Referral criteria

The team welcomes referrals for women registered with a GP and living in Dorset, with a significant mental illness during the perinatal period. Please consider referring women to Steps to Wellbeing for mild to moderate mental illness. We accept referrals from health professionals and social workers. 

We ask that referrers take time to familiarise themselves with the Dorset Perinatal Pathway and referral criteria, so as to ensure women are receiving the most appropriate care, in a timely manner.

Inclusion criteria:

Women who are planning a pregnancy, pregnant or in the postnatal period who have an existing mental illness and women who develop a moderate and complex to severe mental illness during the perinatal period, or have identified risk factors for major mental illness in the postnatal period. This includes:

1)    Pre-pregnancy advice and assessment for high risk women (i.e. those on mood stabilising or antipsychotic medication, or with a history of bipolar disorder, schizophrenia or postpartum psychosis)

2)    Pregnant women with a personal or family history of bipolar affective disorder, or postpartum psychosis.

3)    Pregnant or postnatal women who develop a complex/moderate or severe mental illness.

4)    Previous perinatal mental illness treated by psychiatric services.

5)    Women with other serious non-psychotic illness that severely impact on daily functioning and care of baby.

6)    Medication advice for pregnant or breastfeeding women who are prescribed psychotropic medication for psychiatric purposes.

7)    Women whose difficulties are directly related to their experience of pregnancy and birth.

-       Women within nine months of childbirth with any of the above illness.  Women will be considered outside of this time frame if there is a perinatal specific need and will be discussed on an individual basis.

-       Where a pregnant or postnatal woman is already open on the caseload of mental health services, the perinatal mental health team can offer joint management, as appropriate to the woman’s needs.

-       Any woman who is admitted to a regional mother and baby unit with a perinatal illness will be seen by the perinatal mental health team on discharge.

Recent Key changes: 

-      We will now assess women who have pre-existing or a new episode of moderate and complex to severe mental health illness in the perinatal period. For          example, this may be women with comorbid mental health conditions or moderate episode of illness with psychosocial adversity.We will consider women under 12      weeks of pregnancy on a case-by-case basis, particularly if urgent advice is required regarding medication.

-      The perinatal mental health service can extend beyond the 12m postnatal period up to 24 months in certain circumstances. This will be decided on a case-by-case basis, but there are some overall guidelines to help inform clinical decisions for referrals.

      Treatment into the second postnatal year can be for the following reasons:

1. For women already on the Perinatal Mental Health Service caseload to complete or consolidate a specific intervention, particularly women who presented later in the first postnatal year or there are ongoing concerns regarding the parent infant relationship.
2. New referrals can be accepted by the perinatal mental health service after 12m postnatally if there is a new or recurrent episode of moderate complex and severe perinatal illness identified that has a significant perinatal component requiring a specific perinatal intervention. This may include parent infant psychotherapy, perinatal nursery nurse, psychology or specialist psychiatric assessment. In these situations, the patient should be primarily supported by their local community mental health team, with the perinatal team offering the perinatal aspect of care.
3. Ongoing concerns affecting the parent infant relationship, whilst also experiencing moderate complex to severe mental illness, presenting in the second postnatal year.

-      A new service has been developed, as part of the perinatal offer, the Maternal Mental Health Service (MMHS).  This is for women who have developed moderate and complex to severe mental health illness directly related to or arising from their maternity or birthing experiences. The service will focus on birth trauma and Post-Traumatic Stress Disorder (PTSD), moderate to severe tokophobia (fear of childbirth) which may be primary tokophobia or secondary to a birth trauma, and baby loss including miscarriage including IVF failure, stillbirth, or neonatal death.

Exclusion criteria:

-       Women with a primary diagnosis of organic disorder, or drug and/or alcohol misuse or a learning disability, will only be considered if there is also co-morbid mental illness.

-       Anybody under the age of 18 should be discussed with child and adolescent mental health services (CAMHS Dorset) in the first instance and where appropriate there will be a consultation or joint working with the perinatal mental health team.

Referral criteria guidance

1. You can refer any woman resident in the Dorset area.
2. Women can be referred from pre-conception until 24 months post-natal, the service will decide on referrals between 9-24 months post natal on a case by case basis.
3. Referrals are essential for women with current or previous:
   • schizophrenia/schizoaffective disorder
   • previous postpartum psychosis
   • severe depression/psychotic depression
   • opther psychotic illness
   • family history of postpartum psychosis
   • bipolar affective disorder.

