The Aim of Partaisto

CHAPTER25

Perinatalmentalhealth

The aim of PartAisto:

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•explorethepsychologicalcontextofpregnancy,childbirthandthepuerperiumbyexaminingthefull rangeofhumanemotionsthatmayaffectwomenastheyadjusttochangeand makethe transitiontomotherhood

•emphasizethatawareness ofthemultiplicity ofpsychosocialfactorsand whatconstitutesnormal emotionsandbehaviours arekeycomponentsinenhancingunderstanding ofperinatalmentalhealth.

The aim of PartBisto:

•exploretherangeofperinataldisorders,i.e.psychiatricconditions,thatpre-existorco-existwithpregnancyaswellasthoseconditionspresentingwiththepuerperium

•emphasize,byusing adefinednomenclature,theirrecognitionandmanagement(includingrelevantpharmacologyandtheimplicationsforbreastfeedingand mother–babyrelationship)

•highlightkeyrecommendationsfromNICEandrelevanttriennialreports ontheConfidentialEnquiriesintoMaternal DeathsintheUnitedKingdom

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PartA:Pregnancy,childbirth,puerperium:thepsychologicalcontext

MaureenDRaynor

Stress/anxiety

Pregnancy,labourandthepuerperiumarenormallifeevents,yettheyareperiodsinawoman'slifewhenhervulnerabilityexposeshertoasignificantamountofstressandanxiety.Stressandanxietyarethepsychopathologyofhumans'existenceandapartofnormalhumanemotion.Adegree of stressduringpregnancyisbothessentialandnormalforthepsychologicaladjustmentofpregnantwomen.The‘worrywork’thatwomenencounterassistsintheirpsychologicaladaptationtotheemotionaldemandsandchangesof pregnancy.Conversely,elevatedlevelsofstresshormonesandunnecessaryanxietywillstretchcopingreserves,andcouldprovedisabling.Stressisthebody'spsychophysicalresponsetoanytypeofdemandorthreat,whethergoodorbad.Anxietyontheotherhandisastateofangst,worryorunease,ohentriggeredbyanelementofperceivedthreatoraneventwherethereisanuncertainoutcome,suchasawrifenexaminationorwhenimportantdecisionshavetobemade.Thebrainplaysakeyroleinhowanindividualrespondsandprocessestheperceptionofathreat.Thisisrealizedviaaneurohormonalresponsebyboththeneocortexandlimbicsystem.The‘fightorflight’reflexisproducedwhenthereisathreattotheself.Anxietyandfearcausestheindividualtobecomestressed,releasingstressresponsehormonesnamelycatecholamines(adrenaline/noradrenaline)andcortisol.Ahostofpsycho-physicalsymptomscanmanifest,suchashyperalertness,tension,senseofunease,restlessness,insomnia,fearandforgetfulness.Gastrointestinalupset andmarkedchangesinthecardiovascularsystem,e.g.sweating,palpitations,tachycardia,shortnessofbreath,dizziness,drymouthandnausea,canalsofeature.Stressandanxietythereforehaveacognitive,somatic,emotional,physiologicalandbehaviouralcomponent.

Anxietydisorders,ontheotherhand,areagroupofmentalillnessthatcausesuchmarkeddistressthattheydisruptnormalfunction,overwhelmorimpairtheindividual'sabilitytoleadanormallife.Examplesofanxietydisorderssuchasobsessional–compulsive andphobicanxietystatesarediscussedin moredetailinPartBofthechapter.

Althoughmanystudieshaveraisedtheprofileofelevatedlevelsofstresshormonesduringtheantenatalperiodhavingthepotentialtoleadtodeleteriouseffectsonthefetus(Teixeiraetal1999;Evansetal2001;Milleretal2005;GloverandO'Connor2006;Talgeetal2007;O'Donnell etal2009)orpersistentantenatalanxietyactingasapossibleprecursortomaternalmentalillnesspostpartum,thisisstillanemergingfield.Themechanismbywhichraisedlevels ofstresshormonesmayaffectfetal developmentisnotyetfullyunderstood.Furthermore,theresearchstudieshaveprovidedverylifledatatohelpguidemidwiferypracticeonhowantenatalstresscanbealleviatedinpregnantwomen.

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Thusitcanbeconcludedthattherearemanyfactorsinwomen'slivesthatcanimpactontheirhappiness(Fig.25.1)andaffecttheiremotionalhealthandwellbeing.Understandingtherootcauseandexpressionofanxiety,stressandmentaldistressinwomeniscomplex,asthesocialcircumstancesinwhichwomenliveandintowhichchildrenarebornplayamajorroleintheirhealthandwellbeing.

FIG. 25.1Vulnerabilityfactorsandmentalhealth.

Fearofgivingbirth(tocophobia)

Thefearofchildbirthhasgrowninprominenceoverrecentyears,asdemonstratedbytheemergentstudiesmainlyfromScandinaviancountries.Theexactincidenceofthispsychologicalconditionisunknownbutitisestimatedthatapproximately5–20%of pregnantwomenwithinWesternsocietyarefearfulofchildbirth(Waldenstrometal2006;Rouheetal2009;Adamsetal2012).Thepicturewithindevelopingandmore

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resource-poorcountriesisunreported.Understandingtocophobiaischallengingas thereisanarrayofcomplexsocialfactorsafributedtotherootsofitsexpression,suchasdomesticabuse,communicationdifficulties,previoustraumaticbirthexperience,poorsocioeconomicstatus,lackofsocialsupport,nulliparityandpre-existingmentalillness(Rouheetal2009,2011).Astudyby Adamsetal(2012)suggeststhattocophobiamightresultinlongerdurationoflabourandthereforemoreriskofobstetricinterventionduringchildbirth.Itispostulatedthatthefearandanxietygeneratedinthepresenceoftocophobiaincreasescatecholaminelevels,whichcanaffectthefrequency,strengthanddurationofuterinecontractions.Thiscanaffectwomen'ssatisfactionwiththeirbirthexperienceandleadtomaternaldistress.

Transitiontoparenthood

Postnatally,parentsmayfindcopingwiththedemands ofanewbaby,e.g.infantfeeding,financialconstraints,thewholeprocessoflifestyleadjustmentsandrolechanges,arealstrain.Fornewmothers,thiswillinvolvediverseemotionalresponsesrangingfromjoyandelationtosadnessanduferexhaustion.Fatigue,painanddiscomfortcommonlyresultonce theelationthatfollowsthesafearrivalofthebabywearsoff.Disturbedsleepisinevitablewithanewbaby.Motherswhoaretryingtoestablishbreastfeeding,olderwomen,womenwhoarerecoveringfromacaesareansectionorthosewhohavehadalonganddifficultlabour/birth,twinsorhighermultiples,mayfeelwretchedandconstantly wearyformonthsfollowingchildbirth.Sorenessandpainbeingexperiencedfromperinealtraumawillaffectlibido,sotoowillfeelingsofexhaustion,despairandunhappinessthatmaybeassociatedwiththeround-the-clockdemandsofcaringforanewbaby.Womenmaybeleftfeelingbereftandquitemiserableaftergivingbirth.

Rolechange/roleconflict

Havingababy,andparticularlythetransitiontoparenthoodthataccompaniesthefirstchild, leadsto asignificantshih inacouple'srelationship; social networksaredisrupted,especiallythoseof themother,andthe qualityandquantityof socialsupportsuchnetworkscananddoprovide.Thereisastrongpossibilitythatoldrelationships,particularlywiththosewhoarechildlessorsingle,maybeweakened,leadingtoasenseofsocialisolation.However,somerelationshipsarestrengthenedorevenreplacedgraduallybynewcontactsestablishedwithotherparents.Thedynamicsofrelationshipswithfamilymembersarealsoalteredduringthisprocessoftransitionandchange.Therelationshipwiththewoman'sparentsforexamplealtersasthedaughterbecomesamotherherselfandherparentsdevelopnewrolesasgrandparents. Thecompetingdemandsontimeofcaringforanewbabymayleadtoroleconflictandconfusionforparents.Mothersmayfindthatthereislifletimeforthemtopursueotheractivities,whichcandiminishanyopportunityforcontactwithandsupportfromothers(RaynorandEngland2010).Partners,especiallyyoungfathers,canalsoexperienceasenseofisolationas the dynamicwithinthecouple'srelationalters,becomingmorebaby-centred.Postnatalcareisthereforeessentialtowomen'semotionalwellbeingandshouldbea

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continuationofthecaregivenduringpregnancy.Itscontributionplaysasignificantpartinthepositiveadjustmenttoparenthood,asitassistsintheacquisitionofconfidentandwell-informedparentingskills(DH[DepartmentofHealth]2004;Barlowetal2011).

Communication

Effectivecommunicationduringpregnancyandthepuerperiumisessential.Yetpoorcommunicationisstillthesinglemostcommonfactorthatisassociatedwithwomen'sdissatisfactionwiththeircare.AsurveybytheNationalPerinatalEpidemiologyUnit(NPEU)reportsthatcommunicationremainsamaferofconcernwithinthematernityservice(RedshawandHeikkila2010).Beingprovidedwithadequateinformationwillserveto:

•diminishwomen'sanxietylevelsandallayemotionaldistress

•facilitatechoice

•enablewomentomaintaincontroloverdecision-making.

Theideologyofmotherhood

Motherhood,itisthought,ensuresthatawomanhasfulfilledherbiologicaldestiny,confirmsawoman'sfemininityandraisesherstatusin society,butwithoutfinancial gain(Crifenden2001;Winson2009).Insteadoffeelingelatedbymotherhoodsomewomenexperiencedispleasure,harbourfeelingsofunhappinessandfeeldismayedorevendisappointedintheirroleasnewmothers(Grabowska2009).Manymaybeafraidtospeakoutabouttheirfeelingsincasetheyarejudgeda‘bad’ornota‘goodenough’mother.Painfulemotionsmaybeinternalized,magnifyingdifficultieswithcopingandsleeping,leadingmanywomentosufferinsilence.Distressmaythenmanifestasmothersrageagainsttheirimpossiblesituation.Somewomenmayevengrieveforthelossoftheirformerlifestyle,careerorstatus.Nicholson(1998)contendsthathealthcareprofessionalshavedefinedwomen'spostnatalexperiencethroughproposingthatwell-adjusted,‘normal’andtherefore‘good’mothersarethosewhoarehappyandfulfilled,butthosewhoareunfulfilled,anxiousordistressedare‘ill’andmaybeperceivedas‘bad’mothers.Thismayleadtofeelingsofisolation,inadequacyandconfusion.Theideologyofmotherhoodisthereforeanassumptionandaparadoxwithinherentdichotomiesasthewomanstrivestobe‘supermum,superwife,supereverything’(Choietal2005).Midwiveshaveapivotalroletoplayinassistingwomenand theirpartnerstoprepareforthephysical,social,emotionalandpsychologicaldemandsofpregnancy,labour,thepuerperiumand,perhapsmoreimportantly,parenthood(Barlowetal2011;DH2011).

