Section of Women's Mental Health Research Projects
Our current projects include:
ADEPT: Optimising psychological treatment for Anxiety DisordErs in Pregnancy: a feasibility study for a Trial of time-intensive CBT versus weekly CBT
The aim of this research is to investigate if a shorter format of a well-established psychological therapy for anxiety disorders can be used with pregnant women. It will establish if pregnant women find this format acceptable and useful, and if this way of delivering the treatment can later be tested in a large trial.
Cognitive behaviour therapy (CBT) is known to be an effective treatment for anxiety disorders. Many women prefer psychological treatments to medication during pregnancy and so this is often a good fit for women with these disorders. CBT is usually delivered over a period of three months. Recently, good results have been demonstrated with CBT delivered in fewer but longer sessions over two to three weeks for OCD, PTSD, panic disorder and social anxiety. However this format has not yet been tested with pregnant women.
This research will first develop a protocol for the delivery of time-intensive CBT (IN-CBT) for OCD, PTSD, panic disorder and social anxiety disorder. This will be tested with a small number of pregnant women with anxiety disorders and feedback will be sought from participants on outcome questionnaires and assessments for the study.
The next part of the research will be a small trial (known as a feasibility study). Women taking part will receive either IN-CBT or standard CBT for their anxiety disorder. This will establish if IN-CBT is acceptable for women, the best way to reach potential participants and if enough women will take part in a trial and will complete postnatal outcome measures. Detailed interviews with women undertaking the treatments will investigate views of both versions of CBT and if the study assessments are acceptable and useful.
If found feasible in this study, a larger trial would then examine whether IN-CBT for antenatal anxiety disorders is more effective in reducing negative outcomes for mother and child than standard weekly CBT. Ultimately, if the intensive format of delivery was found to be better in terms of benefits for both mother and child, this research would influence practice regarding treatment of antenatal anxiety disorders across the UK.
Antipsychotics in pregnancy and information needs of women with bipolar considering pregnancy
Antipsychotics in pregnancy
We are currently undertaking research to provide evidence on the risks and benefits of psychotropic drugs in pregnancy through analyses of data from the Case Register Interactive Search (CRIS) system (a unique anonymised secondary care mental health care database). CRIS allows searching and retrieval of anonymised records from the SlaM Patient Journey System and we are carrying out a retrospective cohort study investigating the risk of and time to relapse during pregnancy, and in the postpartum period, after stopping psychotropic medication compared with continuing medication and compared with switching medication, in pregnant women with a history of psychosis.
Find out more about the antipsychotics in pregnancy project
DAWN: Depression: an exploratory parallel-group randomised controlled trial of Antenatal guided self-help for WomeN
DAWN is a randomised controlled trial in which there is a 50:50 chance of women receiving Guided Self Help rather than care as usual. Guided Self-Help is a brief treatment shown to be effective in non-pregnant groups: we will modify it for pregnant women, aiming to provide an economical and effective way of providing prompt treatment not involving the risks of medication.
For the trial we are looking for women who are:
- Pregnant and aged 16+
- Currently experiencing depression
- Not in psychological therapy
- Not taking antidepressants
Recruitment is now closed.
The study protocol has been published and can be accessed here.
To request an electronic copy of the Guided Self-Help workbook, please email firstname.lastname@example.org.
The effects of the asylum process on mental health in Iranians and Afghan asylum seekers
Sohail Jannesari's PhD project investigates the impact of the UK asylum process on mental health, with a particular focus on Iranian and Afghan asylum seekers. The project uses participatory action research research, and the initial part of the project looks at how researchers can work with asylum seekers in a non-exploitative, more equitable manner.
eLIXIR, Early Lifecourse data Cross-LInkage in Research; a Multidisciplinary Partnership
The developing embryo, fetus and newborn child are very sensitive to change in the surrounding environment, whether this arises from problems with the mother's health, the placenta not working properly, complications during birth, or as consequence of being born too early. Adversity in these periods of developmental vulnerability can have persistent effects on the long term health of the child, including physical and mental health disorders. We also know that if a mother has complications in pregnancy, that she may suffer from increased risk of ill-heath in later life, for example cardiovascular disease, diabetes or mental health problems.