These women should be referred even if they are currently well.

4. Referrals are also accepted for women with other moderate, severe or complex mental illness. Such as post-traumatic stress disorder, severe anxiety disorders, obsessive compulsive disorder and personality disorder.
5. If a woman is prescribed a mood stabiliser, please state this in the referral so that these women can be prioritised and urgent advice given regarding medication.
6. The service only works with women who cannot effectively be managed within primary care.
7. The service will work jointly with the community mental health services (CMHT) held cases. The CMHT will hold primary responsibility for care coordination and psychological intervention. Roles and responsibilities including responsible clinician, prescribing and crisis management will be clarified following assessment.
8. If the woman is a psychiatric inpatient during pregnancy or the postnatal period, she should be referred so that the perinatal mental health service can see her during admission, ensure she has antenatal care if she is pregnant and that she is followed up on discharge from the inpatient unit.
9. If substance misuse is the primary problem, please refer to local drug and alcohol misuse services. We can work jointly with substance misuse services if the woman also has a severe mental illness.
10. For women with primary eating disorder diagnosis, please refer to the eating disorder service however, we will joint work if there’s a co-morbid severe mental illness.
11. Women under 18 years old can be referred to child and adolescent mental health services (CAMHS) and the perinatal mental health service will provide advice to CAMHS.
12. The service does not routinely see women who have lost the pregnancy. However if they are already known to the perinatal team and have severe mental illness, we will continue to support them and signpost them to an appropriate service.

How to refer or obtain advice

Please put as much information as possible on the referral form. The completed referral form should be sent either by email to dhc.referrals.perinatalcommunity@nhs.net,  completed through the online referral form or via the referral form on SystmOne.

The perinatal mental health service office is open from 9am-5pm Monday to Friday.

A duty worker is available for telephone advice from 9am-4.30pm Monday to Friday to discuss and advise on potential new referrals or women known to the perinatal mental health service. Telephone: duty worker on 07880 023130 or perinatal administrator on 07818 588641 / 07900 341906.

Once the referral has been accepted it will be reviewed by the team and an initial assessment to gather further information is made with the patient. The patient will receive a letter with the outcome of the acceptance within two weeks. A perinatal practitioner will be allocated and be in contact with the patient to arrange an initial appointment or a medical review may be arranged. A copy of the letter will be sent to the referrer and any other relevant professional involved in the patient’s care and treatment.

If assessment is not considered necessary, referrers will be informed of the decision and offered advice and directed to other appropriate services.

Please note that consent must be obtained before a referral is made, as the service is unable to work with any patient who has not consented. If there is significant concern about a patient who does not wish to be referred this can be discussed anonymously to obtain advice.

You can re-refer at any time throughout the perinatal period if you have any concerns and please call for advice at any time if you are unsure.

For urgent referrals outside these hours:

• urgent referrals from maternity inpatients - contact the hospital liaison psychiatry team.
• urgent referrals for women in the community - contact the GP, out of hour’s service or ask the woman to attend the A&E department.
• Connection is a 24/7 phone helpline 0300 1235440 which can provide direct help or signpost users to a range of other services.

Red flags and risk indicators

Red flags

• Recent significant changes in mental state or emergence of new symptoms.
• New thoughts or acts of violent self-harm.
• New and persistent expressions of incompetency as a mother or estrangement from the infant.
• Ensure that referral with mental health concerns on more than one occasion is considered a ‘red flag’ which should prompt clinical review, irrespective of usual access thresholds or practice. (MBRACE 2020)

Perinatal risk indicators (antenatal and postnatal period)

• Women with a history of bipolar disorder, schizophrenia, and severe depression, other psychotic disorder or previous inpatient/crisis care should be referred to the perinatal team; this group is at increased risk of severe postpartum episodes.
• Women with a family history of a first degree relative with bipolar disorder or puerperal psychosis should be referred even if presenting with mild symptoms of mental disorder.
• Antenatal presentation can be a predictor for post-natal episode of mental ill health; discuss all antenatal referrals with perinatal team.
• High risk period is 1-10 days post-natal but the threshold should be lower for women up to 10 weeks postnatally.
• Women who are presenting with uncharacteristic symptoms and marked changes to normal functioning. This can include symptoms of confusion and general perplexity.
• Partner, family or friends report significant change in presentation and acting out of character.
• Older professional women with depression who appear to be functioning at high level.
• Women who present with anxiety/panic attacks or unusual or overvalued ideas (ideas that seem out of context or extreme)