Perinatal Mental Health
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Transcript of Perinatal Mental Health
Perinatal Mental Health
Dr Cressida ManningConsultant Perinatal PsychiatristFlorence House Mother and Baby
Unit
Contents of Presentation
Confidential Enquiry into maternal deaths. Risks of untreated illness. Risk factors for postnatal depression and psychosis. Discussions around treatment. Medication.
Recent Case Study
Felicia Boots. 35 Mother of 2 ( 14 months and 10 weeks). Manslaughter on grounds of diminished responsibility. Stopped medication as breastfeeding.
Confidential Enquiry
Centre for Maternal and Child Enquiries (CMACE) Most recent report ‘Saving Mothers Lives’ (2011) 2006-2008 29 suicides 1st 6 months 19 past psychiatric history 9 identified of which 4 had care plan
Saving Mothers Lives
38% Psychosis 21% Severe Depressive Illness
Recommendations - Back to Basics 1Saving Mothers Lives Anxiety or depression
Review in 2 weeks Consider psych referral if symptoms persist Refer urgently where:
Suicidal ideation, uncharacteristic symptoms/marked change from normal functioning, morbid fears, profound low mood, personal or family history of serious affective disorder, mental health deterioration, morbid fears, panic attacks and intrusive obsessional thoughts.
Effects of Untreated Illness
Increased morbidity. Increased risks towards self and others.
Links between maternal anxiety and fetal behaviour and heart rate
Stress/anxiety during pregnancy can have long term effects on child
Associated with an increased incidence of: Emotional problems - Anxiety/depression Behavioural problems – ADHD, conduct disorder Impaired cognitive development, esp language Sleep problems in infants
Sensitive early mothering important as what happens in utero for child outcome
Effects of antenatal and postnatal depression Children of mothers depressed in perinatal period compared to
children of well mothers: Lower IQ scores 12x more likely to have a statement of special needs elevated risk of violence at 11 and 16 years More likely to suffer separation anxiety at 11 and a diagnosis of
depression at 16
Suicide
Majority of deaths secondary to postpartum psychosis or very severe depressive illness
Oates (2008) Suicide rate for ppp 2/1000 Common profile; white, older, 2nd or subsequent
pregnancy, married, comfortable circumstances Likely to die violently
Infanticide
Similar profile 1/3rd mental illness Death extended suicide or occasionally altruistic
based on delusional belief Highest concern if delusion involves child e.g baby
changed, not hers, possessed, evil.
Postpartum Psychosis
1st few weeks highest risk Heron et al (2007) Greater than 80%
1st week Link with BPAD
Bipolar Disorder
52% relapse in 1st 40 weeks after stopping treatment
If pregnant and stable on antipsychotic and likely to relapse without medication continue
Up to 70% relapse if untreated in postnatal period 50% psychotic symptoms day 1 - 3
Postpartum Psychosis – Risk Factors 1st Baby Single C- Section Older Fertility Problems Previous episode – 1 in 7 Sleep Loss
Warning Signs
Early signs often non specific Insomnia, agitation/anxious, perplexed and odd
behaviour. Risk overlooked
Can lead to rapid deterioration to Psychotic symptoms
Postnatal Depression
10 -15% Severe 3% 1/3 to ½ continuation of antenatal anxiety and
depression Onset few days to 6 months Increased risk in subsequent pregnancies – approx
25 – 50%
Postnatal Depression – Risk Factors Antenatal anxiety or depression Past history of psychiatric illness Life events Lack of or perceived lack of support Low income Domestic violence FH of psychiatric illness Childhood abuse
Risk Factors cont…
Obstetric factors Sleep deprivation Infant factors –irritability Personality factors – control, interpersonal
sensitivity, ‘neuroticism’ Biological factors – inconsistent results
Early Detection
1st contact;
Past or present mental illness
Previous psychiatric input, including admissions
Family history of severe mental illness
Treatment of pregnant and breast feeding women- NICE guidelines
Importance of balancing risks and benefits Cautious Women requiring psychological treatment should be seen for
treatment within 1 month of assessment and no longer than 3 months.
NICE
Discussion should include: Risk of relapse and not treating disorder Woman’s ability to cope with untreated symptoms Severity of previous episodes and response to treatment Woman’s preference Possibility that stopping drug with teratogenic risk once pregnancy
confirmed may not remove risk
NICE
Risks of stopping medication abruptly Need for prompt treatment due to impact of illness on foetus/child Increased risk of harm of specific drug treatments Treatment option that would allow mother to breastfeed
NICE
Prescribing: Drugs with lowest risk profile Lowest effective dose Monotherapy Risks lower threshold for psychological treatmentImportant to put risks from drug treatment in context of the individual
woman’s illness
Antidepressants
SSRIs Paroxetine in 1st trimester increase in cardiac malformations (VSD) – planning pregnancy or unplanned advise to stop. Other SSRIs now implicated.
SSRI’s taken after 20 weeks may be associated with an increased risk of persistent pulmonary hypertension of the new born Neonatal withdrawal- normally mild and self limiting
Symptoms include; Irritability Hypertonia Jitteriness Difficulties feeding Tremor Agitation Seizures Tachypnoea Posturing
Tricyclics
Tricyclics have lower known risks during pregnancy than other antidepressants
Have higher fatal toxicity index CHD with clomipramine Withdrawal symptoms No effects on long term neurodevelopmental outcomes Imipramine
Other antidepressants
Venlafaxine – Conflicting results for congenital malformations – data too limited to say safe. Possible increased neonatal withdrawal and increased risk of high blood pressure at higher doses. Theoretical risk of PPHN
Mirtazapine – Possible association with increased rate of spontaneous abortion. No evidence to link to congenital malformations but data too limited to say safe.
JAMA 13 – Metaanalysis – preterm birth 3 days - Apgar <0.5 - Weight 75g - Spontaneous abortion not significant.
Benzodiazepines Raised risk of oral cleft (7 in 1000; x10) Withdrawal syndrome – jitteriness, autonomic dysregulation, seizure,
floppy baby syndrome Consider gradually stopping in women who are pregnant Short term use only for severe agitation and anxiety
Lithium – Ebsteins anomoly (1 in 1000) General population 1 in 20000
Overall risk CHD 0.9-12% vs 0.5-1% general population. Floppy baby syndrome, thyroid dysfunction, nephrogenic diabetes
insipidus. High quantities in breast milk.
Valproate NTD 100 to 200 in 10000 IUGR Facial dysmorphias Low IQ
Do not routinely prescribe to women of child bearing age. If no option adequate contraception Discontinue if pregnant
Carbamazepinne Increased risk congenital malformations -6.7% v 2.3% Craniofacial, GIT, cardiac, urinary tract and digit anomalies Advice as valproate
Lamotrigine Cleft palate 8.9/1000
Atypical Antipsychotics
Olanzapine and Quetiapine Limited data to base assessment of safety in
pregnancy, but available data does not suggest a substantially increased risk of congenital malformations or spontaneous abortions
No pattern of malformations observed. Withdrawal symptoms Olanzapine – increased birth weight
What Clinicians need to do
Do not assume it is always better to stop medication Provide prompt and Effective treatment of mental illness in
pregnancy and postnatal period Understand, consider and communicate known risks (and how
these will be managed) of medication Complete risk benefit analysis for individual patient.