Steps Toward Evidence-Based Practices for Parents
with Mental Illness and their Families
San Francisco General Hospital: Consultation/Liaison Program
San Francisco, CA
Program Description
The Consultation/Liaison to OB/GYN (C/L) program at the San Francisco General Hospital is a specialized psychiatric consultation service at the San Francisco General Hospital (San Francisco, California). The program focuses on providing psychiatric consultation to women receiving inpatient and outpatient obstetrical and gynecological (OB/GYN) services at San Francisco General. Psychiatrists and trainees in the program are knowledgeable about the interface of psychiatry and reproductive health, and can see women for emergency consultations in the hospital or scheduled outpatient visits at the hospitals High Risk OB clinic. The outpatient C/L program allows women with psychiatric and/or severe substance abuse problems, including women with Serious Mental Illness (SMI), to receive psychiatric care during their regular prenatal and postpartum healthcare visits. The program is also a training site for medical residents in psychiatry and OB/GYN. The following program description will focus on the outpatient clinic rather than the inpatient consultation service.
Program History
The C/L program began in 1989, and extended the care of the already existing "Women's Issues Consultation Team." It shares its origins with the Inpatient Women's Issues program (please see description in earlier chapter).
Funding History
The program is funded by the Department of Psychiatry at San Francisco General Hospital. All hospital services are required to fund a consultation service. As all programs in the Department of Psychiatry, the C/L program is funded through the Department of Psychiatry's contract with the Community Mental Health Service of the city and county's Department of Public Health. This funding continues to date, but is supplemented with reimbursement from the public state health insurance (MediCal).
Target Population
The C/L Program serves women 18 years and older with psychiatric concerns who receive OB services at San Francisco General Hospital. Women can be seen through their third month postpartum. After the third month, they are referred to clinics in their catchment area.
Theory and Assumptions
Mission. The C/L service supports reproductive choice for women with serious mental illness, and provides high quality mental health care during pregnancy and the postpartum period.
Program Goals. The over-riding goals of the program are to assist women in having a healthy pregnancy, safe delivery, and a smooth transition to home for baby and mother, and to postpartum care. Short-term goals include regular prenatal and psychiatric care during pregnancy, and development of a labor and delivery plan in collaboration with OB providers.
Theoretical Orientation. The C/L program stems from the same feminist psycho-dynamic theoretical base as the Inpatient Women's Issues program (see earlier chapter). This orientation is supplemented with a variety of approaches as needed to address the complex needs of the women seen. It does not have an explicit mission statement separate from the Department of Psychiatry. Similar to the Inpatient Women's Issues program, however, the C/L program's primary objective it to provide information and education to women with SMI who are pregnant or postpartum, help them identify priorities/goals and participate meaningfully in decisions about their care, and provide consultation so that goals can be achieved.
Community Context
California Mental Health System. The California Mental Health System is organized and funded at the county level. Consumers are eligible for case-management services only after they have used over $50,000 in mental health services. Thus, while case-management is available for consumers with the most severe problems, there is a lack of case-management services geared toward individuals at the earlier stages of mental illness, and in particular for women with young children. As a result, potentially manageable conditions progress to more chronic and entrenched disorders that can not be well managed even with case-management that becomes available after high-end service use. Case-management is reported to be a good service once in place, but is not available to many who could benefit in both the short and long-term.
Community Strengths and Weaknesses. San Francisco is rich in resources. However, organization of mental health services at the county level obscures this wealth with respect to those in need. The city of San Francisco is a both a city and a county. As a city, it attracts a large population, including mental health consumers seeking increased resources. As a county, however, San Francisco is small relative to the population it must support. The proportion of poor, inner-city neighborhoods to middle class and affluent ones is high. Thus, although relatively rich in resources, supply does not meet demand.
Mental Health Resources. According to providers and consumers, mental health issues are deeply embedded in local economic and social issues. San Francisco has one of the highest standards of living in the United States. There is little affordable housing available. Adults with mental illness are therefore at high risk for homelessness and substandard housing in crime-ridden neighborhoods. Substance abuse is a major local issue. San Francisco reportedly has the highest rate of substance related Emergency Room visits in the United States.
Community Collaborators
The C/L program works most closely with the OB/GYN department at the hospital, and with referrals from OB clinics in the community. It also has relationships with community-based programs for high-risk families, including the Infant-Parent Program described in this document, and Ashbury House, a one-year residential program for women with SMI and their children. The availability of these resources in the community allows for continuity of care and enhanced follow-up, which can relate to increased stability for the women in the program. Women who grow comfortable or attached to mental health providers they have worked with at San Francisco General can often continue to see these providers in the outpatient mental health clinic.
Agency Context
The C/L program is part of the larger Consult/Liaison service in the Department of Psychiatry at San Francisco General, a public teaching hospital in San Francisco, CA. Staff for the program include an attending psychiatrist, who is the program director and is also the program's founder, and two to six psychiatry residents. Generally, the providers are women. The C/L program works in collaboration with physicians, residents, nurses, and social workers from OB/GYN. Integration of service and education is facilitated by weekly rounds attended by all providers (psychiatry and OB/GYN), and the development of a well-formed, well-integrated, collaborative treatment plan for all women served.
