Mental disorder in reproductive age group female

Nirsuba Gurung MN 2nd YearWHD

Reproductive health •Reproductive health is a state of complete

physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes

•Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.

Why Mental health in Reproductive health!!!

• Mental health conditions, including depression and anxiety,

are common among pregnant, postpartum, and nonpregnant women of reproductive age.

• Poor mental health may adversely affect women’s family relations, social life and their ability to function at school or work.

• Poor mental health is associated with substance use and may put women at risk for future chronic disease, such as diabetes and heart disease.

• Poor mental health may adversely impact pregnancy, maternal infant bonding, maternal functioning, and infant and child health and development.

•Mental health as a component of reproductive health has generally been - and still is - inconspicuous, peripheral and marginal.

•The lack of attention it has received is unfortunate, given the significant contributions of both mental health and reproductive health to the global burden of disease and disability.

•Depression occurs approximately twice as often in women as in men, and commonly presents with unexplained physical symptoms, such as tiredness, aches and pains, dizziness, palpitations and sleep problems

•Of the ten leading causes of disability worldwide, five are neuropsychiatric disorders.

• Of these, depression is the most common, accounting for more than one in ten disability-adjusted life-years (DALYs) lost (Murray & Lopez, 1996).

•It is the most frequently encountered women’s mental health problem and the leading women’s health problem overall.

•Rates of depression in women of reproductive age are expected to increase in developing countries, and it is predicted that, by 2020, unipolar major depression will be the leading cause of DALYs lost by women

Psychological aspect of RH•Mental health dimensions of pregnancy,

childbirth and the postpartum period.•Psychological aspects of contraception and

elective abortion.•Mental health consequences of miscarriage.•Menopause and depression.•Gynaecological morbidity and its impact on

mental health.• Mental health in the context of HIV/ AIDS.• Infertility and assisted reproduction.• Mental health and female genital mutilation.

Depression in pregnancy•Symptoms of depression, including

appetite change, lowered energy, sleep disturbance and reduced libido, are considered “normal” in pregnancy and their psychological significance is therefore underestimated.

• A range of psychosocial factors has been associated with depression in pregnancy, including unwanted conception, unmarried status, unemployment and low income

Depression

Patient has low mood: at least 2 wks

• Depression: 2-4 symptoms out of the 9 below, with at least one being #1 or #2

•Major Depression: ≥5 symptoms out of the 9 below, with at least one being #1 or #2

Symptoms 1. Depressed mood

2. Markedly diminished interest or pleasure in all, or almost all,

activities

3. Significant weight loss when not dieting or weight gain

4. Insomnia or hypersomnia

5. Psychomotor agitation or retardation

6. Fatigue or loss of energy

7. Feelings of worthlessness or excessive or inappropriate guilt

8. Diminished ability to think or concentrate, or indecisiveness

9. Recurrent thoughts of death, suicidal ideation, or a suicide attempt

Postpartum Depression•Postpartum depression is depression that

occurs after having a baby.

•Feelings of postpartum depression are more intense and last longer than those of “baby blues,” a term used to describe the worry, sadness, and tiredness many women experience after having a baby.

•About 1 in 8 women experiences postpartum depression. 

Symptoms of postpartum depression •Crying more often than usual.•Feelings of anger.•Withdrawing from loved ones.•Feeling numb or disconnected from your

baby.•Worrying that you will hurt the baby.•Feeling guilty about not being a good

mom or doubting your ability to care for the baby.

EpidemiologyPoint prevalence Lifetime

prevalence•6 – 8% in women 20% in women•3 – 4% in men 10% in men

Age of Onset•Typically from the mid 20’s through the

50’s with a peak age of onset in the mid 30’s

EpidemiologyGenetics•More prevalent in first degree relatives 3-5x the general population risk

•Concordance is greater in monozygotic than dizygotic twins

• Reproductive health conditions also make a major contribution to the global burden of disability, particularly for women, accounting for

21.9% of DALYs lost for women annually compared with only 3.1% for men (Murray & Lopez, 1998).

• An estimated 40% of pregnant women (50 million per year) experience health problems directly related to the pregnancy, with 15% suffering serious or long-term complications.

Depression is common among women of reproductive age

From the 2005-2009 NSDUH, about 1 out of 10 women (8% of pregnant women and 11% of nonpregnant women of reproductive age) had at least one major depressive episode in the past year.

(National Survey on Drug Use and Health )

•Chen et al. (2004) surveyed pregnant women attending antenatal clinics at a Singapore obstetric hospital, and reported that 20% had clinically significant depressive symptoms. Young women and women with complicated pregnancies were at elevated risk.

