Psychiatric disorders in pregnancy and the puerperium

Transcription

1 Current Obstetrics & Gynaecology (2003) 13, 7^13 c 2003 Elsevier Science Ltd doi: /cuog available online at on Psychiatric disorders in pregnancy and the puerperium R. Cantwell* and J. L. Cox w *Consultant Psychiatrist & Honorary Senior Lecturer, University Department of Psychological Medicine,Gartnavel Royal Hospital,1055 Great Western Road,Glasgow G12 0XH,UK and w Professor of Psychiatry (Emeritus), Academic Suite, Harplands Hospital, Hilton Road, Harp elds, Stokeon-Trent, ST4 6TH, UK KEYWORDS pregnancy; mental illness; depression; puerperal psychosis; screening Summary Suicide is the leading cause of maternal death in the UK. Recognizing risk factors for major postnatal mental illness, and the distinction between normal emotional changes and psychiatric disorder during pregnancy, is critical in routine antenatal care. Recent developments in screening and prevention, and recommendations arising from the Con dential Enquiries into Maternal Deaths will help achieve best practice in caring for mentally ill women during pregnancy and in the early postnatal period.there is a need for such issues to be routinely included in the professional training of obstetric, midwifery, primary care and psychiatric sta. c 2003 Elsevier Science Ltd. INTRODUCTION Suicide is now the leading cause of maternal death in the UK. Psychiatric factors are implicated in a further signi cant number of deaths in the rst postnatal year. However, the risk factors associated with severe postnatal mental illness are well known, preventative treatments are available and women are exposed to a greater number of health professionals during pregnancy and the early postnatal period than at any other time in their lives. Obstetric services and midwifery play a vital role in the early identi cation of risk factors for mental illness and in the appropriate management of pregnant women with pre-existing psychiatric disorder. NORMAL EMOTIONAL CHANGES DURING PREGNANCYAND THE PUERPERIUM Pregnancy is a time of psychological change and challenge and for some it is a developmental crisis. Becoming a good enough mother is often linked to secure experience when a child, and having a harmonious relationship with one s own mother. Ambivalence over the pregnancy, anxieties about physical health or the health and development of the baby, anxious anticipation of changes that will occur in the woman s lifestyle after delivery, and Correspondence to: RC.Tel.: +44 (0) ; Fax: +44 (0) ; r.cantwell@clinmed.gla.ac.uk fears for ability to cope (especially in rst-time mothers) are typical and normal. In the rst trimester a woman maynoticeincreasedemotionallability, whichmaybe exacerbated by nausea, breast tenderness and other physical changes typical of early pregnancy. Later on, further bodily changes, alterations in sexual interest and anxieties about the delivery may all contribute to mood change. Late pregnancy may also be associated with social withdrawal and increased absorption and preoccupation with preparations for delivery and caring for the baby. Obsessional thoughts are not unusual, often focusing on the health of the baby. Such emotional changes are largely bound up with the adjustments necessary in pregnancy but may be contributed to by the hormonal alterations accompanying pregnancy. It is important to be able to distinguish these changes from those more clearly associated with mental illness. While anxiety symptoms are common, they do not usually include panic attacks (overwhelming anxiety with marked autonomic hyperarousal and a sense of dread or impending doom). Similarly, periods of low mood are usually not sustained or accompanied by generalized guilt and low self-esteem, marked agitation or retardation,orpersistentsuicidalthoughts. Certain groups have particular needs in relation to childbearing. Very young, single and unsupported mothers, and women who themselves have poor experiences of mothering, may be especially vulnerable. Their own needs may con ict with those of their babies and early planning to provide appropriate support is essential to help develop the woman s ability to care for her baby. Older mothers may have over-idealized expectations of

