MATERNAL MENTAL HEALTH AWARENESS RAISING HANDOUT

1. MATERNAL MENTAL HEALTH AWARENESS RAISING HANDOUT CITY & SOUTH NOTTINGHAMSHIRE PERINATAL PSYCHIATRIC OUTREACH SERVICE

2. AIMS OFTRAINING To raise awareness of the range of serious mental illnesses and problems which may occur around the time of childbirth. To explore the roles and responsibilities of Primary Care Professionals when working with women (and their families) where there is a maternal mental health issue.

3. PERINATAL PSYCHIATRIC SERVICE Remit of Service • To assess and care for women who are either suffering from severe mental illness in the perinatal period or are at risk of such illness The team are unable to:- • See women with mild antenatal/postnatal illness • See women where substance/alcohol misuse is the primary diagnosis • See women with learning difficulties in the absence of serious mental illness • See women who have personality disorder in the absence of serious mental illness

4. AN OVERVIEW OF MENTAL HEALTH ISSUES FOLLOWING CHILDBIRTH • Common Emotional Changes • Postnatal Depression • Severe Postnatal Depression • Puerperal Psychosis • Enduring Mental Health Problems • Treatment

5. POSTNATAL EMOTIONS Normal emotional response: • Baby Blues – 50-80% of women Disorders: • Postnatal Depression – 10-15% of women • Puerperal Psychosis – 2 women in every 1000

6. THE PINKS • The Pinks – first few days following delivery, feelings of elation and excitement BABY BLUES • 50-80% of women (3-10 days following delivery) • Normal reaction not an illness • Experience emotional changes • Gets better within days • Requires support and understanding

7. MILD POSTNATAL DEPRESSION Symptoms need to have been present for 2 weeks to qualify for diagnosis: • Low mood (usually improved when in company) • Exaggerated emotional response (e.g. tearful, irritable, sensitive) Timing -usually presents between 3-6 months after the baby is born

8. Symptoms need to have been constant for more than 2 weeks and to include 4 of the following: Loss of pleasure/interest Loss of confidence Self reproach/guilt Impaired concentration Agitation or Slowing up Sleep Problems Appetite problems Timing - usually presents within 6 weeks after the baby is born MODERATE POSTNATAL DEPRESSION

9. RISK FACTORS FOR MILD/MODERATE POSTNATAL DEPRESSION • Depression or anxiety continued from pregnancy • Loss of own mother in childhood, or disturbed early life • Loss of previous pregnancy, either through stillbirth, miscarriage or termination • Unrealistic expectations of motherhood • Relationship problems • Lack of support from partner/family/friends • Major upheavals or stress from sixth month of pregnancy • A long period of trying before conception

10. TREATMENTS FOR MILD/MODERATE POSTNATAL DEPRESSION • Usually treat within Primary Care - use a combination of: • Listening visits • Non directive counselling • Problem solving techniques • Cognitive strategies • Behavioural strategies • Social support ACCORDING TO INDIVIDUAL NEED

11. SEVERE POSTNATAL DEPRESSION SYMPTOMS As with moderate PND but also including the following: • Early morning wakening & diurnal mood variation • Appetite loss/Weight loss • Strong feelings of guilt or hopelessness • Marked anhedonia • Suicidal ideation • Detachment from feelings for the baby Other symptoms may be present such as intrusive obsessional ruminations and anxiety/panic attacks, often presenting as distress in the surgery situation.

12. Risk Factors for SEVERE POSTNATAL DEPRESSION • History of severe depression • Close family history of severe depression (especially if this happened after childbirth) • Difficulties in conceiving • Losing a previous baby in pregnancy

13. TREATMENTS FOR SEVERE POSTNATAL DEPRESSION • Referral to Perinatal Psychiatric Outreach Service • Psychological Treatments • Antidepressants - only those compatible with pregnancy and methods of feeding e.g. breast or bottle

14. TREATMENT GUIDELINES FOR A DEPRESSIVE ILLNESS PREGNANCY • Only initiate treatment if moderate/severe illness after first trimester • Mild-moderate illness likely to respond to psychological treatments SSRI’s – Not advisable during pregnancy Tricyclics – First line choice of treatment as these are not known to be associated with increased risk of major foetal abnormalities But should be tapered and discontinued by 36 weeks gestation. Use lowest effective dose and divide (bd or tds)

15. TREATMENT GUIDELINES FOR A DEPRESSIVE ILLNESS (continued) When Breastfeeding: Avoid SSRI’s Tricyclics: First line choice of treatment Divide doses tds and advise that medication should be taken immediately following a feed.

16. DO FATHERS BECOME POSTNATALLY DEPRESSED • 25% of men suffer depressive symptoms after the birth of a child • Figure rises to 50% if partner has depression • (Figures taken from ‘Boys Don’t Cry’)

17. PUERPERAL PSYCHOSIS Symptoms • Delusional beliefs (e.g. unreal thoughts about self, baby,others) • Hallucinations (auditory, visual, smell, touch) • Confusion • Excitement/over activity • Extreme depressive thoughts • Lack of insight into illness Timing • Early, usually within 4 weeks after the baby is born • Transient distress very common at 3-5 days (the blues) and not to be confused with psychotic symptoms

18. RISK FACTORS FOR PUERPERAL PSYCHOSIS • Existing Bi-Polar illness or Schizophrenia/schizo-affective disorder • Previous puerperal psychosis • Family history of both the above in first degree relative • More common in first time mothers who have had an emergency caesarean section

19. TREATMENT FOR PUERPERAL PSYCHOSIS • EMERGENCY REFERRAL TO PERINATAL PSYCHIATRIC SERVICES FOR ADMISSION TO PSYCHIATRIC MOTHER & BABY UNIT

