Pregnancy, and the adaptation to parenthood, can be exciting times in a woman’s life, but can also present a unique set of challenges to mental health. Around one in five women will experience an identifiable mental health problem during the perinatal period (defined here as the period between conception and the infant’s first birthday). Even in the best of circumstances, the perinatal period can be a time of particular vulnerability to mental health problems; this vulnerability is even greater where there is a history of mental disorder, particularly during a previous pregnancy.

Timely intervention to optimise mental health in the perinatal period is of utmost importance, given the risks represented by untreated perinatal mental health problems. These risks concern the safety of both mother and infant, the potential impact on the mother-infant relationship, and the possibility of measurably poorer social and behavioural outcomes for the infant throughout their lives.

We would usually encourage the trial of mental health treatments in Primary Care before a referral to PNIMHT is considered.

These interventions might include:

• Computerised therapies (these might include Silvercloud Space for Perinatal Wellbeing)
• Brief psychological intervention from a Primary Care Mental Health Worker, or Guided Self-Help Worker
• Internet-enabled CBT (CBT delivered via web-chat with a ‘live’ therapist). These treatments have been commissioned by Scottish Government, and are delivered by ieso. The coordinator of these referrals for North NHS Highland can be contacted on nhsh.nhiecbt@nhs.scot
• The use of psychotropic medication (the PNIMHT have protected time from a specialist perinatal clinical pharmacist, who can offer consultation about the use of psychotropics in the perinatal period. This can be accessed via Clinical Dialogue, or by referral to the PNIMHT)

Referrals can be made to the PNIMHT by any member of Health or Social Care staff, either:

• Via SCI Gateway, (Perinatal and Infant Mental Health-Highland North)
• OR By sending a completed referral form to nhsh.nhighlandPNIMHT@nhs.scot

Urgent referral

The PNIMHT are not able to process urgent or emergency referrals.

Requests for urgent or emergency mental health-related assistance should be directed to the local Community Mental Health Team or the Mental Health Assessment Unit at New Craigs Hospital, Inverness as normal, regardless of whether or not the patient is in the perinatal period.

Red flags that might indicate the need for an urgent response include:

• Recent significant changes in mental state or emergence of new symptoms
• New thoughts or acts of violent self-harm
• New and persistent expressions of incompetency as a mother or estrangement from the infant

Routine referral

The PNIMHT accepts routine referrals of women who:

• Are in the perinatal period (conception to one year post-partum)
  Where there is a concern about infant mental health, and/or the parent-infant relationship, referrals can be made up to the infant’s third birthday.
• Are (or will be) the primary caregiver of the infant
• Are experiencing (or are at significant risk of) an identifiable mental health problem. See preconception advice, below.
• Are registered with a GP in the North Highland area

Additionally, at least one of the following criteria must apply:

• Appropriate primary care interventions have been tried, but have not been successful
• The mental health problem is actively interfering with the woman's ability to access appropriate maternity, health visiting, or other health care (e.g. severe needle phobia, phobia of childbirth, etc)
• The mental health problem is actively interfering with the mother’s abililty to bond with or parent her infant effectively
• The mental health problem originated as a result of a previous pregnancy or birth trauma; pregnancy loss; or infant health problems / death

Referral pathway for Needle Phobia in Pregnancy

Devised jointly between PNIMHT, midwifery and obstetric colleagues: click here

Preconception advice

The PNIMHT also offers preconception advice to any woman with a diagnosis of bipolar affective disorder, schizophrenia (or other psychotic illness), or previous major postpartum mental illness, OR who are currently prescribed a mood stabiliser or an otherwise complex psychotropic medication regime. In these circumstances, it is not necessary that the woman is pregnant NOR that she is actively unwell for a referral to be accepted.

Referral Processing

Referrals to PNIMHT are triaged at a weekly clinical meeting, and an outcome letter sent to the patient, referrer and GP. Where a referral is accepted, the letter will include information about PNIMHT, a named point of contact, and information about the first appointment. Where a referral is returned to to the referrer, reasons will be given for this decision, as well as suggestions of alternative sources of appropriate assistance in each particular case.

Assessment

When a referral is accepted for allocation to the PNIMHT, an assessment appointment with the patient will be arranged by telephone if possible, which will be followed up with a confirmation letter. An attempt will be made to match the most appropriate representative of the PNIMHT to each patient, taking into account the particulars of the clinical situation being presented.

Patients will be offered an assessment on a face-to-face basis (usually in a clinic setting), via Near Me, or by telephone. This decision will be made on the basis of clinical need, the practical arrangements required to travel, access to technology and privacy, and patient choice. At the patient’s discretion, other people (e.g. family members, friends, other staff members and/or an advocate) can be involved in an assessment session, and patients are advised in writing that this is the case. At the end of an assessment session, a decision will be made jointly between the PNIMHT representative and the patient about what further intervention (or signposting) may be required. Following assessment, the clinician will prepare a summary of the assessment for distribution to the referrer, GP (if not the referrer), and the patient.

