Postpartum psychiatric disorder: who should be admitted and to which hospital?

The NIMHANS (National Institute of Mental Health and Neuro Sciences) Maternal Behaviour Scale (NIMBUS): Development and validation of a scale for assessment of maternal behaviour among mothers with postpartum severe mental illness in low resource settings

PURPOSE

A mother's behaviour towards her infant is an important aspect of assessment in postpartum severe mental illness (SMI). The existing tools for this purpose need formal training, require time and do not include certain aspects of maternal behaviour. Hence, there is a need for a tool that may overcome some of the above problems and be simple to use, especially in limited resource low and middle income countries (LAMIC) settings. The NIMHANS Maternal Behaviour Scale was constructed for this purpose.

METHODS

The 16 items were compiled based on 100 detailed assessments of mother-infant dyads. The NIMBUS is rated based on observations and information from caregivers, health assistants and nurses. The scale which has six domains was administered to 51 mother-infant dyads admitted to an MBU to establish construct validity and internal consistency. Inter-rater, and test retest reliability were also established. External validity was established using the Bethlem Mother infant Interaction Scale (BMIS) and the Postpartum Bonding Questionnaire (PBQ).

RESULTS

The scale was found to have adequate inter-rater and test retest reliability (Cohen's kappa > 0.81). The Cronbach's alpha for internal consistency was 0.94 and it showed adequate external validity when used with the BMIS (R = 0.947, p = 0.000) and PBQ.

CONCLUSION

The NIMBUS appears to be a useful tool to assess maternal behaviour among mothers with SMI in the postpartum especially in LAMIC situations where observations are often made by family members and health assistants rather than trained perinatal nurses.

A survey of specialist perinatal mental health services in England

Aims and Method

To survey current specialist perinatal psychiatric provisions and opinion about these services in England. A brief semi-structured confidential questionnaire was circulated to the lead clinician or manager responsible for perinatal services of the 78 mental health trusts in England.

Results

Fifty-seven trusts (73%) responded. In 26 trusts (46%), availability of either specialist in-patient facilities and/or intensive home treatment facilities were reported. In only 13 trusts (23%) was there evidence of provision of services covering both in-patient and community components. The number of mother and baby units or their equivalents has reduced in the past decade. The services were generally considered to be inadequate nationwide and opinion remains divided about the best approach for providing them.

Clinical Implications

There is a need for a recommendation of a national standard provision of perinatal services by mental health trusts.

Treatment - mother-infant inpatient units

Infants of parents with psychiatric disorders may be particularly vulnerable and have a higher risk of developing psychiatric disorders in adulthood. Until the second half of the 20th century, women and infants were cared for separately. Today, hospitalisation of women with their babies in psychiatric mother-baby units enables psychiatric care of women and promotion of parent-infant interactions and child development. The distribution of psychiatric mother-baby units around the world, as well as within countries, varies strongly. Reasons for this may be related to the absence of national perinatal mental health policies related to psychiatric mother-baby unit location, differences in sources of referral for admission, and criteria for psychiatric mother-baby unit admission. Two principal national epidemiologic studies, in England and in France and Belgium, have described issues related to discharge from such care, as have smaller local studies, but no epidemiologic studies have yet demonstrated that joint inpatient psychiatric mother-baby unit care is cost-effective compared with separate care.

The contribution of Australian residential early parenting centres to comprehensive mental health care for mothers of infants: evidence from a prospective study

BACKGROUND

Australia's public access residential early parenting services provide programs to assist parents who self-refer, to care for their infants and young children. Treatment programs target infant feeding and sleeping difficulties and maternal mental health. There is limited systematic evidence of maternal and infant mental health, psychosocial circumstances or presenting problems, or the effectiveness of the programs. The aim of this study was to contribute to the evidence base about residential early parenting services.

METHODS

A prospective cohort design was used. A consecutive sample of mothers with infants under one year old recruited during admission to a public access residential early parenting service for a 4 or 5 night stay in Melbourne, Australia was recruited. They completed structured self-report questionnaires, incorporating standardised measures of infant behaviour and maternal mood, during admission and at one and six months after discharge. Changes in infant behaviour and maternal psychological functioning after discharge were observed.

RESULTS

79 women completed the first questionnaire during admission, and 58 provided complete data. Women admitted to the residential program have poor physical and mental health, limited family support, and infants with substantial behaviour difficulties. One month after discharge significant improvements in infant behaviour and maternal psychological functioning were observed (mean (SD) daily crying and fussing during admission = 101.02 (100.8) minutes reduced to 37.7 (55.2) at one month post discharge, p < 0.001; mean (SD) Edinburgh Postnatal Depression Scale at admission = 11.3 (5.7) reduced to 6.78 (4.44), at one month, p < 0.001) which were sustained at six months. Participant satisfaction with the program was high; 58 (88%) found the support of the nurses and 50 (75%) the social support of other mothers very helpful.

