From nucleus - November 2018 - a day in the life: perinatal psychiatry
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Perinatal psychiatry is a relatively new specialty, which has gained new funding and media interest over recent months. Women with existing mental health problems are at increased risk of suffering a relapse during their pregnancy or the first year of their baby's life. 1 Those who become unwell, either for the first time or due to a pre-existing diagnosis, require prompt and specialist treatment. 2 Without this, there is a significant negative impact on the woman's safety and well-being and her baby's intellectual and emotional development. Perinatal psychiatrists work holistically with women and their families, in a specialty at an exciting stage in terms of service development and research.
Perinatal psychiatry does not discriminate. Women of all ages and backgrounds may experience mental ill-health while pregnant or in the postnatal period. For some, this may be the first time that they have had contact with mental health services, while others may be well-known to an existing psychiatric team. In both cases, timely and individualised care and intervention is crucial in helping a woman and her family understand what is happening and to help navigate the vast array of different professionals and agencies (such as midwifery, health visiting and social services). This is especially important given that this is an extremely vulnerable and emotional time for the family, with high stakes if things go wrong.
Perinatal psychiatrists hold in mind three factors; the mother, the infant and the mother-infant relationship. My approach changed compared with other areas of psychiatry in which I had worked. Appointments are longer and contact more frequent, with relationships and communication at the heart of the job. There is strong team involvement, with reflection, co-working and sharing ideas actively encouraged.
The combination of close involvement in patients' lives, coupled with real opportunities to make a clinical difference to vulnerable patients, make this a job where God's care is visibly and daily expressed for those who are struggling.
Interested students may be able to spend time with perinatal psychiatric teams during medical school. Perinatal psychiatrists do general adult psychiatric training, which is a six-year programme after the Foundation years. A higher specialist training post in perinatal psychiatry, or some sessions as a newly qualified consultant, would be helpful for those keen to pursue this work.
I met 'A', a woman in her 30s, just prior to the birth of her second child. She'd suffered an episode of postpartum psychosis after the birth of her first child, meaning that the risk of postpartum psychosis following this delivery was substantially increased (from one to two per 1,000 with no previous history to around one in two).
She became unwell and required admission to hospital. However, my prior involvement meant that there was a clear plan, including how to recognise deterioration, and guidance around medication. As a result, her admission was brief (around 72 hours), as she began medication quickly and robust community follow-up was put in place. This approach helped maintain family relationships and reduced the time she was apart from her husband and children, as well as minimising the time she was actively unwell. 'A' recovered well with no evident long-term effects on her bond with either her children or her husband.
Dr Abigail Crutchlow is a perinatal psychiatrist in Surrey
1. Howard LM, Molyneaux E, Dennis CL, Rochat T, Stein A, Milgrom J. Nonpsychotic mental disorders in the perinatal period. The Lancet. 2014;384:1775-88 bit.ly/2PNcEkc
2. Antenatal and postnatal mental health: clinical management and service guidance. NICE CG192 bit.ly/2xyfYZ4