Program Model: Services and Interventions
Pregnant women receive their psychiatric care during routine prenatal and postpartum visits to the outpatient OB clinic. Psychiatric consultation includes medication management, and where indicated, pregnancy and postpartum psychotherapy, and linkage to community-based resources.
Evaluation
Demographics. The program provides consultation for between 75 and 150 women each year. Of the women seen, 32% are Latina, 28% are African American, 23% are Caucasian, 13% are Asian, and 5% fall into an "other" category for race/ethnicity. The clinic serves more Latina women than the inpatient service, and serves a high percentage of non-documented, recently immigrated women. In addition to requiring bi-lingual staff and translations services, non-documented women are ineligible for many of the community based services and entitlements often accessed for clinic clients. In addition, addressing issues of domestic violence is problematic for women who do not wish to be known to law enforcement authorities.
Diagnoses. The most common diagnoses among the women are Depression, PTSD, Adjustment Disorder, Bipolar Disorder, and Schizophrenia.
Co-occurring Disorders and Issues. Substance abuse and trauma are the most common co-occurring issues, though many women experience housing issues and homelessness. Thirty-three percent of the women served in the outpatient clinic have a history of or current substance abuse, and 34% have history of trauma and/or childhood sexual/abuse.
Family Outcomes. The C/L Program monitors progress toward individual goals established with each woman, for the period of time that women receive services at the high-risk OB clinic. Approximately 10% of the women go on to need a psychiatric hospitalization each year. Because current policy requires women and their children to be transferred to a local clinic for psychiatric care at three months postpartum, neither neonatal nor psychiatric outcomes beyond three months are known. For the same reason, little is known about the ability of women seen in the clinic to maintain child custody beyond three months post-partum.
A Success Story
Women experiencing their first pregnancy and living in difficult social situations often require psychotherapy to problem-solve and develop strengths and self-confidence. In addition, pregnant women are often concerned with body-image issues. Pregnant women with SMI often experience similar concerns and issues as women in the general population. However, for women with psychotic disorders or severe depression, these concerns can become distorted. For example, several women have come to the C/L program describing delusions about people talking about them and their bodies, or fears that their partners will leave them for other women. In addition, women with SMI often lack support from families who are critical of their decision to go through with the pregnancy. In the context of a psychotic illness, women coming to the clinic often believe that family members want to poison them, kill them, or spy on them.
The C/L program at the High Risk OB clinic can provide psychotherapy and medication management to address and normalize these concerns related to pregnancy and relationships with partners, family, and community. For psychotic women a major emphasis is also on the centralization of the administration of psychiatric medication at the OB clinic. Psychiatric consultants at the clinic, using all the information on the impact of medications during pregnancy, are in the best position to provide an accurate risk-benefit analysis, and assist women in choosing the best approach for herself and her baby. Practitioners in the community often lack current information and strongly advise women against using any medication during pregnancy, resulting in rapid decompensation and a negative experience of pregnancy.
Several women with SMI who were closely followed at the OB clinic were able to transition to a local, community-based program for pregnant women with SMI and their children, where over a year's time they were able to develop parenting skills, and achieve greater stability. These women were then able to transition to independent living in the community with their partners or family.
Challenges
The C/L program shares in the same economic, social, and systemic challenges experienced by the Inpatient Women's Issues Program. Challenges more immediate to the C/L program include policies that require women to transition to non-hospital services in their local community (catchment area) after the third month postpartum. Thus women must change health and mental health providers during a particularly vulnerable period for themselves and their infants. Many women who have come to feel "safe" at the clinic, and become accustomed to receiving medical and mental health care at the same location, are fearful of changing providers, and may be less likely to follow through with postpartum and mental health care. This may be particularly difficult for women who are living in the United States illegally, or for whom English is not a first language. In addition, providers at local clinics are often less comfortable than the providers in the C/L program, using psychiatric medications during pregnancy and postpartum (due to lactation issues), and are not often able to coordinate mental health and OB/GYN care. This often results in medication changes despite stability, and less consistent psychiatric and/or medical care. In-home postpartum services for families in which a mother has mental illness are difficult to access. Thus, many mothers end up receiving poor mental health care that can compromise parenting.
An additional challenge for the C/L program is that faculty in the Department of Psychiatry are primarily service providers, while faculty in the OB department are under greater pressure to do research. Thus, psychiatry often finds itself in the position of having to advocate on behalf of the program, and a "holistic" approach to treatment with the OB/GYN faculty, who sometimes place a greater value on conducting research.
Next Steps
The C/L program is currently slated to be continued indefinitely as part of the larger psychiatry consultation service at San Francisco General. Variation in the interest and commitment of the OB/GYN leadership to the collaboration with psychiatry, and holistic care of pregnant women with psychiatric disabilities can influence the strength of the program and care provided. The leadership of the C/L program, however, is committed to advocating for this collaboration, "whatever it takes."
Logic Model: San Francisco General Hospital: Consultation/Liaison Program
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