it is perhaps not surprising that it may contribute to some aspects of schizophrenia and could also be a useful therapeutic agent. In this review, we highlight what is known about Oxt's contributions to schizophrenia and schizophrenia-related behaviors and discuss its potential as a therapeutic agent.

'My special time': Australian women's experiences of accessing a specialist perinatal and infant mental health service

Women who have few social supports, poor health and a history of stressful life events are at risk of poor mental health during the perinatal period. Infants of parents whose parenting capacity is compromised are also at risk of adverse outcomes. Specifically, poor perinatal mental health can impact maternal-infant attachment. To identify women at risk of poor perinatal mental health, psychosocial assessment and depression screening in the antenatal and early postnatal periods are recommended. This qualitative study is part of a larger mixed methods study, which explored two specialist perinatal and infant mental health (PIMH) services in New South Wales (Australia). Eleven women who had accessed and been discharged from a PIMH service participated in either face-to-face or telephone interviews. Data were transcribed verbatim and analysed thematically. One overarching theme, 'my special time' and three sub-themes, 'there is someone out there for me', 'it wasn't just a job' and 'swimming or stranded: feelings about leaving the service', were identified. The themes describe the women's experiences of being a client of a PIMH service. Overall, women reported a positive experience of the service, their relationship with the clinician being a key component. Findings from this study highlight the importance of the relational aspect of care and support; however, women need self-determination in all therapeutic processes, including discharge, if recovery and self-efficacy as a mother are to be gained. Importantly, further research is needed about how clinicians model a secure base and how mothers emulate this for their infants.

Therapeutic interventions in perinatal and infant mental health services: a mixed methods inquiry

Perinatal mental health disorders potentially have long-term negative sequelae for women, their infants and their families. Multidisciplinary perinatal and infant mental health (PIMH) services are an emerging specialty in mental health designed to improve mother-infant outcomes. This mixed methods study explored the characteristics of women referred to a specialist PIMH service and the therapeutic interventions that PIMH clinicians use. Women referred to the service were identified with multiple and complex risk factors. Perinatal and infant mental health clinicians use a range of interventions, dependent upon their training, such as family of origin work/genograms, non-directive counseling, and strategies to manage anxiety and depression. Clinicians also emphasized the therapeutic relationship and the interventions they use within an attachment-based framework, which warrants further research.

A collaborative approach to perinatal and infant mental health service delivery in Australia

OBJECTIVE

The objective of this paper is to report on the development and implementation of a community-based perinatal and infant mental health day program for mothers with psychiatric illness. The program was initiated through interagency collaboration between adult mental health, infant mental health and community child health services in Queensland, Australia in response to calls for an integrated approach that could be delivered state-wide if successful. Preliminary results of the program's evaluation are provided.

METHOD

A pre-post survey design was used to assess the influence the program had on maternal mental and emotional well-being and the maternal-infant relationship. Twenty-one women receiving treatment for perinatal mental illness gave consent to attend the 6-week day program integrating three currently separate and discrete services: adult mental health, infant mental health and community child health.

RESULTS

Clinically and statistically significant improvements were observed for maternal mental health, and parent-infant relationships following the program.

CONCLUSIONS

These findings support interagency collaboration between adult mental health, infant mental health and community child health services to deliver services to women with mental illness with newborns and their families. The utility of using a collaborative approach in a community setting endorses more comprehensive and longer-term evaluation of effectiveness and cost benefit.

Discrimination in relation to parenthood reported by community psychiatric service users in the UK: a framework analysis

BACKGROUND

Experienced discrimination refers to an individual's perception that they have been treated unfairly due to an attribute and is an important recent focus within stigma research. A significant proportion of mental health service users report experiencing mental illness-based discrimination in relation to parenthood. Existing studies in this area have not gone beyond prevalence, therefore little is known about the nature of experienced discrimination in relation to parenthood, and how is it constituted. This study aims to generate a typology of community psychiatric service users' reports of mental illness-based discrimination in relation to becoming or being a parent. A secondary aim is to assess the prevalence of these types of experienced discrimination.

METHODS

In a telephone survey 2026 community psychiatric service users in ten UK Mental Health service provider organisations (Trusts) were asked about discrimination experienced in the previous 12 months using the Discrimination and Stigma Scale (DISC). The sample were asked if, due to their mental health problem, they had been treated unfairly in starting a family, or in their role as a parent, and gave examples of this. Prevalence is reported and the examples of experienced discrimination in relation to parenthood were analysed using the framework method of qualitative analysis.

RESULTS

Three hundred and four participants (73% female) reported experienced discrimination, with prevalences of 22.5% and 28.3% for starting a family and for the parenting role respectively. Participants gave 89 examples of discrimination about starting a family and 228 about parenting, and these occurred in social and professional contexts. Ten themes were identified. These related to being seen as an unfit parent; people not being understanding; being stopped from having children; not being allowed to see their children; not getting the support needed; children being affected; children avoiding their parents; children's difficulties being blamed on the parent's mental health problem; not being listened to; and being undermined as a parent.

