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Perinatal Perinatal mental healthmental health

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Case study

You are visiting a mother called Amal is in the You are visiting a mother called Amal is in the fifirst postpartum week; she feels persistently rst postpartum week; she feels persistently guilty and negative towards herself, cries easily guilty and negative towards herself, cries easily and feels tired and agitated. and feels tired and agitated.

1. What might she be suffering from? 1. What might she be suffering from?

2. What other symptoms would you ask her 2. What other symptoms would you ask her about, to about, to

conconfifirm your diagnosis?rm your diagnosis?

2

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The psychological context of pregnancy and The psychological context of pregnancy and the puerperiumthe puerperium

Stress/anxietyStress/anxiety

Pregnancy and the puerperium are normal life Pregnancy and the puerperium are normal life events, yet they are periods in a woman's life when events, yet they are periods in a woman's life when her vulnerability exposes her to a significant her vulnerability exposes her to a significant amount of anxiety and stress. amount of anxiety and stress.

Stress during pregnancy is both essential and Stress during pregnancy is both essential and normal for the psychological adjustment of normal for the psychological adjustment of pregnant women. pregnant women.

Conversely, elevated levels of stress hormones and Conversely, elevated levels of stress hormones and unnecessary anxiety will stretch coping reserves, unnecessary anxiety will stretch coping reserves, and could prove crippling.and could prove crippling.

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The psychological context of pregnancy and The psychological context of pregnancy and the puerperiumthe puerperium

Stress/anxietyStress/anxiety

there are many factors that contribute to there are many factors that contribute to unhappiness in women's lives and affect their unhappiness in women's lives and affect their emotional health and well-being. emotional health and well-being.

Understanding the root cause and expression of Understanding the root cause and expression of mental distress in women is complex as the social mental distress in women is complex as the social circumstances into which women live and circumstances into which women live and children are born play a major role in their health children are born play a major role in their health and well-being.and well-being.

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NeurotransmittersNeurotransmitters

Serotonin : Serotonin : – Inhibits stress responseInhibits stress response– Regulates sleepRegulates sleep– Pain sensitivityPain sensitivity– Sexual functioningSexual functioning– AppetiteAppetite

Diminished serotonin – result of stress?Diminished serotonin – result of stress?

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Transition to parenthoodTransition to parenthood

- Postnatally, parents may find coping with Postnatally, parents may find coping with the demands of a new baby, e.g. infant the demands of a new baby, e.g. infant feeding, financial constraints, the whole feeding, financial constraints, the whole process of lifestyle adjustments and role process of lifestyle adjustments and role changes, a real strain.changes, a real strain.

- For new mothers, this will involve diverse For new mothers, this will involve diverse emotional responses ranging from joy and emotional responses ranging from joy and elation to sadness and utter exhaustion. elation to sadness and utter exhaustion.

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Who is at risk?Who is at risk?

– Difficult labor or unexpected outcomeDifficult labor or unexpected outcome– Fatigue, pain and discomfortFatigue, pain and discomfort– Disturbed sleepDisturbed sleep– Twins or higher multiplesTwins or higher multiples– Breastfeeding Breastfeeding – C-sectionC-section– Change in libido Change in libido

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Role change/role conflictRole change/role conflict

– Having a baby, and particularly the transition Having a baby, and particularly the transition

to parenthood that accompanies the first child, to parenthood that accompanies the first child,

leads to a significant shift in the couple's leads to a significant shift in the couple's

relationship. Social networks are disrupted, relationship. Social networks are disrupted,

especially those of the mother and the quality especially those of the mother and the quality

and quantity of social support such networks and quantity of social support such networks

can and do provide. can and do provide.

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CommunicationCommunication

– Effective communication during pregnancy and Effective communication during pregnancy and the puerperium is essential. Yet poor the puerperium is essential. Yet poor communication is still the single most common communication is still the single most common factor that is associated with women's factor that is associated with women's dissatisfaction with their care. 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.

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The ideology of The ideology of motherhoodmotherhood

Motherhood, it is thought, ensures that a woman Motherhood, it is thought, ensures that a woman has fulfilled her biological destiny, confirms a has fulfilled her biological destiny, confirms a woman's femininity and raises her status in woman's femininity and raises her status in society, but without financial gain.society, but without financial gain.

Instead of feeling elated by motherhood some Instead of feeling elated by motherhood some women experience displeasure, feelings of women experience displeasure, feelings of unhappiness and feel dismayed or even unhappiness and feel dismayed or even disappointed in their role as new mothers.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’

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Facts about MotherhoodFacts about Motherhood

I will fall in love with my baby immediately.I will fall in love with my baby immediately.

Being a mother will complete me.Being a mother will complete me.

Having a child will strengthen our relationship.Having a child will strengthen our relationship.

Having a child will keep him around.Having a child will keep him around.

Mothering is natural.Mothering is natural.

Breastfeeding is natural, and it will be easy.Breastfeeding is natural, and it will be easy.

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Social supportSocial 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.

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DefinitionDefinition

Psychiatric disorders are relatively common after Psychiatric disorders are relatively common after childbirth and may include:childbirth and may include:

postpartum ‘blues’, postpartum depression (PPD), postpartum ‘blues’, postpartum depression (PPD), and postpartum psychosis.and postpartum psychosis.

