Chapter 19: Care of the Adult with Mental Health Issues

You are on a practice learning experience with the health visiting team and go on a home visit with your mentor to meet Laura, who has a 6-month-old baby called Mia. In the past Laura has experienced periods of anxiety and depression, and has also harmed herself by cutting her forearms and thighs with broken glass or razors. Laura expressed anxiety during her pregnancy about being a mother; particularly as she had a poor relationship with her own mum but was determined she would do things differently. Initially following the birth of her daughter, Laura appeared to be well and enjoying motherhood; however, at the last clinic visit Laura’s mood appeared to have dipped and she stated that she was feeling ‘tired and under pressure’. On this visit Laura states she has been cutting herself to relieve some of the pressure she feels. She says she feels guilty and ashamed of this and thinks she is a ‘terrible mum’. She has been trying to conceal this from her partner Paul but he noticed the injuries and encouraged her to speak with you about this, although he is not around today. Mia appears well and there are no concerns about her development at this time.

Questions

  • What are your initial concerns at this time and why?
  • How might you respond to this?
  • Who else might you involve and why?

Answers

  • You may be concerned about Laura’s mood and current self-harm, as this is a recent change. Laura has a history of depression and self-harm, and is more vulnerable to reoccurrence during this postnatal period. Injuries from self-harm may be painful, leave Laura vulnerable to infection, in need of sutures or cause scarring. You may also be concerned about suicide. Although Laura has not indicated suicide at this time, it is important to assess for this due to increased risk. You may also be concerned about how this is affecting her role as a mum and other aspects of her life. It is important for both Laura and Mia to maintain a secure attachment to encourage healthy development and relationships.
  • An empathic, supportive response in which Laura’s experience is acknowledged and validated. Creating a safe environment for Laura to talk about her experiences without judgement and interruption is important in establishing a relationship. Gathering further information would be helpful:
    • How long has Laura been feeling this way? Is it a sudden dip or gradual?
    • Consider using an assessment tool e.g. Edinburgh Postnatal Depression Scale. This can be used as a baseline and should be followed up to monitor progress. Does this indicate possible depression? Does Laura have suicidal thoughts? Follow the local policy/pathway.
    • How often does self-harm occur? By which method? Is she able to identify triggers to self-harm? (Perhaps discuss last episode to help identify early warning signs) Assist Laura to make links, and perhaps discuss alternative coping strategies. Assess harm – injuries, is there treatment required?
    • Observe and ask Laura about her relationship with Mia –responsiveness to cues, interaction, soothing etc. Is Mia teething, getting up in the night, crying? Is this affecting Laura’s sleep?
    • Support from others? Partner? Parents? Others?
    • What are Laura’s strengths? Coping strategies etc.
    • What does she want help with?
  • This will be largely dependent on severity of depression and risks.
  • However, at the milder end it is important to monitor the situation, you may also inform Laura’s GP and encourage her to make an appointment with him. The GP will conduct a further assessment and will provide medication if appropriate.
  • You may also signpost to any appropriate groups/supports, e.g. PND group, guided self-help.
  • If moderate to severe depression seek guidance from mental health services as per local policy.
  • You may wish to include family, particularly partner. Involving Paul allows opportunity to check out how he is coping, also offer advice/support on how best to support Laura.
  • Remember the safety and welfare of the child is paramount and if there are any concerns this must be communicated appropriately in line with child protection guidelines.