CONCLUSIONS

This psycho-educational approach is an effective and acceptable early intervention for parenting difficulties and maternal mood disturbance, and contributes to a system of comprehensive mental health care for mothers of infants.

The association between pregnancy processes, preterm delivery, low birth weight, and postpartum depressions--the need for interdisciplinary integration

Pregnancy and peripartum/perinatal periods are characterized by significant biologic as well as psychosocial processes and changes that influence the 2 individuals at focus (mother and fetus), as well as their interactions with the immediate environment. Multiple intertwined pathologic pregnancy processes (hormonal, biologic, stress and other mental occurrences) may lead to fetal distress, preterm delivery (PTD), low birth weight (LBW), and other delivery complications as well as to postpartum disorders. PTD and LBW in particular have been demonstrated to be associated with significant mortality as well as short- and long-term morbidity. Underlying processes and risk factors for PTD, LBW and postpartum disorders may overlap. Their impact on the offspring is compounded. Currently, the multiple clinical and research disciplines that are concerned with the various aspects of pregnancy, delivery, and postpartum period are not conceptually and practically integrated. Specifically, obstetricians are more concerned with delivery complications, whereas mental health professionals are concerned with postpartum depression. An interdisciplinary approach is needed for better understanding of developmental processes and the development of measurements and interventions to prevent long-term impact on the offspring.

The history of Mother-Baby Units (MBUs) in France and Belgium and of the French version of the Marcé checklist

Until fairly recently, mentally ill mothers were separated from their new-borns because of the potential danger to the baby. Over the past 50 years, however, we have learned more about the perinatal period, with the development of child psychiatry and interest in maternal postpartum disorders. This knowledge has led psychiatric departments to develop new ways to provide care without separating mentally ill mothers from their babies. Joint full-time admissions began in Great Britain in 1948. The first Mother-Baby Unit (MBU) in France opened in 1979 and in Belgium in 1990. In 2003, there are 17 MBUs in France and 3 in Belgium. From 1995 to 1998, Odile Cazas and Nine Glangeaud, working with a group of child and adult psychiatrists and psychologists, adapted the English Marcé Checklist to the French and Belgian health and child protective systems and added items useful for research.

Nature, severity and correlates of psychological distress in women admitted to a private mother-baby unit

OBJECTIVE

To characterize psychological distress of women admitted with their infants to a private hospital mother-baby unit.

METHODS

A cross-sectional self-report survey including standardized psychometric questionnaires of consecutive admissions to Masada Private Hospital Mother-Baby Unit, Melbourne between 1 June and 30 November 1997. Scores on the Profile of Mood States, Edinburgh Postnatal Depression Scale, Intimate Bonds Measure, Parental Bonding Instrument, Social Support Questionnaire, Vulnerable Personality Scale self-report instruments and responses to a structured self-report questionnaire. Of the women admitted, 109 out of 146 participated in the survey.

RESULTS

Clinically significant fatigue was almost universal in this cohort. Psychological distress clustered into three distinct groups: (i) probable depression; (ii) fatigue and distress; and (iii) fatigue only. It may be more accurate to conceptualise postpartum psychological distress either as a continuum, or as a wide range of distinct states, rather than as a dichotomous condition in which individuals are categorized as being or not being cases. In this cohort, the severity of distress was associated most consistently with the quality of a woman's relationship with her partner and with infants who were difficult to settle.

CONCLUSIONS

It appears that some cases of psychological distress in women following childbirth may be inaccurately conceptualised as depression. Clinically significant fatigue and moderate distress are distinguishable from depression, and warrant specifically tailored assessment strategies and treatments. Following the birth of a baby, the partner of a mother has a strong influence on her emotional health and should be included in any assessment and intervention.

Psychiatric illness in women: a review of the function of a specialist mother-baby unit

OBJECTIVE

The aim of this paper is to describe a specialist program in a psychiatric mother-baby unit and to review the characteristics (including mothering skills) and outcomes on discharge of 36 women consecutively admitted to the unit over an intensive 6-month observation period. Changes in admissions to the same unit over 10 years were also compared.

METHOD

Consecutive admissions were studied in terms of demographics, ethnicity, diagnosis, psychiatric history, psychiatric information and mother-infant data.

RESULTS

The majority of women admitted suffered from schizophrenia or other psychotic disorders, with the second largest diagnostic criteria being depression. For 20 mothers, this was the first psychiatric admission and most admissions were voluntary. The mean length of stay was 21.7 days, representing a highly significant decrease in stay when compared to the past 10 years in the same unit. Mothering skills were found to be incompetent or only passable in 57% of women. A small improvement occurred by discharge, and the majority of women were not separated from their infants.

CONCLUSIONS

The critical need to support these women and their infants in the long term was highlighted, with recommendations of outpatient and day programs, as well as supported accommodation.