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Psychiatric mother and baby units (MBUs) are recommended for severe perinatal mental illness, but effectiveness compared with other forms of acute care remains unknown.
We hypothesised that women admitted to MBUs would be less likely to be readmitted to acute care in the 12 months following discharge, compared with women admitted to non-MBU acute care (generic psychiatric wards or crisis resolution teams (CRTs)).
Quasi-experimental cohort study of women accessing acute psychiatric care up to 1 year postpartum in 42 healthcare organisations across England and Wales. Primary outcome was readmission within 12 months post-discharge. Propensity scores were used to account for systematic differences between MBU and non-MBU participants. Secondary outcomes included assessment of cost-effectiveness, experience of services, unmet needs, perceived bonding, observed mother–infant interaction quality and safeguarding outcome.
Of 279 women, 108 (39%) received MBU care, 62 (22%) generic ward care and 109 (39%) CRT care only. The MBU group (n = 105) had similar readmission rates to the non-MBU group (n = 158) (aOR = 0.95, 95% CI 0.86–1.04, P = 0.29; an absolute difference of −5%, 95% CI −14 to 4%). Service satisfaction was significantly higher among women accessing MBUs compared with non-MBUs; no significant differences were observed for any other secondary outcomes.
We found no significant differences in rates of readmission, but MBU advantage might have been masked by residual confounders; readmission will also depend on quality of care after discharge and type of illness. Future studies should attempt to identify the effective ingredients of specialist perinatal in-patient and community care to improve outcomes.
Background: Perinatal mental health difficulties are highly prevalent. In England, the Improving Access to Psychological Therapy (IAPT) programme provides evidence-based psychological treatment, predominantly in the form of brief manualized cognitive behavioural therapy (CBT), to people with mild to moderate depression or anxiety. Yet little is known about the experiences of women referred to IAPT with perinatal mental health difficulties. Aims: The aim of this qualitative study was to investigate how women view IAPT support for perinatal mental health. We also gained the perspective of IAPT therapists. Method: Semi-structured interviews were conducted with twelve women who had been referred to and/or received therapy from IAPT during the perinatal period. Additionally, fourteen IAPT therapists participated in two focus groups. Thematic analysis was used. Results: Key themes centred on barriers to access and the need to tailor support to (expectant) mothers. Women and therapists suggested that experiences could be improved by supporting healthcare professionals to provide women with more help with referrals, better tailoring support to the perinatal context, improving perinatal-specific training, supervision and resources, and offering a more individualized treatment environment. Conclusions: Overall, women reported positive experiences of support offered by IAPT for perinatal mental health difficulties. However, services should seek to facilitate access to support and to enable therapists to better tailor treatment.
The UK Conservative government has committed to increasing funding for domestic violence and abuse (DVA) services in England but this has not been extended to Wales. Wales has however made clear commitments to developing these services, through the Violence against Women, Domestic Abuse and Sexual Violence (Wales) Act 2015. This article draws on focus groups and interviews with fifty-three service users and thirty-one purposively selected service providers to explore their perspectives on Violence Against Women (VAW) service provision in Wales. There are clear shared priorities and some tensions between service user and provider perspectives on appropriate services. Drawing on the long history of intermediate co-production in VAW services, the article argues that co-production at the strategic level is now needed. This would provide an arena for resolving tensions, setting standards and developing funding criteria to enable co-produced VAW policy and build resistance to funding cuts.
In this paper, we report on how formative research was utilised to design a social marketing campaign commissioned by a Primary Care Trust within an area of high social deprivation in the North of England.
Men represent the majority of perpetrators of domestic violence and there is increasing interest in developing services for this group with the aim of changing abusive behaviour. However, men are known to be less likely to engage in help-seeking behaviours, and this reticence has been attributed to the social construction of masculinity. A further barrier for men seeking help in relation to domestic violence is the cultural construction of domestic violence.
Formative research was undertaken to explore the perceptions and attitudes of a community population of males (n = 84). Focus groups explored barriers and drivers to help-seeking and identified effective communication messages.