Socialsupport

Duringperiodsofstress,supportiveandholisticcarefrommidwiveswillnotonlyassistinpromoting emotionalwellbeingofwomen, butwillalsohelp toamelioratethreatenedpsychologicalmorbidityinthepostnatalperiod(Oakleyetal1996;Websteretal2000;Wesselyetal2000;Hodnefetal2010).Womenwhoaresociallyisolatedorwhohave

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poorsocioeconomiccircumstancesareparticularlyvulnerable tomentalhealthproblemsandneedadditionalhelpandsupport.This includeswomenfromminorityethnicgroupswhodonotspeakEnglish,andoftenhaveproblemsaccessinghealthcare(CMACE2011).Bicketal(2009)provideevidenceregardingthepsychosocialbenefitsofmidwiferycarewellbeyondthehistoricalboundariesofthetraditionallydefinedpostnatalperiod.Therestructuringofpostnatalcaremeans there isnowasocialexpectation thatmidwiveswillrespondflexiblyandresponsivelytowomen'semotionalneedsonanindividualbasis(Brownetal 2002;DH2004,2007a,2007b;NICE[NationalInstitute for HealthandClinicalExcellence]2006).Thiscallsforskilledmultidisciplinaryandmulti-agencycollaborationaswellaseffectiveteamwork,takingintoaccountthediversitywithinteams,forexampletheDepartmentofHealth (DH2003a,2003b)acknowledgesthecontributionofthematernitysupportworkerinmaternitycare.SocialsupportisfurtherexploredinPart B.

Normalemotionalchangesduringpregnancy,labourandthepuerperium

Pregnancy

Sincemanydecisionshavetobemadeitisperfectlynormalforwomentohaveperiodsofself-doubtandcrisesofconfidence.Box25.1outlinesthemanyandvariedemotionswomenmayexperienceduringthedifferenttrimestersofpregnancy.Therealityformanywomenwillencompassfluctuationsbetweenambivalencetopositiveandnegativeemotions.

Box 25.1

Normalemotionalchangesduringpregnancy

Firsttrimester

•pleasure,excitement,elation

•dismay,disappointment

•ambivalenceemotionallability(e.g.episodesofweepinessexacerbatedbyphysiologicaleventssuchasnausea,vomitingandtiredness)

•increasedfemininity

Secondtrimester

•afeelingofwellbeing,especiallyasphysiologicaleffectsoftiredness,nauseaandvomitingstarttoabate

•asenseofincreasedattachmenttothefetus;theimpactofultrasoundscanninggeneratingimagesfortheprospectiveparentsmayintensifytheexperience

•stressandanxietyaboutantenatalscreeninganddiagnostictests

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•increaseddemandforknowledgeandinformationaspreparationsarenowonthewayforthebirth

•feelingsoftheneedforincreasingdetachmentfromworkcommitments

Thirdtrimester

•lossoforincreasedlibido

•alteredbodyimage

•psychologicaleffectsfromphysiologicaldiscomfortssuchasbackacheandheartburn

•anxietyaboutlabour(e.g.pain)

•anxietyaboutfetalabnormality,whichmaydisturbsleeporcausenightmares

•increasedvulnerabilitytomajorlifeeventssuchasfinancialstatus,movinghouse,orlackofasupportivepartner

Labour

Duringlabour,midwivesmustfacilitatechoicetohelpwomenmaintaincontrol.Factorsthatinducestressshouldbeprevented,oratleastminimized,asthewoman'slong-term emotionalhealthmaybeseverelycompromisedbyanadversebirthexperience(Lyons1998;RedshawandHeikkila2010).Choiceandcontrolareimportantpsychologicalconceptstomentalhealthandwellbeing.EvidencefromGreenetal's(1998)prospectivestudyofwomen'sexpectationsandexperiencesofchildbirthsuggeststhathavingchoiceinpregnancyandchildbirth,andasenseofbeingincontrol,leadtoamoresatisfyingbirthexperience.InEngland,thepublicationof‘MaternityMafers’(DH2007a)epitomizesarealphilosophical shihinmaternitycareintermsof the guaranteedchoicesforwomen.RedshawandHeikkila(2010)identifykeyfactorsrelatedtowomen'sperceptionofcontrolduringlabour,theseare:

•continuityofcarewithcarer

•one-to-onecareinlabour

•notbeingleftforlongperiods

•beinginvolvedindecision-making.

Ongoingresearchtodeterminetherelationshipbetweenwomen'sperceptionofcontrolduringchildbirthandpostnataloutcomesisneededinordertomeasurefactorssuchaspostnataldepression, positiveparentingrelationshipsandself-esteem. CommonemotionalresponsesduringlabouraredetailedinBox25.2.

Box25.2

Emotionalchangesduringlabour

•Rangingfromgreatexcitementandanticipation,toutterdread

•Fearoftheunknown

•Fearoftechnology,interventionandhospitalization

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•Tension,fearandanxietyaboutpainandtheabilitytoexercisecontrolduringlabour

•Concernsaboutthewellbeingofthebabyandabilityofthepartnertocope

•Fearofdeath:hospitals maybeconstruedas places ofillness,deathanddying;themagnitudeofsuchfeelingsmayintensifyifthewomanexperienceslife-threateningcomplicationsorevenanemergencycaesareansection

•The processofbirththrustsalot ofprivate dataintotherealms of thepublic,sotherecouldbeafearoflackofprivacyorutterembarrassment

Thepuerperium

Thepuerperiumishailedasthe‘fourthtrimester’–anemotionallycomplextransitionalphase.Bydefinition,itistheperiodfrombirthto6–8weekspostpartum,whenthewomanisreadjustingphysiologically,sociallyandpsychologicallytomotherhood.Emotionalresponsesmaybejustasintenseandpowerfulforexperiencedaswellasfornewmothers.Themajorpsychologicalchangesarethereforeemotional.Thewoman'smoodappearstobeabarometer,reflectingthebaby'sneedsoffeeding,sleepingandcryingpaferns.Newmothers tendtobe easilyupsetandoversensitive.Asenseofproportioniseasilylost,aswomenmayfeeloverwhelmedandagitatedby minormishaps.Thewomanmightstarttoregainasense ofproportionand‘normality’between6and12weeks.Exhaustionis alsoamajorfactorofwomen'semotionalstate.Perhaps themostimportantfactorinregaininganysemblanceofnormalityisthemother'sabilitytosleepthroughoutthenight.Awoman'ssexualurges,emotionalstabilityand intellectualacuitymaytake months,ifnot longer,toreturn.Normalemotionalchanges in thepuerperiumaresummarizedinBox25.3.

Box 25.3

Normalemotionalchangesduringthepuerperium

•Immediatelyfollowingbirth,thewomanmightexperiencerelief.Thewomanmightconveyacooldetachmentfromevents,especiallyiflabourwasprotracted,complicatedanddifficult

•Contradictoryandconflictingfeelingsrangingfromsatisfaction,joyandelationtoexhaustion,helplessness,discontentmentanddisappointmentastheearly weeksseemtobedominatedbythenoveltyandunpredictabilityofthenewbaby

•Afeelingofclosenesstopartnerorbaby;equallythewomanmayfeeldisinterestedinthebaby

•Earlyskin-to-skincontactandbreastfeedingwillhelptonurturetheearlystagesofrelationshipbuildingbetweenmotherandbaby

•Beingveryattentivetowardsthebaby;equallythewomanmayshowdisinterestinthebaby

•Fearoftheunknownandsuddenrealizationofoverwhelmingresponsibility

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•Exhaustionandincreasedemotionality

•Pain(e.g.perineal,innipples)

•Increasedvulnerability,indecisiveness(e.g.infeeding),lossoflibido,disturbedsleepandanxiety

Postnatal‘blues’

Childbirthisanemotionallyintenseexperience.Moodchangesintheearlydayspostpartumareparticularlycommon.Thepostnatal‘blues’isatransitorystate,experiencedby50–80%ofwomendependingonparity(Harrisetal1994).Ithasbeenidentifiedasanantecedenttodepressionfollowingchildbirth(Gregoire1995;CooperandMurray1997).Theonsettypically occursbetweenday 3and5postpartum,butmaylastupto1weekormore,thoughrarelypersistinglongerthan48hours.Themainfeaturesaremildandmayinclude:

•astatewherebythewomanexperienceslabileemotions(e.g.tearfulness,despair,irritabilitytoeuphoriaandlaughter)

•astatewherebythewomanfeelsoverwhelmedbythesuddenrealizationoftherelentlessresponsibilityofthebaby's24-hourdependencyandvulnerability.

Theactualaetiologyisunclearbuthormonalinfluences(e.g.changesinoestrogen,progesteroneandprolactinlevels)seemtobeimplicatedastheperiodofincreasedemotionalityappearstocoincidewiththeproductionofmilk inthebreasts.Thisstateofheightenedemotionalityisself-limitingandwillresolvespontaneously,assistedbysupportfromlovedones.Themidwifeshouldbevigilantduringthistimeaspersistentfeaturescouldbeindicativeof depressiveillness.

Distressordepression?

Repeatedcontactwithwomenduringpregnancyandpuerperiumaffordawealthofopportunitytoexplorefeelings,experienceandemotions,andformidwivestoprovideclearexplanationstowomenaboutthedifferencesbetweendistress–anormalreactiontomajorlifeevents–anddepressiveillness.However,midwivesshouldbemindfulofover-relianceonthemedicalmodeltodescribewomen'smoodsassuch anapproach mayservetopathologizeormedicalizenormalemotionalchanges(Nicholson1998).

Emotionaldistressassociatedwithtraumaticbirthevents

Understandingtherootcauseandexpressionofmentaldistressassociatedwithpregnancyandchildbirthiscomplex.Itisimportanttorecognizetheinter-relationshipbetween traumaticlifeeventsandwomen'smentalhealth.Vulnerabilityfactorssuchasahistoryofchildhoodsexualabuseoramorbidfearofchildbirthcannegateawoman'sexperienceofchildbirth.Whatisintendedtobeoneofthehappiestdaysinawoman'slifecanquicklyturnintoanguishanddistress.Furthermore,environmentalfactorsmayleadto asenseoflossofcontrol, forexampleeffectsofintensepain, useoftechnological

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interventions,insensitiveanddisrespectfulcareoranemergencycaesareansection(CS)mayproveverydistressingandfrightening.Post-traumaticstressdisorder(PTSD),atermmostcommonlyassociatedwithindividualswhohavesufferedtheonslaughtofwar,hasemergedintheliteraturearoundmaternitycare(Lyons1998).ObstetricPTSDoccurswhenwomenfearedtheyortheirbabywereindangerofdying.Notsurprisinglyitiscommonest aheremergencyCSorobstetricemergencies,particularlyinvolvingintensivecare.Itisestimated6%ofemergencyCSare followedbyobstetricPTSD(Beck2009).Box

25.4highlightssomeofthereportedsymptomsofobstretricPTSD.

Box25.4

Re po r t e d sy m pt o m s o f o bst r e t r ic PTSDFeaturesofobstetricPTSD–applieswheresymptomsarepresentformorethan1month(Lyons1998;Beck2009)

•Intrusivethoughtsorimagesresultinginnightmares,panicattacksor‘flashbacks’

aboutthebirth

•Detachmentfromlovedonesanddifficultywithmother–babyrelationship(attachment)

•Avoidanceespeciallyofissuesrelatingtopregnancy/birth

•Hypervigilance/increasedarousal–havingasenseofimminentdisaster

•Sleepdisturbances

•Irritabilityorangryoutbursts

•Anxiety/depression

Otherfeaturesarenotdissimilartothose previouslydiscussedin thetextrelatingtostressandanxiety.

Unlikemildtomoderatedepressioninthe postpartum period,whichseemstohave itsrootsinthebiophysicalandpsychosocialdomains,obstetricdistressaherchildbirthappearstobedirectlylinkedtothestress,fearandtraumaofbirth,yetitsprevalenceisunrecognized(Lyons1998).Psychologicalinterventionssuchas‘debriefing’havebeensuggestedtomanage immediate symptomatologybutthereisnoreliableevidencethatitisausefulinterventioninreducingpsychologicalmorbidity(Alexandra1998;Wesselyetal2000;Bicketal2009).Moreover,clinicalguidelinesfromNICE(2007)havestatedthatfollowingatraumaticbirth,womenshouldnotroutinelybeoffered‘single-sessionformaldebriefingfocusedonthebirth’.Insteadmidwivesandotherhealthcareprofessionalsshouldsupportwomenwhowishtotalkabouttheirexperienceanddrawontheloveandsupportoffamilyandfriends.Neithershouldmidwivesoverlooktheimpactofbirthonthepartner.

