Self-harm in postpartum depression and referrals to a perinatal mental health team: an audit study

Mental disorder following childbirth is common. Around 10 to 15 % of newly delivered women will experience a major depressive episode, 3 to 5 % of which will be moderate to severe depression (Oates 2000). Two per 1,000 women will be admitted to the hospital for postpartum psychosis and 2 per 1,000 for a non-psychotic disorder (Oates 2000). An episode of mental illness following a subsequent delivery occurs in 50 % of women with a history of severe mood disorder and 70 % of women with a further family history of postpartum psychosis (Jones and Craddock 2001). Suicide is known to be a leading cause of death in the first 12 months postpartum in the UK (ConfidentialEnquiry into Maternal and Child Health 2004, 2007). In the most recent Confidential Enquiry (2011), 59 % of maternal suicides were due to psychosis or severe depression. Most of the women (76 %) were married or living in stable cohabitation. More than three quarters were either employed or housewives with employed partners. As in previous enquiries, the majority of women (87 %) died violently from hanging, jumping from height or self-immolation (Oates and Cantwell 2011). However, little is known regarding self-harm in the postpartum period despite suicide being a leading cause of death and high rates of morbidity during this time. There have only been four studies examining this issue, two conducted here in the UK and two in the USA using the data from the same study.

The first was a consecutive 6-month sample of women age 15–44 years attending a local emergency department for non-fatal self-harm in a single catchment area in London (Appleby and Turnbull 1995). The only information collected was on the method of self harm and any deliveries in the previous 12 months. The rate of self-harm (odds ratio 0.43) in the postpartum period was estimated to be about half the rate for non-postpartum women of the same age. The main method of self-harm in this study was self-poisoning. The authors concluded that the rate of self-harm the year following delivery is low despite high rates of mental disorder. As part of a national audit of admissions to mother and baby units, Salmon et al. (2004) examined predictors of maternal self-harm. The only independent predictor was depressed mood, with mothers who had harmed themselves at least four times more likely to experience depressed mood during admission than those who had not.

Schiff and Grossman (2006) compared 520 women hospitalised for a suicide attempt in the postpartum period with 2,000 controls to see if there was any association between maternal complications and suicide attempt. They found that maternal complications were not associated with suicide attempt, but that fetal death or death of the infant in the first year was strongly associated. Those who attempted suicide tended to be younger, from black and minority ethnic groups and socially deprived. The main method of self-harm was self-poisoning. The rate of attempted suicide in the postpartum period was estimated to be approximately two thirds the rate for non-postpartum women of the same age. Comtois et al. (2008) used the data from the same study to examine pre-existing psychiatric risk factors for suicide attempt. They found that a prior mental health, substance use or dual diagnosis all significantly increased the risk of a suicide attempt in the postpartum period.

Many acts of self-harm do not come to the attention of healthcare services, so it is possible that the rates quoted in the studies above are underestimates as they are based on hospital attendances only (Hawton et al. 2001; Meltzer et al. 2002). An individual episode of self-harm might be an attempt to end life, but some acts of self-harm are not directly connected to suicidal intent (NICE 2004). As the term ‘self-harm’ is a broad one, The World Health Organisation defines it as ‘an act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behaviour that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising changes which the subject desired via the actual or expected physical consequences’ (Platt et al. 1992; NICE 2004). Self-harm is more common in young women, people who are disadvantaged in socio-economic terms and those who are single or divorced, live alone, are single parents or have severe lack of social support (Meltzer et al. 2002). Following an act of self-harm, the rate of suicide increases between 50 and 100 times the rate of suicide in the general population (Hawton et al. 2003; Owens et al. 2002). Women who self-harm have an increased risk of suicide which is likely to be further enhanced by the presence of depression during pregnancy and in the postpartum period. Self-harm during pregnancy is estimated to be about half the rate for non-pregnant women (Greenblatt et al. 1997; Weiss 1999). Previous loss of a child, potential loss of a lover and the desire to have a termination were found to be associated with attempted suicide during pregnancy in one study (Lester and Beck 1988). In a further four studies, those suffering domestic violence, dysfunctional family relationships, antenatal depression and socio-economic deprivation were most at risk for attempted suicide during pregnancy (Bayatpour et al. 1992; Farber et al. 1996; Marishane and Moodley 2005; Asad et al. 2010).

As suicide is a leading cause of maternal death in England, the National Institute of Clinical Excellence (NICE 2007) and the Confidential Enquiries (Oates and Cantwell 2011) recommended that all mental health trusts in England have specialised perinatal mental health teams to care for pregnant and postpartum women. They proposed that all pregnant women should be asked about personal mental health history and family history when they first book in for antenatal care. Women with a previous history of serious affective (depression and bipolar disorder) or other psychoses should be referred in pregnancy for psychiatric assessment and management even if they are well. A minimum requirement for management should be regular monitoring and support for at least 3 months following delivery (Oates and Cantwell 2011). There is however a lack of perinatal mental health service provision in the UK with less than a quarter of NHS trusts having both inpatient and outpatient community services (Oluwatayo and Friedman 2005; Rowan and Bick 2008; Green et al. 2008). Consequently, there have only been a handful of studies describing the clinical and socio-demographic characteristics of pregnant women attending perinatal services in the UK and abroad, particularly women who self-harm (Green et al. 2008; Rowen et al. 2010; Wilson et al. 2004).