To reduce the risk of these diseases in the child and in the mother, we need to know more about the processes leading up to them. One approach is to capture the information from hospital and general practice health care records as the child grows up, or as the mother gets older, and through the study of this data and routinely collected blood samples, work out when and why the disorders happen. When we know this, we shall be able to work out how to prevent them. In England routine health records are held in different computer systems and are not easy to assemble.
Our partnership, the eLIXIR partnership of doctors, scientists and IT specialists has developed a way to put all this data together and to collect it continuously. We shall start doing this in a large population from a deprived area of South London, where health is poor compared to other areas of England. When we have shown this system works, we plan to extend the study to a much bigger population in London and elsewhere. This new and important research resource will help us explore the 'life course' of some of the most common diseases, and help scientists and doctors to work out how we may prevent them.
ESMI: Effectiveness of Services for Mothers with Mental Illness
ESMI is a programme of research funded by the National Institute for Health Research (NIHR) to examine the effectiveness and cost-effectiveness of perinatal psychiatry services. The programme consists of several linked studies which will allow us to make recommendations to policy makers, NHS commissioners and providers about the type of perinatal mental health services that are most helpful.
Find out more about the ESMI project
ESMI MBU: Effectiveness and cost-effectiveness of mother and baby units
ESMI MBU investigates the effectiveness and cost-effectiveness of psychiatric Mother and Baby Units (MBUs) compared with general psychiatric wards or care from intensive Crisis Resolution Teams (CRTs) for acute severe postnatal disorders for women in the year post birth. We will compare the effectiveness of these services in preventing further admissions, addressing health and social care needs and supporting mothers in their relationships with their infants. We will also investigate impacts on partners/significant others’ mental health, worries, finances and ability to cope.
We have no language or diagnostic restrictions. We are recruiting women:
- admitted to MBUs, general wards or CRTs for acute severe postnatal disorders in the first year post-delivery
- who are not under these services “prophylactically” (i.e. for close monitoring in high risk cases or for statutory parenting assessments (i.e. not for acute illness))
- whose baby has not been permanently removed from their care before admission
For Baby's Sake
For Baby’s Sake is a new domestic abuse and infant parenting programme for mothers and fathers. It is a trauma-informed, whole-family intervention that works with parents from pregnancy to two years postpartum to break cycles of domestic abuse and improve outcomes for children.
The programme is being delivered by the Stefanou Foundation. It launched in 2015 across two pilot sites and this first phase of implementation is being evaluated by the Section of Women’s Mental Health.
Find out more about the evaluation here.
Gestational diabetes and maternal and infant mental health
This PhD project entitled ‘Is gestational diabetes associated with adverse maternal and child mental health outcomes?’ aims to establish whether or not gestational diabetes is associated with adverse maternal and child mental health outcomes.
Find out more about the gestational diabetes and maternal and infant mental health project
The impact of anxiety disorders and personality dysfunction in pregnancy on mother-infant interactions
Research has shown that depression in pregnancy can be associated with problems in mother-infant interaction. Such difficulties may lead to adverse emotional and behavioural outcomes in children. However, other than depression, there has been little work on mental disorders such as anxiety disorders or personality dysfunction during pregnancy. This has been highlighted as a research area needing attention and perinatal mental health services are currently being prioritised by NHS England.
The aim of this project is to examine mother-infant interactions in women with anxiety disorders and personality dysfunction in pregnancy compared with a cohort of women with no mental disorder. The study population will be recruited from a representative cohort of pregnant women taking part in the 3 month postnatal follow of the WENDY study.
We plan to measure a 5-minute mother-infant free-play session; thus we will be able to investigate whether anxiety and personality are associated with mother-infant interaction difficulties, adjusting for other potential risk factors already collected through pregnancy.