Conclusion

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Aplethoraofsignificantsocialandhealthpoliciesandclinicalguidelineshaveresultedinwiderconsiderationbeinggiventothesocialandpsychologicalcontextofpregnancyandthepuerperium.Midwivesneedtohaveknowledgeandunderstandingofhowtheyinfluencecareprovision.Box25.5providesasummaryofkeypoints.

Box25.5

Summaryofkeypoints

•IntheUKpregnancyandthepostnatalperiodareunparalleledperiodswhenwomenengagewithhealthcareandhaverepeatedcontactwithhealthcareprofessionals

•Womenduringpregnancy,labourandpuerperiumareinastateoftransitionpunctuatedbyheightenedemotionsandanxiety.Familylifeanddailyroutinesbecomedisruptedbythearrivalofanewbaby

•Vulnerabilityfactorssuchasdomesticabuse,povertyandsocialisolation,canimpactonthemother–babyrelationshipwithconsequencesforchilddevelopment

•Riskidentificationofvulnerablegroupsofwomenantenatallypresentsauniqueopportunityformultidisciplinaryandmulti-agencycollaborationinpromotingmentalhealthandwellbeing

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PartB:Perinatalpsychiatricconditions

MargaretROates

Introduction

Perinatalpsychiatricdisorderisnowanacceptedtermusedbothnationallyandinternationally.Itemphasizestheimportanceofpsychiatricdisorderinpregnancyaswellasfollowingchildbirthandthevarietyofpsychiatricdisordersthatcanoccuratthistime,notjusttheubiquitouslyknownpostnataldepression(PND).Italsoplacesemphasisonthesignificance ofpsychiatricdisorders thatwere presentbeforeconceptionaswellasthosethatariseduringthe perinatalperiod(Box25.6).

Box 25.6

Whatisperinatalpsychiatricdisorder?

•Psychiatricdisordersthatcomplicatepregnancy,childbirthandthepostnatalperiod

•Includesnotonlythoseillnessesthatdevelopatthistimebutalsopre-existingdisorderssuchasschizophrenia,bipolarillnessanddepression

•Careinvolvesconsiderationoftheeffects oftheillnessitselfandofitstreatment onthedevelopingfetusandinfant

•Careinvolvesmultidisciplinaryandmulti-agencyworking,especiallycloserelationshipswithMaternityMentalHealthandChildren'sServices

Theemotionalwellbeingofwomenisofprimaryimportancetomidwives.Notonlycanmentalillnessaffectobstetricoutcomesbutalsothetransitiontoparenthoodandemotionalwellbeingandhealthproblemsin theinfant.Overthelast15yearspsychiatricdisorderinpregnancy andthepostpartumperiodhasbeenaleadingcauseofmaternalmortality,ashighlightedinthe‘WhyMothersDieintheUK’(Oates2001,2004)and‘SavingMothers’Lives'(Oates2007;OatesandCantwell2011)reports.ThesereportsoftheConfidentialEnquiryintoMaternalDeathsrecommendthatmidwivesroutinelyaskat earlypregnancyassessmentaboutpreviousmentalhealthproblems,theirseverityandcare.TheserecommendationshavealsobeenmadebytheRoyalCollegeofPsychiatrists(RCPC2000),theWomen'sMentalHealthStrategy(partoftheMentalHealthNationalService Framework;DH1999),MaternityStandard11oftheChildren,YoungPeoplesandMaternityNationalServiceFramework(DH2004),theNICEGuidelines(2007)onthemanagementofantenatalandpostnatalmentalhealthand theClinicalNegligenceStandardsforTrusts(NHSLA[NationalHealthServiceLitigationAuthority]2011).Inaddition,NICE(2007)recommendsthatmidwivesshouldaskquestions(theWhooleyquestions)onatleasttwooccasions–antenatallyandfollowingbirth–aboutwomen'scurrentmentalhealth.Systemsshouldbeinplacelocallytoensurethatwomenwithmentalhealthproblemsandthoseatriskofdevelopingthemreceivetheappropriate

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care.

Itisthereforeessentialthatallmidwiveshaveeducationandtrainingtobefamiliarwithnormalemotionalchanges,commonplacedistressandadjustmentreactionsaswellasthesignsandsymptomsofmoreseriouspsychiatricillnesses.

Typesofpsychiatricdisorder

Theterm‘mentalhealthproblem’iscommonlyusedtodescribealltypesofemotionaldifficultiesfromtransientandtemporarystatesofdistress,ohenunderstandable,tosevereanduncommonmentalillness.Itisalsousedfrequentlytodescribelearningdifficulties,substancemisuseproblemsanddifficultiescopingwiththestressesandstrainsoflife.Itisthereforetoogeneralandtoonon-specifictobeofuseto themidwife.Thetermdoesnotdiscriminatebetweenseverityand needanddoesnothelpthemidwifedistinguishbetweenthoseconditionsthatshecanmanageand thosethatrequirespecialistafention.Forthisreason,inthischapter,theterm‘psychiatricdisorder’ispreferredasitcanbefurthercategorizedandthedifferenttypescanbedescribedaidingrecognitionandtheplanningofcare.

Psychiatricdisordersareconventionallycategorizedinto:

Serious mentalillnesses

Theseincludeschizophrenia,otherpsychoticconditions,bipolarillnessandseveredepressiveillness.Previously,theseconditionswerecalledpsychoticdisorders.

Mildtomoderatepsychiatricdisorders

Thesewerepreviouslyknownas‘neuroticdisorders’.Theseincludenon-psychoticmildtomoderatedepressiveillness,mixedanxietyanddepression,anxietydisordersincludingphobicanxietystates,panicdisorder,obsessive–compulsivedisorderandpost-traumaticstressdisorder.

Adjustmentreactions

Thesewouldincludedistressingreactionstolifeevents,includingdeathandadversity.

Substancemisuse

Thisincludesthosewhomisuseorwhoaredependentuponalcoholandotherdrugsofdependency,includingbothprescriptionandlegal/illegaldrugs.

Personalitydisorders

Thisisatermthatshouldbeusedonlytodescribepeoplewhohavepersistentsevereproblemsthroughouttheiradultlifeindealingwiththestressesandstrainsofnormallife,maintainingsatisfactoryrelationships,controllingtheirbehaviour,foreseeingtheconsequencesoftheirownactionsandwhichpersistentlycausedistresstothemselvesandotherpeople.

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Learningdisability

Thisisatermusedtodescribepeoplewhohavealifetimeevidenceofintellectualandcognitiveimpairment,developmentaldelayandconsequentlearningdisabilities.Thisisusuallygradedasmild,moderateorsevere.

Overallpsychiatricdisordersareverycommoninthegeneralpopulation.TheGeneralHouseholdSurvey2000,asreportedbytheOfficeofNationalStatistics(ONS2002),revealsa prevalenceofover 20%ofthese disorders.RecentfiguresfromONS(2012)haveshownliflechangeinthistrendintheadultpopulationintheUK,reportingthatin2007,approximately1:6adultshadacommon mentaldisordersuchasanxietyordepression.

Theyarecommonerinwomenthaninmenwiththeexceptionofsubstancemisuseproblems.However,themajorityofpsychiatricdisordersinthecommunityaremildtomoderateconditions, particularlygeneralanxietyand depression. Mild to moderatedepressiveillnessandanxiety disordersareatleasttwiceascommoninwomenthaninmen,andareparticularlycommon inyoungwomenwith childrenundertheage of5.Themajorityofthesedisordersaremanaged inprimarycareand donotrequiretheafentionofspecialistpsychiatricservices.Mildtomoderatedepressiveillnessandanxietystatesrespondtopsychologicaltreatments.Despitethis,perhapsbecauseofshortageofsuchtreatments, prescriptionofantidepressantsiswidespreadinthecommunity,particularlyamongwomen.

Serious mentalillnesses are lesscommon.Both schizophreniaandbipolarillnessaffectapproximately1%ofthepopulation.Bipolarillnessaffectsmenandwomenequally.However,schizophrenia,particularlythemoreseverechronicforms,iscommoneramongmen.Theseconditionsrequiretheafentionofspecialistpsychiatricservicesandrequiremedicaltreatmentsaswellaspsychologicalcare.

IntheUKpsychiatricservicesareusuallyorganizedseparatelyforadultmentalhealth(seriousmentalillnesses),substancemisuse(drugandalcoholtreatmentservices)andlearningdisability.Therearealso,butnotrelevanttothischapter,separateservicesforpsychiatricdisordersintheelderly.

Psychiatricdisorderinpregnancy

Ingeneral, psychiatricdisorderisnotassociatedwithadecreasein fertility. Thereforeallthepreviouslydescribed psychiatricdisorderscananddocomplicatepregnancyandthepostpartumperiod.Theprevalenceofpsychiatricdisorderinyoungwomenmeansthatatleast20%ofwomenwillhavecurrentorpreviouspsychiatricdisorderinearlypregnancy,manyofwhomwillbetakingpsychiatricmedicationatthetimeofconception.However,itcanbeseenthat onlyasmallnumberwillhaveapasthistoryofaseriousmentalillnessandanevensmallernumberwill becurrentlysuffering fromsuchanillness.Pregnancyisnotprotectiveagainstarecurrenceorrelapseofapreviouspsychiatricdisorder,particularlyifthemedicationforthesedisordersisstoppedwhenpregnancyisdiagnosed.Womenwithaprevioushistoryofseriousillnessareatincreasedriskofarecurrenceofthatillnessfollowingbirth.Itisforthesereasonsthatit

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issoimportant formidwives toenquireintowomen's currentandprevious mentalhealthatearlypregnancyassessment.Table25.1highlightstheincidenceofperinatalpsychiatricdisorders.

Table25.1

Incidenceof perinatalpsychiatricdisorders

Psychiatricdisorder(%)
'Depression’ / 15–30
PND(postnataldepression) / 10
Moderate/severedepressiveillness / 3–5
Referred psychiatry / 2
Admittedtohospital / 0.4
Admitted psychosis / 0.2
Birthstoschizophrenicmothers / 0.2

Mild–moderateconditions

Theincidence(newonset)ofpsychiatricdisorderinpregnancyismostlyaccountedforbymilddepressiveillness,mixedanxietyanddepressionoranxietystates.Thesedisorderspresentmostcommonlyintheearlyweeksofpregnancy,becominglesscommonasthepregnancyprogresses.Theyareprobablypredominantlyofpsychosocialaetiology,and forsomewomen theywillrepresentarecurrenceofapreviousepisode,ofdepression,anxiety,panicorobsessionaldisordersparticularlyiftheyhavesuddenlystoppedtheirantidepressantmedication.Womenmayalsobevulnerableatthistimebecauseof:

•previousfertilityproblems

•previousobstetricloss

•anxietiesabouttheviabilityoftheirpregnancy

•socialandrelationshipproblems

•ambivalencetowardsthepregnancy

•otherreasonsforpersonalunhappiness.

Inthe past,itwasohen assumedthat hyperemesisgravidarum(severevomiting)wasapsychosomaticmanifestationofpersonalunhappinessandpsychologicaldisturbance.Thisconditionislesscommonthaninthepastandusuallyresolvesby16weeksofpregnancy.Psychologicalfactors,anxietyandcognitivemisafributionremainasignificantfactorinsomewomen.

