Maternal Mental Illness & Sleep An overview of the day Dr Andrew Mayers

2 Maternal mental illness and sleep  Overview of today  Postnatal depression  Features, causes, risk factors and treatment  Consequences for mother and child  Postnatal psychosis  Sleep problems  For mother and baby  Complementing your existing skills  Partnership between academic knowledge and professional practice  Interactive sessions

Postnatal depression Features, causes and treatment Dr Andrew Mayers

4 Postnatal depression  Overview  Contrast with baby blues  Diagnosis  Causes and risk factors  Treatments

5 Post-natal depression (PND)  Baby blues  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

6 Major depressive disorder (DSM-IV TR)  Low mood AND/OR …  Markedly diminished interest/pleasure in ‘usual’ activities  PLUS four from:  Significant weight loss/gain/changes in appetite  Insomnia or hypersomnia  Psychomotor agitation or retardation  Fatigue/low energy  Feelings of worthlessness or excessive/inappropriate guilt  Poor concentration/indecisiveness  Recurrent thoughts of death/suicide  Symptoms must be ‘continually’ present for at least 2 weeks

7 PND: Features  PND needs same DSM-IV diagnosis as major depressive disorder  But relates specifically to the postpartum period  But within 4 weeks of birth (is that enough?)  Additional features may also indicate presence  Sense of inadequacy, inability to cope  Feeling guilty  Being unusually irritable  Being hostile/indifferent to husband/partner/baby  Panic attacks  Excessive unwarranted anxiety  Obsessive fears about the baby's health or wellbeing

8 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?  Is this sufficient?  Is there more we can do?

9 PND: Prevalence  PND affects about 10% of new mums  Compare to baby blues (up to 75%)  Although DSM-IV 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 visitors about it  Scared it will lead to social services taking child away  Or that they would be seen as bad mothers

10 PND: Causes  Causes of PND uncertain  But there are a number of known risk factors  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 (we will talk about this later)

11 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

12 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  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)

13 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

14 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

15 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

16 Organisation of care

17 Summary  PND often confused with baby blues  PND more serious and longer lasting  But less common  We need to understand risk factors  Extend beyond Whooley questions  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?