Maternal Mental Illness Antenatal and postnatal depression Dr Andrew Mayers amayers@bournemouth.ac.uk Maternal Mental Illness Overview What is maternal mental illness? Consequences for child and the mother Effect on relationship between them Types of illness Antenatal depression Antenatal anxiety Postnatal depression We will look at these illnesses in this session Serious illnesses (later session) Postpartum psychosis Maternal OCD 2 Who am I? What am I doing here? First worked in Hampshire perinatal MH unit in 2003 Co-ordinated research programme Now associated with Dorset MBU in Bournemouth Formerly, Director of PANDAS National pre- and postnatal mental illness charity Member of Maternal Mental Health Alliance Member of Perinatal Mental Health Partnership Commissioned by NHS in Hampshire and IOW to train health profs Presented at CPHVA conference, York (Oct 2013) For more information: http://www.andrewmayers.info/perinatal-mental-health.html Follow me on Twitter @DrAndyMayers 3 1
Postnatal period Correlation between antenatal mental distress and postnatal maternal distress and antenatal attachment and postnatal attachment...prevention!! Change/transition Psychological distress (anxiety, stress, low mood) Stress, daily hassles of bring up an infant, change in identity, relationship changes, loss of control 4 Impact on developing child Significant intellectual deficits found in children (aged 4) whose mothers had suffered with depression (Cogill, et al., 1986) Postnatal depression may be associated with later difficulties in child s adjustment-problems when starting school Anxiety in girls; conduct problems in boys Affects child s social and emotional development Ability to form relationships Depression in fathers associated with emotional and behavioural outcomes in children aged 3½ years Increased risk of conduct problems in boys Effects remain after controlling for maternal postnatal depression (Ramchandani et al., 2005) 5 Impact of postnatal depression PND associated with several negative outcomes Increased marital stress Disturbances in child s emotional and cognitive development (Cogill, et al., 1986) Children of dep mums more likely to be associated with: Insecure attachment Eating difficulties Sleep disturbance Being overly clinging PND affects mum s ability to cope with care of baby See Murray, et al., 2003 6 2
Impact of maternal sensitivity 7 The importance of attachment Why is attachment important between mother and infant? Early mother infant bond may have sig. impact on developing infant (e.g. Bowlby, 1953; Ainsworth, 1993) Infant s internal working model (IWM) is very important Expectations about themselves in relation to others Model of self and of other If infant s carer attends positively and responds to needs Infant has positive IWM: High self-worth, availability of others, resolution of crises Infant s carer inconsistent response and attention Infant s has negative IWM: Low or ambivalent self-worth, unavailable others, crises not resolved 8 What can health visitors do? Health visitors CAN play a crucial role in identifying mental health difficulties Spotting signs and risk factors Early intervention Signposting to relevant services For the well-being of mother AND the developing infant Important to: Acknowledge distress Offer an empathic response Assess risk But WHAT are we looking for? 9 3
Antenatal depression At any one time during pregnancy one in every ten women will be depressed and around one in every thirty will be depressed in pregnancy and the postnatal period Dr Vivette Glover Symptoms Chronic anxiety Guilt Incessant crying Lack of energy Relationship worries Worrying their partner may leave once the baby is born Conflict with parents Isolation Fear to seek help 10 Causes of antenatal depression Physical Body changes! Weight gain (only clothes that fit are tatty or were previous used for painting ), swollen breasts, dizziness and nausea, bladder issues, exhaustion, heart rate, blood pressure, swollen ankles/wrists... Hormonal changes Nausea morning sickness For some mums-to-be these experiences (and/or perception of them) worse than for others 11 Causes of antenatal/postnatal depression Emotional causes Mood swings First-time mum experience Change of identity Previous pregnancy difficulties Complications, difficult labour, miscarriage, stillbirth Chronic anxiety Especially new mums NEVER dismiss anxiety - EMPATHISE 12 4
