The importance of perinatal psychiatry
Interview with Professor Carmine Pariante
Theme: Perinatal mental health
Professor Carmine Pariante seems to be ubiquitous these days. This affable London-based Italian professor of psychiatry gave an incredibly well-received plenary lecture; „Stress and perinatal mental health – from mechanisms to clinical practice“ at the ECNP congress in Vienna this October. He has received many of the most prestigious awards psychiatrists and biological scientists can obtain, has published over 400 scientific papers and also finds the time to be the editor of a mental health digital magazine, Inspire the Mind (https://www.inspirethemind.org/) and tweets as @ParianteLab. Pariante's research focuses on depression and fatigue, and the role of stress and inflammation in the causes and treatments of mental disorders, with a special focus on the perinatal period. His clinical work is within perinatal psychiatry.
The Nordic Psychiatrist was fortunate enough to get hold of Professor Pariante at the recent ECNP, and this gentle, softly spoken psychiatrist was more than happy to discuss the importance of perinatal mental health with collegues in the north. The interviewer actually did his psychiatric training with Carmine at the Maudsley Hospital, so it was nice to revisit old times.
So Carmine, why do you think it is important for psychiatry to pay more attention to the perinatal period?
Many mental illnesses affect mothers, both as a first onset issue and as an exacerbation of previous illnesses, from anxiety and depression and bipolar illness to other diagnoses, including post-partum psychosis. So contrary to the general expectation of pregancy and the peri-natal period as periods of happiness, where women are protected from mental health difficulties, in reality this is a period of great vulnerability. So you can capture a lot of psychopathology. And it is also a period when women are more committed to engage with treatment, because they are motivated to get better for the sake of the babies. So women who have previously not been engaged with mental health services may be more likely to engage and accept treatment. This may be one of the few opportunities for women not routinely in contact with health services to actually talk to a nurse, talk to a midwife and through them get in touch with mental health services. It is an ideal time to try and connect with women and help them. So that´s the first important reason. A second reason is that every aspect of the mental health of mothers will have an effect on the children. We know very well from epidemiological studies that mental health problems of mothers especially during pregancy and the post-partum period are associated with increased mental health problems in the children later when they become adolescents and young adults. Some of it will be shared genetic liability but there is also an influence in utero, through biological communication between mother and baby through the placenta, and postnatally, due to the difficulties that mental health problems may bring to the mother – infant interaction, which can create a trajectory of risk. For both reasons this is really a time when we must intervene, we must try to find the women and offer our support.
In your talk here at the ECNP there was a mixture of hardcore molecular science and therapeutic interventions some would regard as „soft“, like mothers being coached to sing for their children. Is there an underlying trend or focus in the clinical approaches being developed now within perinatal psychiatry.
It is really mixed and different groups are working in different ways. I tend to be quite ecclectic in my research approach and that may be why I have been able to combine molecular research with art and creativity inventions. Many other research and clinical groups focus on other things; the development of medications, new psychological approaches, e.g. CBT that is more focused on the content that is relevant to the post-natal period, there are psychodynamic approaches that work with the mother-infant interaction and there has been research on using hormonal therapy, although that is not delivering as much as people hoped. And then the whole issue of social prescribing, because a lot of the mental health problems in the peri-natal period are driven by social or psychosocial diffulties (isolation, poverty, lack of social support), and it is important to elicit help for these women, not only be the mental health services and health services in general but through government support or local agencies. Because if you can address the isolation and loneliness that the most vulnerable women experience, it helps. There is no „one size fits all“. It is very likely for example that the woman may need an antidepressant, yet at the same time will benefit from an opportunity to experience social connection through for example the singing group we are experimenting with. So the approaches are all mutually potentiating, not exclusive.
In England there is a long tradition of perinatal psychiatry and mother and baby units in mental hospitals. This is less the case in the Nordic countries (with noteable exceptions), but there is growing awareness of the importance of the field. How would you advice our healthcare systems to proceed in building up knowledge and skills in perinatal psychiatry?
There are two parallel pieces of work that need to be done. One is the general training of psychiatry trainees and psychiatrists, but actually of a broad range of health professionals, including midwifes, health visitors, obstetricians and other physicians routinely in contact with women during the peri-natal period. Awareness must be raised about the importance of mental health difficulties, detecting them, having a system so women don´t fall through the net if signs of suffering are picked up. There must be an understanding of the importance of detection and follow up, and referral to mental health services in hospital. England has a long tradition of peri-natal services, but until recently it was still a postcard lottery, where some places were centres of excellence and others had very little. The minimum requirement that the Royal College of Psychiatrists was trying to organise was to have at least one psychiatrist who had a special interest in the field and would take responsibility to develop the knowledge at the personal level through courses, conferences etc. and would be the contact person for at least a discussion of difficult cases. One of the problems we often see is that women with mental health problems become pregant and then get conflicting advice about medication and may even be told to immediately stop their antidepressant from primary care physicians or midwifes, without consultations with a psychiatrist. There is a lot of myth and misconception about the risks and benefits of mental health medication in pregnancy and breast feeding. So having at least one person who is a reference point within the local health community or hospital is paramount. This definitely is the first step. You can then of course build on this through courses and discussions with trainees.