Prognosisandmanagement

Mostoftheconditionsarelikely toimproveasthepregnancyprogresses.Psychological

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treatmentsandpsychosocialinterventionsareeffectivefortheseconditionsandcautionneedstobeexercisedbeforepharmacologicalinterventionsareinitiatedduringpregnancy,althoughmedicationmaybenecessaryforthemoresevereillnesses.

Forothers,particularlythosewhodevelopapsychiatricillnessinthelaterstagesofpregnancy,theirconditionislikelytocontinueandworseninthepostpartumperiod.

Seriousconditions

Thistermreferstoschizophrenia,otherpsychoses,bipolarillness(manicdepressiveillness)andseveredepressiveillness.

Incidence

Womenareatalowerriskofdevelopingaseriousmentalillnessforthe firsttimeduringpregnancythanatothertimesintheirlives.Thisisinmarkedcontrasttotheelevatedriskofsufferingfromsuchaconditioninthefirstfewmonthsfollowingchildbirth(Kendelletal1987).Whiletheseconditionsareuncommon,theyrequireurgentandexperttreatment,particularlyasanacutepsychosisinpregnancycanposearisktothemotheranddevelopingfetus,bothdirectlybecauseofthedisturbedbehaviourandindirectlybecauseofthe treatments.Thereisapossibilitythatsuchanillnesscaninterferewithproperantenatalcare.

Prevalence

Whilenewonsetpsychosisinpregnancyisrelativelyrare,theprevalenceoftheseillnesses(pre-existing)atthebeginningofpregnancywillbethesameasatothertimes.Womensufferingfromschizophreniaorbipolarillnessareaslikelytobecomepregnantastherestofthegeneralpopulation.Thismeansthatapproximately2%ofwomeninpregnancywilleitherhavehadsuchanillnessinthepastorbecurrentlysufferingfromone.Itisimportanttorealize thatthese womenmayrange fromwomenwhoare wellandstable,leadingnormallivesthroughtothosewhoaredisabled,chronicallysymptomaticandonmedication.Themanagementofthesewomeninpregnancythereforehastobeindividualizedandplansmadeonacase-by-casebasis.Nonetheless,therearethreebroadgroupsofwomen.

Group1

Thefirstgroupincludeswomenwhohavehadapreviousepisodeofbipolarillnessorapsychoticepisodeearlierintheirlives.Theyareusuallywell,stablenotonmedicationandmaynotbeincontactwithpsychiatricservices.Thesewomen, iftheir lastepisodeofillnesswasmorethan2yearsago, maynotbeatanincreasedriskofarecurrenceoftheirconditionduringpregnancybutfaceatleasta50%riskofbecomingpsychoticintheearlyweekspostpartum.Themostimportantaspectoftheirmanagementisthereforeaproactivemanagementplanforthefirstfewweeksfollowingbirth.

Group2

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Thesecondbroadgroupofwomenarethosewhohavehadapreviousand/orrecentepisodeofaserious mentalillness,who arerelativelywellandstablebutwhosehealthisbeingmaintainedbytakingmedication.Thismaybeantipsychoticmedicationorinthecaseofbipolarillness,amoodstabilizer(lithiumorananticonvulsant).Thesewomenareatriskofarelapseoftheirconditionduringpregnancy.Thisriskisparticularlyhighiftheystoptheirmedicationatthediagnosisofpregnancy.Assomeofthesemedicationsmayhaveanadverseeffectonthedevelopmentofthefetusandyetanacuterelapseoftheillnessalsoishazardous,itisimportantthatthesewomenhaveaccesstoexpertadviceontherisksandbenefitsofcontinuingthetreatmentorchangingitasearlyaspossibleinpregnancy.

Group3

Thethirdbroadcategoryincludeswomenwhoarechronicallymentallyillwithcomplexsocialneeds,persistingsymptomsandonmedication.Thesewomenwillusuallybeincontactwithpsychiatricservices.Midwiferyandobstetriccareneedstobecloselyintegratedintothecasemanagementofthesewomenandthereneedstobeacloseworkingrelationshipbetweenmaternity,psychiatricandsocialservices.

Ideally,allwomenwhohaveacurrentorprevioushistoryofseriousmentalillnessshouldhaveadviceandcounsellingbefore embarkinguponapregnancy.Theyshouldbeabletodiscusstherisktotheirmentalhealthofbecomingpregnantandbecomingaparentaswellastheriskstothedevelopingfetusofcontinuingwiththeirusualmedicationandperhapstheneedtochangeit.However,inthegeneralpopulation,atleast50%ofallpregnanciesareunplannedatthepointofconception.Midwivesshouldthereforeenquireatearlypregnancyassessmentaboutthewomen'sprevious andcurrentpsychiatrichistoryandalertpsychiatricservicesassoonaspossibleaboutthepregnancysothatrelapsesofthepsychiatricillnessduringpregnancyandrecurrencespostpartumcanbeavoidedwhereverpossible.

Psychiatricdisorderafterbirth

Themajorityofpostpartumonsetpsychiatricdisordersareaffective(mood)disorders.However,symptomsotherthanthoseduetoadisorderofmoodarefrequentlypresent.Conventionallythreepostpartumdisordersaredescribed:

•the‘blues’

•puerperal(postpartum)psychosis

•postnataldepression.

The‘blues’isacommondysphoric,self-limitingstate,occurringinthefirstweekpostpartum(seePartA).

Puerperal(postpartum)psychosis

Globally,puerperalpsychosis,themostsevereformofpostpartumaffective(mood)disorderhasbeenrecognizedanddescribedsinceantiquity.Itleadsto2in1000women

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beingadmifedtoapsychiatrichospitalfollowingchildbirth,mostlyinthefirstfewweekspostpartum.Althougharelativelyrare condition,there isamarkedincrease in the riskofsufferingfromapsychoticillnessfollowingchildbirth(Kendelletal1987;Munk-Olsenetal2012).Itisalsoremarkablyconstantacrossnationsandcultures.

Riskfactors

Mostwomenwhosufferfromthisconditionwillhavebeenpreviouslywell,withoutobviousriskfactors,andtheillnesscomesasashocktothemandtheirfamilies.However,somewomenwillhavesufferedfromasimilarillnessfollowingthebirthofapreviouschild,somemayhavesufferedfromanon-postpartumbipolaraffectivedisorderfromwhichtheyhavelongrecoveredortheymayhaveafamilyhistoryofbipolarillness.Forotherstheremaybemarkedpsychosocialadversity.Itisgenerallyacceptedthatbiologicalfactors(neuroendocrineandgenetic)arethemostimportantaetiologicalfactorsforthiscondition.Thisimpliesthatpuerperal psychosiscananddoesstrikewithoutwarning,womenfromallsocialandoccupationalbackgrounds–thoseinstable marriageswithmuch-wantedbabiesaswellas thoselivinginlessfortunatecircumstances.

Clinicalfeatures

Puerperalpsychosisisanacute,earlyonsetcondition.Theoverwhelmingmajorityofcasespresentinthefirst14dayspostpartum.Theymostcommonlydevelopsuddenlybetweenday3andday7,atatimewhenmostwomenwillbeexperiencingthe‘blues’.Differentialdiagnosisbetweentheearliestphaseofadevelopingpsychosisandthe‘blues’canbe difficult. However,puerperalpsychosissteadilydeterioratesoverthefollowing48hourswhilethe‘blues’tendstoresolvespontaneously.

Duringthefirst2–3daysofadevelopingpuerperalpsychosisthereisafluctuatingrapidlychanging,undifferentiatedpsychoticstate.Theearliestsignsarecommonlyofperplexity,fear–eventerror–andrestlessagitationassociatedwithinsomnia.Othersignsinclude:purposelessactivity,uncharacteristicbehaviour,disinhibition,irritationandfleetinganger,andresistivebehaviourandsometimesincontinence.

Awomanmayhavefearsforherownandherbaby'shealthandsafety,orevenaboutitsidentity.Evenatthisearlystage,theremaybe,variablythroughouttheday,elationandgrandiosity,suspiciousness,depressionorunspeakableideasofhorror.

Womensuffering frompuerperalpsychosisareamong themostprofoundlydisturbedanddistressedfoundinpsychiatricpractice(DeanandKendell1981).Inadditiontothefamiliarsymptomsandsignsofamanicordepressivepsychosis,symptomsofschizophrenia(delusionsandhallucinations)mayoccur.Depressivedelusionsaboutmaternalandinfanthealtharecommon.The behaviourandmotivesofothersarefrequentlymisinterpretedinadelusionalfashion.Amoodofperplexityandterrorisohenfound,asaredelusionsaboutthepassageoftimeandotherbizarredelusions.Womencanbelievethattheyarestillpregnantorthatmorethanonechildhasbeenbornorthatthebabyisolderthanitis.

Womenohenseemconfusedanddisorientated.Intheverycommonmixedaffective

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psychosis,alongwiththefamiliarpressureofspeechandflightofideas,thereisohenamixtureofgrandiosity,elationandcertainconvictionalternatingwithstatesoffearfultearfulness,guiltandasenseofforeboding.Thesufferersareusuallyrestlessandagitated,resistive,seekingsenselesslytoescapeanddifficulttoreassure.However,theyareusuallycalmerinthepresenceoffamiliarrelatives.

Thewomanmaybeunabletoafendtoherownpersonalhygieneandnutritionandunabletocareforherbaby.Herconcentrationisusuallygrosslyimpairedandsheisdistractibleandunabletoinitiateand completetasks.Overthenextfewdaysherconditiondeterioratesandthesymptomsusuallybecomemoreclearlythoseofanacuteaffectivepsychosis.Mostwomenwillhavesymptomsandsignssuggestiveofadepressivepsychosis,asignificantminorityamanicpsychosisandverycommonlyamixtureofboth–amixedaffectivepsychosis.

Relationshipwiththe baby

Somewomenaresodisturbed,distractibleandtheirconcentrationsoimpairedthattheydonotseemtobeawareoftheirrecentlybornbaby.Othersarepreoccupiedwiththebaby,reluctanttoletitoutoftheirsightandforevercheckingonitspresenceandcondition.Althoughdelusionalideas frequentlyinvolvethebabyandthere maybedelusionalideasofinfantillhealthorchangedidentity,itisrareforwomenwithpuerperalpsychosistobeovertlyhostiletotheirbabyandfortheirbehaviourtobeaggressiveorpunitive.Therisktotheirbabyliesmorefromaninabilitytoorganizeandcompletetasks,andtoinappropriatehandlingand tasksbeing impairedbytheirmentalstate.Theseproblems,directlyafributabletothematernalpsychosis,tendtoresolveasthemotherrecovers.

Management

Mostwomenwithpsychoticillnessfollowingchildbirthwillrequireadmissiontohospital,whichshouldbetoaspecialistmotherandbabyunit,theonlysefinginwhichthephysicalneedsofthemotherwhohasrecentlygivenbirthcanbemetandwherespecialistpsychiatricnursingisavailable.Thisensuresthatthephysicalandemotionalneedsofbothmotherandbaby aremetandthedevelopingrelationshipwiththebabypromoted.