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Spectrum of disordersSpectrum of disorders

Depression/AnxietyDepression/Anxiety Obsessive/Compulsive DisorderObsessive/Compulsive Disorder Panic AttacksPanic Attacks Post-traumatic StressPost-traumatic Stress BipolarBipolar Postpartum PsychosisPostpartum Psychosis

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Postnatal BluesPostnatal Blues

Occurs in about 80% of mothersOccurs in about 80% of mothers Onset 1st week, lasts up to 3 weeksOnset 1st week, lasts up to 3 weeks Mood instability, weepiness, sadness, Mood instability, weepiness, sadness,

anxiety, lack of concentrationanxiety, lack of concentration Treatment supportiveTreatment supportive Not considered part of the spectrum of Not considered part of the spectrum of

perinatal mood disordersperinatal mood disorders

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Depression and/or AnxietyDepression and/or Anxiety

Incidence: 15-20% of new mothersIncidence: 15-20% of new mothersSymptoms:Symptoms: Excessive worry or anxietyExcessive worry or anxiety Irritability, short temperIrritability, short temper Feeling overwhelmed by responsibilities, Feeling overwhelmed by responsibilities,

difficulty making decisionsdifficulty making decisions Sad mood, feelings of guilt, fear, phobiasSad mood, feelings of guilt, fear, phobias HopelessnessHopelessness Sleep disturbances (insomnia or Sleep disturbances (insomnia or

hypersomnolence), fatiguehypersomnolence), fatigue

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) Somatic symptoms without apparent Somatic symptoms without apparent causecause

Discomfort around babyDiscomfort around baby Lack of feelings towards babyLack of feelings towards baby Loss of focus and concentrationLoss of focus and concentration Loss of interest and pleasureLoss of interest and pleasure Changes in appetite – significant wt Changes in appetite – significant wt

gain or lossgain or loss

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Obsessive-Compulsive DisorderObsessive-Compulsive Disorder

Incidence: 3-5% of new mothersIncidence: 3-5% of new mothersRisk factors: Personal or family hx OCDRisk factors: Personal or family hx OCDSymptoms:Symptoms:

– Intrusive, repetitive and persistent thoughts Intrusive, repetitive and persistent thoughts or mental picturesor mental pictures

– Thoughts often about harming the babyThoughts often about harming the baby– Tremendous sense of horror and shame Tremendous sense of horror and shame – Behaviors to reduce anxiety and protect babyBehaviors to reduce anxiety and protect baby– Counting, checking, cleaning, other repetitive Counting, checking, cleaning, other repetitive

behaviorsbehaviors

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Panic DisorderPanic Disorder

Incidence: 10% of postpartum womenIncidence: 10% of postpartum womenRisk Factors: Risk Factors: Personal or family hx of anxiety or panic Personal or family hx of anxiety or panic

disorderdisorder Thyroid dysfunctionThyroid dysfunction

Symptoms:Symptoms: Episodes of extreme anxietyEpisodes of extreme anxiety chest painchest pain Sensations of choking, smothering, Sensations of choking, smothering,

dizzinessdizziness

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) Hot or cold flashes, trembling, Hot or cold flashes, trembling, tachycardia, numbness or tinglingtachycardia, numbness or tingling

Restlessness, agitation, irritabilityRestlessness, agitation, irritability During attack, may fear she is going During attack, may fear she is going

crazy, losing her mindcrazy, losing her mind Panic attack may wake her up from Panic attack may wake her up from

sleepsleep Excessive worry or fear (incl. fear of Excessive worry or fear (incl. fear of

another panic attack)another panic attack)

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Posttraumatic Stress DisorderPosttraumatic Stress Disorder

Incidence: up to 6% of postpartum Incidence: up to 6% of postpartum womenwomen

Risk factors: Past traumatic eventsRisk factors: Past traumatic events

Symptoms:Symptoms: Recurrent nightmaresRecurrent nightmares Extreme anxietyExtreme anxiety Reliving past traumatic events (sexual, Reliving past traumatic events (sexual,

physical, emotional, childbirth)physical, emotional, childbirth)

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Bipolar DisorderBipolar Disorder

Incidence: no dataIncidence: no dataRisk factors: personal or family hx of bipolar Risk factors: personal or family hx of bipolar

disorderdisorder

Symptoms:Symptoms: Mania – racing thoughts, high energy and Mania – racing thoughts, high energy and

little sleep, compulsive activitylittle sleep, compulsive activity DepressionDepression Rapid and severe mood swingsRapid and severe mood swings

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Postpartum PsychosisPostpartum Psychosis

Incidence: 0.1-0.2%Incidence: 0.1-0.2% Onset usually 2-3 days postpartumOnset usually 2-3 days postpartum 5% suicide and 4% infanticide rate5% suicide and 4% infanticide rateRisk factors: Risk factors: Personal or family hx psychosis, Personal or family hx psychosis,

bipolar, schizophreniabipolar, schizophrenia Previous hx postpartum psychosis or Previous hx postpartum psychosis or

bipolar episodebipolar episode

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Symptoms:Symptoms:

Visual or auditory Visual or auditory hallucinationshallucinations

Delusional thinkingDelusional thinking Delirium or maniaDelirium or mania Very obviously Very obviously

psychoticpsychotic

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Medical ManagementMedical Management

ACOG/APA guidelines (2009)ACOG/APA guidelines (2009)– PsychotherapyPsychotherapy– Pharmacotherapy Pharmacotherapy – Individualized plan of care Individualized plan of care – Consider continuing medications during Consider continuing medications during

pregnancy to avoid risk of relapse (bipolar, pregnancy to avoid risk of relapse (bipolar, psychosis, severe depression)psychosis, severe depression)