1. PERINATAL PSYCHIATRY Dr N U Mir Consultant in Perinatal Psychiatry Hon Senior Clinical Lecturer Perinatal Mental Health Service Michael Carlisle Centre Sheffield

2. KEY TOPICS History and role of perinatal psychiatry Clinical presentation of common perinatal psychiatric disorders Baby blues Antenatal and postnatal depression Postpartum (puerperal) psychosis Prescribing in pregnancy and breastfeeding

3. HISTORY Louis Victor Marcé Paris 1828-1864 ‘Traité de la Folie des femmes enceintes, des nouvelles accouchées et des nourrices’

4. NEED FOR PERINATAL PSYCHIATRY Depression leading cause of world wide disability WHO Global burden of disease study Suicide third leading cause of indirect maternal death CEMACE: Saving Mothers’ lives 2006 - 2008 Untreated perinatal disorders => morbidity / bonding / risk Pre-existing psychiatric disorders => increased relapse risk Bipolar disorder => Puerperal psychosis risk Confidential Enquiry into Maternal Deaths in UK, Saving Mothers’ Lives 2006 – 2008, RCOG 2011 Lopez et al. Global and regional burden of disease and risk factors, 2001:systematic analysis of population Health data. Lancet 2006 367:1747-57

5. MEDIA SPOTLIGHT

6. ROLE OF PERINATAL PSYCHIATRY Managing high risk women with previous postnatal episodes or complex circumstances Treating antenatal moderate / severe anxiety and mood disorders Managing pre-existing psychoses (eg. Bipolar disorder) during pregnancy Pre-conceptual counselling Advising on risks of medication during pregnancy and breastfeeding

7. CLINICAL PRESENTATION -IN CONTEXT- ANTENATAL Depression Generalised anxiety Panic disorder Pre-existing psychoses (eg. Schizophrenia, Bipolar disorder) POSTNATAL Baby blues Depression Postpartum (Puerperal) psychosis

8. EFFECT OF CHILDBIRTH Kendell RE et al 1987 Epidemiology of puerperal psychoses Br J Psych;150:662-73

9. NOSOLOGY Wide variety of disorders occur in relation to parturition Psychiatric illness may be precipitated by pregnancy and childbirth New onsets or recurrence Pregnancy can influence pre-existing psychiatric illness Psychiatric disorders can influence obstetric course

10. ANTENATAL DEPRESSION Estimated rates vary: 7-15% developed countries / 19-25% in developing countries Poverty, lack of education, young age, poor social support, unplanned pregnancy associated with antenatal depression 50% postnatal depression starts during pregnancy 2/3 women with recurrent depression will relapse if discontinue antidepressants after conception Association with low birth weight and IUGR, preterm delivery Chung et al. 2001. Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes. Psychosom Med 63:830-4

11. CLINICAL PRESENTATION Negativity towards pregnancy Thoughts re termination of pregnancy Worry about course and outcome of pregnancy - will I have a miscarriage? - will baby be healthy? - I won’t be able to cope with labour - I will be a bad mother Ideas and acts of self harm Relationship difficulties

12. TREATMENT OF ANTENATAL DEPRESSION Treatment dependent on severity Mild depression – psychological interventions counselling, CBT Moderate depression – Risk benefit analysis - Antidepressant therapy (NICE) - CBT Severe depression – Antidepressant therapy (NICE) CBT CMHT / Perinatal service follow up

13. PSYCHOSIS DURING PREGNANCY Early referral to Perinatal Mental Health Service Regular community follow up by Perinatal Mental Health Service Maintenance antipsychotic therapy for high risk patients Schizophrenia, schizoaffective disorder, bipolar disorder with history of relapse, residual symptoms or previous postnatal episodes Consider change to trifluoperazine Care coordinator CPA Planning meeting pre-childbirth Liaison with Children & Families / Social Services

14. POSTNATAL DISORDERS Baby Blues Postnatal Depression Postpartum (Puerperal)Psychosis

15. BABY BLUES Incidence per delivery: ~ 50% Typical onset after delivery: Around 2 – 5 days Symptoms: Depressed mood, irritability, lability of mood, crying Prognosis: Transient. Increased risk of subsequent postnatal depression Treatment: Requires no intervention. Self limiting.

