You can’t have one without the other: The case for integrated perinatal and infant mental health services

Perinatal and infant psychiatry has been described as ‘a specialty in search of a home’ (Newman, 2020), referring to its awkward placement between adult and child mental health services. Inherent tension comes from bringing together two distinct clinical traditions – infant mental health, with its focus on parent–child relationships and infant development, and perinatal psychiatry, with its focus on maternal mental illness in pregnancy and the postpartum. The practical challenge lies in holding the interests of parents and infants in mind as one works with a parent–child dyad. At a systems level, this can produce structurally separate services for parents and infants, resulting in the fragmentation of care for families in need.

A fundamental challenge for perinatal and infant psychiatry is integration. Psychiatrists working in this field must attend to the mental health of new and expectant parents, the social-emotional well-being and development of young children, the quality of parent–child and co-parenting relationships, and the cohesion of the family-as-a-whole. Such a holistic and complex view of the life of families with young children demands interdisciplinary collaboration, as the different perspectives brought to bear by clinicians from various professional backgrounds help shed light on the distinct but interconnected facets of this crucial developmental transition.

At the heart of integrated care is a commitment to prioritising the needs and perspectives of families who use these services, a recognition that the whole is greater than the sum of the parts, and an understanding of the primacy of relationships – within the family, between the family and the service system, and between various parts of the system that support families. We present the case for an integrated approach to perinatal and infant mental health (PIMH) services, to help guide review and reform.

Why integration is essential

Australian longitudinal studies have found that parental mental illness in the perinatal period is a leading risk factor associated with adverse developmental outcomes for children, including mental illness in adulthood (Guy et al., 2016). Perinatal mental illness, in addition to genetic effects, exerts a negative impact on the long-term trajectory of children directly through the effects of prenatal stress on foetal development and indirectly through impaired caregiving interactions and other effects on the family environment.

Furthermore, economic modelling shows that the majority of the long-term costs of perinatal mental illness are borne by the child, in terms of their lifetime morbidity, quality of life and career prospects (Bauer et al., 2015). Early intervention focussing on the social-emotional well-being and development of infants and their caregivers improves the mental health and social outcomes across the lifespan and is cost-effective compared to intervening later in life. Unfortunately, infants and young children are underserved by the Australian and New Zealand mental health systems, and the opportunity to intervene is often missed (Segal et al., 2018).

In the PIMH context, integration means providing care for the mental health needs of parents including recovery from illness and adaptation to the parenting role. In conjunction, such care incorporates the quality of the parent–child relationship, crucial for promoting the neurological and psychological development of the infant. Hence, clinical intervention involves the infant to synergistically enhance parental competence and recovery. These interventions provide opportunities for psychoeducation about the attachment and emotional needs of infants and improve the quality of parent–child interaction.

It is sometimes assumed that effective treatment of parental mental illness alone brings about recovery for infants. This assumption is not supported by the research evidence (Stein et al., 2014), as the maladaptive changes in parent–child relationships can persist even after the symptoms of parental mental illness have resolved. Parents may have ongoing parenting anxiety and infants may similarly have anxiety about the emotional availability of parents.

Clinical approaches that work with both parent and infant are uniquely positioned to address: (1) parent–child relational stress and its role in maintaining mental illness; (2) disrupted parenting behaviours and distorted mental representations of the infant; and (3) lack of parenting confidence and sense of self-efficacy. The infant’s role in parental recovery is multifaceted and complex, and active involvement of the infant is a vital component of effective perinatal mental health care.

A model of integrated care

The composition of an integrated PIMH team varies depending on the context, including local needs and resources. The model below emphasises the balance between parental, infant and family needs through the inclusion of clinicians with different skill sets and perspectives into an integrated team. Such a team values the importance of mutual respect and avoids sole clinicians needing to hold competing priorities, reducing the likelihood of ineffective treatment and clinician burnout. There is a wide variety of PIMH models of care, but truly integrated teams remain rare, and are not supported by current funding models that focus solely on individual care needs.

A comprehensive PIMH team includes clinicians who are skilled in:

• The assessment and treatment of parental mental illness in the perinatal period;

• The assessment of infant social-emotional development and well-being, including clinical disorders of infancy, and appropriate therapeutic interventions;

• The assessment and treatment of parent–child relationship disturbance, including family formulation and parent–child psychotherapy;

• Providing consultation and capacity building to other parts of the service system, such as child protection and family services;

• Providing reflective supervision and professional support to other clinicians in the team;

• Facilitating access to maternal and child health services, especially in relation to common issues in the perinatal period such as sleep and feeding;

• Developing and evaluating therapeutic programmes for families with young children, including all key caregivers and siblings.

A systems approach to change and integration

Families benefit from a PIMH care system that responds to the whole family and creates flexible and tailored approaches to meet changing needs from pregnancy to early parenting. Service fragmentation and resultant barriers to access and timely support contribute to loss of trust and engagement.

Planning a comprehensive, integrated approach to PIMH services should involve a broad range of stakeholders across disciplines and levels of care, with an intentional focus on including the lived experience of families and the most marginalised members of our communities. The focus of this system should be the identification of families at high risk of relational disturbance, and the provision of preventive care and early intervention.

Crucially, a paradigm shift is required in funding models and service structures to reflect a philosophy of integration that recognises the primacy of relationships across all levels of the PIMH care system.