2 8 CURRENTOBSTETRICS &GYNAECOLOGY pregnancy and delivery, and have problems adjusting to life changes after the birth. Other groups who may experience particular di culties include those with previous pregnancy loss, those who have undergone assisted conception, women who have high-risk pregnancies and those who have had emergency Caesarean sections. PRACTICE POINTS * When distinguishing normal emotional changes from depressive illness the presence of the following symptoms should alert one to the possibility of depressive illness: Sustained lowering of mood (42 weeks). Biological symptoms such as impaired memory and concentration, reduced appetite with weight loss, early morning wakening, mood worsening in mornings, generalized loss of interest and energy. Generalized ideas of guilt or hopelessness. Suicidal thoughts, especially if there is evidence of speci c plans or previous acts. On examination, lack of reactivity of mood and accompanying agitation or motor retardation. Postnatal blues In the puerperium, postnatal or maternity blues occurs in 50^80% of women.this is a mild and self-limiting condition with onset typically in the rst postnatal week (although generally not in the rst couple of days), resolving within 1^2 weeks. The most common symptoms include depressed mood, tearfulness, insomnia, fatigue and irritability. Reassurance for the woman and increased support from professionals, family and friends are usually su cient to speed resolution. Its signi cance lies in the fact that more severe blues may progress to postnatal depression. Increased anxiety and depression in the third trimester predicts postnatal blues but no association has been found with obstetric variables.while it has been assumed that the similarly timed rapid falls in oestrogen and progesterone are responsible, research evidence in support of this hypothesis remains poor. Emotional changes associated with pregnancy loss and termination Miscarriage may be associated with grief reactions, anxiety and depression. For most women, these symptoms are greatest in the rst few weeks and resolve spontaneously thereafter. Women with a previous psychiatric history may be at risk of more severe psychiatric disorder. There is no evidence that therapeutic abortion is, of itself, associated with increased psychiatric morbidity. Risks may be greater, however, for women who have experienced some pressure in deciding in favour of termination, whether from family, because of other social pressures, or for medical reasons, and in women with a past history of psychiatric disorder. PSYCHIATRIC DISORDERS IN PREGNANCY Disorders arising in pregnancy Despite common perception, there is little evidence to suggest that pregnant women are at any less risk of mental illness than their non-pregnant comparators. Any psychiatric illness may have its onset during pregnancy, although certain disorders may come to attention more frequently, either because of their general prevalence or because there may be some link to the pregnant state. Some of these are considered below. Adjustmentdisorders These are states of emotional disturbance, interfering with social functioning, which arise when adapting to signi cant life change. They may be associated with unwanted pregnancy, pregnancy loss, or other major changes occurring during pregnancy e.g. separation from a partner or change in employment status. Adjustment disorders can present with depressed mood, anxiety and feelings of inability to cope, although not of a severity to warrant a diagnosis of depressive disorder. Patients may describe overwhelming irritability and frustration. Counselling or brief psychotherapy is often e ective. Anxiety, phobic and depressive disorders Anxious and depressive symptoms occur in at least one-third of women during pregnancy. Frequently, presentations overlap and, even when speci c disorders are diagnosed, there is often an admixture of symptoms. To meet criteria for disorder, symptoms must be of signi cant severity and be present for the majority of time over at least a number of weeks. They are particularly prominent in women from the developing world perhaps because pregnancy itself is a time of high risk to the life and wellbeing of the mother. Anxiety may be free- oating or may be speci cally associated with episodes of panic. Predominant symptoms include nervousness, tremulousness, sweating, lightheadedness, palpitations, nausea and dizziness, together with an overwhelming sense of dread or apprehensiveness. Non-pharmacological treatments include cognitive therapy (a form of psychotherapy that helps the patient recognize maladaptive or unhelpful patterns of thinking

3 PSYCHIATRIC DISORDERS IN PREGNANCYANDTHE PUERPERIUM 9 and, using diaries to record and then challenge such thoughts, enables the patient to develop new and more realistic beliefs about themselves and the world about them) and behavioural techniques such as anxiety management (teaching the patient about the nature and genesis of symptoms and engaging in relaxation exercises to reverse them). Drug treatments include benzodiazepine anxiolytics and selective serotonin re-uptake inhibitor (SSRI) antidepressants. The risks and bene ts of using such drugs during pregnancy or in lactation are discussed below. Phobias are fears that are out of proportion to real risk and lead to anxious avoidance of the feared object or situation. Tokophobia is the speci c fear of labour and delivery. It may arise for the rst time during pregnancy or be associated with poor experiences of a previous delivery. In many cases it is a symptom of underlying depression but may have more distant antecedents, such as