If we find that anxiety disorders and/or personality difficulties are associated with mother-infant interaction problems at 3 months postnatal, antenatal identification of these problems could enable earlier interventions to be put in place during pregnancy by health and social care. This could support more positive mother-infant interaction and improve long-term child outcomes. Existing mother-child interventions suitable for the antenatal period could be adapted for these risk groups if we provide evidence for the nature of interaction difficulties.
Implementing a pilot intervention for perinatal mental health and intimate partner violence in rural Ethiopia
World Health Organization (WHO) guidelines recognise that intimate partner (domestic) violence (IPV) adversely affects health, and recommend identification, training and woman-centred support. In Ethiopia, IPV is commonest in pregnancy, making antenatal care an important intervention opportunity. Integrating WHO IPV guidelines within perinatal psychosocial interventions could improve physical and mental health, but evidence from rural Africa is lacking.
Roxanne Keynejad's PhD project is funded by King's College London and a King's IoPPN Clinical Investigator Scholarship and supervised by Dr Charlotte Hanlon and Professor Louise Howard. It aims to test the hypothesis that IPV moderates women's responses to psychosocial interventions for mental health problems, and to pilot and evaluate a perinatal psychosocial intervention adapted to integrated WHO IPV guidelines, in rural Ethiopia.
Linking Abuse and Recovery through Advocacy for Victims and Perpetrators (LARA-VP)
LARA-VP is funded by the Medical Research Council and King’s Health Partners and aims to improve the identification and response to domestic violence and abuse (DVA) within mental health services. People with pre-existing mental disorders are at increased risk of experiencing DVA, and there is some evidence to suggest that there may also be an association between psychiatric diagnoses and the perpetration of physical abuse against a partner.
Research conducted in this project will inform a future trial of our piloted intervention study (“LARA” – “Linking Abuse and Recovery through Advocacy”) that involved reciprocal training between mental health professionals and DVA specialists, and integrated DVA advisors into community mental health teams to improve the identification and care of DVA among mental health service users. This intervention includes the provision of an educational manual on DVA for mental health professionals; this will be updated to reflect recent research and guidance. Natural Language Processing (NLP) methods will also be exercised on pseudo-anonymised clinical records from the Case Register Interactive System (CRIS) to derive the best possible measure of mental health professionals’ ability to identify DVA victimisation and perpetration.
Maternal near misses in perinatal mental illness
Maternal deaths have been systematically studied in the UK for over 50 years, at both local and national levels. While there has been a significant decrease in the number of maternal deaths due to direct causes (i.e. attributed to pregnancy or birth), deaths resulting from indirect causes (i.e. attributed to coexisting conditions) have remained stable over the last 10 years. Mental illness remains a leading indirect cause of maternal death.
In developed countries such as the UK, where maternal deaths are rare, it is becoming increasingly recognised that studying near misses (or severe life-threatening complications not resulting in death) can provide important additional information about the processes, or lack of, in place for recognising and responding to clinical deterioration and help guide interventions aimed at improving patient safety.
Several frameworks and checklists for identifying maternity and obstetric near misses exist. Despite the high proportion maternal deaths relating to mental rather than physical health, these frameworks focus almost entirely on physical health indicators (such as sepsis and postpartum haemorrhage), with limited consideration psychiatric indicators.
In order to identify near miss events among women with perinatal mental illness there is a need for a national framework that includes both physical and psychiatric indicators of clinical complications.
A two phase study is being undertaken to develop and pilot a framework for identifying near miss events in women with perinatal mental illness. Qualitative interviews and focus groups will be conducted with key stakeholders (patients and clinicians) to guide the development of the framework. A mixed methods study of electric health records of women who have had contact with secondary mental health services will then be undertaken to test its feasibility and determine rates of near miss events in a population of women with severe mental illness. A qualitative study of patients notes be undertaken to explore the contextual influence on detection and response to maternal near misses and deaths among women with severe perinatal mental illness.