16. POSTNATAL DEPRESSION Incidence per delivery: 10 – 15% Typical onset: Within 6 months of delivery Distinct from non-postpartum depression? Little evidence to support distinction Lack of consistent data on hormonal aetiology

17. DEPRESSIVE EPISODE (ICD-10 F32) Group A symptoms Depressed mood, loss of interest and enjoyment, decreased energy Group B symptoms a) reduced concentration and attention b) reduced self-esteem and self-confidence c) ideas of guilt and worthlessness d) bleak and pessimistic outlook e) ideas of self harm and suicide f) disturbed sleep g) diminished appetite Four, six or eight symptoms required for TWO weeks Mild, Moderate, severe

18. RISK FACTORS FOR POSTNATAL DEPRESSION Antenatal depression or anxiety Past history of depression Past history other psychiatric illness Recent stressful life events Poor social support Musters et al. 2008. Management of postnatal depression. BMJ, 37, 399 - 403

19. CLINICAL PRESENTATION Persistent low mood and tearfulness Low confidence / self esteem (‘bad mother’) Difficulty coping with childcare Difficulty bonding Extreme anxiety about health of baby Overconcern about feeding / sleeping regime Odd / overvalued ideas - eg. ‘Cord still attached to baby’ ‘Baby’s eyes are eyes of the devil’ Physical anxiety symptoms / panic attacks Suicidal thoughts Infanticidal thoughts Relationship difficulties / conflict

20. ASSESSMENT OF RISK History - Feelings of worthlessness, hopelessness - History of attempted suicide or harm to baby - Situational or environmental factors affecting risk - Mental state - Thoughts of suicide or harm to baby - Psychotic symptoms, delusions / hallucinations re baby

21. SCREENING – THE WHOOLEY QUESTIONS Recommended by NICE If the answer to either of first two questions is positive, proceed to third question During the past month have you often been bothered by feeling down, depressed or hopeless? During the past month have you often been bothered by having little interest or pleasure in doing things? Is this something you feel you need or want help with? Whooley et al. 1997. Case-finding instruments for depression: two questions are as good as many. J Gen Intern Med, 12:439-45

22. EDINBURGH POSTNATAL DEPRESSION SCALE Developed for diagnosis of Postnatal depression Simple self-rating 10 item scale Effective screening tool 0-3 scoring 13 and above => Depressive illness likely Cox et al. 1987. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 150: 782-786

23. TREATMENT OF POSTNATAL DEPRESSION (I) MILD to MODERATE DEPRESSION Self help strategies Non-directive counselling Brief Cognitive behaviour therapy Interpersonal therapy Support groups / organisations eg. Surestart

24. TREATMENT OF POSTNATAL DEPRESSION (II) MODERATE DEPRESSION Psychological therapy Antidepressant therapy* - if psychological therapy declined - if psychological therapy ineffective / partial response - if history of severe depression - requested by patient *Consider breastfeeding issue

25. TREATMENT OF POSTNATAL DEPRESSION (III) MODERATE to SEVERE Combination therapy Psychological + Pharmacological Referral to Secondary care / Specialist Perinatal service CMHT follow up – CC Clinical psychology / Psychotherapy Inpatient care – Mother – Baby Unit - if risk issues - if community care ineffective - ECT

26. POSTPARTUM (PUERPERAL) PSYCHOSIS Incidence: 1-2 / 1000 deliveries Typical onset: Acute within 2-4 weeks of delivery Mean age of onset: 26.3 yr Risk factors: Past history of PP Family history of PP History of Bipolar disorder

27. BIPOLAR WOMEN AND RISK OF POSTPARTUM (PUERPERAL) PSYCHOSIS Jones & Craddock, Am J Psych 2001

28. TYPES of PSYCHOSIS IN RELATION TO CHILDBIRTH Chronic - Schizophrenia Acute - Organic psychoses (becoming rarer) - Schizophrenia (rare) - Affective – manic / depressed / mixed / schizoaffective “Puerperal Psychosis”

