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Rebecca presents a very complex scenario. I had a patient as a first year trainee in Psychiatry who also presented with Bipolar Disorder and it was a team effort to decide if suppressing breastfeeding was the best option for herself and the baby given the severity of her presentation. Rebecca has added components, like domestic violence, so as usual, I would think of her in a biopsychosocial approach.
1) the fact that she has a history of BPAD is the first red flag. She was treated by her GP and apparently showed poor compliance, it would be imperative for the Perinatal Psychiatrist to do a full assessment of past and current needs and mental issues, including medication compliance and the possibility of introducing a new mood stabiliser together with a benzodiazepine if needed. How that will be managed having young children and a small baby needs to be discussed thoroughly with her and input from the obs team is required.
2) Rebecca needs urgent social support. The MDT will have to intervene on the social aspect. A Social Worker and a Public Health Nurse will need to do assessments of abuse, functionality at home, risks for herself and the children. This isn't my area of expertise as a psychiatrist, that's why I would rely on other disciplines to assess this area and act accordingly. There is a child protection service in Ireland called Tusla, where any concerns regarding domestic abuse or neglect of minors have to be reported. They offer a network of support for mothers, especially single parents. I wouldn't hesitate in involving them.
3) since the scenario seems so acute and complex both biologically and socially, I think a Midwife with training in Mental Health should give Rebecca initial therapeutic support and links with the community. Once she's stable and able to receive further help, she can be transferred to a local Mother Baby Unit (if available) or Community Mental Health Service to attend psychotherapy, groups, medication follow up, social service support, etc.
Thank you Claire, Great insight into the support available in Ireland. I think we all work in very different systems even at a local level. Although the government has invested millions into perinatal mental health, its not enough, so some of us (like here in Sheffield) have a great new PMH service, other areas not too far away don't.
Cath

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Aimee

Who else do you want to talk to?
- GP – to ask if Rebecca has had a follow up appointment? How much medication did he prescribe has she currently ran out of medication until she attends a review appointment or did the new medication prescription cover her for longer than 1 month? During the GP's review of medication was a mental health assessment or referral considered? Is the GP working with the mental health worker and Rebecca to put an effective management plan in place?
- As Rebecca is an adult attending appointments and having further mental health input is maternal choice. However she is a parent, with history of previous neglect so if she has uncontrolled mental health issues that has a knock on effect to Krystal's care this is a safe guarding concern, especially when she is on a child protection plan already.

-  A MDT would be arranged with the HV, social worker, mental health link to discuss situation.

-  Would want to discuss with Rebecca why she has not attended GP appointment and how she is feeling since the medication has been changed

-          Probation officer and see if the times given from neighbour match when he has been seeing Rebecca. Social worker needs to be aware. Is there a pattern on what days the man appears at Rebecca's house

Develop some questions that you need to answer?

-          Is the man the neighbours have seen attending Rebecca’s house Aaron. Discuss with Rebecca what are the arguments about?

-          Does Rebecca feel threatened, why is she having contact with Aaron?  Is she wanting the support from Aaron is she struggling with being a single mum with the responsibility? Or is it Aaron who is wanting to contact them and is still abusing?  Does Rebecca miss the relationship with Aaron does she see the risk to herself and Krystal?

-          How is Rebecca feeling after the change in medication is this suiting her does she need another review by both the GP and mental health team

-          Is there going to be a MDT meeting to discuss these new concerns?
- What support has Rebecca currently got in place both professionally and family/friends

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I would also consider the idea that Aaron is being called by Rebecca at times when she cant cope and that he may be the stability. I know its unlikely given their history, but what if its Rebecca abusing him?
Cath

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Claire

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I would take Rebecca's neighbour's concerns very seriously. It would appear that potentially Rebecca's mental health could be deteriorating. I would make contact with the GP to find out if she has collected her prescription for her new medication. I would make contact with Margaret the family support worker as she seems to know Rebecca really well. I would also make contact with Rebecca's health visitor to find out if she has been in contact with Rebecca recently. I would again speak to Aaron's probation officer for more background information on Aaron. I would potentially contact Aaron's GP to see if I could get some history on Aaron's mental health and also try and find out if he has a history of substance misuse.  I would also try and have an honest conversation with Rebecca about what is really going on and refer her for mental health assessment if required. It could be the fact that Rebecca is terrified of Aaron and does not want to disclose his recent contact out of fear from him and also fear about her baby being removed. I would give Rebecca information on local organisations such as Women's Aid who provide support for domestic violence.

The main thing to take into consideration would be the safety of Krystal.  It is imperative that all professionals are communicating and keeping each other updated with all the latest information.

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Amy

Rebecca: There is already a family history of Schizophrenia and Rebecca herself has been diagnosed with Bi-polar, so from reading the scenario’s, my first though is the link between bi-polar and an increased risk of developing post-partum psychosis in the postnatal period. This would also relate to the fact that her medication was altered by her GP and Rebecca did not attend any further follow up appointments, so it could be that the changes made to her medication are not adequate.
There may still be a strong possibility of domestic violence between Rebecca and Aaron, even though he does not appear to live with her. Having read around the subject area, it could also be a possibility that even though they are not in a relationship, Rebecca could be frightened of Aaron and worries about the consequences if she does not let him in. There may also be a link between areas such as financial concerns, drugs/alcohol, which in turn could also be related to Rebecca being on edge and looking unkempt at the meeting she had.

There appear to be many factors interlinked within this scenario and it is crucial when dealing with this that the multidisciplinary team approach is used in order to access specialised care/information in order to provide support to all affected. Due to the complexity of this case and the previous history, it would be worth keeping an open mind and exploring every avenue without appearing judgmental, in order to find the problems and provide the correct care.

The teams to be involved/I would want to talk to would include GP, Health Visitor, Social services, Social worker, Domestic Violence midwife (if available within the local Trust), police (if drug related). If I was Margaret, the family support worker visiting and had further potential information from the neighbour, I would escalate this to my manager in order for me to gain further support/advice.

I would want to ensure the neighbour is a trusted source of information and would want to explore whether there were any issues between her and Rebecca. I would want to know I could trust the source of this potential very important information.

For areas of knowledge to gain greater breadth and depth for would include the referral processes for each team/professional and the time it would take for this referral to be dealt with.

I would also wish to have more knowledge of local support groups, if Rebecca would access these.