Highlights of this issue

I was shocked when I learned that the leading cause of maternal deaths in the first year after birth is suicide. It's one of the leading causes during pregnancy too, after thrombosis and thromboembolism. The vital UK and Ireland Confidential Enquiry into Maternal Deaths and Morbidity (MBRRACE-UK) recorded 62 deaths by suicide in the perinatal period in the UK in 2017–2019 – a rate of 2.64 suicides per 100 000 maternities.¹ Substance misuse is also a significant contributor to morbidity and mortality in the postpartum period. Yet mental health causes of maternal ill health are often neglected in research.² Perinatal mental health problems not only deeply affect mothers, but also have an impact on children, partners and families and send ripples across the wider community.

Research into the causes and treatment of perinatal mental ill health is vital. This month, BJPsych features three important articles spanning these areas. Gastaldon et al (pp. 591–602) publish their umbrella review of systematic reviews and meta-analyses exploring risk factors for postpartum depression – the most comprehensive review on this topic to date, analysing data from over 3 million participants. The most robust risk factors for postpartum depression were premenstrual syndrome, violent experiences and unintended pregnancy.

Research into perinatal self-harm led by Holly Hope and Kathryn Abel at the University of Manchester (pp. 621–627) uses an important new feature of the Clinical Practice Research Datalink – a pregnancy register – which enables researchers to identify women in this national primary care database who have previously been pregnant. Interestingly, they found that risk of self-harm halves during pregnancy for all women; however, there is a small increased risk between 6 and 12 months postpartum. Women with mental illness are more likely to self-harm during pregnancy than women without mental illness, but they have an overall greater reduction in risk during this period. Younger women and women who experience miscarriage or elective termination are more vulnerable to self-harm postpartum.

All of these findings could be useful in identifying women who are more vulnerable during the perinatal period – whether for developing depression or experiencing self-harm – and may benefit from additional support.

Mental health problems during the perinatal period can be terrifying for women and their families – for this reason NHS England have specifically identified perinatal mental health services as an area for development in their Long Term Plan.³ A research paper by Howard, Trevillion and colleagues this month (pp. 628–636) provides further evidence about the types of services that could be funded to meet the specific needs of women at this important time in their lives. Using a quasi-experimental methodology, they assessed the effectiveness and cost-effectiveness of psychiatric mother and baby units (MBUs). They found no difference in readmission rates for women with severe acute postpartum mental disorders accessing MBUs compared with those accessing non-MBUs (i.e. general acute psychiatric wards and crisis resolution teams) and no difference for most secondary outcomes. However, satisfaction with care was considerably higher for the women admitted to MBUs. The study was not able to measure longer-term outcomes for women, nor the impact of the different treatment modalities on their infants and families – important outcomes to consider in future research.

The pandemic was particularly difficult for women in the perinatal period – strict social restrictions for pregnant women, experiencing labour alone in hospital, a lack of health visiting, limited social support and increased rates of domestic abuse. Rapid reports by MBRRACE on maternal deaths during the pandemic have as yet been unable to include women who died from mental-health-related causes during this period owing to delays in coronial and/or inquest processes. Another BJPsych research paper this month by Steeg et al (pp. 603–612) addresses the question of how the pandemic affected all people's experience of self-harm, particularly their experiences of health services. Their systematic review found a majority of evidence from high-income countries, with reductions in presentation frequency for self-harm between 17% and 56%. This does not tell us whether there was less self-harm occurring, or whether people were simply less likely to seek help or find appropriate treament afterwards.

Di Gessa and Price (pp. 637–643) also consider the impact of shielding policies for older people during the pandemic. They used the English Longitudinal Study of Ageing to assess people's level of activity and degree of shielding at a number of different time points and found that those who shielded were more likely to report depressive symptoms, display increased anxiety and have lower quality of life.

Two editorials this month address very different topics. Rousseau et al (pp. 587–588) argue for the importance of training in cultural safety – and a more explicit acknowledgement of the ongoing discomfort and multiple layers of oppression and inequality inherent in training and healthcare – They suggest the assumption in many equality, diversity and inclusion policies that such historical inequalities can just be talked about and resolved are unrealistic. Greenberg et al (pp. 589–590) highlight the importance of the bidirectional relationship between mental health and a person's ability to function well at work and urge us as psychiatrists to always consider our patients willingness and ability to work as part of our assessment. Finally, Peel et al (pp. 613–620) use the Twins Early Development Study to demonstrate that genetic predisposition to autism spectrum disorder and post-traumatic stress disorder may increase liability to interpreting events we experience as traumatic.