Mental healthcare needs are markedly different in the perinatal period than at other times. The Mental Health (Scotland) Act (2015) gives a woman the right of access to appropriate mental healthcare regardless of her place of residence or severity of her condition. The Delivering Effective Services report (Scottish Government, 2019) made recommendations across all tiers of service delivery. There was an emphasis on the development of expertise by all professionals involved in maternal and infant mental healthcare and the importance of close working links between different services that women encounter.
The Delivering Effective Services report (Scottish Government, 2019) led to the establishment of the Perinatal and Infant Mental Health Programme Board in the same year, which followed on from the establishment of the Perinatal and Infant Mental Health Network Scotland (PMHNS) in 2017. The network has developed standards and pathways for referral and management of women experiencing perinatal mental illness, established competencies and training for health professionals, and aims to ensure all pregnant and postnatal women have equitable access to appropriate care. Since the inception of this managed clinical network, it has also overseen the expansion of specialist perinatal support including perinatal mental health multi-agency teams, infant mental health specialist midwives and maternity and neonatal psychological intervention services. The clinical psychologists providing these maternity and neonatal psychological intervention services are co-located with hospital based maternity services. They have a specific remit to provide interventions that address psychological need for parents with previous or current pregnancy and neonatal complications, or who have mental health problems that directly affect maternity care.
The development of the Scottish perinatal mental healthcare pathways has recognised the need for inclusion of psychological interventions for women with common, mild-to-moderate mental health problems or mental health difficulties that arise from pregnancy, birth or neonatal complications, trauma or loss. The perinatal mental healthcare pathways developed in Scotland (NHS Scotland, 2021) cross all health and social care services, so that those using services, their families and all professionals know what should be expected at any point along a woman's journey of care to ensure a consistent and coordinated response.
Provision of support may be freely accessed through a range of routes, including third sector providers, primary care psychological therapies services or specialist maternity and neonatal psychological intervention services. Restrictions to accessing these important interventions include meeting the referral criteria, waiting times and service availability, but are also greatly impacted by the inequalities arising for those from minoritised and marginalised groups (Darwin et al, 2022). With restrictions to the timeline of the perinatal period, which is recognised as the optimum time for interventions, and consideration on availability of qualified professionals to deliver care, access to digital platforms is indicated.
Digital tools are available in Scotland that could provide meaningful interim support; however, gaining access to tools such as SilverCloud® Perinatal often requires a referral code to be provided by a GP following mental health assessment. As a result of workforce pressures in general practice, this can mean several days or in some cases weeks to gain access. However, it is also important to consider the potential inequity of access to GP services for those from marginalised groups, especially those whose immigration status precludes them registering with a GP (Khan, 2021).
Workforce education and development is the primary function of NHS Education for Scotland (2019), with their Perinatal Mental Health Curricular Framework setting out the knowledge and skills required by perinatal healthcare professionals, including midwives, alongside other training plans for the wider workforce related to trauma informed care and infant mental health.
Further developments have included training and development of perinatal and infant mental health champions across Scotland through the Institute of Health Visiting. Perinatal and infant mental health training programmes and training in psychologically informed approaches, psychological interventions and psychological therapies for perinatal and infant mental health teams have also been developed. The Scottish government, in partnership with NHS Education for Scotland, also support free access to the Solihull Approach Online resource for parents and carers living in Scotland, to help them understand their child's behaviour in the context of their child's development and the parent–child relationship.
Diagnosis of a mild-to-moderate metal illness in the perinatal period is more common than severe and psychotic illness (Howard and Khalifeh, 2020), and in Scotland, these are predominantly managed by midwifery, primary care, third sector and maternity/neonatal psychological therapy services. Midwives are often the best-placed professional to identify mental health concerns and refer to appropriate care, and with waiting lists and delays accessing services, they provide vital support. However, lack of available training for midwives in recognising changes in women's mental health and lack of time during appointments are notable barriers to the provision of timely support (Savory et al, 2022)
Overview of digital mental health provision in Scotland
In Scotland, the ‘Matrix’ (NHS Education for Scotland, 2024) was formally launched on a new digital platform on 1 November 2023. It is designed to support evidence-based practice for the delivery of psychological therapies and interventions through four key elements:
- Overview of psychological services in Scotland
- Evidence summaries
- Explore the recommended interventions and therapies
- Supports for training and implementation.
The ambition, as set out by the Scottish government, is for everyone to have timely access to high-quality, person-centred, evidence-based psychological therapies and interventions that are effective in improving health, mental health and wellbeing when it is needed for the people of Scotland. The Matrix supports this by providing guidance on what the evidence is for effective and accessible delivery, with the goal of the right therapy or intervention, accessible at the right time and delivered by a well-trained and supported workforce in the most efficient way possible.
The Scottish experience
This summary outlines the extent of current digital mental healthcare service provision in midwifery with reported outcomes. Introduced as a test of change project in November 2020, the Perinatal Wellbeing Programme from SilverCloud® was used in three territorial health boards in Scotland. The programme comprises six key modules that combine education to support understanding emotions and techniques to mitigate symptoms of worry, low mood and sleep difficulties. Access to the computerised cognitive behavioural therapy package during this test of change was via the established referral routes of perinatal services, midwives, health visitors, specialist psychologist and GPs. Safety-netting of three weekly ‘patient reviews’ were included during this 7-month test period. In this time, 174 referrals across the three health boards were made, which collectively hold 30% of the national population.
