Perinatal Mental Health - UiO

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Perinatal Mental Health: An Obstetrician´s Perspective Ganesh Acharya, MD, PhD, FRCOG Professor and Head of Division of Obstetrics and Gynecology Institute of Clinical Science, Intervention and Technology Karolinska Institutet, Stockholm, Sweden Adjunct Professor, UiT - The Arctic University of Norway

Transcript of Perinatal Mental Health - UiO

Page 1: Perinatal Mental Health - UiO

Perinatal Mental Health: An Obstetrician´s Perspective

Ganesh Acharya, MD, PhD, FRCOG Professor and Head of Division of Obstetrics and Gynecology Institute of Clinical Science, Intervention and Technology Karolinska Institutet, Stockholm, Sweden Adjunct Professor, UiT - The Arctic University of Norway

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Preeclampsia Pulmonary embolus Preterm labor Postpartum bleeding Perineal trauma Puerperal or postabortal sepsis Perinatal depression and psychosis

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Ignác Semmelweis (1818–1865) Alexander Fleming (1881-1955)

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Birth of Perinatal Psychiatry Treatise on insanity in pregnant, postpartum, and lactating women (1858) by Louis-Victor Marcé

Source: Wikipedia

Maternal mental health Paternal mental health Fetal Mental health Neonatal mental health

Fetal behavior Fetal awareness Fetal perception of pain Fetal response

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Scope of the problem © Royal College of Obstetricians and Gynaecologists 2017

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Prevalence of perinatal mental ill-health is high but varies widely Collins et al. Arch Womens Ment Health 2011;14:3–11.

• High income countries 13%

• Low and middle income countries (LNIC) 20%

• Immigrants 42%

• Recent SR of studies from LMIC * 17% (major depressive disorder) 31% (any depressive disorder)

* Fellmeth G, Fazel M, Plugge E. Migration and perinatal mental health in women from low- and middle-income countries: a systematic review and meta-analysis. BJOG 2017;124:742–75.

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Prevalence of antenatal distress

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Prevalence of postnatal distress

Prevalence estimates of postnatal distress*

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Perinatal Maternal Mental Health: Causes & Associations

The underlying biological mechanisms have not been fully understood

Women´s Mental Health

Biology (Inherited and

acquired predisposing

factors)

Family, social network and

society

Education and Awareness

Physiological and

pathological changes in pregnancy

Women´s Mental Health

Personality traits, genetic

predisposition pre-existing

mental health problems

Mental trauma including

violence, rape, abuse

Adverse pregnancy outcomes

Antenatal stressors,

Comorbidities, and pregnancy complications

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Risk Factors for Perinatal Mental Disorders

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Risk factors are many, but some are more important • History of mental health problems, education, age

• Unwanted pregnancy

• Complications in pregnancy (Preterm birth, Twins, C-Section, PPH)

• Intimate and social relationship/support problems

• Financial problem

• Stressful events/emotional problems

• Substance abuse

• Sick baby and/or problems with breast feeding

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THE WOUNDED ANGEL BY HUGO SIMBERG

The Spectrum of Presentation is Very Wide

Baby Blues (mood swings, crying spells, insomnia) Anxiety (Tokophobia, panic) Postnatal depression Postnatal Psychosis Self-harm/Suicide

Eating disorders Personality disorders Substance abuse (alcohol, tobacco, opioids etc) Post-traumatic stress

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Screening, Risk Stratification and Diagnosis

Sometimes, the reality may be different from what you see!

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Perinatal Maternal Mental Disorder: Predictive Model

Women´s Mental Health

Genetic makeup

Family, social

network and society

Education and

Awareness

Changes caused by pregnancy

Women´s Mental Health

Personality traits, pre-

existing mental health

problems

Mental trauma including

violence, rape, abuse

Adverse pregnancy outcome

Antenatal stressors,

Comorbidities, and pregnancy complications

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What test to perform? Screening questionnaires and Psychological assessments

• WHO Self Reporting Questionnaire (SRQ12 or the SRQ20)

• Edinburgh Postpartum Depression Scale (EPDS) (Cox, 1987)

• Generalized Anxiety Disorder (GAD7) (Spitzer et al. 2006)

• Perceived Stress Scale (PSS-14) (Cohen, 1983).

• Structured Clinical Interview for DSM-IV-R for Axis I disorders (SCID-IV-R)

• Beck Depression Inventory

Biomarkers

• Hormones (dopamine, homovanillic acid, prolactin, oxytocin, estrogen, progesterone, testosterone)

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Could other tests that may be useful? They are not/cannot be routinely performed

• Eye blink count to test for adrenergic activity

• Functional transcranial Doppler

• Functional Magnetic resonance imaging

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Too many questions and too much time consuming Effect of physical comorbidity is ignored

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Effect on Fetus is not well evaluated

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Can personality tests be useful for screening?

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Leopold Szondi (1893-1986)

Sadism Hysteria Paranoia Mania Hermaphroditism Epilepsy Catatonia Depression

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Problems

• A comprehensive multidimensional assessment of a pregnant woman's physical health, psycho-social circumstances (e.g. life style, sources of support, quality of her relationships, recent life stressors, past or current physical or sexual abuse) during the antenatal period may not always be realistic.

• Physical comorbidities and complications arising during pregnancy may not be easily accounted for.

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Changing times and new challenges

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Rise of CS rates globally Only 3 percent of women elect to have the procedure because they are afraid of vaginal birth

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Comorbidity

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The uterus can be repaired but not the damage

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Our patients are fragile and vulnerable: Manage them with empathy & care

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Stigmatization of Mental Health Disorders Don´t see + don´t talk + don´t hear = Don´t care

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Care Pathways and Guidance

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Management: What works and what does not?

Counselling and support (coping vs autonomy), Cognitive behavioral therapy (individual vs group), Pharmacotherapy

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CONCLUSIONS • Longitudinal trends from preconception period, first trimester,

second trimester to third trimester and postnatal period need to be clarified.

• Screening once in pregnancy may not be enough to diagnose perinatal depression.

• Simple, sensitive and reliable screening and diagnostic test are needed.

• A reliable biomarker for screening/diagnosis is still to be found

• Awareness is important be able to get timely help.

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Integrating research and education into clinical practice is the way forward

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Thank you for listening