childhood sexual abuse or other sexual assault. Women often seek alternatives to vaginal delivery and without an empathic professional presence they may see termination as their only option. Severe needle phobia may also be a barrier to good antenatal care. Early recognition and referral for psychological therapy will help prevent crises in late pregnancy and childbirth. Depressive disorders of a severity to warrant speci c pharmacological or psychological treatment occur in women with an approximate lifetime risk of 3^5%. Milder disorders may occur as frequently as 1 in 7^10 women. Therefore, they may arise coincidentally during pregnancy. However, the same factors that give rise to adjustment disorders may also lead to the development of more severe depression. Depressive illness is characterized by a ective symptoms such as low mood, decreased interest and enjoyment, behavioural symptoms such as anergia, fatigue and changes in appetite, weight, sleep, concentration and memory, and by cognitive symptoms of lowered self-esteem and con dence, ideas of guilt and pessimism and, in more severe cases, selfharm or suicide. Treatment is by cognitive behavioural approaches or antidepressant drug therapy. Depression during pregnancy is a strong predictor of postnatal depression. Hyperemesis gravidum Reasons for severe and persistent nausea and vomiting in pregnancy remain poorly understood. Elevated levels of human chorionic gonadotrophin (hcg), changes in thyroid function and alterations in gastric motility and ph may play a part. Treatment is symptomatic, directed at correcting dehydration and metabolic disturbance and reducing nausea. While it is unlikely that psychological distress acts as a sole precipitating factor, it may play a role in maintaining and exacerbating symptoms. Behavioural approaches including relaxation training and desensitization may be of bene t as part of management and medical hypnosis has also been used to good e ect. Pre-existing disorders Predicting the course of illness during pregnancy in women who su er from pre-existing psychiatric disorder is fraught with di culty but it is fair to say that, again, there is little evidence that their illness will run a more benign course by reason of pregnancy. There are often speci c di culties in deciding about the appropriateness of maintenance medication and, for most women with enduring mental illness, such discussions should take place with their psychiatrist or general practitioner well in advance of conception. It hardly needs saying that the presence of mentalillness per se does notmean a woman cannot make informed reproductive decisions. All too often, however, she is not given this opportunity. Mental health services and, ideally, specialist perinatal services, should be involved early on in the antenatal care of women with these disorders. Schizophrenia There is good evidence to suggest that the fertility of women with enduring severe mental illnesses such as schizophrenia is now not dissimilar to that of the general population. Important reasons for this include the move to community care models and increasing use of novel antipsychotic medications, which have a much lower propensity to suppress ovulation. Women who switch from older drugs may not be aware of this and may place themselves inadvertently at risk of unwanted pregnancy. Although not universally poor, the outcome in terms of themotherremainingtheprimarycarerforherchildis often unfavourable, leading to great distress for the mother and for those (including health professionals) who support her. Appropriate supports, including social services, should be engaged at an early stage in pregnancy to ensure su cient help is available to the mother and her family. It is often di cult for women with schizophrenia to cope with the frequent contact with health professionals during pregnancy and there is a risk that they will receive suboptimal care. Advance planning will also help reduce this risk. Most women with schizophrenia will be on maintenance antipsychotic medication. The implications of relapse during pregnancy are severe for both mother and child and, unless there are strong reasons to the contrary, treatment should continue, with appropriate monitoring, throughout pregnancy. Bipolar a ective disorder Women with bipolar a ective disorder (also known as manic depressive disorder) are also likely to be on