We also need lobbying at the political and governmental level, both locally and nationally. The UK would never have been able to develop the services it has without money and financial support from successive governments. Different governments of different political colour, have maintained funding for perinatal mental health services, so we have increased them, sometimes against the tide, when other services were cut out. This was obtained through constant informed lobbying of politicians, explaining the cost-benefits of money spent in the peri-natal period. There was a famous study a few years ago from the London School of Economics, demonstrating that 2/3 of the costs of mental health problems are due to the child developing difficulties, either at school or in their working life, so there are long-term costs of mental health problems in the peri-natal period that go well beyond the mother and justify long-term savings by investing in the peri-natal period. This is the kind of message policiticans need to hear and they only know if people tell them. This is done through lobbying of stakeholders, collaborations with patient organisations and charities, finding journalists interested in the topic or sometimes you only need one or two members of parliament who are champions of the course, which can make a big difference. Having famous people endorsing the issue can also be very helpful. So you need the lobbying to secure funding and the training so that when the money comes there are people there who can do the job.
"Through helping the mother during the peri-natal period you are helping more than one person at the same time. This is very rewarding"
Particularly vulnerable pregnant mothers (because of mental illness, drug use, poverty) are a special challenge. Do you have any thoughts on how to build resilience in them and their children, to reduce the trans-generational risk?
This is one of the things you need to approach from a variety of points of view. From those who suffer from clinical mental health illnesses, they need to have proper treatment. If the woman is suffering from a clinically incapacitating mental illess even outside pregancy, then of course she is going to be even worse during pregancy. We have now good treatments from a pharmacological point of view which should be considered for the women who need them. You need to start with treating the most severe ones. Specific psychological interventions, there are CBT methods that have been developed for thoughts occurring around the time around pregnancy and they should be delivered as soon as possible. Then there is the social support, if the woman is suffering because of homelessness, immigration status, lack of family, other young children, then there is the state´s role to step up and support the women financially, to keep pushing the social justice agenda.
What about pre-conception counselling to people with severe enduring mental illness?
As peri-natal services at the Maudsley Hospital we also offer pre-conception advice, for women with a history of mental health problems, who are on medication and/or they may have had previous episodes, like in a previous pregancy. It is certainly important, not least if the woman has suffered post-partum psychosis in the past or if there is a family history of it, that they seek advice. It is a delicate balance. It is a very rare exception when a woman should not have a child because of mental health difficulties, when planning or wanting to do so. We know enough about treatment and prevention, including of post-partum psychosis, the most severe disorder, so that we can support women through the pregnancy and perinatal period and ensure that their outcome is good. So what pre-conception advice does is discuss with mothers the risk-benefit of continued medication, make sure they understand the importance of being seen by peri-natal services, when they become pregnant. We routinely have women with bipolar disorder who are considered high or very high risk, but they are monitored extensively both during and especially after birth, even with daily visits by members of the team, and if necessary an admission to the mother and baby unit where you don´t need to separate them from the baby, so you maintain the development of the attachment from the earliest time. So it is really about the planning of next steps. If women come with the desire to become mothers, our duty is to support them and we do have the understanding, the medication and in the UK the facilites to do that.
You have on the mental health blog Inspire the Mind written about fathers' mental health, their reluctance to seek help and the importance of helping them talk about their difficulties. How important is the role of fathers' mental health in peri-natal psychiatry and is it growing?
It is certainly growing, there is a growing awareness. When I started in peri-natal psychiatry 20 years ago fathers were not seen or even considered. Then more and more research and clinical needs have come up. Usually mental health difficulties are in the whole family. So post-natal depression correlates strongly with fathers having depression themselves. Fathers who are supporting members of the family tend to resonate with the difficulties of mothers. Fathers interact with children more now, they had a more distant role 50 years ago before but this has changed now. The role of fathers is changing. For all these reasons fathers are becoming more important. The peri-natal services are for mothers, so if fathers need support, they go to the standard adult mental health services, which is a problem, but awareness is important. We also must keep in mind that men express differently their suffering, through irritability, violence, drinking, suicides.
If any young psychiatists reading this interview „catch the bug“ and want to develop their interest in the area, where should they look?
I don´t know the details of the training facilities within the Nordic and Baltic countries, if there are key centres of excellence focusing on the topic for example. Certainly you need direct experience of the best services internationally, so consider a visit, e.g. to a mother and baby unit, like at the Maudsley Hospital. Also use the few conferences that exist, societies with a focus on the topic that bring together the clinical and research side of things. – So finding academic centres and a place to shadow, if only for a few weeks to see how services work.
Any final sound words?
For me , what I really like about perinatal services, is that you have the feeling that you are helping more than one person at the same time. Through helping mothers you help the fathers, the family, and of course the baby, even if you don´t meet the baby later, you know you are helping that baby becoming a more resilient child and later grown person, and that your help will count for many years in the future. That is very rewarding. □