Prognosis

Inspiteoftheseverityofpuerperalpsychoses,theyfrequentlyresolverelativelyquicklyover2–4weeks.However,initialrecoveryisohenfragileandrelapsesarecommoninthefirstfewweeks.Asthepsychosisresolves,itiscommonforwomentopassthroughaphaseofdepressionandanxietyandpreoccupationwiththeirpastexperiencesandtheimplicationsofthesememoriesfortheirfuturementalhealthandtheirroleasa mother.Sensitiveandexperthelpisrequiredtoassistwomenthroughthisphase,tohelpthemunderstandwhathashappenedandtoacquirea‘workingmodel’oftheirillness.Theoverwhelmingmajorityofwomenwillhavecompletelyrecoveredby3–6monthspostpartum.However,theyfaceatleasta50%riskofarecurrenceshouldtheyhave

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anotherchildandsomemaygoontohavebipolarillnessatothertimesintheirlives(Robertsonetal2005).

Postnataldepressiveillness

Approximately10% ofall postnatalwomenwilldevelopadepressive illness.The studies,fromwhichthisfigureisderived,areusuallycommunitystudiesusingtheEdinburghPostnatalDepressionScale(EPDS)eitherasadiagnostictoolorasascreenpriortotheuseof otherresearchtools.Studies usingacut-offpointof 14usuallygivean incidenceof10%;thoseusinglowerscoreswillgiveahigherincidence.Ascoreonascreeninginstrumentisnotthesameasaclinicaldiagnosis.Nonethelessascoreof14issaidtocorrelatewithaclinicaldiagnosisofmajordepressionandthelowerscoreswiththatofmajorandminordepression(Elliot1994).Theincidenceofwomenwhowouldmeetthediagnosticcriteriaformoderatetoseveredepressiveillnessislower,probablybetween3%and5%(Coxetal1993).Depressionfollowingchildbirthhasthesamerangeofseverityandsubtypesasdepressionatothertimes.Accordingtothesymptomatology,durationandseverity,theymaybegradedasmildtomoderateorsevere,andsubtypesmayhaveprominentanxietyandobsessionalphenomena.

Postnataldepressiveillnessofalltypesandseveritiesisthereforerelativelycommonandrepresentsaconsiderableburdenofdisabilityanddistressinthesewomen.Althoughpostnataldepressiveillnessispopularlyaccepted,withtheexceptionofthemostsevereforms,itisnomorecommonthanduringpregnancyorinnon-childbearingwomenof thesameage(O'HaraandSwain1996). However,thisdoesnotdetractfromitsimportance.Depressive illness ofanyseverityoccurringatatimewhen theexpectationisofhappinessandfulfillmentandwhenmajorpsychologicalandsocialadjustmentsarebeingmadetogetherwithcaringforaninfant,createsdifficultiesnotfoundatothertimesinthehumanlifespan.

Theterm‘postnataldepression’isohenusedasagenerictermforallformsofpsychiatricdisorderpresentingfollowingbirth.Whileinthepastthishasundoubtedlybeenhelpfulinraisingtheprofileofpostpartumpsychiatricdisorders,improvingtheirrecognitionand reducing stigma,ithasalso becomeproblematic.Useoftheterminthiswaycandiminishtheperceivedseriousnessofotherillnesses,andhasledtoa‘onesizefitsall’viewofdiagnosisandtreatments(Oates2001).Thetermpostnataldepressionshouldonly beusedforanon-psychoticdepressiveillnessofmildtomoderateseveritywhichariseswithin3monthsofchildbirth.

Severedepressiveillness

Severedepressiveillnessaffectsatleast3%ofallwomenwhohavegivenbirth,withaseven-foldincreaseinriskinthefirst3months(Coxetal1993).Again,themajorityofwomenwhosufferfromthisconditionwillhavebeenpreviouslywell.However,womenwithaprevioushistoryofseverepostnataldepressiveillnessorseveredepressionatothertimesorafamilyhistoryofseveredepressiveillnessorpostnataldepressionareatincreased risk.Psychosocialfactorsaremoreimportantintheaetiologyofthisconditionthaninpuerperalpsychosis,althoughbiologicalfactorsplayanimportantroleinthe

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mostsevereillnesses.Nonetheless,severepostnataldepressioncanaffectwomenfromallbackgroundsnotjustthosefacingsocialadversity.

Likepuerperal psychosis,severedepressiveillnessisanearlyonsetconditioninwhichthewomancommonlydoesnotregainhernormalemotionalstatefollowingbirth.However,unlikepuerperal psychosis,theonsettendsnottobeabrupt;rather,theillnessdevelopsoverthenext2–4weeks.Themoresevereillnessestendtopresentearly,by4–6weekspostpartum,butthemajoritypresentlater,between8and12weekspostpartum.Theselaterpresentationsmaybemissed.Thisispartlybecausesomeofthesymptomsmaybemisafributedtotheadjustmenttoanewbabyandpartlybecausethemothermay‘putonabraveface’,concealinghowshefeelsfromothers.

Riskfactors

Avarietyofrisk factorsforpostnataldepressiveillnesshavebeenidentified and includethoseassociatedwithdepressiveillnessatothertimes.Tothesecanbeaddedambivalenceaboutthepregnancy,highlevelsofanxietyduringpregnancyandadversebirth experiences,previousperinataldeathtonamebutafew. Manyofthese riskfactors,thoughstatisticallysignificantaresocommonastohaveliflepositivepredictivevalue.Howeveraclusteringoftheseriskfactorsmightleadto thosecaringforthewomanto beextravigilant.Ofmoreusearethoseriskfactorsthathaveahigherpositivepredictivevalue.Theseincludeafamilyhistoryofsevereaffectivedisorder,afamilyhistoryofseverepostnataldepressiveillness,developingadepressiveillnessinthelasttrimesterofpregnancyandthelossofthepreviousinfant(including stillbirth).TheremayalsobeanincreasedriskinthosewomenwhohaveconceivedthroughIVF.

Clinicalfeatures

Thefamiliarsymptomsofseveredepressiveillnessareohenmodifiedbythecontextofearlymaternityandtherelativeyouthofthosesufferingfromthecondition:

The‘somaticsyndrome’(biologicalfeatures)of brokensleepandearlymorningwakening,diurnalvariationofmood,lossofappetiteandweight,slowingofmentalfunctioning,impairedconcentration,extremetirednessand lackofvitalitycaneasilybemisafributedtoacryingbaby,understandabletirednessandtheadjustmenttonewroutines.

Theall-pervasiveanhedoniaorlossofpleasure inordinaryeverydaytasks, thelackofjoyandfearfulnessforthefuturemaybemisafributedbythewomanherselfto‘notlovingthebaby’or‘notbeingapropermother’and alltooeasilydescribedas‘bondingproblems’byprofessionals.Anhedoniaisa particularlypainfulsymptomatatimewhenmostwomenwouldexpecttofeeloverwhelmedwithjoyandhappinessandinturncontributestofeelingsofguilt,incompetenceandunworthinessthatareveryprominentinpostnataldepressiveillness.Theseovervaluedideascanvergeonthedelusional.

It isalsocommontofindovervaluedmorbidbeliefsandfears forthe woman's ownhealthandmortalityandthatofherbaby.Shemaymisafributenormalinfantbehaviourtomeanthatthebabyissufferingordoesnotlikeher.Ababythatseflesinthearmsofmoreexperiencedpeoplemayconfirmthemother'sbeliefthatsheisincompetent.Commonplaceproblemswithestablishingbreastfeedingmaybecomethesubjectof

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morbidrumination.

Somewomenwithseverepostnataldepressiveillnessmay beslowed,withdrawnandretreateasilyinthefaceofoffersofhelp,avoidthetasksofmotherhoodandtheirrelationshipwiththebaby.Othersmaybeagitated,restlessandfiercelyprotectiveoftheirinfant,resentingthecontributionofothers.

Anxiety andobsessive–compulsive symptoms

Althoughwomenwithpre-existinganxietyandpanicdisorderorobsessional–compulsivedisorder(OCD)frequentlyexperiencerelapsesorrecurrencespostpartum,itisnotknownwhetherthereisanincreaseinincidence(new onset)oftheseconditionsfollowingbirth.Nonetheless,severeanxiety,panicafacksandobsessionalphenomenaare commonfollowingbirth.These symptomsmaydominatetheclinical pictureoraccompanyapostnataldepressiveillness.Theyfrequentlyunderpinmentalhealthcrises,callsforemergencyafentionandmaternalfearsfortheinfant.Repetitiveintrusive,andohendeeplyrepugnant,thoughtsofharmcomingtolovedones,particularlytheinfant,arecommonplace,ohenleadingtorepetitivedoubtingandchecking.Thewomanmaydoubtthatsheissafeasamotherandbelievethatsheiscapableofharmingherinfant.Crescendos ofanxietyandpanicafacksmayresult fromthebaby's cryingorbeingdifficulttosefleandmayleadthemothertobefrightenedtobealonewithherchild.Thisiseasilymisinterpretedbyprofessionalswhomayfearthatthechildis atrisk.

Obsessional,vacillatingindecisivenessis alsocommonandcontributestoanoverwhelmingsenseofbeingunabletocopewitheverydaytasksinmarkedcontrasttopremorbidlevelsofcompetence.Whilecomplexobsessive–compulsivebehaviouralritualsarerelativelyrare,obsessivecleaning,houseworkandcheckingarecommon.Intrusiveobsessionalthoughtsandthetypicalcatastrophiccognitionsassociatedwithpanicattacksfrequentlyleadtoafearofinsanityandloss ofcontrol.

Relationshipwiththe baby

Severedepressivesymptomatology,particularlywhencombinedwithpanicandobsessionalphenomena,can havea profoundeffectontherelationship withthebaby, inmany,butbynomeansallwomen.Mostwomenwhosufferfromseverepostnataldepressiveillnessmaintainhighstandardsofphysicalcarefortheirinfants.However,manyarefrightened oftheirownfeelingsandthoughtsandfewgainanypleasureorjoyfromtheirinfant.Theymayfindsmilingandtalkingtotheirbabies difficult.Mostaffectedwomenfeeladeep senseofguiltandincompetenceanddoubtwhether theyarecaringfortheirinfantproperly.Normalinfantbehaviourisfrequentlymisinterpretedasconfirmingtheirpoorviewsoftheirownabilities.Whileafearofharmingthebabyiscommonplace,overthostilityandaggressivebehaviourtowardstheinfantisextremelyuncommon.Itshouldberememberedthatthemajorityofmotherswhoharmsmallbabies arenotsufferingfromaseriousmentalillness. Thespeedyresolutionofmaternalillnessusuallyresultsinanormalmother–infantrelationship.However,prolongedchronicdepressiveillnesscaninterferewithafachment,socialandcognitivedevelopmentinthelongerterm,particularlywhencombinedwithsocialandmental

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problems(CooperandMurray1997).

Management

Theseconditionsneedtobespeedilyidentifiedandtreated,preferablybyaspecialistperinatalmentalhealthteam.Thevalueofearlycontactwithprofessionalswhorecognizeandvalidatethesymptomsanddistress,andcanre-afributetheovervaluedideasof themother andinstillhopeforthefuturecannot beunderestimated.Thetreatmentofthedepressiveillnessisthesameasthetreatmentofdepressiveillnessatothertimes.Theuseofantidepressantstogetherwithgoodpsychologicalcareshouldresultinanimprovementofsymptomswithin2weeksandtheresolutionoftheillnessbetween6and8weeks.

Prognosis

Withtreatment,thesewomenshouldfullyrecover.Without,spontaneousresolutionmaytake manymonthsandup toone-thirdofwomencanstillbeillwhentheirchildis1 yearold.