4 10 CURRENTOBSTETRICS &GYNAECOLOGY maintenance therapy. There are teratogenic risks associated with most mood stabilizers, but high risk too with regard to relapse on discontinuation. Pregnancy itself does not confer protection against relapse. Decisions regarding continuation of treatment should be made on an individual basis and always with the woman s fully informed involvement. Factors such as the previous natural history of the disorder (number, severity and time interval between episodes of illness) and response to previous treatment discontinuations, will help in reaching a decision on discontinuing maintenance treatment all through pregnancy, reinstating after the rst trimester, or continuing throughout. Pre-existing bipolar disorder is one of the greatest risk factors for puerperal psychosis ^ recent studies estimate that up to 60% of women with bipolar disorder will experience relapse in the rst 6 postnatal months. Irrespective of decisions about medication during pregnancy, all women should be o ered prophylactic medication (usually lithium) immediately following delivery. Finally, it is important to remember that, unlike the case with schizophrenia, there is little evidence that bipolar women are any less able to care appropriately for their children ^ except in the acute phase of the illness. Substance use disorders Substance use disorders can be classi ed as either harmful use i.e. use that adversely a ects the patient s physical or mental health, or leads to social, occupational, nancial, relationship or forensic problems, or dependent use i.e. use associated with a speci c physiological and psychological syndrome that includes craving, altered tolerance and withdrawal symptoms. Women with alcohol or drug problems may engage poorly with antenatal care and their impaired physical health may place them and their pregnancy at risk. Alcohol misuse may give rise to a number of physical complications for the woman, which may threaten or complicate pregnancy.these include nutritional de ciencies, liver and pancreatic disease. Withdrawal complications such as delirium tremens and tting may also have adverse consequences. Excessive alcohol use is associated with disturbed organogenesis in early pregnancy and growth and neurodevelopmental retardation in later pregnancy. The combination of these, fetal alcohol syndrome, is characterized by growth retardation, intellectual and behavioural impairment and characteristic facial dysmorphology. Other drug use e ects vary depending on the properties of the speci c drug, although it is important to recognize that patients may frequently use a combination of substances and research in the area is not extensive. In pregnancy, in the mother, cocaine is associated with hypertension and opiates with fatality in overdose. For the fetus, cocaine, solvents and possibly benzodiazepines may have teratogenic e ects. Neonatal withdrawal is seen with opiates and benzodiazepines. In the longer term, developmental delay has been demonstrated with cocaine and amphetamine. Pregnant women with substance misuse should receive specialist support, with the aim of minimizing, stabilizing or stopping their use. Interventions include detoxi cation, substitution therapies, harm reduction and behavioural techniques such as relapse prevention. Joint clinics with substance misuse services are often a preferred model, although these services require evaluation. Personality disorder Personality disorders are conditions where deeply ingrained, lifelong maladaptive personality traits detrimentally a ect most aspects of a patient s life, causing harm to themselves and usually to others about them. While the core disorder is di cult to change, we know that people with personality disorders cope less well with stressful situations and are more likely to develop other co-morbid mental illnesses that may respond to treatment. Pregnancy and motherhood may represent just such increased stress and women with personality problems are likely to require increased support to strengthen coping skills and prevent onset of mental illness. PSYCHIATRIC DISORDERS ARISING IN THE PUERPERIUM Puerperal psychosis Psychotic disorders arise after 1 in 500 ^1000 births. Although the absolute risk for any woman is low, relative to other times in a woman s life, this period carries the highest risk.the illness has its onset in the early postnatal period ^ usually within the rst month ^ but not commonly in the rst 1^2 days. Organic causes are now very rare in the developed world and almost all cases are a ective in nature, i.e. they present predominantly with mood disturbance in addition to the characteristic symptoms of any psychosis ^ delusions, hallucinations, marked behavioural disturbance and loss of insight. Non-a ective or schizophrenic presentations are much less common. Typically, the presentation is one of rapid uctuations of mood (often a mixture of manic and depressive symptoms), perplexity, confusion and markedly altered behaviour. Ideas of self-harm may be driven by delusions of guilt, self-worthlessness or hopelessness. Thoughts of harm concerning the baby or other children are rare but should always be assessed. Several factors have been identi ed that signi cantly increase the risk of psychosis (seetable1).of greatest importance are a previous history of puerperal psychosis