Depression in women often goes undiagnosed and untreated

Theories of Etiology

1. Biological a. Neurotransmitters b. Neuroendocrine

2. Psychosocialc. Risk factorsd. Cognitive factors

1. Biologicala. Neurotransmitters

Clearly over simplistic theories regarding Monoamine(norepinephrine, dopamine) and serotonin.

•Deficiency states depression

•States of excess mania

Cont…b. Neuroendocrine

•Hyperactivity of HPA axis:▫Elevated cortisol

▫Nonsuppression of cortisol following dexamethasone challenge

▫Hypersecretion of CRF

Cont…- Blunting of TSH response to TRH

- Blunting of serotonin mediated increase in plasma prolactin

- Blunting of the expected increase in plasma growth hormone

Functional Neuroimaging (PET,SPECT)demonstrates

•White mater hyperintensities, Change in blood flow, and decreased metabolism in parts like:• Dorsal prefontal cortex

▫Anterolateral (concentration, cognitive processing)

▫Cingulate (regulation of mood and affect)

•Subcortical▫Caudate (psychomotor changes)

2. Psychosocial

A. Risk Factors▫Poor social supports▫Early parental loss▫Introversion▫Female gender▫Recent stressor (especially medical

illness)

B. Cognitive Theory

▫Patients have distorted perceptions and thoughts of themselves, the world around them and the future.

▫Possible to treat by restructuring.

Secondary Causes of Depression

•Toxic•Endocrine•Vascular•Neurologic•Nutritional•Traumatic•Infectious•Autoimmune

High risk group for poor mental health

•Risk factors for major depression in nonpregnant women 18-44 years of age include;

▫older age, ▫less education, ▫being unmarried, ▫inability to work or being unemployed,▫ and lower income.

•Postpartum depressive symptoms are associated with;

▫ young maternal age, ▫partner-related stress or physical abuse, ▫traumatic or financial stress,▫ tobacco use during pregnancy,▫ and delivery of a low birth weight infant.

Others risk •Stress•Low social support•Difficulty getting pregnant•Being a mom to multiples, like twins, or

triplets.•Losing a baby•Being a teen mom•Preterm (before 37 weeks) labor and delivery•Having a baby with a birth defect or disability•Pregnancy and birth complications•Having a baby or infant who has been

hospitalized

Reproductive and infant outcome of depressed women

• Among low income women, those with frequent mental distress are more likely to use less effective forms of contraception.

• Women with frequent mental distress are more likely to smoke, be overweight or obese, and have less social support before becoming pregnant.

• In an insured population, infants of mothers with postpartum depression or anxiety had more sick/emergency visits and an increased risk of hospitalization than infants of mothers with no depression or anxiety

Depressed women are at increased risk of chronic disease and substance use.

• Among U.S. women with major depression, most (89%) have one or more chronic physical conditions or risk factors, such as diabetes, smoking, binge or heavy drinking, obesity, and physical inactivity.

• Women who quit smoking during pregnancy are almost twice as likely (1.8 times) to start smoking again during the postpartum period if they experienced postpartum depressive symptoms.1

• A higher percentage of women with current major (18%) or minor (18%) depression, or a past diagnosis of depression (20%) reported binge or heavy drinking compared to women with no history of depression (15%)

Treatment1. BIOLOGICAL

2. PSYCHOSOCIAL

Treatment 1. Biologic

•Tricylclic antidepressants

•Monoamine oxidase inhibitors

•Second generation antidepressants▫SSRI’s, Venlafaxine, bupropion,

martazapine

•Electoconvulsive therapy

CONT…

2. Psychosocial Treatments

•Education

•Specific pscychotherapies

•Vocational training

•Exercise

PROGNOSTIC FACTORSGOOD POOR1. Abrupt or acute onset.2. Severe depression3. Typical clinical

features.4. Well adjusted pre-

morbid personality.5. Good response to

treatment.

1. Double depression2. Co-morbid physical

disease3. Chronic on-going stress4. Poor drug compliance.5. Mood incongruent

psychotic features/hypochondrical features.

PROGNOSISCourse•An average depressive episode lasts for

4-9 months. •One episode – 50% chance of

reoccurence•Two episodes – 70% chance of

reoccurence•Three or more episodes - >90% chance

of re-occurrence.

NURSING MANAGEMENT1. ASSESSMENT•Severity of disorder•Risk factors for suicide.•Possible causes•Available social resources•Effects of disorder on other people.•Family, interpersonal,socio-economic and

medical history.

Commonly used Tools to measure depression