بسم الله الرحمن الرحيم Part B: Perinatal psychiatric conditions

Part B: Perinatal psychiatric conditions Introduction Perinatal psychiatric disorder is now an accepted term used both nationally and internationally. It emphasizes the importance of psychiatric disorder in pregnancy as well as following childbirth and the variety of psychiatric disorders that can occur at this time, not just the ubiquitously known postnatal depression (PND). It also places emphasis on the significance of psychiatric disorders that were present before conception as well as those that arise during the perinatal period

W ha t is pe r ina t a l psy chia t r ic diso r de r ? Psychiatric disorders that complicate pregnancy, childbirth and the postnatal period pre-existing disorders such as schizophrenia, bipolar illness and depression Care involves consideration of the effects of the illness itself and of its treatment on the developing fetus and infant Care involves multidisciplinary and multi-agency working, especially close relationships with Maternity Mental Health and Children's Services

The emotional wellbeing of women is of primary importance to midwives The emotional wellbeing of women is of primary importance to midwives. Not only can mental illness affect obstetric outcomes but also the transition to parenthood and emotional wellbeing and health problems in the infant. Over the last 15 years psychiatric disorder in pregnancy and the postpartum period has been a leading cause of maternal mortality, as highlighted in the ‘Why Mothers Die in the UK’

and ‘Saving Mothers’ Lives' midwives routinely ask at early pregnancy assessment about previous mental health problems, their severity and care. These recommendations have also been made by the Royal College of Psychiatrists

midwives should ask questions (the Whooley questions) on at least two occasions – antenatally and following birth – about women's current mental health. Systems should be in place locally to ensure that women with mental health problems and those at risk of developing them receive the appropriate care. It is therefore essential that all midwives have education and training to be familiar with normal emotional changes, commonplace distress and adjustment reactions as well as the signs and symptoms of more serious psychiatric illnesses.  

Types of psychiatric disorder The term ‘mental health problem’ is commonly used to describe all types of emotional difficulties from transient and temporary states of distress, often understandable, to severe and uncommon mental illness. It is also used frequently to describe learning difficulties, substance misuse problems and difficulties coping with the stresses and strains of life. It is therefore too general and too non-specific to be of use to the midwife.

The term does not discriminate between severity and need and does not help the midwife distinguish between those conditions that she can manage and those that require specialist attention. For this reason, in this chapter, the term ‘psychiatric disorder’ is preferred as it can be further categorized and the different types can be described aiding recognition and the planning of care. Psychiatric disorders are conventionally categorized into:

Serious mental illnesses These include schizophrenia, other psychotic conditions , bipolar illness and severe depressive illness. Previously, these conditions were called psychotic disorders. Mild to moderate psychiatric disorders These were previously known as ‘neurotic disorders’. These include non-psychotic mild to moderate depressive illness, mixed anxiety and depression, anxiety disorders including phobic anxiety states, panic disorder, obsessive–compulsive disorder and post- traumatic stress disorder.

Adjustment reactions These would include distressing reactions to life events, including death and adversity.  Substance misuse This includes those who misuse or who are dependent upon alcohol and other drugs of dependency, including both prescription and legal/illegal drugs.

Personality disorders This is a term used only to describe people who have persistent severe problems throughout their adult life in dealing with the stresses and strains of normal life , maintaining satisfactory relationships, controlling their behaviour , foreseeing the consequences of their own actions and which persistently cause distress to themselves and other people.

Learning disability used to describe people who have a lifetime evidence of intellectual and cognitive impairment, developmental delay and consequent learning disabilities. This is usually graded as mild, moderate or severe.

They are commoner in women than in men with the exception of substance misuse problems. However, the majority of psychiatric disorders in the community are mild to moderate conditions, particularly general anxiety and depression. Mild to moderate depressive illness and anxiety disorders are at least twice as common in women than in men, and are particularly common in young women with children under the age of 5.

The majority of these disorders are managed in primary care and do not require the attention of specialist psychiatric services. Mild to moderate depressive illness and anxiety states respond to psychological treatments. Despite this, perhaps because of shortage of such treatments, prescription of antidepressants is widespread in the community, particularly among women.

Serious mental illnesses are less common Serious mental illnesses are less common. Both schizophrenia and bipolar illness affect approximately 1% of the population. Bipolar illness affects men and women equally. However, schizophrenia, particularly the more severe chronic forms, is commoner among men. These conditions require the attention of specialist psychiatric services and require medical treatments as well as psychological care.

psychiatric services are usually organized separately for adult mental health (serious mental illnesses), substance misuse (drug and alcohol treatment services) and learning disability. separate services for psychiatric disorders in the elderly.

Psychiatric disorder in pregnancy In general, psychiatric disorder is not associated with a decrease in fertility. psychiatric disorders can and do complicate pregnancy and the postpartum period. The prevalence of psychiatric disorder in young women means that at least 20% of women will have current or previous psychiatric disorder in early pregnancy, many of whom will be taking psychiatric medication at the time of conception.

only a small number will have a past history of a serious mental illness and an even smaller number will be currently suffering from such an illness. Pregnancy is not protective against a recurrence or relapse of a previous psychiatric disorder, particularly if the medication for these disorders is stopped when pregnancy is diagnosed. Women with a previous history of serious illness are at increased risk of a recurrence of that illness following birth. is so important for midwives to enquire into women's current and previous mental health at early pregnancy assessment.

Mild–moderate conditions The incidence (new onset) of psychiatric disorder in pregnancy is mostly accounted for by mild depressive illness, mixed anxiety and depression or anxiety states. These disorders present most commonly in the early weeks of pregnancy, becoming less common as the pregnancy progresses. They are probably predominantly of psychosocial aetiology, and for some women they will represent a recurrence of a previous episode, of depression, anxiety, panic or obsessional disorders particularly if they have suddenly stopped their antidepressant medication.

Women may also bevulnerable at this time because of: previous fertility problems previous obstetric loss anxieties about the viability of their pregnancy social and relationship problems ambivalence towards the pregnancy other reasons for personal unhappiness.

In the past, it was often assumed that hyperemesis gravidarum (severe vomiting) was a psychosomatic manifestation of personal unhappiness and psychological disturbance. This condition is less common than in the past and usually resolves by 16 weeks of pregnancy. Psychological factors, anxiety and cognitive misattribution remain a significant factor in some women.

Prognosis and management Most of the conditions are likely to improve as the pregnancy progresses. Psychological treatments and psychosocial interventions are effective for these conditions and caution needs to be exercised before pharmacological interventions are initiated during pregnancy, although medication may be necessary for the more severe illnesses. For others, particularly those who develop a psychiatric illness in the later stages of pregnancy, their condition is likely to continue and worsen in the postpartum period.

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