5 PSYCHIATRIC DISORDERS IN PREGNANCYANDTHE PUERPERIUM 11 Table 1 Risk factors associated with the development of puerperal psychosis and postnatal depression A.Puerperal psychosis K Previous history of puerperal psychosis K Personal history of a ective psychosis K Family history (1st/2nd degree relative) of a ective psychosis B.Postnatal depression K Past history of psychiatric disorder K Depression during pregnancy K Poor social support K Lackofcon dingrelationship K Recent adverse life events K Severe postnatal blues and pre-existing or family history of bipolar a ective (manic-depressive) disorder. With one or more of these risks, a woman may have up to a1in 2 chance of developing puerperal psychosis. Identi cation of risk is particularly important, since there is evidence that lithium therapy, when started in the immediate postpartum period, is e ective in preventing onset. All women with puerperal psychosis should be managed by psychiatric services. Most will require admission to hospital. Where facilities are available, her baby will usually accompany her. Treatment consists of a combination of antipsychotic medication, antidepressants or mood stabilizers depending on the speci c presentation. Electroconvulsive therapy is also an e ective, safe and rapid treatment. Supervised support for the patient s care of her infant and help for the family are crucial to good management. Recovery usually takes place over a period of 1^2 months but there is great individual variation. Most women will make a complete recovery but remain at very high risk of future puerperal and non-puerperal episodes. The aetiology of puerperal psychosis remains uncertain. The dramatic, early presentation is suggestive of a link with major hormonal changes after childbirth. The strong association with bipolar disorder implies a genetic predisposition and recent evidence has emerged of a speci c familial risk for puerperal episodes in bipolar disorder. It has been suggested that the rapid reduction in oestrogen levels is linked to the development of dopaminereceptorsupersensitivity,which,inturn,maytrigger the onset of psychosis in predisposed individuals. Serotonergic neurotransmitter systems have also been implicated in causation. Postnatal depression In contrast to puerperal psychosis, non-psychotic depression often presents later in the postnatal period, with a peak occurrence at around 6 weeks. While there is some evidence of a telescoping in the incidence of depression in the rst postnatal weeks, the overall prevalence of10^15% in the rst year is not very di erent from the prevalence of mild-to-moderate depression at any other time in a woman s life. Similarly, the symptoms of depression in the postnatal period do not di er greatly from those at other times, depression usually presenting with a combination of the triad of a ective, cognitive and behavioural symptoms mentioned earlier. Some studies suggest a greater predominance of obsessional symptoms in depression at this time. For some women, these may take the form of obsessional worries or fears that she may cause harm to her baby. Much less commonly there may be true infanticidal thoughts. Thoughts of self-harm are not uncommon and should be followed up with sensitive enquiry as to the depth and strength of these feelings. The majority of depressions occurring at this time are mild and do not require speci c psychiatric intervention. Most will be uncovered during routine postnatal screening by the general practitioner or health visitor.the provision of extra support and non-directive counselling by health visitors is usually adequate to bring about resolution. A smaller number of women, approximately 3^5%, will require antidepressant medication, but fewer than half that number will bene t from referral to psychiatric services. Of these, only a small number will be admitted to psychiatric care, although it is important to identify those with the most severe disorders. There is no evidence that progesterone or synthetic progestagens are e ective treatments for postnatal depression. Unlike puerperal psychosis, where risk factors are largely biological, psychosocial factors play the greatest part in the development of postnatal depression (see Table1). Most important are a past history of depression, psychological problems during pregnancy, poor social support and marital relationship and recent adverse life events. Baby blues also increase risk.weaker associations have been found with obstetric complications, history of abuse, lower socio-economic status and perception of poor obstetric experience. Unfortunately, these risk factors have poor speci city and so, while allowing for heightened awareness, cannot be used to accurately predict the development of depression in any one individual. Untreated postnatal depression is also closely associated with disturbed mother^ baby interaction and with adverse e ects on infant cognitive and emotional development. PSYCHOTROPICS DURING PREGNANCYAND BREASTFEEDING There is an understandable and correct caution about prescribing drugs to pregnant and breastfeeding women.

