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A giant leap forward

As the second anniversary of the publication of Ireland’s first specialist perinatal mental health services model of care approaches, June Shannon
looks at the implementation of the service to date

November 2017 marked a turning point for maternal mental health in Ireland with the publication of the Specialist Perinatal Mental Health Services Model of Care for Ireland, which for the first time heralded the arrival of a comprehensive perinatal mental health service for mothers and their babies in this country.

Prior to new model, the perinatal mental health service was solely concentrated in Dublin and consisted of just three part-time perinatal psychiatrists in the three Dublin maternity hospitals, while liaison psychiatrists in other parts of the country did their best to meet the mental health needs of  the women and babies in their care.

According to the model of care, in 2016, “there were approximately 64,000 births in Ireland. Approximately 2,240 women are likely to have suffered from more serious mental illness and so would likely benefit from advice from or referral to a specialist perinatal mental health service.”

It is estimated that up to 20 per cent of women in Ireland will suffer from a depressive disorder in the antenatal or postnatal period.

Post-traumatic stress disorder (PTSD) is estimated to occur in up to 3 per cent of maternities and 6 per cent of women following emergency Caesarean section.

Studies also show that between one and two women per 1,000 will develop a puerperal psychosis — a serious mental health condition that without immediate treatment, can tragically lead to suicide and/or homicide.

While extremely rare, suicide in pregnancy does happen and it is one of the leading causes of maternal death.

Between 2013 and 2015, seven new mothers died in Ireland within one year of the birth of their baby — four by suicide.

Pregnancy, therefore, is not a protective factor for mental illness. On the contrary, it is a time in a woman’s life when her mental health and the wellbeing of her baby can be most at risk.

Psychiatry services

Psychiatrists specialising in maternal mental health or perinatal psychiatry see women with a range of mental health illnesses, similar to that seen in the general population. These include depressive disorders, anxiety disorders, and severe and enduring mental illness.

They also see women suffering from PTSD or bereavement related to early miscarriage and stillbirth.

Their work also involves counselling women prior to conception who might have a history of mental illness and want to discuss their medications before they conceive.

It is estimated that 50 per cent of all new mothers with postnatal depression might have been suffering from depression while pregnant that was not identified, underlining the importance of early diagnosis and treatment.

A new model

Dr Margo Wrigley, National Clinical Lead for Specialist Perinatal Health Services, former Clinical Programmes Group Lead for Mental Health and retired consultant psychiatrist was, and continues to be, the main driving force behind the model of care.

Dr Wrigley chaired the expert working group, which developed the model of care, and together with Programme Manager Ms Fiona O’Riordan, is responsible for its implementation.

Central to the model of care is that women who may be experiencing a mental health difficulty are cared for in a holistic manner and receive their care in tandem with their obstetric or midwifery care.

Speaking to the Medical Independent (MI), Dr Wrigley said it was important that the service was set up in this way, as it allowed women to access mental health care in an accessible and acceptable manner, free from stigma.

“It’s about being accessible and acceptable to women and also normalising mental health issues as being part and parcel of pregnancy, as physical issues might be for some as well,” Dr Wrigley added.

Hub-and-spoke

The model of care is based on the six Hospital Groups and the perinatal specialist mental health service is delivered via a hub-and-spoke model. In each of the six Hospital Groups, the maternity hospital with the greatest number of births acts as the hub.

Each hub within a Hospital Group provides a specialist perinatal mental health service via a multidisciplinary team led by a consultant psychiatrist in perinatal psychiatry.

The six hub maternity hospitals are: The Coombe Women and Infants University Maternity Hospital in the Dublin Midlands Hospital Group; the National Maternity Hospital, Holles St, in the Ireland East Hospital Group; the Rotunda Hospital in the RCSI Hospital Group; Galway University Hospital in the Saolta University Health Care Group; Cork University Maternity Hospital in the South/South West Hospitals Group; and University Maternity Hospital Limerick in the University of Limerick Hospitals Group.

Under the model of care, the teams should comprise a full-time consultant perinatal psychiatrist; an NCHD (preferably senior registrar); two mental health nurses (clinical nurse specialist grade); one senior psychologist; one senior occupational therapist; one senior social worker; and one administrator.

 According to the document, in the remaining maternity units (13) referred to as ‘spokes’, the liaison psychiatry team will continue to provide input to the maternity service. This team will be linked to the hub specialist perinatal mental health teams for advice, regular meetings, training and education.

Referral pathway

The model of care sets out a perinatal mental health referral pathway within the maternity services. This ensures that every pregnant woman is screened for any mental health problems by midwives at their initial booking visit.

According to the model of care, “women should be referred to the perinatal mental health services if they are suspected of having a mental illness or have any history of mental illness. Women with milder problems would be seen by a mental health midwife, and those with severer problems by the specialist perinatal mental health team.”