Womenwhohavehadaseveredepressiveillnessfacea1:2to 1:3 risk ofa recurrenceoftheillnessfollowingthebirthofsubsequentchildren(CooperandMurray1995).Theyarealsoatelevatedriskfromsufferingfromadepressiveillnessatothertimesintheirlives.However,thelong-termprognosiswouldappeartobebeferthanwhenthefirstepisodeisinnon-childbearingwomen,bothintermsofthefrequencyoffurtherepisodesandintheiroverallfunctioning(Roblingetal2000).

Mildpostnataldepressiveillness

Thisisthecommonestconditionfollowingchildbirth,affectingupto10%ofallwomenpostpartum.Itisinfactnocommoneraherchildbirththanamongothernon-childbearingwomenofthesameage.

Riskfactors

Somewomenwhosufferfromthisconditionwillbevulnerablebyvirtueofpreviousmentalhealthproblemsorpsychosocialadversity,unsatisfactorymaritalorotherrelationshipsorinadequatesocialsupport.Othersmaybeolder,educatedandmarriedforalongtime,perhapswithproblemsconceiving,previousobstetriclossorhighlevelsofanxietyduringpregnancy.Unrealisticallyhighexpectationsofthemselvesandmotherhoodandconsequentdisappointmentarecommonplace.Alsocommonarestressfullifeeventssuchasmovinghouse,familybereavement,asickbaby,experienceofspecialcarebabyunitsandothersucheventsthatdetractfromtheexpectedpleasureandharmonyofthisstageoflife.

Clinicalfeatures

Theconditionhasaninsidiousonsetinthedaysandweeksfollowingchildbirthbutusuallypresentsaher thefirst3monthspostpartum.Thesymptomsarevariable, butthemotherisusuallytearful,feelsthatshehasdifficultycopingandcomplainsofirritability

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andalackofsatisfactionandpleasurewithmotherhood.Symptomsofanxiety,asenseoflonelinessandisolationaswellasdissatisfactionwiththequalityofimportantrelationshipsarecommon.Affectedmothersfrequentlyhavegooddaysandbaddaysandareohenbeferincompanyandanxiouswhenalone.Thefullbiological(somaticsubtype)syndromeofthemoreseveredepressiveillnessisusuallyabsent.However,difficultygefingtosleepandappetitedifficulties,bothover-eatingandunder-eating, arecommon.

Relationshipwiththe baby

Dissatisfactionwithmotherhoodandasenseofthebabybeingproblematicareohencentraltothiscondition,particularlywhencompoundedbydifficultyinmeetingtheneedsofolderchildren.Lackofpleasureinthebaby,combinedwithanxietyandirritability,canleadtoaviciouscircleofafractiousandunsefledbaby,misinterpretedbyitsmother ascriticalandresentfulofherandthusadeterioratingrelationshipbetweenthem.However,itshouldalsoberememberedthatthedirectionofcausalityisnotalwaysmothertoinfant.Someinfantsareveryunsefledinthefirstfewmonthsoftheirlife.Ababywhoisdifficult tofeedandcries constantlyduringthedayorisdifficulttosefleatnightcanjustasohenbethecauseofamildpostnataldepressiveillnessastheresultofit.Evenmildillnesses,particularlywhencombinedwithsocioeconomicdeprivationandhighlevelsofsocialadversity,canleadtolonger-termproblemswithmother–infantrelationshipsandsubsequentsocialandcognitivedevelopmentofthechild(CooperandMurray1997).Averysmallminorityofsufferersfromthisconditionmayexperiencesuchmarkedirritabilityandevenoverthostilitytowardstheirbabythattheinfant is at riskofbeingharmed.

Management

Earlydetectionandtreatmentisessentialforbothmotherandbaby.Forthemildercases,acombinationofpsychologicalandsocialsupportandactivelisteningfromahealthvisitorwillsuffice.Forothers, specificpsychologicaltreatments,suchascognitivebehavioural psychotherapyandinterpersonal psychotherapy,areaseffective,ifnotmorethan,antidepressantsasoutlinedinAntenatalandPostnatalMentalHealthguidelines(NICE2007).

Prognosis

Withappropriatemanagement,postnataldepressionshouldimprovewithinweeksandrecoverbythetimetheinfantis6monthsold.However,untreatedtheremaybeprolongedmorbidity.This,particularlyinthepresenceofcontinuingsocialadversity,hasbeendemonstratedtohaveanadverseeffectnotonlyonthemother–infantrelationshipbutalsoonthelatersocial,emotionalandcognitivedevelopmentofthechild.

Breastfeeding

Thereisnoevidencethatbreastfeedingincreasestheriskofdevelopingsignificantdepressive illness, nor that its cessation improves depressive illness. Continuing

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breastfeedingmayprotecttheinfantfromtheeffectsofmaternaldepressionandimprovematernalself-esteem.

Treatmentofperinatalpsychiatricdisorders

Theroleofthemidwife

Midwives needknowledgeandunderstandingofthedifferentmanagementstrategies forperinatalpsychiatricdisorderandoftheuse ofpsychiatricdrugs in pregnancyandlactation.Thisknowledgeisrequiredbecause thewomenthemselvesmaywish foradvice,becausethemidwifemayhavetoalertotherprofessionals,forexamplegeneralpractitionersandpsychiatrists,toaskforareviewofthewoman'smedicationandbecauseincaseofseriousmentalillness,themidwifewillbepartofamultiprofessionalteamcaringforthewomen.

Midwivesshouldroutinelyaskallwomenatantenatalbookingclinicwhethertheyhavehadanepisodeofseriousmentalillnessinthepastandwhethertheyarecurrentlyincontactwithpsychiatricservices.Thosewomenwho haveapreviousepisode ofseriousmentalillness(schizophrenia,otherpsychoses,bipolarillnessandseveredepressiveillness) shouldbereferredtoapsychiatricteam duringpregnancyeveniftheyhavebeenwellformanyyears.Thisisbecausetheyfaceatleasta50%riskofbecomingillfollowingbirth.Themidwifeshouldalsourgentlyinformthepsychiatricteamifthewomaniscurrentlyincontactwithpsychiatricservices.Thepsychiatricteammaynotbeawareofthepregnantwomanwhoistakingpsychiatricmedicationatthetimewhenthemidwifefirstseeshershouldbeadvisednottoabruptlystophermedication.Themidwifeshouldurgentlyseekareviewofthewoman'smedicationfromthegeneralpractitioner,obstetricianorpsychiatristasappropriate.Thismay resultinthewomanbeingadvisedtoreduce,changeorundertakeasupervisedwithdrawalofhermedication.

Thereare three componentstothe managementofperinatalpsychiatricdisorder:psychologicaltreatmentsandsocialinterventions,pharmacologicaltreatmentsandtheskills,resourcesandservicesneeded.

Thosewhoareseriouslymentallyillwillrequireallthree.Thosewiththemildestillnessesmayrequireonlypsychologicalandsocialinterventions,whichcanbecarriedoutinprimarycare(NICE2007).

Psychologicaltreatments

Allillnessesofallseveritiesandindeedthosewhoarenotillbutexperiencingcommonplaceepisodesofdistressandadjustmentneedgoodpsychologicalcare.Thiscanonlybebaseduponanunderstandingofthenormalemotionalandcognitivechangesandcommonconcernsofpregnancyandthepuerperium.Italsorequiresafamiliaritywiththesymptomsandclinicalfeaturesofpostpartumillnesses.

Formostwomenwithmilddepressiveillnessoremotionaldistressanddifficultiesadjusting,extratimegivenbythemidwifeorhealthvisitor,‘thelisteningvisit’,willbeeffective.Forothers,particularly thosewithmorepersistentstatesassociatedwithhigh

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levelsofanxiety,briefcognitivetherapytreatmentsandbriefinterpersonalpsychotherapy areaseffectiveasantidepressantsandmayconferadditionalbenefitsintermsofimprovingthe mother–infantrelationshipsandsatisfaction.Similarclaimshavebeenmadeforinfantmassageandothertherapiesthatfocusthemother'safentiononenjoyingherbaby.Itisparticularlyimportantduringpregnancytousepsychologicaltreatmentswhereverpossibleandavoidtheunnecessaryprescriptionofantidepressants.

Socialsupport

Lackofsocialsupport,particularlywhencombinedwithadversityandlifeevents,haslongbeenimplicatedintheaetiologyofmildtomoderatedepressiveillnessinyoungwomen.Socialsupportnotonlyincludespracticalassistanceandadvicebutalsohavinganemotionalconfidante,femalefriendsandpeoplewhoimproveself-esteem.Thereisevidencethatorganizationsthatareunderpinnedbysocialsupporttheory,suchas HomeStartandSureStart,canhaveabeneficialeffectonmaternalandinfantwellbeingandperhapsonmildpostnataldepression(Oakleyetal1996;Barlowetal2007).

Pharmacologicaltreatment

Ingeneral,psychiatricillnessesoccurringduringtheperinatalperiodrespondtothesametreatmentsasatothertimes.Therearenospecifictreatmentsforperinatalpsychiatric disorder. Moderatetoseveredepressive illnessesrespondtoantidepressants,psychoticillnessestoantipsychoticsandmoodstabilizersmaybeneededforthosewithbipolarillnesses.However,thepossibilityofadverseconsequencesontheembryoanddevelopingfetusand viabreastmilkontheinfantmakesthechoiceand doseofthedrugimportant.

Theevidencebaseforthesafetyoradverseconsequencesofpsychotropicmedicationisconstantlychangingbothinthedirectionofincreasedconcernandofreassurance.AnytextdetailingspecificadviceisindangerofbeingquicklyoutofdateandthereaderisdirectedtotheregularlyupdatedinformationpublishedbytheNationalTeratology InformationService(NTIS)–viaToxbasewebsite: toNICE(2007)GuidelinesonAntenatalandPostnatalMentalHealthorDrugsandLactationDatabase(LactMed).

Nomatter whatthechangingevidenceis,somegeneralprinciplesapply:

•Theabsence ofevidence ofharmis notthesame as evidence ofsafety.

•Itmaytake20–30yearsaftertheintroductionofadrugforitsadverse consequencestobefullyrealized.Anexample ofthisissodiumvalproate inpregnancy.

•Ingeneralthereismore evidence onolderthanonnewerdrugsalthoughthis does notnecessarilymeantheyaresafer.

•Allpsychotropicmedicationpassesacrosstheplacentaandintothebreastmilk.

•Boththearchitectureandfunctionofthefetalcentralnervous systemcontinuestodevelopthroughoutpregnancyandinearlyinfancy.Concernshouldnotbeconfinedtothe adverseeffectsinthefirst3months ofpregnancy.

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•Thethresholdforinitiatingmedicationinpregnancyandbreastfeedingshouldbehigh.Ifthereisanalternative,non-pharmacologicaltreatment,ofequalefficacythenthatshouldbethetreatmentofchoice.

•Seriousmentalillnessrequiresrobusttreatment.Inallcasesofillness,occurringinapregnantorbreastfeedingmother,theclinicianmustendeavourtobalancetheriskofnottreatingthemotheronbothmotherandbabyagainst therisktothefetus orinfantoftreatingthemother.The moreserioustheillnessis,themorelikelyit is thattherisksofnottreatingoutweightherisksoftreating.

•Theriskstobothmotherandbabyofaseriousmaternalmentalillness aregreaterthantherisksofmedication.

•Thefetusandbabyisnolesslikelytosufferfromtheside-effectsofpsychotropicmedicationthananadult.Fetalandinfanteliminationofpsychotropicmedicationisslowerandlessthanadultsandtheircentralnervoussystemsmoresensitivetotheeffectsofthesedrugs.

•Adverseconsequencesofmedicationonthefetusandinfantaredose-related.Ifmedicationisuseditshouldbeusedinthelowest effectivedoseandgivenindivideddosagethroughouttheday.