6 12 CURRENTOBSTETRICS &GYNAECOLOGY Occasionally, there is a con icting need to relieve signi cant distress and disability in women with mental illness. Increasingly also, women of childbearing age will be taking prescribed psychotropic medication at the time of conception and sudden discontinuation may have its own attendant risks. General principles governing prescribing at these times include the need to establish a clear indication for the drug (and the absence of e ective alternative treatments), to use the lowest e ective dose for the shortest time necessary, to use drugs with a better evidence base of absence of harm (generally older preparations) and to make individual assessments of the bene ts and risks that fully involve the patient. Current evidence is gleaned from case reports and series and while we can be more con dent of major teratogenic e ects, evidence remains scant for long-term neurodevelopmental risk. The recent Scottish Intercollegiate Guideline Network (SIGN) Guideline on Postnatal Depression and Puerperal Psychosis provides an evidencebased review of prescribing in pregnancy and during the breastfeeding period. last month to 6 weeks of pregnancy with reinstatement after delivery. All neonates should be monitored for withdrawal e ects. Breastfeeding For the majority of tricyclic and SSRI antidepressants, there is little evidence of short-term adverse e ects on the infant and their prescription is not, in itself, a contraindicationtobreastfeedingprovidingthebabyishealthy and its progress is monitored. Regarding other psychotropics, antipsychotic prescribing would not necessarily lead to discontinuation of breastfeeding, given the same provisos. Again, older drugs are preferable. Breastfeeding should be avoided with benzodiazepine use, unless the woman has used it throughout pregnancy, in which case, breastfeeding will protect the infant against acute withdrawal. Women who require lithium should not breastfeed because of the high concentration in breastmilk leading to a risk of toxicity in the baby. Pregnancy In the rst trimester, there is no evidence of increased risk of major malformations or spontaneous abortion with most tricyclic and SSRI antidepressants. Sudden discontinuation may be associated with withdrawal phenomena (agitation, insomnia, anxiety and mood disturbance) and relapse of illness.the evidence is less comprehensive for antipsychotic drugs, but the risks of discontinuation in women with schizophrenia are so signi cant that continuation throughout pregnancy is usually recommended. In general, older preparations are preferable. Mood stabilizing drugs, such as lithium, carbamazepine and sodium valproate, which are used to prevent recurrence in women with bipolar a ective disorder, have clear teratogenic risks. However, the risks for lithium have been overestimated in the past and the consequences of discontinuation may be severe in some women with unstable or frequently relapsing bipolar disorder. Individual judgement, with the woman making informed decisions on her care, should be made case by case and the woman s care should be supervised by psychiatric services. If lithium is prescribed in later pregnancy there are potential risks of hypothyroidism, nephrogenic diabetes insipidus, polyhydramnios and oppy baby syndrome in the neonate. Evidence remains controversial over the association of benzodiazepine use with oral cleft abnormalities. It wouldseemwisetolimittheuseofthesedrugsthroughout pregnancy. Beyond the rst trimester, the main concerns are for e ects on the newborn infant. In most cases, these can be minimized by a slow dose reduction over the SCREENING AND PREVENTION Antenatal screening Antenatal screening for the speci c risk factors associated with puerperal psychosis is straightforward. All women should be asked about a past history of puerperal psychosis and past or family history of bipolar disorder when attending the initial booking clinic. Sometimes proxy measures of severe illness can be enquired about, such as treatment with medication or admission to psychiatric hospital. Ideally, women with positive risk factors for puerperal psychosis should have antenatal psychiatric contact to assess risk and the value of prophylaxis. Lithium, when given to women at high risk of puerperal psychosis immediately after delivery, can signi cantly reduce risk. Antenatal screening for postnatal depression is less effective, although women who have a previous history of depressive illness, whether or not associated with childbearing, who are depressed during pregnancy, or who are at signi cant psychosocial disadvantage should be followed up more closely in the postnatal period. PRACTICE POINTS * Booking clinic screening questions to identify women at high risk of postnatal mental illness are: Did you su er any mood problems after previous pregnancies? Did these need treatment with tablets or admission to hospital?