20. SUPPORT/TREATMENT FOR SEVERE AND ENDURING MENTAL ILLNESSES IN THE PERINATAL PERIOD A package of care that may include a mixture of any of the teams below: • Adult Mental Health Services • Social Services • Identified Carers • Midwife/Health Visitor • General Practice • Primary Care Mental Health Practitioners • Perinatal Psychiatric Outreach Team • Home Start • Children’s Centres • Other Services (e.g. Drug and Alcohol, Psychotherapy, Personality Disorder Service)

21. MEDICATION IN PREGNANCY • OUR TEAM PHILOSOPHY • If you can manage without any medication, this is always the best policy • Definitely avoid SSRI’S - especially Paroxetine - as recommended by: • Nice Guidelines • FDA (Federal Drug Administration) • Committee of Safety of Medication • All antidepressants, including tricyclics, are associated with withdrawal in the neonate and should be reduced and withdrawn before delivery

22. MANAGEMENT OF ENDURING MENTAL ILLNESS Pregnancy • Onset of serious illness in pregnancy is rare • If possible avoid conception on Lithium and anticonvulsant mood stablisers e.g. valproate. If conception occurs prescribe high dose folic acid, and refer for detailed scans. • No rationale for abrupt cessation of medication in early pregnancy • Taper dose of neuroleptics before delivery • Gradual withdrawal and stop.

23. MANAGEMENT OF ACUTE PSYCHOTIC EPISODE Pregnancy • Medication should be prescribed at the lowest effective dose and in divided doses This is normally managed jointly by the GP, Adult Mental Health and Perinatal Psychiatric Service

24. MANAGEMENT OF ACUTE PSYCHOTIC EPISODE (continued) Post Partum • Restart medication for SMI • Breast feeding • No SSRI No Lithium • No Trazadone • No MAOI • No Benzodiazepines • No atypical antipsychotic • In the first instance these women are usually managed within the Mother & Baby Unit

25. ANTENATAL/POSTNATAL DISORDER ON INFANT/CHILD DEVELOPMENT • Some evidence that maternal antenatal anxiety increases the risk of behavioural problems in early childhood • Evidence that postnatal depression can significantly effect child development i.e babies are highly sensitive to communication which can be affected by depression • It has not been consistently proved that an acute psychotic episode following childbirth has an adverse effect on the development of the child

26. THE FIFTH REPORT OF THE CONFIDENTIAL ENQUIRIES INTO MATERNAL DEATHS IN THE UK “Why Mothers Die 1997 - 1999” • Psychiatric Disorder was found to be the leading cause of maternal morbidity • Suicide was found to be the leading cause of maternal death • MATERNAL MENTAL ILLNESS IS SERIOUS!

27. CULTURE AND MENTAL ILLNESS • Risk of misdiagnosis: cultural differences viewed as symptoms of illness e.g. use of EPDS which is not culturally sensitive • Barriers to effective treatment: differing cultural conceptions of mental illness • Danger of misconstruing differing forms of cultural expression/interpersonal skills • Asylum seekers can present particular challenges which can best be understood on a case by case basis. There is a need to be aware that interpreters MUST translate and NOT interpret

28. Please note these complications: • Side effects of Tricyclic antidepressants are possibly increased by Oestrogens. (BNF)

29. Bibliography: Useful Books etc. • Social Baby: Understanding Babies' Communication from Birth (2000) Lynne Murray and Liz Andrews • Why Mothers Die 2000-2002 Report (Report on confidential enquiries into maternal deaths in the United Kingdom, 2004) at http://www.cemach.org.uk/Publications/CEMACH-Publications/Maternal-and-Perinatal-Health.aspx • Saving Mothers’ Lives - Reviewing maternal deaths to make motherhood safer 2003-2005 (Report on confidential enquiries into maternal deaths in the united kingdom, 2007) at http://www.cemach.org.uk/getattachment/ee9ca316-2a9a-4de6-9d48-ecaf5716e2b4/Why-Mothers-Die-2000-2002.aspx • Antenatal and postnatal mental health: clinical management and service guidance (NICE guidelines) at http://guidance.nice.org.uk/CG45/?c=91523 • Motherhood and mental Health (1996) Brockington, I. • Psychiatric Disorders and Pregnancy (2006) O’Kane, V., Marsh, M., and Seneviratne, G. (eds) • Google it! There’s new evidence all the time.

30. Studies re impact of maternal mental illness on child development. • Sharp, D., Hay, D. F., Pawlby, S., et al (1995) The impact of postnatal depression on boys’ intellectual development. Journal of Child Psychology and Psychiatry and Allied Disciplines, 36, 1315 –1336 • Murray, L., Cooper, P. J., Wilson, A., et al (2003b) Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression: 2. Impact on the mother–child relationship and child outcome. British Journal of Psychiatry, 182, 420 –427. • Murray, L., Sinclair, D., Cooper, P., et al (1999) The socioemotional development of 5-year-old children of postnatally depressed mothers. Journal of Child Psychology and Psychiatry and Allied Disciplines, 40, 1259 –1271. • Murray, L. & Cooper, P. J. (1996) The impact of postpartum depression on child development. International Review of Psychiatry, 8, 55 . • Murray, L., Cooper, P., Hipwell, A., et al (2003a) Mental health of parents caring for infants. Archives of Women’s Mental Health, 6 (suppl. 2), S71 –S77

31. Contacts • Perinatal Medical Secretary: 0115 9709339 • Perinatal CPNs: 0115 8754627 • Out of Hours or when no availability on the other numbers and it is an emergency: A45/Mother and Baby Unit: 0115 8493391