•Theexposureofthebabytopsychotropicmedicationinbreastmilkwilldependonthevolume ofmilk,thefrequencyoffeeding,weightandage.Atotallybreastfedbabyunder6weeksoldwillreceiverelativelymorepsychotropicmedicationthananolderbabywhoispartiallyweaned.

Antidepressants

Tricyclicantidepressants

Pregnancy

Tricyclicantidepressants(e.g.imipramine,lofepramine,amitriptylineanddosulepin)havebeeninusefor40years.Tricyclicantidepressantsarenotassociatedwithanincreasedriskoffetalabnormality,earlypregnancylossorgrowthrestrictionwhenusedinlaterpregnancy.Howeverclomipramine(Anaframil)hasbeenlinkedtocardiacabnormalities.Newbornbabiesofmotherswhowerereceivingatherapeuticdoseoftricyclicantidepressantsatthepointofbirthareatriskofsufferingfromwithdrawaleffects(jiferiness,poorfeedingandonoccasionfits).Considerationshouldthereforebegiventoagradualtaperingandreductionofthedosepriortobirth.

Breastfeeding

Theexcretionoftricyclicantidepressantsinbreastmilkisverylow.Howeverdoxepinshouldnotbeusedbecauseithasbeenreportedtocause sedation in babies.Anyadverseeffectsinthefullybreastfednewbornbabycanbeminimizedbydividingthedose,e.g.50mgofimipraminet.d.s.

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Selectiveserotoninreuptakeinhibitors

Pregnancy

Selectiveserotoninreuptakeinhibitors(SSRIs)(e.g.fluoxetine,paroxetine,citalopram)havebeeninuseforapproximately15yearsandarenowtheantidepressantsmostusedinthetreatment ofdepressiveillnessatothertimes.

TherehasbeensomeconcernaboutthepossibleadverseeffectsofcertainSSRIsinearlypregnancy.Theevidencecontinues toemerge andthe risksarethereforedifficulttoquantify.TheremaybeanincreasedriskofmiscarriageassociatedwiththeuseofallSSRIs.ItislikelythatthereisanincreasedriskofcardiacabnormalitiesrelatedtofirsttrimesterexposuretoSSRIs,particularlyventricularseptaldefects(VSD)withparoxetine(Seroxat).Thishasledtoboththemanufacturerandthedrugregulationauthoritiesinthe USAandtheUKadvisingagainstthe use of paroxetinein pregnancy.Atthemoment,thisrestrictiondoesnotapplytofluoxetine(Prozac)andsertraline(Lustral)butitremainstobeseenwhetherthisadverseeffectisrelatedtoallSSRImedications.TheNICE(2007)guidelinesrecommendthateithertricyclicantidepressantsorsertralineshouldbethetreatmentofchoiceifantidepressants arerequiredduringpregnancy.Theyalsorecommendthatantidepressantsshouldnotbeusedformildtomoderateillnessandthatpsychological treatmentsshouldbeusedwhereverpossible.However,thewithdrawalofSSRIantidepressantsinearlypregnancy,particularlyifthewomanhasbeenreceivingthemforsometime,isohenassociatedwithawithdrawalsyndromeortherecurrenceofhercondition.In suchcircumstances,considerationshould begiventochangingthewomantoa‘safer’alternativeorreducingthedoseandsupervisedwithdrawal.

ContinueduseofSSRImedicationduringpregnancyhasbeenassociatedwithpre-termbirth,reducedcrown–rumpmeasurementandlowerbirthweight.BabiesborntomothersreceivingSSRImedicationatthepointofbirtharelikelytoexperiencewithdrawaleffects,particularlythose babieswhoarepreterm.SSRIs,suchascitalopramandfluoxetinethathavealonghalf-life,arealsoassociatedwith aserotonergicsyndromeinthe newborn(jiferiness,poorfeeding,hypoglycaemiaandsleeplessness).Considerationshouldthereforebegiventoreducingandwithdrawingthismedicationbeforebirth.

Breastfeeding

TheexcretionofSSRIsinbreastmilkishigherthanthatoftricyclicantidepressants.Thefullybreastfednewbornmaybevulnerable toserotonergicside-effects.ThoseSSRIs withalonghalf-life(fluoxetineandcitalopram)shouldbeavoidedwhenbreastfeedingthenewborn.Venlafaxineandparoxetinearenotrecommendedforuseinbreastfeedingmothers.However,inolderandlarger-weightinfants,particularlythosewhoare partiallyweaned,otherSSRIs,particularlysertraline,maybelessproblematic.

Tricyclicantidepressantsorsertralineshouldbetheantidepressantsofchoiceinbreastfeeding.

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Antipsychotics

Therearetwogroupsofantipsychoticmedications,theolder‘typical’antipsychotics(e.g.trifluoperazine,haloperidol,chlorpromazine)andtheneweratypicalantipsychotics(e.g.risperidone,olanzapine,clozapine).

Typicalantipsychotics

Pregnancy

Typicalantipsychoticshavebeeninusefor40years.Thereisnoevidencethattheiruseinearlypregnancyisassociatedwithanincreasedrisk offetalabnormalitynorthattheircontinuinguseinpregnancyisassociatedwithgrowthrestrictionorpre-termbirth.However,antipsychoticmedicationfreelypassestothedevelopingfetusanditsbrainandthedoseshouldbereducedtothatwhichistheminimumforclinicaleffectiveness.Babiesborntomothersreceivingrelativelyhighdosesoftypicalantipsychoticsmayexperienceawithdrawalsyndromeandextrapyramidalsymptoms(musclestiffness,rigidity,jiferinessandpoorfeeding).Considerationthereforeshouldbegiventoareductionofthedosebeforebirthandapossibilityofinductionatterm.Withdrawalofmedicationatanystageinpregnancymaybeassociatedwithariskofarelapseofthematernalcondition.

Breastfeeding

Typicalantipsychoticsare present in breastmilk,althoughthe amounttowhich theinfantisexposedislikelytobeverysmall.Theaddedbenefitsofbreastfeedingtotheinfantprobablyjustifythecontinuationofbreastfeedingprovidingthatthedoserequiredissmallanddivided.Drugssuchasprocyclidine,giventopreventextrapyramidalside-effects,arenotrecommended.

Atypicalantipsychotics

Themanufacturersadviseagainsttheuseofatypicalantipsychoticsinpregnancyandbreastfeedingbutthisreflectslackofdataratherthanevidenceofharm.Theuseofolanzapineinpregnancyhasbeenassociatedwithanincreasedriskofgestationaldiabetes.Womenwhobecomepregnantwhiletakingthesenewerantipsychoticsshouldbeurgentlyreviewed.Insomecases,itmaybepossibletochangetheirmedicationtotheoldertypeofantipsychotic.Inothers,becauseofthesubstantialriskofrelapseoftheircondition,itmaybenecessarytocontinuewiththeirmedication.Againthisshouldbereducedtothe lowestpossibledoseandconsiderationgiventoafurtherreductionimmediatelypriortobirthand,ifnecessary,amanageddelivery.Clozapineshouldnotbeusedinpregnancyandbreastfeedingbecauseoftheriskofblooddyscrasiasintheinfant.

Moodstabilizers

Thisisagroupofdrugsusedtotreatthemaniccomponentofbipolarillnessand,longterm, to prevent relapses of the condition.The drugs usedas moodstabilizers are

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lithiumcarbonate(Priadel)andvariousanti-epilepticdrugs,commonlysodiumvalproateandcarbamazepinebutalsoonoccasionlamotrigine.

Pregnancy

Lithiumcarbonateinpregnancyisassociatedwithariskofdevelopingarare,seriouscardiaccondition,Ebstein's anomaly.Althoughtherelative riskislarge,theabsolute riskislow,being2in1000exposedpregnancies.However,thereisalsoanincreasedriskofarangeofcardiacabnormalities,includingmilderandlessseriousconditions.Theabsoluteriskofalltypesofcardiacabnormalityis10per100exposedpregnancies.Lithiuminearlypregnancyisnotassociatedwithanincreasedriskofneuraltubeabnormalities.

Thecontinueduseoflithiumthroughoutpregnancyisassociatedwithanincreasedriskoffetalhypothyroidism,diabetesinsipidus,fetalmacrosomiaandthe‘floppybaby’syndrome(neonatalcyanosisandhypotonia).Theserisksaredifficulttoquantify.Anadditionalproblemisthatthewomanwillrequireincreasingdosesoflithiuminlaterpregnancytomaintainatherapeuticserumlevelbecause oftheincreasedmaternalclearanceoflithium.However,thefetalclearancedoesnotincrease.Womenreceivinglithiuminpregnancy thereforerequirefrequentestimationsoftheirserumlithiumandclosemonitoringoftheircondition.Duringlabourandimmediatelyfollowingbirth,physiologicaldiuresiscanresultintoxic levelsofmaternallithium.Thewomanthereforerequiresfrequentestimationsofherserumlithiumthroughoutlabourandintheearlypostpartumdays.

Womenwhoaretakinglithiumcarbonateshouldbeadvisedtocarefullyplantheirpregnanciesandtoseek medicaladvice.Abruptcessationoflithiumisassociated withasubstantialriskofarecurrenceoftheircondition.Thesewomenwillusuallybeadvisedtoeitherslowlywithdrawtheirlithiumpriortoconceptionorconsiderchangingtoanothermedication.However,therewillberareoccasionswhenitisnecessarytocontinuelithiumthroughoutpregnancy.Suchapregnancywillneedtobemanagedbyanobstetricianworkingcloselywithpsychiatricservicesandafullycompliant,well-informed woman.

Breastfeeding

Lithiumshouldnotbeusedinbreastfeedingasitispresentinsubstantialquantitiesinbreastmilkandcanresultininfantlithiumtoxicity,hypothyroidismand‘floppybaby’syndrome.

Anticonvulsants

Anticonvulsantshavebeenusedasmoodstabilizersfor30years.Carbamazepinewasfirstusedinthisway,sodiumvalproateisnowincreasinglythemoodstabilizer ofchoiceandrecentlytheneweranticonvulsantssuchaslamotrigineandtopiramatearebeingused.

Pregnancy

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Allanticonvulsantsareassociatedwithadoublingofthebase-lineriskoffetalabnormalityifusedinthe first trimesterofpregnancy.Atotal of4in100infantsexposedtocarbamazepinewillhaveamajorcongenitalmalformation.Theriskofclehlipandpalate isfurtherincreasedwithexposuretolamotrigine.The risksare highestwithsodiumvalproate:8per100exposedpregnancies.Theuseoffolicacidreducesbutdoesnoteliminatetheriskofneuraltubeabnormalities.Continueduseofanticonvulsantsthroughoutpregnancyisassociatedwithanincreasedriskofneurodevelopmentalproblemsinthechild.Thisisparticularlyhighwithsodiumvalproate.Forthisreason,NICE(2007)guidelinesadviseagainst the useofsodiumvalproateinpregnancy.Womenreceivingthesemedicationsshouldcarefullyplantheirpregnancieswithexpertadvice.Theyshould,whereverpossible,eitherhaveasupervised withdrawalof theirmedicationorchangetoa‘safer’alternative.Theyshouldalsotakefolicacid.Ifawomanbecomespregnantwhilestilltakingthesemedications,sheshouldbeurgentlyreferred forexpertadviceandforanearlyfetalanomalyscan.As allharmis dose-related,thewomanshouldbeadvisedwhereverpossibletoreducehersodiumvalproate tobelow1000mgdaily.