These findings were translated into the ‘Strength to Change’ campaign that minimised stigmatisation and blame while emphasising help-seeking as a ‘strength’ rather than a perceived weakness. Social marketing techniques facilitated an in-depth appreciation of local barriers to help-seeking and generated context-specific messages to encourage take-up of a new service for male perpetrators.
The aims of this study were to improve responses to students in distress and who are feeling suicidal, to help practitioners to increase their responsiveness to those at high risk of suicide and to develop effective responses to those affected by their deaths. The study sought to build a detailed picture of students’ patterns of service use.
National suicide prevention strategies emphasise that suicide prevention requires the collaboration of a wide range of organisations. Among these, primary care services play a key role in relation to suicide prevention for young people in crisis.
This study, undertaken between 2004 and 2007, focused on 20 case studies of student suicide that took place in the United Kingdom between May 2000 and June 2005. It adopted a psychological autopsy approach to learn from a wide range of informants, including parents, friends, university staff and the records of coroners or procurator fiscals. Twenty families gave permission for their son’s or daughter’s death to be included in the study and agreed to participate in the study. Informants were interviewed in person and the data were analysed thematically. Analysis of the case study data suggested that in a number of cases students had failed to engage with services sufficiently early or in sufficient depth. Primary care practitioners need to be proactive in communicating concerns about vulnerable students to student support services. At local levels, collaboration between student support and National Health Service practitioners varied considerably and channels of communication need to be developed.
Exploring the five principles of the newly enacted Mental Capacity Act 2005, this article sets these in the context of day-to-day decisions over care and treatment. These areas figure strongly in the lives of people who have problems making decisions, but there is little consideration of them in contrast to major decisions about financial planning, deprivation of liberty, and healthcare and treatment. Social policy has often found it difficult to encroach upon areas covering intimate and family-based care relationships or the private domain of care at home. This legislation touches on this controversial area.
Increasingly, attention is shifting away from a focus on postnatal depression to the recognition that depression may be a recurrent experience in many women’s lives with the perinatal period constituting a time of particular vulnerability. This article reports on a study undertaken in one primary care trust which explored mothers’ and practitioners’ experience and awareness of antenatal depression and considered the service response offered by midwives and health visitors. The mothers who participated in focus groups felt ill prepared for the possibility that depression could occur during pregnancy. They identified social and role expectations as well as professional attitudes and service delivery models as barriers to disclosing feelings of depression during this period. The midwives and community nurses surveyed placed rather less emphasis than mothers on the value of continuity of care in pregnancy in promoting disclosure of mental health problems. Community midwives appeared less confident than health visitors in detecting and responding to antenatal depression but both groups of professionals had little knowledge of relevant community services. Co-ordination between midwives and health visitors appeared limited and contact with mental health services was lower than might have been anticipated; the general practitioner (GP) was still seen as the key resource in cases of antenatal depression. However, many of the mothers participating in the study found GPs unresponsive to expressions of negative feelings in pregnancy. The article considers approaches for increasing awareness and detection of antenatal depression and improving co-ordination between services.
This chapter reports on the interviews undertaken with mothers with mental health problems in the two study sites, A and B. While there has been significantly more readiness in recent years to acknowledge and identify differing professional perspectives in work with families with mental health needs (Falkov, 1998; Weir and Douglas, 1999; Reder et al, 2000a), the consequences of these differences for families have not as yet been fully explored. That research which explores the perspectives of parents with mental health needs has emphasised parents’ experiences of being pathologised by services (Hugman and Phillips, 1993) and of services being targeted on crises rather than delivered in a preventive or aftercare form (Green and Hyde, 1997). Our study aimed to interrogate service users’ experience of both mental health and child care services in more depth and to examine need alongside attitudes to services.
For this stage of the research, health and social services staff in the two study sites were asked to identify mothers whose children had been the subject of a child protection case conference in the previous 18 months and who had a diagnosis of mental illness. This could be a diagnosis provided by any health professional and could include diagnoses of personality disorder and repeated episodes of self-harm, but not diagnoses of substance misuse alone. Fewer interviews took place in site B, despite repeated attempts by local practitioners to recruit appropriate interviewees for the study. In this area, in particular, a number of practitioners from different agencies identified the same women as potential participants: this might be explained by the smaller size of the locality.
