Title: The Effectiveness and cost-effectivenesS of perinatal Mental health servIces (ESMI)
Funder: Department of Health and Social Care

Abstract: Aims and objectives: This research programme plans to: investigate how best to identify depression at antenatal booking, estimate the prevalence of common mental disorders in early pregnancy, develop and evaluate Guided Self Help modified for pregnant women for antenatal depression, evaluate services for women with acute severe postnatal mental disorders i.e. admissions to a psychiatric unit (general wards or psychiatric Mother and Baby Units) or care from Crisis Resolution Teams, investigate women s and partners/significant others experiences of different types of care Background and rationale: There is growing evidence that mental disorders are a significant problem during and after pregnancy. National policy emphasises the importance of early identification and appropriate treatment by perinatal mental health services. Research environment: This bid is led by a multidisciplinary team with an international reputation for clinical and academic excellence in mental health, based at King's Health Partners, one of only five accredited Academic Health Science Centres in the UK. King's Health Partners aims to integrate clinical service delivery, education and research for the benefit of patients in London and worldwide, and is therefore an ideal base for a multidisciplinary perinatal mental health research programme. Co-applicants are also based at other world class universities with expertise in applied research: University College London, University of Manchester, University of Cardiff, UCLAN and the University of Melbourne. Research plan: Workpackage 1 (WP1) Module 1 - cross-sectional survey in maternity service booking clinics to compare the sensitivity, specificity and positive predictive value of the two Whooley questions (currently used by midwives) with the Edinburgh Postnatal Depression Scale, and a gold standard diagnostic interview, for the identification of depression. We will also estimate rates of depression and other commonly occurring disorders. WP1, Module 2 - RCT of Guided Self Help (modified for pregnancy) compared with care as usual. WP2 &ndash; Qualitative investigation of the experiences of perinatal mental health care from the perspectives of women with a range of mental disorders (mild to severe, during pregnancy and postnatally) and partners/significant others, and professionals WP3 - Cohort study of women with severe postnatal mental illnesses treated in psychiatric Mother and Baby Units, general wards or under Crisis Resolution Teams to compare how well services prevent re-admission in the following year, address health and social care needs, and help women return to optimal mothering. We will also investigate impacts on partners/significant others mental health, worries, finances and ability to cope. Projected outputs & Dissemination plans: This programme will establish the most effective ways to identify depression in maternity services; provide up to date evidence on the prevalence of common mental disorders during the first trimester and the efficacy of Guided Self Help modified for pregnancy; and provide data on the experience, and effectiveness and cost-effectiveness of different service models including psychiatric Mother and Baby Units. We will publish in high impact peer reviewed international journals; disseminate our results to policy makers, NHS commissioners and NHS providers; summarise findings on a programme website, charities leaflets, newsletters and websites; provide reports for stakeholders, general media and our international networks. Relevant expertise & experience of research team: Our research team includes leading experts in perinatal mental health, health economics, midwifery, service user research, statistics, social sciences, social care, developmental psychology and health services research. They have extensive experience of conducting ethical research with vulnerable populations. The applicants have worked together previously on maternal mental health projects and are therefore well placed to deliver this research programme. Justification of costs: Costs are mainly research staff salaries. Other costs include travel (research will involve considerable travel to many areas of England); payment, travel and childcare for our PPI group and our independent steering group; data management; RCT costs (randomisation etc) and thank you shopping vouchers for participants. Management & Governance: The investigators have extensive experience of managing multi-disciplinary multi-centre projects. The CI, Prof Louise Howard, will be responsible for the overall management of the project including financial management assisted by a full time Programme Manager. An independent Programme Steering Committe will meet at least annually, the Programme Management Group (grant holders and research workers) will meet every 2 months and individual module research teams will meet weekly. NIHR and MRC research governance guidance will be adhered to. Patient and public involvement: Dr Diana Rose (co-applicant) is a service user researcher, PPI lead and Workpackage 3, module 1 lead. We will employ a service user researcher in WP2 and wherever possible in other WPs. As part of our Programme Development Grant, we established a perinatal advisory group of service users and carers of perinatal mental health services and maternity services, and this advisory group will meet every 3 months. This PPI group will continue to comment on research design, procedures, Participant Information Sheets and topic guides, interpretation and dissemination.

Lay abstract: There is growing evidence that many women experience mental health problems during pregnancy and following childbirth. Difficulties that result include prematurity and low birth weight infants, disruption of the bond between mothers and children, later psychological problems in children, and difficulty in maintaining family relationships. Evidence about how NHS services can best prevent or reduce these problems is limited. Our programme consists of several linked studies to fill gaps in this evidence. It will allow us to make recommendations to policy makers, NHS commissioners and providers about the type of perinatal mental health services that are most helpful. One strand in our research will examine the best ways of identifying disorders and treating depression in pregnant women seeing midwives. We will compare how well the two questions currently used by midwives to assess depression really do identify depression by comparing them with more detailed assessment methods. We will measure the frequency in pregnancy of depression and other disorders such as anxiety and eating disorders. Women found to have depression will be invited to participate in a trial in which there is a 50:50 chance of receiving Guided Self Help rather than care as usual. Guided self help is a brief treatment shown to be effective in non-pregnant groups: we will modify it for pregnant women, aiming to provide an economical and effective way of providing prompt treatment not involving the risks of medication. Our second Work Package is a qualitative study of women s views and experiences of perinatal mental health care, complemented by clinicians and significant others views. We will carry out in depth interviews with women who have experienced mental health problems (mild to severe, experienced during pregnancy and postnatally) and partners/significant others to explore their experience of services and help us assess which type of services are most helpful and for whom. The views of clinicians will also be sought, including GP commissioners. The third strand in our programme involves women with severe illnesses who need intensive treatment urgently following birth. The main settings for such treatment are general psychiatric wards in local hospitals, specialist Mother and Baby psychiatric units, whose availability varies greatly across the country, and crisis resolution teams, which can provide frequent visits to women at home. The effectiveness of these services in preventing further admissions, addressing health and social care needs and supporting mothers in their relationships with their infants will be compared. We will also investigate impacts on partners/significant others. Some participants will be very vulnerable and our team will ensure close supervision of researchers to safeguard maternal and child welfare. Our team includes leading experts in perinatal mental health, health economics, statistics, midwifery, social sciences, service user and health services research.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH;MENTAL HEALTH