What’s new in Perinatal Anxiety?

PROFESSOR CAROLYN CHEW- GRAHAM Professor of General Practice Research Keele University

Sixty people joined us on a webinar (PNA) on 6 June 2024. The webinar was supported by NIHR School for Primary Care Research (SPCR) and brought together researchers, clinicians and community organisations from across the UK to discuss the latest evidence about PNA – including ‘hot off the press’ findings from a number of key studies.

Janine Proctor opened the webinar sharing her experience of living with PNA, the lack of support and her response – establishing Just Family CIC https://justfamily-cic.org. Janine’s account was very moving and set the context for our topic incredibly well. Heather O’Mahon, Professor in Perinatal Clinical Psychology at the University of Exeter, summarised the evidence around prevalence and impact of PNA, which is more common than perinatal depression (PND), yet has been unrecognised by clinicians and women and birthing persons (bp), partly due to the ‘normalisation’ of anxiety in pregnancy. Heather reminded us of the importance of untreated PNA on the woman or bp, family and infant – with impacts in infant and child development. Fortunately, ‘pregnancy-specific anxiety’, is being increasingly recognised, and the need for support and acceptable services emphasised. Victoria Silverwood, GP and Wellcome-funded PhD student at Keele University, described the findings from her PhD study which emphasised the need for a choice of interventions for women and bp with PNA – management options which are not commissioned and available for women.

Tamsin Fisher and James Bailey, researchers at Keele University, presented findings from the CLASP study – a mixed methods study with semi-structured interviews with women, healthcare professionals and practitioners in community organisations alongside two studies using ‘big data’ [CPRD and IQVIA Medical Research Database (IMRD)]. Key findings suggested that risk of PNA increased with alcohol and smoking use and white ethnicity; and mothers with PNA had a higher rate of primary care consultations, and infants were more likely to be vaccinated. Most women were positive about the identification of an increased risk of PNA but emphasised that there must be services to support women so identified. Findings suggest that not all ‘risk factors’ are coded in primary care records and women not seen in primary care until postnatally, so the potential for women at increased risk pf PNA to be identified in primary care is limited. The need for liaison and collaboration between services was emphasised.

Andrea Sinesi, from the University of Stirling, presented early findings from the MAP study led by Professor Susan Ayers, (City University, London), which aims to identify which is the most effective method of assessing PNA. Using diagnostic interviews, the study team identified that nearly 20% of women met the diagnostic criteria for anxiety, with Obsessive-Compulsive Disorder, General Anxiety Disorder and Agorophobia being most common. The role of the restrictions associated with the COVID-19 pandemic, at the time when the MAP study was conducted, was postulated to account for this prevalence.

Heather O’Mahon, University of Exeter, described learning from the ACORN study, including the ease of recruitment of women and bp in the scanning department – a lesson for future researchers in this area. Professor O’Mahon reflected on the keenness of midwives to be involved in the ACORN studies – this awareness of PNA has certainly increased over the past few years. The ACORN intervention, a group problem-solving intervention was tested in a feasibility study and was well received by women, bp and their partners/supportive others. The multi-centre ACORN trial is now underway.

Janine Proctor, Director of Just Family CIC, managed to describe the important work of her organisation despite technical difficulties. The range of peer support offered by Just Family CIC is incredible. Janine emphasised the importance of the wellbeing of the whole family and how this can be nurtured. The responsive nature of the services offered was obvious, but also how constrained the offers are, depending on short-term funding.

We moved into breakout rooms – by this time we had lost a few participants on the webinar (perhaps a three-hour webinar was just too long).

Key messages from each group included:

• The importance of listening to the lived experience of women and bp – to shape research and practice.

• How do we differentiate ‘normal anxiety’ and PNA which needs an intervention?

• The need to increase awareness of PNA amongst women and bp, partners, families and clinicians – the audience is everyone! But any health messages must not be ‘scary’ and we must also ensure that if we raise awareness there must be support available to women and bp with PNA.

• Women may self-refer to midwife services – so do not encounter primary care until postnatal check.

• IT systems need to speak to each other – or clinicians need to liaise!

• The value and role of self-management must be emphasised.

• Peer support groups are important – but how do you ensure safety and integrity and support the peer supporters?

• How can we reduce health inequalities? There is a need to offer culturally-sensitive interventions for women and bp for PN mental health problems.

• How do you maintain community services? Short-term commissioning decisions are unhelpful.

• Research needs to make a difference – how do we disseminate key messages?

• Information burden: “there are leaflets on everything”.

• How do we reach out to people not on the webinar?

The webinar ended with Dr Bala Sankarasubbu [GP Principal & Training Programme Director (North Staffs)] reflecting on the research presented and messages from group discussions. She emphasised the need to put research into action – for PNA raising awareness in women and bp that they can seek help and that support is available, and for clinicians, the need for the identification of PNA and offer support tailored to the person. The role of community organisations in supporting families came over loud and clear.

Useful References:

Ayers, S., Coates, R., Sinesi, A., Cheyne, H., Maxwell, M., Best, C., ... & MAP Study Team. (2024). Assessment of perinatal anxiety: diagnostic accuracy of five measures. The British Journal of Psychiatry, 1-7. https://doi.org/10.1192/bjp.2023.174

Ayers, S., Sinesi, A., Coates, R., Cheyne, H., Maxwell, M., Best, C., ... & MAP Study Team. (2024). When is the best time to screen for perinatal anxiety? A longitudinal cohort study. Journal of Anxiety Disorders, 102841. https://doi.org/10.1016/j.janxdis.2024.102841

O’Mahen, H. A., Ramchandani, P. G., King, D. X., Lee-Carbon, L., Wilkinson, E. L., Thompson-Booth, C., ... & Fearon, P. (2022). Adapting and testing a brief intervention to reduce maternal anxiety during pregnancy (ACORN): report of a feasibility randomized controlled trial. BMC psychiatry, 22(1), 129.

Silverwood V, Nash A, Chew-Graham CA, Walsh-House J, Sumathipala A, Bartlam B, Kingstone T. Healthcare Professionals’ perspectives of identifying and managing Perinatal Anxiety: a qualitative study. BJGP. Sept 2019. DOI: https://doi.org/10.3399/bjgp19X706025

Ooh S, Chew-Graham CA, Silverwood V, Shaheen S, Walsh-House J, Sumathipala A, Kingstone T. Women’s experiences of identifying and managing Perinatal Anxiety: a qualitative study. BMJ Open. 2020;10:e040731. doi:10.1136/bmjopen-2020-040731

Silverwood VA, Bullock L, Turner K, Chew-Graham CA and Kingstone T (2022) The approach to managing perinatal anxiety: A mini-review. Front. Psychiatry 13:1022459.

doi: 10.3389/fpsyt.2022.1022459

Silverwood V, Bullock L, Jordan J, Turner K, Chew-Graham CA, Kingstone T, Dawson S. Non-pharmacological interventions for the management of perinatal anxiety in primary care: A meta-review of systematic reviews. BJGP Open June 2023  DOI: https://doi.org/10.3399/BJGPO.2023.0022

Smith H, Archer C, Bailey J et al. Maternal perinatal anxiety and infant primary care use in 1998-2016: a UK cohort study. Under review.