A total of 11 women were interviewed across both sites using a structured interview schedule devised by the research team. This schedule was developed with the help of the project advisory groups in each site. Representatives from service user groups were included on both steering groups, and their comments were particularly valuable in relation to the development of these interview schedules. An initial pilot interview was completed with one mother and the schedule was refined in the light of her feedback.
A second series of slightly less structured interviews was undertaken after a period of at least six months. A total number of eight second-stage interviews were completed. Three of the original sample proved unwilling to be interviewed or inaccessible (one having moved out of the area).
This final chapter draws together the key themes of our research and develops some recommendations for policy and practice. The study findings have relevance for transactions between practitioners and users as well as for the relationships between different groups of professionals and their organisations. Our proposal for a dyad of keyworkers in cases where mothers have mental health problems and where there are child protection issues is designed to impact on each of these interfaces. However, some of the problems identified for mothers with mental health problems are not only confined to how professional roles are defined and played out, but also concern the availability and distribution of resources. Access to resources is increasingly determined at a national level, although new initiatives still tend to have local beginnings. Therefore, the messages here are directed at policy makers at all levels as well as at the full range of practitioners in statutory and voluntary settings.
The centrality of trust
The interviews with mothers highlighted their capacity to distinguish clearly between different professionals and their primary responsibilities. Mothers were aware that child care social workers’ predominant task was the protection of children's welfare. They resented the scrutiny of their parenting by child care social workers and experienced child protection case conferences, supervised contact and other formal processes as threatening and disempowering. Such accounts are consonant with the evidence of other research studies (Cleaver and Freeman, 1995; Farmer and Owen, 1995) that have explored families’ perspectives on the child protection process. However, for mothers with mental health problems, the alienation and powerlessness experienced in relation to the child protection system are likely to exacerbate existing feelings of low self-esteem, loss of control and stigma.
The women in this study also criticised child care social workers’ lack of availability and the attitudes they displayed towards service users. Such comments may in part be a response to the statutory role of child care social workers with its implicit threat of coercion; however, they also reflect child care social workers’ limited opportunities for the exercise of interpersonal and counselling skills in the job. These restrictions can be attributed to a combination of limited resources and an emphasis on a bureaucratic, care management model of practice that prioritises assessment and the construction of care packages over therapeutic interactions with service users.
Since no previously validated questionnaires that addressed the issues tackled by the study were available, the research team was faced with the task of developing one that was appropriate for a wide range of professional groups, spanning both mental health and child care services. Qualitative approaches have been used extensively in the pilot phase of projects, both to inform the formulation of research questions and the selection of variables for study and to develop survey instruments (Barbour, 1999). In this study, focus group discussions with health and social care staff working in an area outside the two research sites were held to assist the development of contextually relevant questions for inclusion in the survey of professionals (Dumka et al, 1998). Focus groups have been shown to be particularly effective in accessing members’ constructions and attributions of meaning (Bloor et al, 2001), and are thus ideal for testing the acceptability and interpretations of the language used in questionnaires. Since the aim was to develop a survey instrument that was relevant for a variety of professional groups, a range of practitioners needed to be involved in this stage of the study. Given the potentially large number of workers involved in service provision for families where parents have mental health problems, it was not feasible to hold profession-specific groups. Instead, the research team opted for three interprofessional focus groups. These mirrored or approximated the real-life context of case conferences and had the added advantage that they were likely to afford insights into the issues arising for professionals in the practice environment (Kitzinger and Barbour, 1999).
Since the principal reason for holding focus groups was to inform the design of the questionnaire, it was more important for recruitment purposes than is usually the case in focus group research to convene groups that were representative of the wider population to be studied (Bloor et al, 2001). Therefore, the groups involved a range of staff with different professional roles and remits, working in both the statutory and voluntary sector, and with varying levels of seniority and experience. Those recruited included representatives of the following professional groups: child care social workers; health visitors; adult psychiatrists; mental health social workers; community psychiatric nurses (CPNs); children's guardians; practitioners from voluntary organisations serving mental health services users, and from similar organisations for children; and middle managers from both community health and social services.
