Perinatal depression and anxiety Women s Mental Health Symposium UCT Department of Psychiatry and Mental Health Simone Honikman www.pmhp.za.org
Outline Common perinatal mental disorders (depression & anxiety) Psychosocial risk and protective factors Outcomes Detection How to support mothers
What is mental ill health? Home Thoughts Mood Behaviours Functioning Work Relationships
Perinatal depression PPD/PND - any time in first year after birth Most have symptoms during pregnancy (same for anxiety) PPD same as Major Depressive Episode - not a different illness For 60% first time depression Often presents like anxiety Recurrence rate 10-35% Symptoms usually within first 4 wks, but women at risk several months after delivery (4% beyond one year)
Perinatal depression In High Income Countries (HIC) 11-12% (Witt 2010, Strat 2011; Woody et al 2017) In Low and Middle Income Countries (LMICS) In South Africa 16-20% (Fisher, 2011) 22-47% (Hartley 2011, Tomlinson 2014, Cooper 1999, Rochat 2006; van Heyningen 2016) Higher prevalence than general population
Depression Symptoms Tearfulness Sleep & appetite or Low self-esteem Difficulty coping Rumination Fear of being alone Feelings of guilt & inadequacy Feelings hopeless Slowing down or blunted concentration planning/decision making motivation enjoyment in things Lack of joy in infant Thoughts of self harm or to infant PHYSICAL COMPLAINTS Depression = several of above - more than 2 weeks AND impaired functioning
Perinatal Anxiety Effects antenatal anxiety separate from and additional to those of PND More significant than depression on child development Different types of Anxiety disorders Generalised Anxiety Disorder (Post Traumatic Stress Disorder) Phobias Panic Disorder (Obsessive Compulsive Disorder) Others Most disorders - need >= 6 months presentation Associated with impaired functioning often assoc with avoidance behaviours
Perinatal anxiety Prevalence any anxiety disorder (perinatal) HICs 4-13% (Sawyer et al. 2010; Goodman et al. 2014) LMICs 15-39% (Adewuya et al. 2006; Tesfaye et al. 2010; Fadzil et al. 2013) In South Africa - diagnostic prevalence 3% - 30% for PTSD (Spies et al. 2009; Choi et al. 2015) 1.5% for panic disorder 2.3% for phobia 0.8% for social phobia (Spies et al. 2009)
Perinatal anxiety + comorbidity Hanover Park N=376 Diagnostic data (MINI) Van Heyningen et al 2017 in press, Archives Womens Mental Health * Includes: generalised anxiety disorder, obsessive-compulsive disorder, social phobia, agoraphobia, specific phobia and panic disorder
Anxiety Symptoms Mind Symptoms Agitated, on edge, worked up Fearful Feelings of terror or panic Hypervigilant Irritable Poor concentration Difficulty with sleep MAY PRESENT WITH DEPRESSION Body Symptoms Trembling, Muscle aches and tension Restlessness Shortness of breath, Palpitations (heart racing) Dry mouth Sweaty and Dizzy Diarrhoea and Abdominal pain Weakness / fatigue
Risk Factors socioeconomic disadvantage (2.1 13.2) unintended pregnancy (1.6 8.8) (Anx 2.1) being younger (2.1 5.4) being unmarried (3.4 5.8) lacking intimate partner empathy and support (2.0 9.4) having hostile in-laws (2.1 4.4) Experiencing intimate partner violence (2.11 6.75) having insufficient emotional and practical support (2.8 6.1) having a history of mental health problems (5.1 5.6) (Depr 5.2; Anx 4.1) Food insecurity (Dep 2.5; Anx 2.6) Threatening life events (Depr 2.1; Anx 1.3) Fisher et al, Systematic Review Bull World Health Organ 2012 Onah et al 2016 Van Heyningen et al 2016 Onah et al 2017
Protective Factors having more education (OR 0.5) having a permanent job (OR 0.64) Perceived support from friends (Anx OR o.95) having a kind, Perceived family support (Depr OR 0.9) trustworthy intimate partner (OR 0.52) Fisher et al, Systematic Review Bull World Health Organ 2012
Relationships of risk Gender based violence Thoughts Feelings Behaviours Mental Illhealth HIV
Relationships of benefit Gender based violence Thoughts Feelings Behaviours Mental Illhealth HIV
Isolation Photo: Alexia Beckerling
Maternal Outcomes Complications during birth Drinking /drugs Suicide Problems with bonding Poor use of services Domestic violence Loss of economic potential
Child outcomes sickness and immunisation nonadherence Low Birth Weight, prematurity Trouble breastfeeding Impaired language and motor skills Difficulty bonding Mental health and conduct problems Abandonment, abuse or neglect Crying and irritability
Impact infant and child antenatal depression and anxiety Foetal development Birth outcomes Lasting childhood development outcomes behavioural; cognitive; motor; psychological Possible mechanisms Poor uptake of health and social services Increase in stress-hormones intrauterine Co-occurrence with worse physical health, poor nutrition, substance/alcohol abuse These are independent from impact of postnatal depression and anxiety
The intergenerational cycle Pregnancy = Window of vulnerability vicious? Mother or virtuous? Pregnancy = Window of opportunity Society Infant/Child first 1000 days (28% is preg)
How to detect perinatal depression and anxiety Clinical judgement A good history look for a change, duration of symptoms Look for impaired functioning Observe the person Screening Consider time factor Screen or ask about risk factors Screen for symptoms Depression Anxiety Suicidality Tools Edinburgh Postnatal Depression Scale (EPDS) Patient Health Questionnaire (PHQ 9) The Whooley Generalised Anxiety Disorder scale (GAD -7) The PMHP s 4QD tool
PMHP s 4 Question Distress Tool In the last four weeks 1. have you often felt unable to stop worrying, or thinking too much? 2. have you often felt down, depressed or hopeless? 3. have you often felt little interest or pleasure in doing things that you used to enjoy before? 4. have you often had thoughts and plans to harm yourself or commit suicide?
Action If yes to Number 4 (suicidality) refer to mental health nurse/doctor immediately (no matter the other scores) If she has any self harm thoughts or plans, urgent referral is required to trauma unit or mental health nurse same day! If total 2 or more yes answers for counselling Explain that this shows she may (not for sure) have a common mental health problem such as depression or anxiety that about 1 in 5 women have these problems around pregnancy; that with the right help, women can and do get better ask if she would like to talk to someone about her problems.
How to support mothers Prevent development of mental disorders assess risk and manage risk Prevent worsening of disorders assess risk and manage risk and symptoms Manage common mental disorders Transdiagnostic increasing evidence; +++ comorbidity; scalability; similar elements (Bolton, Chorpita, Barlow) Common set of strategies (Murray et al, 2013) Engagement Psychoeducation Relaxation Behavioral Activation Cognitive Coping & Restructuring Problem Solving Brief Intervention for Substance Abuse Non-specific elements (Singla et al 2017) empathy, connection What? Where? Who? How? Managing disorders improves psychosocial adversity (virtuous cycle)
Acknowledgements PMHP clients since 2002 PMHP staff: clinical, research, training, admin, advocacy DoH frontline staff and management DoH programmes, leadership Department of Social Development UCT PMHP donors, friends, supporters NGO partners Research partners
Dr Simone Honikman PMHP Director Simone.Honikman@uct.ac.za www.pmhp.za.org http://perinatalmentalhealth.wordpress.com/ make-a-difference/