29. CLINICAL FEATURES ICD 10 F53.1 Severe mental and behavioural disorder associated with puerperium, not elsewhere classified ‘Kaleidoscopic’ Quickly changing from one thing to another

30. CLINICAL FEATURES Mood symptoms - Depressed mood, lability, elation, rambling speech, overactivity Psychotic symptoms - Delusions – fleeting not fixed, systemetisation not usual - re baby, mood incongruent, persecutory, reference, jealous, grandiose - Hallucinations – Auditory, visual, olfactory Perplexity and confusion Sit et al. 2006. A review of postpartum psychosis. J Women’s Health, 15, 4: 352-68

31. SUICIDE AND INFANTICIDE CEMACH: Saving Mothers Lives 2003 – 2005 - Suicide second leading cause of indirect deaths 1000 women with PP => 2 suicides More likely to be violent means eg. Hanging, self incineration, jumping from height More likely to express homicidal ideation though homicidal behaviour rare Confidential enquiry into Maternal deaths, Saving Mothers Lives 2003 – 2005, RCOG 2007 Sit et al. 2006. A review of postpartum psychosis. J Women’s Health, 15, 4: 352-68

32. TREATMENT OF POSTPARTUM (PUERPERAL) PSYCHOSIS 1) Inpatient (M-B) Unit admission – under MHA if necessary 2) Symptom focussed pharmacotherapy - Atypical antipsychotic - Antidepressant 3) Lithium - bottle feeding v breast feeding - Regular level checks – neonatal toxicity risk - Prophylaxis if past history of PP 4) - Valproate, Carbamazepine, Lamotrigine

33. TREATMENT OF POSTPARTUM (PUERPERAL) PSYCHOSIS 5) ECT - Deteriorating self care - Suicidality - physical risk 6) Maintenance pharmacotherapy / follow up 7) Consider past treatment response / side effects profile / acuity of illness as guide

34. STEPPED CARE MODEL GPs, obstetricians, midwives, health visitors, practice nurses General healthcare services (maternity and primary care) Detection of history of and current mental illness; referral GPs, obstetricians, psychological therapists, PCMHWs Primary care mental health services Assessment and referral; treatment of mild to moderate illness CMHT (psychiatrists, psychologists, nurses social workers) Specialist mental health services Assessment; treatment; referral to specialist services; inpatient care Specialist perinatal mental health services Psychiatrists, nurses, nursery nurses, psychologists Prevention, management & treatment of moderate/severe illness; specialist advice and consultation to primary care PersonnelServiceCore functions

35. PRINCIPLES OF PRESCRIBING PSYCHOTROPIC MEDICATION Careful risk-benefit assessment If mild to moderate severity, use non-pharmacological intervention Avoid first trimester exposure if at all possible Choose drugs with lower risk profiles for mother / foetus / infant Start lowest effective dose and increase slowly Tricyclic antidepressants (amitryptiline, imipramine, nortripyline) lowest known risks in pregnancy but dangerous in overdose SSRI’s: Relatively safe, fluoxetine lowest risk, Sertraline (breast feeding) Trifluoperazine, haloperidol antipsychotics of choice Avoid polypharmacy if at all possible

36. RISK-BENEFIT ANALYSIS RISK OF DRUGS Risk of teratogenicity Risk of neonatal withdrawal Risk of longer-term neurobehavioural / cognitive problems Risks in breastfeeding RISK OF ILLNESS Untreated illness may affect birth weight and gestational age at delivery Possible detrimental effect of sress in pregnancy on foetus May impact on mother-infant attachment and later infant development

37. ANTIDEPRESSANTS IN PREGNANCY Tricyclic antidepressants (amitryptiline, imipramine, nortriptyline) lowest known risks in pregnancy but more dangerous in overdose SSRI’s: Fluoxetine lowest risk; Sertraline, citalopram Association with Persistent pulmonary hypertension, septal heart defect (Tuccori et al, 2009; Pedersen et al, 2009) though absolute risk small Neonatal withdrawal symptoms possible with antidepressants - taper if clinically appropriate prior to delivery Tuccori et al. 2009. Safety concerns associated with the use of Serotonin Reuptake inhibitors and other Serotonergic/Noradrenergic antidepressants during pregnancy: a review. Clinical Therapeutics 31:1426 -1453 Pedersen et al. 2009. Selective serotonin reuptake inhibitors in pregnancy and congenital malformations: Population based cohort study. BMJ 339, 3569-3575