Dr Wrigley explained that this approach meant that the whole range of difficulties were being picked up from the mild-to-severe and it also ensured there is an appropriate response.

“The milder problems will be dealt with by the mental health midwife and then the moderate-to-severe in the hubs will be responded to by the perinatal mental health service or in the spokes, by the liaison psychiatry service,” she said.

The mental health midwife is a relatively new position in Ireland and was pioneered in the Rotunda Hospital in Dublin. Dr Wrigley explained that the professional discipline of mental health midwife is being further developed nationally as part of the implementation of the model of care.

According to the model of care, “the National Women and Infants Health Programme has committed to providing two of these midwives to the four larger hubs and one to the two smaller hubs and each spoke. The role of these midwives is crucial in ensuring parity between physical and mental health in maternity services. They will work with midwives across the maternity services to raise awareness of mental health problems, thereby increasing identification of and response to such problems.”

Dr Wrigley paid huge credit to Mental Health Midwife in the Rotunda Hospital Ms Ursula Nagle, who is taking the lead in developing the discipline of mental health midwife here in Ireland. To date, a total of 16 mental health midwives have been recruited, one for each of the hubs and spokes (mental health midwives were already in place in the Rotunda, the National Maternity Hospital, the Coombe and University Maternity Hospital Limerick), which have been funded by the National Women and Infants Health Programme. 

Implementation

When the model of care was launched in 2017, funding of €1 million was provided and with that, Dr Wrigley set out to ensure that each of the six hubs had a consultant perinatal psychiatrist in place.

In 2018, the programme received €2 million, which was announced Minister of State at the Department of Health with special responsibility for Mental Health Jim Daly when he launched the model of care in November 2017. A further €0.6 million was promised for 2019.

Dr Wrigley explained that the first two hubs to get off the starting blocks were the National Maternity Hospital, with the full-time appointment of consultant perinatal psychiatrist Prof Anthony McCarthy and University Maternity Hospital Limerick (UMHL), with the appointment of Consultant Perinatal Psychiatrist Dr Mas Mahady Mohamad.

Prof McCarthy was appointed full-time Consultant Perinatal Psychiatrist in the National Maternity Hospital in April 2018. He now heads the perinatal mental health service in the hospital (one of the six hubs) and is well on the way to having a full-time multidisciplinary team in place.

Prof McCarthy is one of the longest-serving perinatal psychiatrists in the country. For more than 20 years he ran the service in Holles St single-handedly on a part-time basis 1.5 days a week.

According to Prof McCarthy, before the implementation of the new model, the care available to women in Ireland was “very partial”, with no formal service in place outside of part-time services in the three Dublin maternity hospitals. While he paid credit to some “excellent general liaison psychiatry services in some general hospitals around the country”, he said there was no specialist services or screening, etc.

Describing his experience over the past two decades in Holles St, Prof McCarthy said that while it was “highly enjoyable and rewarding”, it was also “frustrating… knowing it should be so much better and every woman attending every maternity service, and their unborn baby and family, deserved better”.

Prof McCarthy said that the biggest benefit of Ireland’s first perinatal mental health strategy and subsequent model of care is “the provision of better services in those hospitals that had some service before and the development of services for the very first time in so many hospitals, and such necessary and valuable ones, which should have been there a very long time ago”.

First service outside Dublin — Limerick

University Maternity Hospital Limerick is the second-largest maternity hospital outside Dublin, with an average of 5,000 births per year and the sole provider of obstetrical, midwifery and neonatal intensive care to the mid-west region. It serves Limerick, Clare and North Tipperary and also accommodates patients from outside the mid-west region. These include women from North Cork, Tipperary, North Kerry and areas of Offaly.

Until the roll-out of the model of care, there was no maternal mental health service in the mid-west and many women, particularly those with a history of serious mental health difficulties, were forced to travel to Dublin for support.

 Dr Mas Mahady Mohamad was appointed Consultant Perinatal Psychiatrist in Limerick at the end of April 2018 and is responsible for heading the first specialised perinatal mental health service outside of Dublin.

Over the past year-and-a-half, the service in University Maternity Hospital Limerick has gone from strength-to-strength, with the appointment of a mental health midwife (Ms Maria Gibbons), administrator, clinical psychologist, and NCHD, and the team is hoping to appoint two clinical nurse specialists and a social worker shortly. There are also plans to appoint an art and music therapist.

Speaking to MI, Dr Mahady Mohamad said that over the past 15 months, the new service has been receiving an average of 55 new referrals and 115 patient contacts a month.

Dr Mahady Mohamad said that the vast majority of referrals to the service came from the antenatal clinic, where women have screened positive for mental health difficulties at their initial 12-week booking clinic and from local GPs.