7 PSYCHIATRIC DISORDERS IN PREGNANCYANDTHE PUERPERIUM 13 Have you ever su ered from nervous or emotional problems that have lead to you being put on tablets or admitted to hospital? Was this for problems such as manic-depressive or bipolar disorder? Has anyone in your family been treated for severe mental health problems, and, in particular, problems such as manic-depressive or bipolar disorder? * Judgement must be used when asking about speci c disorders, but not enquiring will lead to high numbers of false positives. Postnatal screening In the postnatal period, it has become routine in the UK for health visitors to administer the Edinburgh Postnatal Depression Scale (EPDS) at two or three time-points in the rst 6 ^ 8 months. The EPDS is a simple 10-item selfreport scale that reliably identi es women at high risk of developing depression. Most health visitors are also trained in non-directive counselling techniques, which can be employed as listening visits to women at increased risk. Such extra visits have been shown to lower the rate of progression to depressive illness. To be e ective, such universal screening should be undertaken by trained primary care workers, as part of a programme of care, where there are agreed criteria for administration of the EPDS, interpretation of results and referral on for intervention by secondary psychiatric services, where appropriate. THE CONFIDENTIAL ENQUIRIES INTO MATERNAL DEATHS Chapter 11 of the most recent Con dential Enquiry into Maternal Deaths identi es suicide as the leading cause of maternal death, once numbers from linkage studies are taken into account. The report makes stark reading and identi es a number of important pointers to good practice for obstetric, psychiatric and primary care services. Unlike suicide in women at other times in their lives, postnatal suicides are characterized by their violent nature (indicating a high degree of intent and the probable presence of major mental illness) and di erent social class distribution (not being biased toward those with lower socio-economic status). The signi cance of substance misuse as a contributing factor in maternal death is also highlighted. Table 2 Recommendations from the Con dential Enquiry into Maternal Deaths K Enquiryaboutpreviouspsychiatric history, its severity, clinical presentation and care received should be routinely made at booking clinics K Women with a past history of serious psychiatric disorder (whether postpartum or non-postpartum) should be referred for psychiatric assessment K Women with previous serious mental illness should be counselled about risks of recurrence in future pregnancies K The term postnatal depression or PND should not be used as a generic term for all types of psychiatric disorder K Women attending antenatal clinics should have open access to substance misuse services K Specialist perinatalpsychiatric services, including the provision of mother and baby inpatient units, should be available to all women Recommendations include: the avoidance of the term postnatal depression as a generic descriptor for all postnatal illness, since it may give false reassurance regarding the severity of previous episodes of illness; the importance of screening for past psychiatric disorder at booking clinics; the need for good communication between disciplines caring for women at this time; and the availability of specialist perinatal psychiatric services to o er liaison, advice and treatment (including mother and baby admission facilities where appropriate) for all women with, or at risk of, severe postnatal mental illness (Table 2). FURTHER READING Boath EH, Henshaw C. The treatment of postnatal depression: a comprehensive review. J Reprod Inf Psychol 2001; 19: 215^248. Cox J, Holden J. Perinatal Psychiatry: Use and Misuse of the Edinburgh Postnatal Depression Scale. London: Gaskell,1994. Hod M, Orvieto R, Kaplan B, Friedman S, Ovadia J. Hyperemesis gravidarum: a review. J Reprod Med1994; 39: 605^612. Nonacs R,Cohen LS. Depression during pregnancy: diagnosis and treatment options. J Clin Psychiatry 2002; 63 (supplement 7): 24 ^30. Oates M. Normal emotional changes in pregnancy and the puerperium. Baillie' re s Clin Obstet Gynaecol1989; 3: 791^804. O Hara MW, Swain AM. Rates and risk of postnatal depression ^ a meta-analysis. Int Rev Psychiatry1996; 8: 37^54. Royal College of Obstetricians and Gynaecologists. Why Mothers Die 1997^1999: the Fifth Report of the Con dential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG, (Also available at Scottish Intercollegiate Guideline Network. Guideline 60: Postnatal Depression and Puerperal Psychosis. Edinburgh: SIGN, (Also available at Yonkers K, Little B. Management of Psychiatric Disorders in Pregnancy. London: Arnold, 2001.