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Clinical work with mothers and babies

A description of the perinatal psychiatric work in a consultation-liaison psychiatric department in Sweden


 

Contrary to especially Anglo-Saxon countries, Sweden lacks dedicated perinatal psychiatric services. Maternal mental health care is included in general maternal health care but cooperative care models for patients in need of psychiatric expertise are lacking. The aim of this text is to exemplify the development of a perinatal psychiatric service based on a local agreement at Karolinska University Hospital Huddinge in Stockholm.



The tragic event of a postnatal suicide on the maternal ward 15 years ago accelerated discussions on a closer cooperation between the obstetric and psychiatric clinics at Karolinska University Hospital Huddinge. The initial perinatal psychiatric service at the specialist maternal clinic consisted of a midwife and obstetrician and a consultation-liaison psychiatrist employed at the psychiatric clinic. The aims for the service were defined as being a referral instance for the maternal health care services in the catchment area concerning women with current/prior mental health or severe social problems. By 2009 about 5% of pregnant women in the catchment area of the delivery hospital were seen by the team. While most cases concerned depression and anxiety disorders about 15% of cases dealt with advanced delivery and postnatal care planning for bipolar and psychotic disorders.

Since then, the perinatal psychiatric unit has extended to three midwives, four psychiatrists, three perinatal psychiatric nurses and a social worker. The service is co-financed by the obstetric hospital and the psychiatric clinic. Furthermore, the psychiatric clinic also co-finances research time for a psychologist and a midwife. 2021 about 7% of pregnancies in the catchment area were referred to the service from predominantly maternal health care services but even primary care and psychiatric outpatient departments (approximately 350 referrals per year).

Referrals are triaged at weekly 1.5-hour team meetings and planned for assessment by midwife, psychiatric nurse, social worker and/or psychiatrist based on need. Patients are assessed at the specialist maternity clinic where one of the psychiatrists and nurses are present one day and midwives two days per week. All patients receive an individual perinatal care plan which is documented both in the psychiatric and the obstetric electronic chart. Psychiatrists perform assessments and initiate treatment for pregnant patients without a current psychiatric caregiver and refer women to psychological/psychiatric care if necessary. Patients in contact with psychiatric caregivers are assessed by midwives and/or nurses who cooperate with psychiatric caregivers and, if necessary, child health care and social services. Care that is available at the unit is pharmacological treatment, psychoeducation and support, yoga, and internet CBT for antenatal depression (research project). Assessment and care are followed-up and supervised at the weekly team-meetings. There is a close cooperation with neonatal and obstetric specialists which allows for timely consultation and planning in case of e g pharmacological implications for delivery and breastfeeding. Usually, patients are followed until 6-10 weeks postpartum and planned for continued care based on need.


The tragic event of a postnatal suicide on the maternal ward 15 years ago accelerated discussions on a closer cooperation between the obstetric and psychiatric clinics at Karolinska University Hospital Huddinge. Image by Wix Media.
The tragic event of a postnatal suicide on the maternal ward 15 years ago accelerated discussions on a closer cooperation between the obstetric and psychiatric clinics at Karolinska University Hospital Huddinge. Image by Wix Media.

The perinatal psychiatric competence at Karolinska University Hospital Huddinge is today recognized as a resource for other psychiatric caregivers in the Stockholm Region who consult the unit for advice on perinatal treatment and care planning. We also have seen an increase of referrals of patients with serious antenatal mental disorders from other psychiatric hospitals in the region to the psychiatric inpatient wards at the hospital where the perinatal team can be involved as consultants concerning treatment and delivery care planning. Currently, there are ongoing discussions on development of a mother-baby-unit at the psychiatric clinic. The caregiver model has also recently become a blueprint for development of a perinatal psychiatric service at another large delivery hospital in Stockholm implying that now all pregnant women in the southern Stockholm region have access to perinatal psychiatric services.

The development of subspecialist perinatal expertise has led to regional and national involvement in the production of treatment guidelines. We partake in educational activities for caregivers from all Sweden and offer training periods for psychiatric trainees. Last, but not least, the perinatal psychiatric unit is also involved in university education and research projects e g concerning internet-based psychological treatment of antenatal depression.

In summary, economic long-term dedication of local obstetric and psychiatric caregivers has resulted in the development of a perinatal psychiatric collaborative care model with impact not only for perinatal patients with mental disorders but even for education and research. □


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