1. Perinatal Mental Health
Dr Cressida Manning
Consultant Perinatal Psychiatrist
Florence House Mother and Baby Unit

2. Contents of Presentation
Confidential Enquiry into maternal deaths.
Risks of untreated illness.
Risk factors for postnatal depression and psychosis.
Discussions around treatment.
Medication.

3. Recent Case Study Felicia Boots. 35
Mother of 2 ( 14 months and 10 weeks).
Manslaughter on grounds of diminished responsibility.
Stopped medication as breastfeeding.
Husband found children lying side by side walk in wardrode. She had also tried to end her own life.
High lights the ultimate tradgedy of untreated perinatal illness but also the importance of continuing treatment of women with existing illness and diagnosis and treatment of new episodes where required

4. Confidential Enquiry Centre for Maternal and Child Enquiries (CMACE)
Most recent report ‘Saving Mothers Lives’ (2011)
29 suicides 1st 6 months
19 past psychiatric history
9 identified of which 4 had care plan

5. Saving Mothers Lives
38% Psychosis
21% Severe Depressive Illness

6. Recommendations - Back to Basics 1 Saving Mothers Lives
Anxiety or depression
Review in 2 weeks
Consider psych referral if symptoms persist
Refer urgently where:
Suicidal ideation, uncharacteristic symptoms/marked change from normal functioning, morbid fears, profound low mood, personal or family history of serious affective disorder, mental health deterioration, morbid fears, panic attacks and intrusive obsessional thoughts.

7. Effects of Untreated Illness
Increased morbidity.
Increased risks towards self and others.
Links between maternal anxiety and fetal behaviour and heart rate
Stress/anxiety during pregnancy can have long term effects on child
Monk et al 2000 mental arithmetic fetal heart rate increases in anxious group. – no clear mech as cortisol takes 20 mins to increase

8. Associated with an increased incidence of:
Emotional problems - Anxiety/depression
Behavioural problems – ADHD, conduct disorder
Impaired cognitive development, esp language
Sleep problems in infants
Sensitive early mothering important as what happens in utero for child outcome
ALSPAC study effect of antenatal stress/anxiety on behav devel – mental health disorder in children exposed around double the risk. Attributable load due to antenatal stress/ anxiety is about % ( 50% genetic and lot of postnatal influence)

9. Effects of antenatal and postnatal depression
Children of mothers depressed in perinatal period compared to children of well mothers:
Lower IQ scores
12x more likely to have a statement of special needs
elevated risk of violence at 11 and 16 years
More likely to suffer separation anxiety at 11 and a diagnosis of depression at 16
SLCDS – south london child development study Longitudinal prospective study

10. Suicide
Majority of deaths secondary to postpartum psychosis or very severe depressive illness
Oates (2008) Suicide rate for ppp 2/1000
Common profile; white, older, 2nd or subsequent pregnancy, married, comfortable circumstances
Likely to die violently
50% female non perinatal and 75% male die by violent means – 90% perinatal period

11. Infanticide Similar profile 1/3rd mental illness
Death extended suicide or occasionally altruistic based on delusional belief
Highest concern if delusion involves child e.g baby changed, not hers, possessed, evil.

12. Postpartum Psychosis
1st few weeks highest risk
Heron et al (2007) Greater than 80% 1st week
Link with BPAD

13. Bipolar Disorder 52% relapse in 1st 40 weeks after stopping treatment
If pregnant and stable on antipsychotic and likely to relapse without medication continue
Up to 70% relapse if untreated in postnatal period
50% psychotic symptoms day 1 - 3

14. Postpartum Psychosis – Risk Factors
1st Baby
Single
C- Section
Older
Fertility Problems
Previous episode – 1 in 7
Sleep Loss

15. Warning Signs Early signs often non specific
Insomnia, agitation/anxious, perplexed and odd behaviour. Risk overlooked
Can lead to rapid deterioration to Psychotic symptoms

16. Postnatal Depression 10 -15% Severe 3%
1/3 to ½ continuation of antenatal anxiety and depression
Onset few days to 6 months
Increased risk in subsequent pregnancies – approx 25 – 50%

17. Postnatal Depression – Risk Factors
Antenatal anxiety or depression
Past history of psychiatric illness
Life events
Lack of or perceived lack of support
Low income
Domestic violence
FH of psychiatric illness
Childhood abuse

18. Risk Factors cont… Obstetric factors Sleep deprivation
Infant factors –irritability
Personality factors – control, interpersonal sensitivity, ‘neuroticism’
Biological factors – inconsistent results

19. Early Detection Past or present mental illness
1st contact;
Past or present mental illness
Previous psychiatric input, including admissions
Family history of severe mental illness
Monk et al 2000 mental arithmetic fetal heart rate increases in anxious group. – no clear much as cortisol takes 20 mins to increase

20. Treatment of pregnant and breast feeding women- NICE guidelines
Importance of balancing risks and benefits
Cautious
Women requiring psychological treatment should be seen for treatment within 1 month of assessment and no longer than 3 months.