In the future, we aim to test the framework at a national level and to develop an implementation toolkit to aid identification and response to clinical deterioration among women with perinatal mental illness.
This study is being undertaken by Dr Abigail Easter (Senior Research Fellow in Implementation Science) as part of a King’s Improvement Science Postdoctoral Fellowship. The project is supervised by Professor Louise Howard, Professor in Women’s Mental Health, Consultant Perinatal Psychiatrist and Head of the Section of Women’s Mental Health and Professor Jane Sandall, Professor of Social Science and Women's Health in the Division of Women’s Health.
The work of King’s Improvement Science is funded by King’s Health Partners (Guy’s and St Thomas’ NHS Foundation Trust, King’s College Hospital NHS Foundation Trust, King’s College London and South London and Maudsley NHS Foundation Trust), Guy’s and St Thomas’ Charity, the Maudsley Charity and the Health Foundation.
For more information please contact email@example.com
Mental health and relationship difficulties: the experiences of mental health service users who have perpetrated domestic violence and abuse
Dr Marilia Calcia, MD(Res) student
Domestic violence and abuse (DVA) is any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those who are (or have been) intimate partners or family members aged 16 and above, regardless of gender or sexuality. Reviews have shown that people with mental health problems are at increased risk of experiencing and perpetrating DVA compared to the general population. Research has also found that mental health professionals face challenges in identifying and managing the risk of DVA perpetration among their service users. This study aims to investigate the experiences of mental health service users who are, or have been, perpetrators of DVA. Individual semi-structured interviews will be conducted with mental health service users to explore their experiences of relationship difficulties, including DVA perpetration, and of talking about these problems with mental health professionals. Participants will be recruited with help from staff at mental health teams and through a computer system that allows researchers to contact service users who have agreed to be contacted for the purposes of research. People will be eligible to take part if they are receiving care and treatment from the South London and Maudsley NHS Foundation Trust, aged 18 or above, of any gender, who are able to communicate in English, and have experienced difficulties in their relationships with intimate partners or adult family members, including perpetration of DVA.The interviews will be audio recorded, transcribed and analysed by the researcher using qualitative methods. Findings may be used to develop interventions to improve mental health services' responses to DVA perpetration.
Migration and Perinatal Mental Health (MPMH)
Mood and anxiety disorders during pregnancy and the postpartum period (the perinatal period) are common and can have adverse outcomes for both the mother and baby. Migrant women (women born outside the UK) may be at higher risk of mental disorders during the perinatal period, but it is not clear why. Previous research has shown that low levels of social support and experiences of discrimination or anticipated discrimination (e.g. on the basis of nationality, ethnicity or gender) have been associated with mental disorders, but this has not been investigated among perinatal migrant women in the UK.
There is also evidence of health and social service inequalities in this population, but the reasons for this have not been explored. This study aims to explore the experiences of social support, discrimination, and support from health and social services among migrant women in the perinatal period. A sample of migrant women participating in a larger study on mental health during pregnancy (the WENDY study) will be recruited to include a range of migration statuses, ethnicities, languages and ages.
The women will take part in one in-depth interview, which will seek to add detail to the information they have given as part of the larger, quantitative study, and to expand on potential stressors not included in the quantitative study, such as experiences of discrimination. This research aims to highlight the challenges of having a baby in the UK as a migrant woman, identify areas that services can improve in terms of providing support and challenging discrimination, and to capture the heterogeneity of experiences among this population by collecting rich and detailed data.
Obesity and Mental Disorders During Pregnancy
Antenatal mental disorders and obesity are both risk factors for adverse pregnancy outcomes. Evidence from non-pregnant women suggests that obesity and mental disorders may be associated, but there has been limited research investigating the relationships between these factors during pregnancy.
This mixed methods PhD project will therefore investigate the associations between obesity and mental disorders during pregnancyresearch into the relationship between obesity and mental health in pregnancy, how this impacts on pregnancy outcome and how interventions can reduce adverse outcomes.