Causes of antenatal depression Social causes Antenatal depression is NOT new (despite only being recognised relatively recently) Mums just did not have chance to talk about it then Family support Families often lived closer together than they do now Work and finance Greater pressure for mum to work in modern age Expectations Media perceptions of perfect nursery/bedroom Pressure to live to societal standard Good enough mum NOTE: Majority of cases of antenatal depression disappear at birth BUT - one third of these mums develop postnatal depression 13 Post-natal depression (PND) Baby blues (see O Hara, 2009) Two to four days after birth (quite normal but not PND) Emotional/liable to burst into tears, for no apparent reason Difficult sleeping (even when baby permits) Loss of appetite Feeling anxious, sad, or guilty Questioning maternal skills Effects up to 75% of mums May relate to changes in post-birth hormone levels Or could be related to being in hospital Key is that this doesn't last long usually only a few days If it persists it may develop into PND 14 PND: DSM-5 diagnosis PND needs same DSM-5 diagnosis as major depressive disorder But relates specifically to the peripartum period Pregnancy and/or within 4 weeks of birth Five (or more) of (but at least one of symptom 1 or 2) 1. Depressed mood (for most of day, nearly every day ) 2. Markedly diminished interest in all/almost all activities 3. Significant weight loss (not dieting) or decease/increase appetite 4. Insomnia or hypersomnia 5. Psychomotor agitation/retardation (observable) 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive/inappropriate guilt 8. Diminished ability to think/concentrate or indecisiveness 9. Recurrent thoughts of death suicidal ideation/attempt/plan 15 5
PND: Features Additional features may also indicate presence Sense of inadequacy, inability to cope Feeling guilty Being unusually irritable Which makes the guilt worse Being hostile/indifferent to husband/partner/baby Losing interest in sex Panic attacks Excessive unwarranted anxiety Such as being alone in the house Obsessive fears about the baby's health or wellbeing 16 PND: Prevalence PND affects about 10% of new mums Compare to baby blues (25-75%) Although DSM-5 states must be within 4 weeks of birth Most clinicians/researchers extend this to several months Vulnerable mums usually referred in perinatal period During pregnancy up until baby is 1 year Can come on gradually or all of a sudden Can range from being relatively mild to very hard-hitting About 50% PND women afraid to tell health professionals about it Scared it will lead to social services taking child away Or that they would be seen as bad mothers See O Hara (2009) for good overview of PND 17 PND: Causes Causes of PND uncertain But there are a number of known risk factors (Kim, et al. 2008) Having had depression before Especially PND Not having a supportive partner Having a premature or sick baby Having lost your own mother as child Having had several recent life stresses Bereavement, unemployment, housing or money problems Poor sleep (see later) 18 6
PND: Causes Some additional risk factors for PND Shock of becoming a mother Women often unprepared for physical impact of childbirth Plus new and daunting skills to learn New full time responsibility Helpless human being who cannot communicate Other than cry (distressing in itself) Some mums get anxious when they don t hear crying! Lie awake listening out Loss of freedom and independence Exhaustion and fatigue 19 PND: Causes Hormones Oestrogen and progesterone affect emotions Levels of progesterone are very high during pregnancy PND maybe due to sudden drop progesterone after birth In one study women given progesterone to try prevent PND But it had the reverse effect and got worse Oestrogen treatment via patch can be helpful Otherwise, hormones not a major influence Diet Lack of certain nutrients during pregnancy may cause PND Omega 3 oils (found in oily fish, seeds and nuts) Magnesium (leafy green vegetables and seeds) Zinc (seeds and nuts) 20 PND Treatment Antidepressants Huge amount of evidence of benefit in treating depression First line choice in most adults BUT it is not that simple in PND Some antidepressants serious side effects and interaction Consider this if mum is breastfeeding Some antidepressants are not safe for infants 21 7
Medication for PND what is safe? Tricyclic antidepressants Lower known risks than other antidepressants But more dangerous in overdose SSRIs (after 20 weeks) greater risk hypertension in neonate Fluoxetine fewer known risks of SSRIs Paroxetine (in 1 st trimester) some risk foetal heart defects Venlafaxine some risk high blood pressure (at high doses) Most antidepressants pass into the breast milk Imipramine, nortryptiline and sertraline - at relatively low levels Citalopram and fluoxetine - at relatively high levels 22 PND Treatment Counselling and talking therapies (CBT etc.) very effective Group or individual care BUT rare - can take time to get into a programme We need more Perinatal Mental Health teams! Self-help strategies Counselling (listening visits) Brief cognitive behavioural therapy Interpersonal psychotherapy 23 Whooley questions During the past month 1. Have you often been bothered by feeling down, depressed or hopeless? 2. Have you often been bothered by having little interest or pleasure in doing things? Consider a third question: Is this something you feel you need or want help with? 24 8
What we have learned We have examined several aspects of maternal mental illness What is maternal mental illness? Types of illness Antenatal depression Antenatal anxiety Postnatal depression 25 Exercise Group task Are Whooley questions enough? What are the risk factors? What signs should we watch out for? Why are mums reluctant to tell us about mental health problems? How far should we pursue this? 26 9