CONCLUSIONS

This research highlights the need for: greater support for parents with mental illness, those wishing to have children, and those who lose access or custody; services to better meet the needs of children with a mentally ill parent; training about discrimination for professionals; and parenting issues to be included in anti-stigma programmes.

Collaboration and integrated services for perinatal mental health: an integrative review

BACKGROUND

  An integrative review was undertaken to synthesise the research related to professionals' perceptions and experiences of working in collaborative and integrated models of perinatal care for women with mental health problems.

METHOD

  A search of the databases CINAHL, Medline, PubMed, Psychinfo and Scopus was conducted. Studies were limited to English language papers published from 2000 to 2010. Fourteen papers were included in the review.

RESULTS

  The overarching theme identified in the review related to the process of 'making it happen'. Eight key elements were identified as central components of this process: funding and resources for collaboration; shared vision, aims and goals; pathways and guidelines; continuity of care; building relationships and trust; role clarity; training and education of staff and support to work in new ways.

CONCLUSION

  Perinatal mental health is an emerging field that is particularly challenging as it requires professionals to work across disciplines and timeframes, where there is a risk of dichotomising care, compounding existing barriers to service uptake. Professionals need resources and to feel supported to change clinical practice and work in more collaborative ways. The voices of women and families are missing in the literature.

Experiences of motherhood when suffering from mental illness: a hermeneutic study

Being a mother is inseparable from women's existential life. Mothers with mental illness struggle with conflicting and distressing feelings related to motherhood. They seldom obtain the necessary support to increase their control over the determinants of their role as a mother, thus their opportunity of improving their own and their children's mental health is weakened. The aim of this study was to explore the experiences of being a mother with mental illness. The research question was: How can mothers' experiences of motherhood when suffering from mental illness be understood? The understanding emerged through a hermeneutical interpretation of the empirical material on four different levels of abstraction. The inductive-deductive approach, inspired by the philosophy of Gadamer, was used. The mothers' experiences were understood in their way of struggling to become good enough mothers, managing to become the mother they longed to be, being present in the caring relationship with their child, as well as being recognized as a mother and living openly and honestly in relationships with others. Addressing the existential needs of motherhood is important for their improvement and recovery, as well as for promoting their children's mental health and well-being.

Intervention to prevent child custody loss in mothers with schizophrenia

Depending on jurisdiction, time period studied, and specifics of the population, approximately 50 percent of mothers who suffer from schizophrenia lose custody of their children. The aim of this paper is to recommend interventions aimed at preventing unnecessary custody loss. This paper reviews the social work, nursing, psychology, psychiatry, and law literature on mental illness and custody loss, 2000-2011. Recommendations to mothers are to (a) ensure family health (b) prevent psychotic relapse, (c) prepare in advance for crisis, (d) document daily parenting activities, (e) take advantage of available parenting resources, and f) become knowledgeable about legal issues that pertain to mental health and custody. From a policy perspective, child protection and adult mental health agencies need to dissolve administrative barriers and collaborate. Access to appropriate services will help mothers with schizophrenia to care appropriately for their children and allow these children to grow and develop within their family and community.

Increased mortality risk among offspring of mothers with postnatal depression: a nationwide population-based study in Taiwan

BACKGROUND

There is compelling evidence that children of mothers with postnatal depression (PD) experience poor developmental outcomes. However, no studies have specifically ascertained the risk of mortality for offspring during preschool years, the most catastrophic outcome in the vulnerable period. This nationwide population-based study aimed to investigate whether maternal depression in the first year after giving birth was associated with increased mortality risk among their preschool children aged up to 5 years.

METHOD

Three nationwide population-based datasets [the National Health Insurance Research Database (NHIRD), birth certificate registry and death certificate registry] were linked in this study. A total of 10 236 offspring of mothers with PD were recruited, together with a comparison cohort of 81 888 births matched with the affected women in terms of maternal age and year of delivery. Each child was traced for 5 years from delivery between 2001 and 2003 until the end of 2008 to determine mortality during preschool years.

RESULTS

During preschool years, 98 (0.96%) deaths were identified among the offspring of mothers with PD and 470 (0.57%) children in the comparison cohort died. For children up to 5 years old, exposure to maternal PD was independently associated with a 1.47-fold [95% confidence interval (CI) 1.16-1.87] increased mortality risk, after adjusting for family income, urbanization level and the characteristics of mother, father and infant. The risk of death by unnatural causes was even higher (about 2.23 times the risk, 95% CI 1.34-3.70) among exposed offspring.

CONCLUSIONS

PD places preschool children at significantly increased risk of mortality, especially from unnatural causes of death.

Homelessness, a state of mind?: a discourse analysis

This article presents a discourse analysis of a woman's written account of mental illness and homelessness. In her preparation as a co-presenter at a conference for decision- and policy-makers, Anna wrote eight distinct drafts of her speaking notes; each time emphasizing different aspects of her experiences with mental illness and homelessness. By sharing her preparatory writings, Anna offers a rare insight into the 'evolution' of the thinking that went into representing her story to an audience of professionals. In addition, this analysis represents an interpretation and alternative forum to learn from Anna's story.