Implementation of the project was managed through the national programme team working in collaboration with local computerised cognitive behavioural therapy services. Each local service was asked to liaise with local specialities to ensure appropriate clinical input and oversight was provided. Local computerised cognitive behavioural therapy services remained responsible for operational development, patient safety and clinical governance. Clinical effectiveness was measured using the Patient Health Questionnaire-9 and General Anxiety Disorder-7 scores for those using the programme. In all boards, a reduction in both scores was measured, with an example from one board shown in Figures 1 and 2.
At onset, 89% of clients had an initial Patient Health Questionnaire-9 score of at least 10 or an initial General Anxiety Disorder-7 score of at least 8. Thereafter, of those completing the computerised cognitive behavioural therapy treatment package:
- An overall 24% recovered, meaning moved to ‘non-caseness’, scoring <10 on the Patient Health Questionnaire-9 and <8 on the General Anxiety Disorder-7
- Almost half (45%) reliably improved, showing a decrease of at least 6 on the Patient Health Questionnaire-9 scale or at least 4 on the General Anxiety Disorder-7 scale
- Almost a quarter (23%) reliably recovered, meaning they met the criteria for both recovery and reliable improvement.
Feedback from those engaging with the package was gathered on completion of each of the six modules. Although the package is suitable for men and women, most users were women. In total, 232 individual module responses were gathered from a potential of 1044, had all 174 participants provided feedback on all six modules they had completed. Overall, >80% rated the modules as interesting, relevant, helpful and helped them to progress. Following this initial test of change, a national implementation of this perinatal wellbeing package followed. The Patient Health Questionnaire-9 and General Anxiety Disorder-7 improvements continued, with the 2022 data presented in Figure 3.
In Scotland, digital therapies use has grown from 5247 referrals in 2015/16 to 70 026 referrals in 2022/23. In this most recent period, self-referrals have contributed 38 777 and have represented a substantial portion of all referrals since 2019/20, potentially influenced by challenges in accessing support during the pandemic. The perinatal wellbeing package represents one component of 48 platforms working at local and national levels across Scotland to support positive mental health and wellbeing.
However, despite the improvements seen in patient health and anxiety scores for participants, a significant challenge with this programme was identified. Digital exclusion, broadly defined as a lack of digital skills, access to a suitable device, reliable internet connection or motivation to use the internet (Holmes and Burgess, 2021), contributes to the presence of a digital divide in society and an inability to access this type of mental health support. In Scotland, most digital exclusion was identified in Glasgow, with material deprivation recognised as both a key cause of this exclusion and a multifaceted and difficult factor to address (Greer et al, 2019). The predictive power of ill-health related to socioeconomic circumstances throughout the life course is well-recognised, with increased morbidity linked with increasing socioeconomic disadvantage (Kivimäki et al, 2020), which can further compound the digital divide and exclusion from supportive online therapies.
NHS Education for Scotland (2021) conducted a comprehensive review of technology enabled psychological therapies, and identified several important points for consideration when implementing these digital approaches in the general population. How these might align or differ for the perinatal period is not specified. First, although the research literature suggests comparable benefits and acceptability by people with anxiety and depression between video/telephone treatment and those delivered face to face, this was limited by the quality of this research and lack of interrogation of the cost-effectiveness and safety. Second, attrition (drop out) can arise when computerised cognitive behavioural therapy is not guided by a clinician, impacting the efficacy of this therapeutic approach, although it is still likely to confer greater benefits than self-help alone. This relationship is summarised in Figure 4. Finally, the impact of digital poverty and issues of accessibility was highlighted, emphasising the need for those organisations subscribing to and advocating for the use of computerised cognitive behavioural therapy to consider in their equipment provision and governance processes.
Conclusions
Intelligence from the use of digital mental health programmes in Scotland, such as the Perinatal Wellbeing Programme from SilverCloud®, is favourable and suggests it can overcome some of the identified barriers to accessing traditional mental health support. This includes reduced out-of-pocket travel expenses, increased convenience and privacy (reducing stigma of attending a mental health clinic) and the ability for individuals to complete at their own pace, with their infant present. This is in a context where this mode of delivery carries some risk of programme attrition when compared to clinician-guided therapies, warranting further research to understand if this risk can be mitigated.
Key points
- In Scotland, engagement with the Perinatal Wellbeing Programme from Silvercloud has yielded favourable results from users of this digital tool.
- Further research is needed to understand the risks of attrition from digital mental health programmes compared with clinician-guided therapies.
- This flexible approach and interface appears to overcome some of the barriers to accessing traditional mental health support.
CPD reflective questions
- Have you considered the enablers and barriers associated with digital mental health support?
- Having read this article, are there lessons from the Scottish experience you could apply in your local area or to your practice?
- Were you aware of the relationship between delivery of differing types of mental health support with efficacy and attrition?