This book examines interprofessional work with families in which mothers have a mental health problem and where there are also concerns about child protection. Breakdowns in interprofessional collaboration, issues of risk and resources are all addressed. Mothers' views and experiences are contrasted with professional perspectives.
This chapter examines the ways in which the mental health needs of mothers are conceptualised within health and social care. Mothering is simultaneously identified as a prime site of origin for women's mental health problems and a key determinant of children's mental health. It is widely acknowledged that mothering is a stressful, demanding activity that offers many opportunities for failure and consequent loss of self-esteem. However, it is also defined as a cluster of psychological and practical skills which deliver nurturing and care to other family members. ‘Competent mothering’, difficult as it is to pin down, is construed in both popular and professional debates as the foundation of children’s mental health. While the successful exercise of parenting skills and the intimate relationships that mothers experience with their children can be a source of satisfaction and pride, in the context of mothers with mental health needs, research has tended to focus on adverse outcomes. Positive outcomes for parents with mental health problems and their children are rarely noted.
The dual representation of motherhood is supported by a wide range of popular media images of mothers (Coward, 1997). These include the ‘harassed mum’, the ‘dual-career mum’, the ‘stay-at-home mum’, the ‘feckless teenage mum’, the ‘glamorous Victoria Beckham mum’ and (an image popularised by Cherie Booth, the wife of the Prime Minister) the ‘juggling mum’. The juxtaposition of images and the diversity evident in these representations of motherhood reflect mothers’ subjective experience of ambivalence. Featherstone (1997) identifies this ambivalence as a key characteristic of modern mothering and suggests that, in the face of the conflict between the adult's need for autonomy and the child's need for dependence, some feminist theorists have ducked the question of how children's developmental needs are best met. Mental health and child care services have also been slow to identify the significance of this conflict for their clients, and it can be argued that services have made little progress in offering mothers solutions to the dilemmas that arise when their own mental health needs conflict with their children's needs for secure parenting.
The chapter explores the different theoretical models that have been developed to explain women's mental health needs. In particular, research that draws attention to social roles and life events, especially experience of abuse, will be discussed.
Identifying difficulties in interprofessional coordination
This chapter reports on practitioners’ experiences of interprofessional communication and coordination and examines their views on which services were best equipped to take a lead in work with families where mental health needs and child care concerns coincided. Our survey asked respondents to identify the frequency of difficulties in coordinating work on such cases with a wide range of professional groups. As Table 10.1 shows, 35% of practitioners reported always or frequently having problems in coordinating their work with GPs, while 27% reported the same frequency of problems with adult psychiatrists. These rates were substantially higher than the levels of difficulties identified for other professional groups. For example, only 17% reported consistent or frequent difficulties in working with child care social workers, and 12% had a similar level of problems with community psychiatric nurses (CPNs).
The professionals with whom respondents were least likely to experience difficulties were health visitors: 58% reported that they hardly ever or never had problems in coordinating work. Lupton et al (2001) report similar levels of satisfaction from other professionals commenting on their work with health visitors. The other groups of practitioners with whom respondents appeared to have fewer problems were child and family centre workers (49% reported hardly ever or never having difficulties) and child care social workers (42% reported hardly ever or never having difficulties).
Child care social workers, child and family centre workers and children's guardians (formerly known as Guardians ad Litem, this group of professionals will all have trained and practised as child care social workers) were the professional groups most likely to report frequent or constant difficulties with GPs. Over half of the respondents in these three professional groups described a high level of difficulties. In contrast, GPs did not identify similar difficulties in relation to these groups. Few health visitors and CPNs reported high levels of problems with GPs. The professionals who themselves worked in primary care settings, such as health visitors and GPs, were most likely to report very seldom having difficulties in coordinating work with GPs. About half of CPNs sometimes had difficulties with GPs. Professionals working in adult psychiatry were also likely to report that they sometimes had difficulties.
The child care social workers’ evaluations of work with GPs are consonant with the findings of both Hallett's (1995) research and Lupton et al's (2001) study.