“We are seeing a lot of anxiety and also depression. The benefit of having a mental health midwife on the team and [Ms] Maria Gibbons is really excellent and we have been able to help mums with previous negative experiences or traumatic experiences of labour.”

According to Dr Mahady Mohamad, while traditionally mental health services would tend to concentrate on women with more severe conditions like schizophrenia or bipolar disorder, perhaps referring those with milder conditions back to primary care, the new service at UMHL aims to support all women.

The new service in Limerick is also providing pre-conceptual advice for women with more significant mental health difficulties whom, Dr Mahady Mohamad explained, were at an increased risk of becoming unwell or suffering a relapse of their illness in pregnancy and the postpartum period.

Having the specialist perinatal mental health service in Limerick now means that the team can provide specialist advice to women and their GPs, without new mothers having to travel to Dublin for this service.

Dr Mahady Mohamad added that a recent patient feedback survey carried out on 70 mothers who accessed the new service had been very positive, with the vast majority of women citing accessibility as one of the main benefits of the service.

“Some mums felt in the past that their mental health issues weren’t asked about in the maternity hospital; the focus was on physical heath and obstetric health, but more recently, we have been able to look at mental health and they feel that they have been able to get a different experience compared to their previous pregnancies.

“What we find as well, is a lot of the women who had a history of postnatal depression in a previous pregnancy and they would say as well, that maybe they have actually suffered for a number of months before attending their GP of getting help for it. In some cases, we have had mums who have been depressed from a previous postnatal period and it is only in a subsequent pregnancy, now that the service is available, that they have been able to access help,” he said.

While the service in Limerick has seen tremendous progress in the past 15 months, it is not without its difficulties and chief among these is a lack of accommodation for the new multidisciplinary team.

Dr Mahady Mohamad explained that due to the constraints on space, there is currently just one office available for three clinical staff and the team’s clinical psychologist has been forced to see patients off-site in St Camillius Community Hospital.

With more staff due to come on-stream in the coming months, he said they were currently looking at potential solutions to the space difficulties; however, it was not ideal to not have all the team together in one space in the longer term.

After Holles St and Limerick, the next hubs to come on-stream were the Rotunda and Cork.

There are now full-time consultant perinatal psychiatrists in both the Rotunda and Cork University Maternity Hospital and work on fully completing the multidisciplinary teams in these hubs is at an advanced stage. 

The specialist perinatal service at the Coombe is also progressing well. Consultant Perinatal Psychiatrist Dr Joanne Fenton has been providing the service there on a part-time basis prior to the implementation of the new model of care. Dr Fenton will continue in the Coombe on a part-time basis and a second consultant perinatal psychiatrist is due to start at the hospital shortly, bringing it up to a full-time post. The Coombe is also working on building up its multidisciplinary team.

Galway

The last hub to come on-stream is Galway. Unfortunately, due to the current recruitment pause in the HSE, there is still no perinatal mental health service available to the women in the west of Ireland.

Dr Wrigley explained that there is currently a fully-trained consultant perinatal psychiatrist ready to take up the post in Galway University Hospital. However, to date, formal written approval has not been received to recruit the consultant and the members of the specialist multidisciplinary team.

“Given it is so hard to recruit consultants, it is very disappointing not to be able to proceed.  We are continuing to advocate strongly for these posts to be given the formal go- ahead,” she said.

In a statement, the HSE said: “There is not a recruitment ban in place in the HSE. There is ongoing capacity to recruit new funded posts and also to replace critical clinical posts within front-line services. There are, however, controls in place to ensure that the HSE is demonstrating that it is living within the available resources provided to it by Government… Regarding the recruitment of a consultant perinatal psychiatrist in Galway, the recruitment process is currently ongoing.”

Mother and baby unit

After the staffing of the hub-and-spoke hospitals, the next significant project for Dr Wrigley and her team will be the development of the first mother and baby unit on the island of Ireland.

The model of care recommends that one mother and baby unit should be provided as a national unit and this should be based in St Vincent’s University Hospital in Dublin.

Prof McCarthy is leading on the development of the unit, which the model of care recommends should be a six-bedded unit with the capacity of expanding to 10 if the need arises and should be located in the acute mental health unit on the St Vincent’s campus. 

“That’s a really important piece of work for us, but it’s going to take a while,” Dr Wrigley stated.

Progress

In just two short years, the perinatal mental health service in Ireland has taken important strides from one that was largely only available to women in Dublin, to one that is now finally expanding outside the capital.

Despite the recruitment pause that is having a detrimental impact on the establishment of the fledgling service in the west of Ireland, the development of specialist perinatal mental health services in Ireland is a good news story and one that needs to be told, particularly for the many women and their families in Ireland who, after decades of neglect, are finally receiving the care they deserve.

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