Breastfeeding

Theadvantagesof breastfeedingprobablyoutweigh the risksof takingcarbamazepineorsodiumvalproateduringbreastfeeding.However,theinfantshouldbemonitoredforexcessivedrowsinessand,inthecaseofsodiumvalproate,rashes.Lamotrigineshouldnotbeusedinbreastfeedingbecauseoftheincreasedriskofsevereskinreactionsintheinfant.

Serviceprovision

Thereareanumberofnationalrecommendationsfortheneedsofwomenwithperinatalpsychiatricdisorders Box25.7.Thedistinctiveclinicalfeaturesoftheconditions,theirphysicalneedsandtheprofessionalliaisonwithmaternityservicesallrequirespecialistskillsandknowledge(Oates1996).Thefrequencyoftheseriousconditionsatlocalitylevelmakesitdifficultforgeneraladultpsychiatricservicestomanagethecriticalmassofpatientsrequiredto developandmaintaintheir experienceandskills. Itisdifficultformaternityservicestorelatetomultiplepsychiatricteams.However,atsupra-locality(regional)level,thefrequencyofseriousperinatalpsychiatricdisorderissufficienttojustifythejointcommissioningandprovision ofspecialistservices.Mothers,whorequireadmissiontoapsychiatrichospitalintheearlymonthspostpartumshould,unlessitispositivelycontraindicated,beadmifedtoamother andbabyunit.Thisisnotonlyhumanebutalsointhebestinterestsoftheinfantandcost-effectiveasitshortensinpatientstayandpreventsre-admission.Thereshouldbespecialistperinatalcommunityoutreachservicesavailabletoeverymaternityservice,todealwithpsychiatricproblemsthatarisepostpartumbutalso toseewomeninpregnancywhoareathighriskofdevelopingapostnatalillness.

Box 25.7

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Perinatalmentalhealth:nationaldocuments(regularly updated) RoyalCollegeofPsychiatrists CR88

SIGNGuidelines–postnatalandpuerperalpsychosis

CNST2004

NationalScreeningCommittee

NICEguidelinesonantenatalcare:routinecareforthehealthypregnantwomanNICEguidelinesonantenatalandpostnatalmentalhealth

NICEguidelinesonpostnatalcare:routinepostnatalcareofwomenandtheirbabiesDepartmentofHealthReports:

Children's,youngpersonandmaternityNSF.MaternityStandard11

Women'smentalhealthintothemainstreamRespondingtodomesticabuse

CEMACH/CMACE‘Whymothersdie’triennialreports

Themajorityofwomensufferingfrompostnatalmentalillnesswillnotrequiretobeseenbyspecialistpsychiatric services.However,thereisaneedforintegratedcarepathwaystoensurethatwomenareeffectivelyidentifiedandmanagedinprimarycareand,ifnecessary,referredontospecialistservices.Thereisaneedtoenhancetheskillsandcompetenciesofhealthvisitors,midwives,obstetriciansandGPstodealwiththelesssevereillnessesthemselves.

Preventionandprophylaxis

Prevention

TheNationalScreeningCommifee(2001)andNICE(2007)guidelinesdonotrecommendroutinescreeningusingtheEPDSandother‘paperandpen’scalesintheantenatalperiodforthoseatriskofpostnataldepression.Theyalsofindthatthereisalackofevidencetosupportantenatalinterventionstoreducetheriskofnon-psychoticpostnatalillness.Incontrast,these andotherbodies(DH2004;NICE2008;CMACE2011)allrecommendthatwomenshouldbescreenedatearlypregnancyassessmentforapreviousorfamilyhistory ofseriousmentalillness,particularlybipolarillness,becausetheyfaceatleasta50%riskofrecurrenceofthatconditionfollowingbirth.Thosewhoundertakeearlypregnancyassessmentwillneedtrainingtorefreshtheirknowledgeofpsychiatricdisorder.

Thereisliflepointinscreeningforwomenathighriskofdevelopingseverepostnatalillnessifsystemsforthepro-activeperipartummanagementoftheseconditionsarenotin place andif appropriateresources arenot available.Itis recommendedthat allwomenwhoareathighriskofdevelopingaseverepostpartumillnessbyvirtueofaprevioushistoryareseenbyaspecialistpsychiatricteamduringthepregnancyandawrifenmanagementplanplacedinthematernityrecordsinlatepregnancyand sharedwiththe

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woman,herpartner,herGP,midwife,obstetricianandpsychiatrist.

Prophylaxis

Ifawoman hasaprevioushistoryof bipolarillnessorpuerperalpsychosis,considerationshouldbegiven tostartingmedicationondayonepostnatally. For bipolarillnessthe useoflithiumcarbonatehasbeenshowntoreducetheriskofarecurrence.Itisplausiblethattheuse ofantipsychoticmedicationmayalsoreduce theriskofrecurrence.However,lithiumisnotcompatiblewithbreastfeeding.Somewomenwillnotwishtotakemedicationwhentheyperceivethereisa50%chanceofthemremainingwell.Theymayalsoplaceapriorityoncontinuingtobreastfeed.Breastfeedingmothersatriskofdevelopingabipolarormixedaffectiveillnessmaytakecarbamazepineorsodiumvalproate.Theevidencethatantidepressantstakenprophylacticallymaypreventtheonsetofadepressivepsychosisislacking.Antidepressantsshouldbeusedwithgreatcaution in anywomanwhohasbipolardisorderin herpersonalorfamilyhistorybecauseofthepropensityofantidepressantstotriggeramanicillness.

Hormones

Thereisnoevidencethatprogesterone,naturalorsynthetic,preventsortreatspostnataldepressionorpuerperalpsychosis.Indeedthereisevidencetosuggesttheymaycausedepression.Whilethereissomeevidencethattransdermaloestrogensareeffectiveintreatingpostnataldepression,thepotentialadversephysicaleffects(Dennisetal1999)andtheknownefficacyofantidepressantsmeanthisshouldnotbethetreatmentofchoice.

Themostimportantaspectofpreventativemanagementandonethatwillpromoteearlyidentificationandtheavoidanceofalife-threateningemergencyisclosesurveillance,contactandsupportintheearlyweeks,theperiodofmaximumrisk.Aspecialistcommunityperinatalpsychiatricnursetogetherwiththemidwifeshouldvisitonadailybasisforthefirsttwoweeksandremaininclosecontactforthefirstsix.Thelocalmotherandbabyunitshouldbeawareofthewoman'sexpecteddateofbirthandsystemsput inplacefordirectadmissionifnecessary.

TheConfidentialEnquiriesintoMaternalDeaths:psychiatriccausesofmaternaldeath

ConfidentialEnquiriesintoMaternalDeaths(Oates2001,2004,2007,2011)havefoundthatsuicideandother psychiatriccausesofdeatharealeadingcause(indirect)ofmaternaldeathintheUK, between1997and2008,contributingtoover15%ofmaternaldeaths.

Maternalsuicideismorecommon thanpreviouslythought.Overall,the maternalsuiciderateappearstobeequivalenttothatofthegeneralrateinthefemalepopulation.Suicideinpregnancyislesscommon.Themajorityofsuicidestookplaceintheyearfollowingbirth,mostinthefirst3months.Notonlyistheassumptionofthe‘protectiveeffectofmaternity’calledintoquestionbutalsotherelativeriskofsuicideforseriously

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mentallyillwomenfollowingchildbirthiselevated.Anelevatedstandardizedmortalityratio(SMR)of70forwomenwithseriousmentalillnessinthepostpartumyearhaspreviously beenreported(Applebyetal1998)andfurtherconfirmedbyevidencefromtheEnquirieswithimprovedcaseascertainment.

Incontrasttoothercausesofmaternaldeath,suicidewasnotassociatedwithsocioeconomicdeprivation.Themajorityofsuicideswereolder,marriedandrelativelysociallyadvantagedandseriouslyill.Aworryingnumber were healthprofessionals.Thisunderlinestheerrorofmergingissuesofmaternalmentalhealthwiththoseofsocioeconomicdeprivation.

Themajorityofthesuicidesoccurredviolentlybyjumpingfromaheightorbyhanging.Thisstandsincontrasttothecommonestmethodofsuicideamongwomeningeneral(self-poisoning),andunderlinestheseriousnessoftheillnessfromwhichthewomendied.

Halfofthesuicideshadaprevioushistoryofadmissiontoapsychiatrichospital.Infewcaseshadthisriskbeenidentifiedatbookingandinevenfewerhadanyproactivemanagementbeenputintoplace.Hadthesewomen'sillnessesbeenanticipated,asubstantialnumberofthesedeathsmighthavebeenavoided.

Women alsodiedfrom otherconsequencesofpsychiatric disorder.Someofthesewereduetoaccidentaloverdosesofillicitdrugs.However,deathsalsooccurredfromphysicalillnessthatwouldnothaveoccurredintheabsenceofapsychiatricdisorder.Someofthesewerethephysicalconsequencesofalcoholorillicitdrugmisuse,othersfromside-effectsofpsychotropicmedication.However,aworryingnumberofdeaths,someofwhichtookplaceinapsychiatricunit,wereduetophysicalillnessbeingmissedbecauseofthepsychiatricdisorderormistakenlyafributedtoapsychiatricdisorder.Thesefindingsunderlinetheimportance of rememberingthatphysicalillnesscanpresentasorcomplicatepsychiatricdisorder.Suicideisnottheonlyriskassociatedwithperinatalpsychiatricdisorder.Box25.8identifiesthefourmaincategoriesofpsychiatricdeathsemergingfrom‘SavingMothers’Lives'(OatesandCantwell2011).

Box 25.8

Thefourmaincategoriesofpsychiatricdeathsemergingfrom‘SavingMothers’Lives'(Oates2007;OatesandCantwell2011)

•Suicide

•Overdoseofdrugsabuse

•Medicalconditionscausedbyormistakenforpsychiatricdisorder

•Violenceandaccidentsrelatedtopsychiatricdisorders

Note:Newthemesareincluded,concerningchildprotectionandterminationofpregnancy.

These findings have major implications for psychiatric and obstetric practice. If

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psychiatristsdiscussedwithwomenplansforparenthoodpriortoconception;ifobstetriciansandmidwivesdetectedthoseatriskofseriousmentalillness;ifpsychiatricandmaternityprofessionalscommunicatedfreelywitheachotherandworkedtogether;ifspecialistperinatalmentalhealthserviceswereavailable forthosewomenwhoneededthem;andifallhadagreaterunderstandingofperinatalmentalillness,thennotonlywouldasubstantialnumberofmaternaldeathsbeavoidedbutalsothecareandoutcomeofothermentallyillwomenwouldbegreatlyimproved.

Conclusion

Thefullrangeofpsychiatricdisorderscancomplicatepregnancyandthepostpartumyear.Theincidence of affectivedisorder,particularlyatthemostsevereendof thespectrum,increasesfollowingbirth.Thefamiliarsignsandsymptomsofpsychiatricdisorderareallpresentinpostpartumdisordersaswell,buttheearlymaternitycontextandthedominanceofinfantcareandmother–infantrelationshipsexertapowerful effectonthecontent,ifnottheform,ofthesymptomatology.Earlymaternityisatimewhenthereisanexpectationof joy,pleasureandfulfillment.Thepresence of psychiatricdisorderatthistime,howevermild,isdisproportionatelydistressing.Nomaferhowillthewomanfeels, thereisstillababyandohenotherchildrentobecaredfor.Shecannotrestandisremindedonadailybasisofhersymptomsanddisability.Compassionatecareandunderstandingandskilledcareaimedatspeedysymptomreliefandre-establishingmaternalconfidencearethusessential.

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