Perinatal mental health

1. Perinatal mental health

2. Case study You are visiting a mother called Amal is in the first postpartum week; she feels persistently guilty and negative towards herself, cries easily and feels tired and agitated. 1. What might she be suffering from? 2. What other symptoms would you ask her about, to confirm your diagnosis? 2

3. The psychological context of pregnancy and the puerperium Stress/anxiety • Pregnancy and the puerperium are normal life events, yet they are periods in a woman's life when her vulnerability exposes her to a significant amount of anxiety and stress. • Stress during pregnancy is both essential and normal for the psychological adjustment of pregnant women. • Conversely, elevated levels of stress hormones and unnecessary anxiety will stretch coping reserves, and could prove crippling.

4. The psychological context of pregnancy and the puerperium Stress/anxiety • there are many factors that contribute to unhappiness in women's lives and affect their emotional health and well-being. • Understanding the root cause and expression of mental distress in women is complex as the social circumstances into which women live and children are born play a major role in their health and well-being.

5. Neurotransmitters • Serotonin : • Inhibits stress response • Regulates sleep • Pain sensitivity • Sexual functioning • Appetite • Diminished serotonin – result of stress?

7. Transition to parenthood • Postnatally, parents may find coping with the demands of a new baby, e.g. infant feeding, financial constraints, the whole process of lifestyle adjustments and role changes, a real strain. • For new mothers, this will involve diverse emotional responses ranging from joy and elation to sadness and utter exhaustion.

8. Who is at risk? • Difficult labor or unexpected outcome • Fatigue, pain and discomfort • Disturbed sleep • Twins or higher multiples • Breastfeeding • C-section • Change in libido

9. Role change/role conflict • Having a baby, and particularly the transition to parenthood that accompanies the first child, leads to a significant shift in the couple's relationship. Social networks are disrupted, especially those of the mother and the quality and quantity of social support such networks can and do provide.

10. Communication • Effective communication during pregnancy and the puerperium is essential. Yet poor communication is still the single most common factor that is associated with women's dissatisfaction with their care. • Being provided with adequate information will serve to: • diminish women's anxiety levels and allay emotional distress • facilitate choice • enable women to maintain control over decision-making.

11. The ideology of motherhood • Motherhood, it is thought, ensures that a woman has fulfilled her biological destiny, confirms a woman's femininity and raises her status in society, but without financial gain. • Instead of feeling elated by motherhood some women experience displeasure, feelings of unhappiness and feel dismayed or even disappointed in their role as new mothers. • The ideology of motherhood is therefore an assumption and a paradox with inherent dichotomies as the woman strives to be ‘super mum, super wife, super everything’

12. Facts about Motherhood • I will fall in love with my baby immediately. • Being a mother will complete me. • Having a child will strengthen our relationship. • Having a child will keep him around. • Mothering is natural. • Breastfeeding is natural, and it will be easy.

13. Social support • During periods of stress, supportive and holistic care from midwives will not only assist in promoting emotional well-being of women, but will also help to ameliorate threatened psychological morbidity in the postnatal period. • Women who are socially isolated or who have poor socioeconomic circumstances are particularly vulnerable to mental health problems and need additional help and support.

14. Definition Psychiatric disorders are relatively common after childbirth and may include: postpartum ‘blues’, postpartum depression (PPD), and postpartum psychosis.

15. Spectrum of disorders • Depression/Anxiety • Obsessive/Compulsive Disorder • Panic Attacks • Post-traumatic Stress • Bipolar • Postpartum Psychosis

16. Postnatal Blues • Occurs in about 80% of mothers • Onset 1st week, lasts up to 3 weeks • Mood instability, weepiness, sadness, anxiety, lack of concentration • Treatment supportive • Not considered part of the spectrum of perinatal mood disorders

17. Depression and/or Anxiety Incidence: 15-20% of new mothers Symptoms: • Excessive worry or anxiety • Irritability, short temper • Feeling overwhelmed by responsibilities, difficulty making decisions • Sad mood, feelings of guilt, fear, phobias • Hopelessness • Sleep disturbances (insomnia or hypersomnolence), fatigue

18. Somatic symptoms without apparent cause • Discomfort around baby • Lack of feelings towards baby • Loss of focus and concentration • Loss of interest and pleasure • Changes in appetite – significant wt gain or loss

19. Obsessive-Compulsive Disorder Incidence: 3-5% of new mothers Risk factors: Personal or family hx OCD Symptoms: • Intrusive, repetitive and persistent thoughts or mental pictures • Thoughts often about harming the baby • Tremendous sense of horror and shame • Behaviors to reduce anxiety and protect baby • Counting, checking, cleaning, other repetitive behaviors

20. Panic Disorder Incidence: 10% of postpartum women Risk Factors: • Personal or family hx of anxiety or panic disorder • Thyroid dysfunction Symptoms: • Episodes of extreme anxiety • chest pain • Sensations of choking, smothering, dizziness

21. Hot or cold flashes, trembling, tachycardia, numbness or tingling • Restlessness, agitation, irritability • During attack, may fear she is going crazy, losing her mind • Panic attack may wake her up from sleep • Excessive worry or fear (incl. fear of another panic attack)

22. Posttraumatic Stress Disorder Incidence: up to 6% of postpartum women Risk factors: Past traumatic events Symptoms: • Recurrent nightmares • Extreme anxiety • Reliving past traumatic events (sexual, physical, emotional, childbirth)

23. Bipolar Disorder Incidence: no data Risk factors: personal or family hx of bipolar disorder Symptoms: • Mania – racing thoughts, high energy and little sleep, compulsive activity • Depression • Rapid and severe mood swings

24. Postpartum Psychosis Incidence: 0.1-0.2% • Onset usually 2-3 days postpartum • 5% suicide and 4% infanticide rate Risk factors: • Personal or family hx psychosis, bipolar, schizophrenia • Previous hx postpartum psychosis or bipolar episode

25. Symptoms: • Visual or auditory hallucinations • Delusional thinking • Delirium or mania • Very obviously psychotic

26. Medical Management • ACOG/APA guidelines (2009) • Psychotherapy • Pharmacotherapy • Individualized plan of care • Consider continuing medications during pregnancy to avoid risk of relapse (bipolar, psychosis, severe depression)