Find out more about the obesity and mental health in pregnancy project
A Patient Decision Aid for Antidepressant Use in Pregnancy: Study
We are conducting a pilot trial of a patient decision aid on antidepressant use in pregnancy. This study is looking for individuals who can take part.
The study website can be found at: www.kcl.ac.uk/decisionaid
Patient decision aids help people make informed decisions about their treatment by providing information about the pros and cons of each treatment option, and by clarifying personal values and preferences.
Find out more about the Patient Decision Aid study
A patient decision aid for antidepressant use in pregnancy: a Canada-UK collaboration
Around 10% of women experience depression in pregnancy. Antidepressant medication may be the treatment of choice for women with moderate to severe depression. Women who might benefit from continuing or starting an antidepressant during pregnancy face a difficult decision. This is because both depression itself and the antidepressant medications used to treat it can carry risks for the mother and her unborn child.
It has been shown that routine clinical care and the provision of information on the benefits and harms of antidepressant use in pregnancy do not always allow women to make a choice that they feel satisfied with, and that is in line with their values.
In other fields of medicine, patient decision aids (PDAs) are used to make this process easier. A PDA is a tool that allows patients to (a) access information about an illness and its treatments, (b) clarify the decision that they have to make and (c) clarify their personal values and preferences in relation to that decision. There are no existing up-to-date PDAs on the use of antidepressants in pregnancy.
Dr Simone Vigod and her colleagues, from the University of Toronto in Canada, have developed an electronic, evidence-based PDA on antidepressant use in pregnancy. The PDA can be accessed electronically by a patient at home or in the clinic, and is designed to be used flexibly alongside usual clinical care. The PDA is currently being tested by patients who are considering using an antidepressant in pregnancy, to assess how acceptable and useful it is to patients and their clinicians.
These pilot trials will be conducted in Canada and in the UK (in patients accessing SLAM services). Findings from these acceptability and feasibility trials will be used to design a large international randomized controlled trial (RCT), which will assess how effective the PDA is.
Specifically, it will assess whether the PDA reduces the conflict that women feel in relation to decisions about antidepressant use in pregnancy. The trial will also assess whether the PDA improves patients’ knowledge on treatment options, patient-clinician interactions and the likelihood of women suffering from postnatal depression and anxiety. The PDA is a relatively simple, low-cost intervention with the potential to help a significant number of women and unborn children. The pilot and future planned trials will ensure that is rigorously evaluated.
PRIMH: Promoting Recovery in Mental Health
PRIMH (Promoting Recovery in Mental Health) is an evaluation of an intervention developed and delivered by the non-governmental organisation AVA (Against Violence and Abuse) to improve service responses to domestic and sexual violence at two mental health trusts: Camden and Islington NHS Foundation Trust and Sussex Partnership NHS Foundation Trust.
Find out more about the Promoting Recovery in Mental Health project
PROTECT – Provider Responses, Treatment, and Care for Trafficked People
PROTECT is a mixed methods research programme on the health needs of trafficked people in England.
It aimed to develop evidence to inform the NHS response to human trafficking. It provides evidence about the healthcare needs and experiences of trafficked adults and children; documents NHS experience, knowledge and gaps about trafficked people’s healthcare needs; and will provide recommendations on the content and format of training materials to support NHS staff to identify, refer and care for trafficked people. Read the PROECT Final Report for the Department of Health Policy Research Programme (PDF 2MB).
Find out more about PROTECT
Risk of Domestic Violence Perpetration in Mental Health Service Users
Mental illness is a known risk factor for behaving violently towards others. However, there is currently limited evidence exploring the link between mental illness and violence in a domestic setting (DV), for example towards partners or family members. This project will assess the risk, prevalence, and risk factors involved in DV perpetration among individuals with mental illness.
