Managing postnatal depression: Lessons for the NHS from the voluntary sector

1. Dr Anna Conway Morris, MRCPsych, Royal Edinburgh Hospital, Edinburgh Managing postnatal depression: Lessons for the NHS from the voluntary sector

2. Background information • Postnatal depression (PND) is a devastating mental illness affecting 10-15% of women following childbirth. • PND has been shown to adversely affect social and emotional development in children of affected mothers. • PND often goes untreated due to women’s reluctance to attend for treatment.

3. The consequences of PND • For affected women: chronic depression, self-harm, suicide, incapacity to work, failure to breastfeed. • For their children: developmental delay, behavioural difficulties and depression in later life. Boys are particularly affected. • For families: depression in partner, financial hardship, marital breakdown.

4. Standard PND management • All women screened for PND by health visitors following childbirth. • Women with PND are cared for by their GP and/or psychiatric services. • Treatment mostly with antidepressants and/or talking therapies. • Access to NHS talking therapies varies widely.

5. Questions for NHS services • How can we encourage women with PND to seek help in order to improve outcomes for them and their children? • How can we help them attend for treatment on a regular basis? • What should services for these women and their families look like?

6. PND Project • The PND project offers individual/group counselling, art therapy, telephone support and a free creche to women with PND. • There are several such projects run by Crossreach in Scotland. • The projects are staffed by trained counsellors and volunteers.

7. Aims of research How does PND impact on the lives of women attending the project? How does the project “work” for patients and their families? How do women perceive services they receive at the project?

8. Methods • All patients attending the project were invited to participate in the study. • Informed consent was obtained. • All participants were interviewed individually using a semi-structured questionnaire. • The interviews were audiotaped and transcribed. All data was analysed using a qualitative approach.

9. The participants • Of 33 women attending the project 31 agreed to take part. • All patients had been diagnosed with PND and referred to the project by their health visitor. • Patients attend once a week for therapy. • Most patients attend for 6 months to 2 years and there is no time limit set on therapy.

10. Demographic features of study group

11. Psychiatric history in patients

12. Results • Push and pull factors in help seeking • Push and pull factors in attendance • Clients’ views on service development

13. Factors encouraging help seeking • Supportive partner or other family member • Good relationship with GP or health visitor • Previous personal history of depression or being aware of the symptoms of depression

14. Women’s voices “If it hadn’t been for my partner, it would have been taken out of my hands to care for my baby” (M, 29) “My health visitor kept visiting but it took us a long time for her to ask and question it and for me to admit, that yes, I thought I had postnatal depression.” (N, 37)

15. Factors discouraging help seeking • Fear of being stigmatised or judged harshly by others. • Fear of children being taken into care by health visitor or social services. • Lack of social support and child care to attend for appointments. • Not recognising symptoms of depression or normalising symptoms as part of motherhood.

16. Women’s voices “ I didn’t admit to being depressed. I just always said it was tiredness. It was probably something inside of me that wouldn’t accept that I was depressed because of my son.” (A, 36). “ My health visitor thought I was really depressed but I had that fear that if I admit it, my son will be taken away.” (C, 30)

17. Factors encouraging attendance • Welcoming atmosphere • Choice of therapeutic options • Time to build relationships • Telephone support • Free creche

18. Women’s voices “ I find group therapy better than going to a counsellor for one on one therapy. It is easier to talk to real girls with real life situations. And you feel good about helping other people with your experiences.” (K, 28). “Coming here gave me the confidence that my daughter could be with someone else and be okay.” (R, 34)

19. Factors discouraging attendance • Restrictive opening hours “ I have to leave work to come here and nobody knows where I am going apart from my boss. It upsets my whole day.” (J, 34) • Frequent change of therapists “We had a leader that has left. When we found out, everybody shut up. We didn’t want to speak.” (K, 24)

20. Future service developments • Nearly all participants thought it would be useful to offer services to fathers. • Two thirds of women were in favour of offering services during pregnancy. • Most women felt that sessions for mothers with their babies were already offered by other agencies.

21. Conclusions • Reluctance to seek help can be modified by a good relationship with health professionals • Women with PND rate services that offer a range of therapeutic options, long term input to build relationships, free childcare and telephone support. • There is demand for services including the whole family and for preventative measures during pregnancy.

22. Acknowledgements • I would like to thank the patients, staff and volunteers at the PND project who made this study possible. • I would also like to thank Dr Sandra Davies for inspiring this study and for Dr Michael van Beinum for his help and supervision.