Treatment

Following assessment, if there is indication for a formal intervention that can be delivered by PNIMHT, we would aim to start this within six weeks of receiving the referral. PNIMHT members are trained in a range of therapeutic interventions including:

• Cognitive Behaviour Therapy (CBT)
• Eye Movement Desensitisation and Reprocessing (EMDR)
• Interpersonal Psychotherapy (IPT)
• Video Interaction Guidance (VIG)
• Circle of Security Parenting (CoSP)

Where there is indication for an intervention which cannot be delivered within PNIMHT, we would direct the patient to an alternative service, and/or make an onward referral.

Perinatal advice meeting / Professional reflection (PAMPR) sessions:

Anyone working in a professional capacity with a woman in the perinatal period (or up to the infant’s third birthday where there are concerns about parent-infant relationship and/or infant mental health) can book a half-hour Perinatal Advice Meeting / Professional Reflection (PAMPR) session. This can be booked by using the following link, which is also included in PNIMHT email signatures, and in the quarterly PNIMHT newsletter: /calendar/PAMPR/bookings/

Or by using the following QR code:

Staff members who book a PAMPR session will be asked to complete a Pre-PAMPR Information Form and email it to nhsh.nhighlandpnimht@nhs.scot

Pre-PAMPR form: (link to be added)

During the course of the PAMPR session, the staff member will be encouraged to reflect on the problem under discussion, and some recommended steps will be agreed. A Post-PAMPR Session Record will be produced, for distribution to the staff member who booked the session. With their agreement, this will be made available via SCI Store and Care Portal, and the recommendations sent to the patient.

Other Formal Multidisciplinary Liaison

PNIMHT members will play an active role in Care Programme Approach, where patients on their caseload are subject to these procedures.

PNIMHT members will endeavour to attend ward rounds (in person, or remotely) where patients on their caseloads are admitted to a psychiatric inpatient setting e.g. New Craigs Hospital or the Mother and Baby Unit (St John’s Hospital, Livingston). They would also expect to be actively involved in discharge planning and transfer back to the community setting as appropriate. In these circumstances, PNIMHT staff would aim to have contact with the patient within three working days of discharge to the community.

Given that, at present, the PNIMHT contains no medical staff, there may be occasions where the Community Mental Health Team is a more appropriate source of intervention, for example, where a mental health problem occurs in a complicated medical context, or the involvement of a consultant psychiatrist is required for statutory reasons.

In certain situations, a local CMHT will be a more appropriate source of intervention than the PNIMHT, particularly where there are risks that cannot be well managed via remote means. This may be particularly relevant where patients are registered in outlying areas, where geographical factors may preclude in-person involvement from the PNIMHT. There may also be situations in which a CMHT is able to offer a wider range of appropriate interventions (for example, group treatments) that would not be viable to run via the PNIMHT. In these scenarios, the PNIMHT would expect to liaise with the CMHT to agree the respective roles for each service, and this may result in the PNIMHT and CMHT having parallel involvement in shared cases.

Discharge from the PNIMHT will be a collaborative process with patients, and will be negotiated as the agreed intervention nears its conclusion. Upon discharge, a summary document outlining the intervention, and any resultant changes in the presentation of the referred problem, will be sent to the referrer and patient (and to the GP, if they are not the referrer).

There is no time bar on re-referral of patients discharged from the PNIMHT, provided they still meet the referral criteria outlined above.

Third sector organisations: 

• Advocacy Highland: Advocating on behalf of those with mental ill health, learning disabilities, personality disorders, autistic spectrum disorders, or dementia
• Breastfeeding Network: an independent source of support and information for breastfeeding women and others.
• Dadpad: Resources for new and expectant dads, developed with the NHS
• Dads Rock: Improving outcomes for children, inspiring dads and families
• Fathers Network Scotland: improving children's lives through the positive involvement of dads, father-figures & whole families
• Held in our Hearts: pregnancy and baby loss support
• Home-Start: Support for families
  • Home-Start East Highland 
  • Home-Start Caithness   
• Inverness Counselling Hub: Counselling for perinatal women is pre-funded by Scottish Government, and therefore free to users 
• LATNEM (Let’s All Talk, North-East Mums): Peer support for mums and birthing people 
• PANDAS Foundation: Postnatal Depression Awareness and Support 
• Peep: Supporting parents and children to learn together 
• Pelvic Partnership: support and information about pregnancy-related pelvic girdle pain 

Patient information leaflets: 

• Perinatal and infant mental Health Team.
  A patient information leaflet about the NHS Highland (North) Perinatal and Infant Mental Health Team. The leaflet contains contact details, and describes what the team is for, and the services they can provide. It also outlines the circumstances in which someone might be referred to the team.
• Crying and your baby
• Emotional support for families in the Neonatal Unit

• The work of PNIMHT aims to reflect the Women & Families Maternal Mental Health Pledge and Infant Pledge: PMHN-Women-Families-Pledge.pdf (nhs.scot)
• The design and service delivery of PNIMHT is informed by the Perinatal Mental Health Network Scotland document: Delivering effective services
• Whilst the PNIMHT does not have any Psychiatry cover at present, the Royal College of Psychiatrists: Standards for Community Perinatal Mental Health Services have been used to guide some aspects of service evaluation:
• SIGN 169 Perinatal mental health conditions
• Best Use of Medicines in Pregnancy (Bumps): provided by the UK Teratology Information Service (UKTIS), Bumps provides scientific information to health care providers on the effects that use of medicines, recreational drugs and chemicals during pregnancy may have on the unborn baby.