A systematic review of the existing literature will be conducted, and if the sufficient high quality studies are available a meta-analysis will also be performed, estimating the odds and risk of DV perpetration in individuals with mental illness. This will provide an update to Oram et al’s (2014) systematic review and meta-analysis. An individual participant data meta-analysis will also be conducted on data collected from national surveys and datasets collected directly from researchers. This will allow further exploration into associations, confounders and moderators.
A particularly detailed analysis will be conducted using the 2014 England and Wales Adult Psychiatric Co-morbidity Survey (APMS), as questions on DV perpetration were added to the 2014 questionnaire. This survey provides data on the prevalence of psychiatric disorders in the UK. It uses a stratified, multi-stage probability sample of UK households of individuals aged between 16 and 74. This provides a unique and novel opportunity to allow analysis into the relationship between mental illness and different types of DV perpetration. Associations between DV and mental illness variables will be calculated, and logistic regressions will enable the influence of multiple factors to be examined.
As well as addressing gaps in the literature, this research will aid in identifying risk factors that can guide identification of at-risk victims and perpetrators, and guide the development of appropriate DV interventions.
This PhD is being carried out by Katherine Saunders, under the supervision of Professor Louise Howard, Professor in Women’s Mental Health, Consultant Perinatal Psychiatrist and Head of the Section of Women’s Mental Health, Professor Sabine Landau, Professor of Biostatistics, and Dr Sian Oram, Lecturer in Women’s Mental Health.
The project is funded by a NIHR Maudsley BRC PhD Studentship.
For more information on this project, contact firstname.lastname@example.org.
Self-Harm in the Perinatal Period
Suicide is a significant cause of maternal deaths and frequently preceded by self-harm during the perinatal period (pregnancy and the year post-birth). However little is known about the prevalence, risk factors and consequences of perinatal self-harm (PSH) itself. We therefore aim to investigate, in (a) the general population, and (b) secondary mental-healthcare service-users, the prevalence and risk factors for PSH and estimate the extent to which PSH is associated with later suicide.
We will carry out a systematic review and two cohort studies. The first cohort study, is of women with hospital deliveries >24-weeks gestation (1996–2011) and ICD coded PSH contacts with outpatient, inpatient and A&E departments of medical/psychiatric hospitals, using national registry data from the National Center for Register-Based Research in Denmark. The second cCohort study uses secondary mental-healthcare data of service users with hospital deliveries >24-weeks gestation (2007–2014), and ICD-coded/free-text PSH events, using clinical informatics (using comprehensive de-identified mental-healthcare records of South London and Maudsley NHS Foundation Trust service-users (the Clinical Records Interactive Search system see http://www.slam.nhs.uk/research/patient-involvement/current-opportunities/cris).
Who is involved?
Dr Karyn Ayre’s clinical doctoral training research fellowship is funded by the National Institute for Health Research Doctoral Training Fellowship scheme.
WENDY: Well-being in pregnancy in an inner city maternity service
WENDY investigates the best ways of identifying disorders and treating depression in pregnant women seeing midwives. We will compare how well the two questions currently used by midwives to assess depression during antenatal booking appointment really do identify depression by comparing them with more detailed assessment methods. We will measure the frequency in pregnancy of depression and other disorders such as anxiety and eating disorders. Women found to have depression will be invited to participate in the DAWN trial.
Women with Bipolar Disorder and Pregnancy
This project aims to investigate the views of women with bipolar disorder who are contemplating pregnancy or who are pregnant. Qualitative and quantitative methods will be used to discover what factors affect their decision to become pregnant and their choice of treatments to help them stay well.
Women with bipolar disorder are at very high risk of having a severe episode of illness in relation to pregnancy and childbirth, with 25-50% of births precipitating postpartum psychosis, a severe condition which usually requires hospitalisation. They face many difficult decisions, including whether to optimize their chance of remaining well by staying on their mood-stabilising medication and risking harm to the foetus, or to stop medication and risk becoming ill.
Learn more about the women with bipolar disorder and pregnancy project