38. ANTIDEPRESSANTS AND BREASTFEEDING Antidepressants transfer readily into human milk though often at levels far below clinical range Certain considered safer than others though in general long term outcomes for exposure unknown Low levels in breast milk: Imipramine, nortripyline, sertraline Higher levels in breast milk: fluoxetine, citalopram Other SSRI’s / SNRI’s / newer antidepressants should be avoided until more data available

39. BENZODIAZEPINES Associated with cleft palate, neonatal withdrawal and floppy baby syndrome Only for short-term treatment of extreme anxiety and agitation Consider gradually stopping in pregnant women If prescribed, keep to lowest possible dose for shortest possible time Avoid if possible or decrease in late pregnancy Dolovich et al. 1998. Benzodiazepine use in pregnancy and major malformations or oral cleft: meta-analysis of cohort and case-control studies. BMJ, 317, 839-43

40. LITHIUM Ebstein’s anomaly risk raised from 1 in 20,000 to 10 in 20,000 Do not prescribe routinely esp 1 st trimester or breastfeeding Well and LOW RISK => stop gradually over 4 weeks Not well and HIGH RISK=> switch gradually to antipsychotic stop & restart 2 nd trimester continue if high risk monthly level monitoring National Institute for Health and Clinical Excellence. Antenatal and postnatal mental health: clinical management and service guidance. Clinical guideline 45

41. VALPROATE Neural tube defects risk raised from 6 in 10,000 to 100 -200 in 10,000 Developmental problems / Autistic spectrum disorder ‘Foetal valproate syndrome’ Do not routinely prescribe to women of childbearing potential Explain risks Consider alternative in bipolar (eg. Antipsychotic) If no alternative, limit to maximum 1g daily in divided doses and slow release form, with 5mg folic acid Kini, U 2006. Fetal valproate syndrome: a review. Ped & Perinatal Drug Ther 7(3) 123 - 30

42. ANTIPSYCHOTICS Trifluoperazine : safest in pregnancy and breastfeeding Risperidone, amisulpiride: raised prolactin levels Olanzapine: weight gain, gestational diabetes Clozapine: Do not routinely prescribe but some case reports of its successful use Avoid depot medication Current evidence not suggestive that antipsychotics are major teratogens. Possibly small risk of cardiovascular malformation (1-1.5%) though no specific drug implicated Reis & Kallen 2008. Maternal use of antipsychotics in early pregnancy and delivery outcome. J Clin Psychopharmacol 28(3):279-88

43. EXPLAINING RISKS Before making treatment decisions discuss absolute and relative risks associated with treating and not treating the mental disorder during pregnancy and postnatal period Acknowledge uncertainty surrounding risks Explain background risk of fetal malformations for pregnant women without mental disorder (2-4%) Describe risks using natural frequencies (1 in 10 vs 10%) Use decision aids Written material Audiotaped records of consultation if possible

44. PSYCHOLOGICAL TREATMENTS Women requiring psychological treatment during pregnancy should have rapid access to it Should be seen normally within 1 month and no longer than 3 months afterwards Lower threshold for access due to time-limited nature of pregnancy and changing risk- benefit ratio for psychotropic medication Counselling Cognitive behaviour therapy (CBT) Interpersonal therapy Psychodynamic therapy

45. SOCIAL INTERVENTIONS Housing Employment Benefits Support network (Surestart, postnatal groups) Children & Families (Social Services) liaison

46. SUMMARY Role for Perinatal Psychiatry in recognition and management of mental disorders during pregnancy and child birth Antenatal & postnatal depression, baby blues common may be managed in primary care Puerperal psychosis needs secondary care / perinatal service Special consideration of risk / benefit issues in pregnancy & breastfeeding Outcomes after treatment of most perinatal disorders good