POSTNATAL DEPRESSION DR MEENA PATEL ASSOCIATE SPECIALIST COOMBE WOOD PERINATAL MENTAL HEALTH SERVICE 6 th March

INTRODUCTION TO PERINATAL MENTAL HEALTH Psychiatric conditions complicating pregnancy and first year post-natal New onset disorders e.g. PND, Puerperal psychosis UK-Sub speciality of adult psychiatry; now a section of RCPsych Considerable psychiatric morbidity Serious consequences for mother foetus, infant Specialist management: medical & psycho social management of mother, foetus/infant Multi agency- mental health, obstetrics, neonatal paediatrics, children social services, GP, health visitors 2

3 The Ideal!

4 The Reality for some Mothers!

BABY BLUES 50-70% newly delivered mothers 4 to 10 days post partum, last 1-2 days Disturbed sleep, vivid dreams Fluctuating mood Headache No treatment required 5

PUERPERAL PSYCHOSIS 1-2/1000 newly delivered mothers Within hours to first few weeks Past/family history of BAD, PP Rapid deterioration of mood-lability Confusion, insomnia, agitation, over activity Delusions, hallucinations Risks involved Need urgent psychiatric treatment 6

ANTENATAL DEPRESSION Traditionally not recognised/treated Symptoms of depression, overlap symptoms of pregnancy Tearfulness/irritability attributed to hormone Often persist into post partum period 10-15% pregnant women experience depression and anxiety 7

POSTNATAL DEPRESSION 10-15% women experience PND following birth On set within days upto one year of delivery More insidious onset Untreated, may persist for one to two years 8

SYMPTOMS OF PND For at least two weeks Persistent low, irritable, anxious mood Sleep disturbance Impaired appetite Lack of energy, loss of interest Poor memory and concentration Inability to cope with daily chores Guilt feeling Anxiety of harming baby Suicidal thoughts 9

NEWS FLASH By Martin Evans, Crime Correspondent –Daily Telegraph 11:45AM GMT 30 Oct 2012Martin Evans Felicia Boots, 35, suffocated 9-week-old Mason and 14- month-old Lily-Skye just two weeks after the family, who are originally from Canada moved into a new £1.4 million home in south west London. The judge in the case Mr Justice Fulford described her as a loving mother who has been suffering from a depressive disorder and whose judgement "was simply not functioning". On the morning of the tragedy Mrs Boots had become "fixated and deluded" that her children were going to be taken away, the judge said. The court heard how she had suffered post natal depression following the birth of her first child, Lily-Skye in March She was prescribed anti-depressants and had begun to feel much better, the court heard. 10

NEWS FLASH continued But when she became pregnant with her son she became concerned about the effects the medication might have on him. The court heard how Mrs Boots had stopped taking her medication because she was breast feeding and she was "irrationally worried about the consequences for him". She made an attempt on her own life after killing her children. 11

WHY DOES IT HAPPEN? Don’t know enough Probably multiple stresses Large number of risk factors researched Strongest to emerge: – Previous history /family history of depression – Antenatal depression – Lack of support from partner, domestic violence – Life events- moving house, bereavement, loss of job, money worries Can occur even with no risk factors hormones: no conclusive evidence 12

RISKS OF UNTREATED PND Mothers: protracted suffering, suicide Practical parenting difficulties Attachment difficulties- less responsive Fathers: increased rate of depression and general health problems, if mother depressed Both parents depressed-impact on infant 13

RISKS OF UNTREATED PND continued Infant: attachment difficulties Short/long term cognitive behavioural emotional social developmental difficulties Risk of neglect, rejection Infant’s temperament and resilience modify negative outcomes 14

MANAGEMENT Detection Guidelines and protocols in primary care and maternity services NICE: all pregnant women to be asked – Past/current mental health problem – Past/current psychiatric treatment – Family history of mental health problems – Last month feeling low or hopeless – Loss of interest, pleasure – Need for help 15

MONITORING MOOD Mid wives to monitor mood at all antenatal appointments Postnatally: HVs and GPs screen for PND at 6 weeks, 3 months, 6 months Use EPDS and GHQ for screening Assess further if high score 16

PREVENTION Don’t know enough about PND to prevent it Sensible tips during pregnancy: – Don’t try to be super woman – Don’t move house – Friends with other expecting couples – Antenatal classes with partner – Identify someone to confide in – If previous history, discuss with GP +HV 17

PREVENTION continued After delivery: – Rest, accept/ask for help – Healthy diet, exercise – Build in leisure – Don’t blame yourself/partner – Never too late to have treatment 18

TREATMENT OF PND Diagnosis of PND helps: – Common, – anyone can experience it – Will get better – Not her fault, not a bad mother Involve partner: – Relieved by diagnosis – Guidance for what to do – Practical help with baby – Patience, being positive – Time together 19

20

PHARMACOLOGICAL TREATMENT Hormonal therapy: considerable debate and research Little reliable evidence for effectiveness Concerns about side effects 21

ANTIDEPRESSANTS Not in mild depression Risk: benefit ratio important before prescribing ADs not tranquilisers/pep pill Not addictive Take two or more weeks to work Need not stop breast feeding Need to continue for 6 months to reduce risk of relapse 22

TALKING THERAPIES Guidelines suggest easy and quick access Evidence for equal effectiveness for: – Non directive counselling (supportive listening), 6 to 8 sessions by trained HVs – CBT: structured therapy to solve problems b y changing unhelpful thoughts, beliefs, behaviours – Interpersonal therapy: focus on mothers past and present relationships 23

24

SOCIAL SUPPORT Social circumstances, cultural issues Home start, family support worker, befriending Mother and baby groups, NCT Children centres/Sure Start Family focused interventions: Couples-individual or groups focused on parenting help to improve depression and general health Mother infant therapy help to improve attachment Infant massage: Significant positive effect on mother infant relationship and depressive symptoms 25

RESOURCES Books: Coping with PND-Fiona Marshall 1993 Overcoming PND-Williams, Cantwell Robertson 2009 Understanding PND : MIND Postnatal depression : Factsheet: RCPsych Support Organisations: Association of Postnatal Illness: Meet-a-Mum Association (MAMA) National Childbirth Trust: NETMUMS : HOMESTART UK : FAMILY WELFARE ASSOCIATION: CRY-sis