The aim of this study was to describe the clinical and socio-demographic characteristics of pregnant women referred to a new perinatal mental health team (PMHT) with an estimated date of delivery from April 2009 to March 2010. In accordance with the National Institute of Clinical Excellence (NICE 2007) and the Clinical Negligence Scheme for NHS Trusts guidelines (Litigation Authority 2010), data on care pathways would also be collected including the information on those who were referred but refused to engage with the PMHT. The aim of the second stage of the study was to determine the veracity of data recorded for a subgroup of 73 pregnant women referred to the team for previous postpartum depression (PPD), 58 % of whom disclosed an episode of self-harm with the ‘intent to kill themselves’ to the maternity staff when they first booked in for antenatal care.

The findings from this audit suggest that screening for a significant mental health history at the first antenatal appointment identifies those at risk of psychiatric complications during pregnancy. Over 50 % of those referred to the PMHT had self-harmed in the past, 8 % were unwell enough to require a psychiatric admission and 21 % had child protection issues. A referral rate of 2.81 % is efficient as clearly these women did have significant current as well as past mental health issues. At the time of the audit, the PMHT was only resourced to offer care to pregnant women up to the point of delivery, despite NICE (2007) recommendations. However, 75 % of those referred to the PMHT and around half of those with the most severe mental disorders were not under the care of a psychiatrist or specialist mental health team. Had the risks in the postpartum period not been identified by the PMHT, these women may have easily slipped through the net. The pregnant woman who failed to attend appointments had a health professional notification completed by the PMHT to inform the family doctor and if involved secondary mental health services of the pregnancy. Interestingly, a high percentage (85 %) of the total number referred did engage with the PMHT, and the risks during pregnancy were managed up to the point of delivery. Forty percent of referrals were referred on to primary or secondary mental health services after an initial assessment by the PMHT. The reason for this was that the women were currently doing well and considered not to be at high risk of recurrence after delivery. Again, the GP and if involved secondary mental health services were informed of the pregnancy, and the PMHT copied into all future correspondence up to the point of delivery. Similar to the findings of Green et al. (2008), those with psychotic disorders including schizophrenia, bipolar disorder and schizoaffective disorder accounted for only 9 % of the total number of referrals, despite referrals being accepted from family doctors, psychiatrists and secondary mental health services. Referrals for these disorders have gradually increased since the audit took place, but the reason for the low numbers is unknown. One possible explanation is that family doctors and mental health staff may not realise that bipolar disorder and psychosis are risk factors for puerperal psychosis. It is possible to project the number of postpartum women, including those with psychotic disorders, likely to need specialist perinatal mental health care. (National Institute for Clinical Excellence 2008) recommends using 40 per 1,000 deliveries in estimating a benchmark for referral to a specialist perinatal mental health team. For 8,000 deliveries, this translates to 320 women per year, including the 4 per 1,000 deliveries to women who are likely to require admission to hospital (National Institute for Clinical Excellence 2008).

During stage one of the audit, the extraordinarily high rate of attempted suicide in previous PPD became apparent, and the final figure could be as high as 49 % in this subgroup. As self-harm was a reason to warrant referral to the PMHT, a high rate in those attending might be expected, but a diagnosis of severe mental disorder, severe PPD requiring hospital admission, current care from a psychiatrist, current care from a mental health team and family history were also reasons for referral. Those referred for past or current self-harm and no other mental health diagnoses made up only 10 % of the total number of referrals with those referred for previous PPD accounting for the majority of cases of past self-harm. This suggests that self-harm in PPD is an issue that warrants further investigation. Only 9 % of those with definite and possible suicide attempt were in touch with secondary mental health services, despite 40 % presenting with current symptomatology. A greater number of women with a history of previous self-harm and PDD were self-harming during the current pregnancy and admitted to the hospital, which suggest that self-harm in previous PPD might be a risk factor for self-harm in subsequent pregnancies. It is important to note that even if self-harm takes place outside of an episode of PPD, the risk for suicide is still increased, a risk likely to be enhanced by a relapse of depression during pregnancy and the postpartum period. The possible cases of attempted suicide, including the 44 % who repeatedly self-harmed, shared many of the characteristics known to be associated with women who self-harm. Similar to the findings of Schiff and Grossman (2006), they were mostly young, single, experienced high levels of social deprivation and were known to child protection services. This is in contrast to the suicides reported to the Confidential Enquiries. These women tended to be older, married or in stable cohabitation and employed (Oates and Cantwell 2011). But, the team were unable to confirm or refute a definite suicide attempt in these cases due to not being able to access additional medical records. This was also the case in determining a definite or probable diagnosis of previous PPD. The higher proportion of child protection issues, current self-harm, previous and current psychiatric admissions and current care from a psychiatrist in this particular group could possibly be explained by a different diagnosis, such as borderline personality disorder (BPD). It is estimated that around 41 to 83 % of those with BPD report a history of major depression (Lieb et al. 2004).

From the literature on self-harm, it is known that the method and ‘reason’ for self-harm can and often will change not only between episodes but also within the same episode. It is therefore very difficult to estimate the degree of suicidal intent unless it is disclosed by the individual (Williams 2001). Similar to the findings of Appleby and Turnbull (1995) and Schiff and Grossman (2006), the main method of self-harm in this study was self-poisoning. This differs to the methods of suicide in the Confidential Enquiries where the majority of women (87 %) died violently (Oates and Cantwell 2011). As this was an observational study, the odds ratio cannot be compared to the studies presented in the ‘Introduction’ (Appleby and Turnbull 1995; Schiff and Grossman 2006); however, it is important to note that 58 % of pregnant women with previous PPD disclosed a past suicide attempt to maternity staff during the first antenatal appointment, despite the consequences of disclosing such sensitive information in terms of the child protection issues it raises.