21. NICE Discussion should include:
Risk of relapse and not treating disorder
Woman’s ability to cope with untreated symptoms
Severity of previous episodes and response to treatment
Woman’s preference
Possibility that stopping drug with teratogenic risk once pregnancy confirmed may not remove risk

22. NICE Risks of stopping medication abruptly
Need for prompt treatment due to impact of illness on foetus/child
Increased risk of harm of specific drug treatments
Treatment option that would allow mother to breastfeed

23. NICE Prescribing: Drugs with lowest risk profile Lowest effective dose
Monotherapy
Risks lower threshold for psychological treatment
Important to put risks from drug treatment in context of the individual woman’s illness

24. Antidepressants self limiting SSRIs
Paroxetine in 1st trimester increase in cardiac
malformations (VSD) – planning pregnancy or
unplanned advise to stop. Other SSRIs now implicated.
SSRI’s taken after 20 weeks may be associated
with an increased risk of persistent pulmonary
hypertension of the new born
Neonatal withdrawal- normally mild and
self limiting
Are SSRIs assoc with increase riskof congenital malformations. Conflicting but probably yes. 0.5 to 0.9. But implications of stopping increase 6 fold PND. PPH around 0.5 to 1 in 1000 reis et al chambers higher 6-12/1000

25. Symptoms include; Irritability Hypertonia Jitteriness
Difficulties feeding
Tremor
Agitation
Seizures
Tachypnoea
Posturing
Also association with decreased gestational age (1 week),, spontaneous abortion and decreased birth rate

26. Tricyclics
Tricyclics have lower known risks during pregnancy than other antidepressants
Have higher fatal toxicity index
CHD with clomipramine
Withdrawal symptoms
No effects on long term neurodevelopmental outcomes
Imipramine

27. Other antidepressants
Venlafaxine – Conflicting results for congenital malformations – data too limited to say safe. Possible increased neonatal withdrawal and increased risk of high blood pressure at higher doses. Theoretical risk of PPHN
Mirtazapine – Possible association with increased rate of spontaneous abortion. No evidence to link to congenital malformations but data too limited to say safe.
JAMA 13 – Metaanalysis – preterm birth 3 days
- Apgar <0.5
- Weight 75g
- Spontaneous abortion not significant.

28. Benzodiazepines Raised risk of oral cleft (7 in 1000; x10)
Withdrawal syndrome – jitteriness, autonomic dysregulation, seizure, floppy baby syndrome
Consider gradually stopping in women who are pregnant
Short term use only for severe agitation and anxiety

29. Lithium – Ebsteins anomoly (1 in 1000) General population 1 in 20000
Overall risk CHD % vs 0.5-1% general population.
Floppy baby syndrome, thyroid dysfunction, nephrogenic diabetes insipidus.
High quantities in breast milk.
Ebstein anomaly- distorted and displaced tricuspid valve with abn of right atrium and ventricle

30. Valproate NTD 100 to 200 in 10000 IUGR Facial dysmorphias Low IQ
Do not routinely prescribe to women of child
bearing age.
If no option adequate contraception
Discontinue if pregnant
Limit dose 1g per day and 5mg folic acid

31. Carbamazepinne Lamotrigine
Increased risk congenital malformations -6.7% v 2.3%
Craniofacial, GIT, cardiac, urinary tract and digit anomalies
Advice as valproate
Lamotrigine
Cleft palate 8.9/1000
Matalon 2002

32. Atypical Antipsychotics
Olanzapine and Quetiapine
Limited data to base assessment of safety in pregnancy, but available data does not suggest a substantially increased risk of congenital malformations or spontaneous abortions
No pattern of malformations observed.
Withdrawal symptoms
Olanzapine – increased birth weight

33. What Clinicians need to do
Do not assume it is always better to stop medication
Provide prompt and Effective treatment of mental illness in pregnancy and postnatal period
Understand, consider and communicate known risks (and how these will be managed) of medication
Complete risk benefit analysis for individual patient.