PERINATAL PSYCHIATRY

Dr N U MirConsultant in Perinatal PsychiatryHon Senior Clinical LecturerPerinatal Mental Health ServiceMichael Carlisle CentreSheffield

KEY TOPICS

History and role of perinatal psychiatry

Clinical presentation of common perinatal psychiatric disorders

Baby blues

Antenatal and postnatal depression

Postpartum (puerperal) psychosis

Prescribing in pregnancy and breastfeeding

HISTORY

Louis Victor Marcé

Paris

1828-1864

‘Traité de la Folie des femmes enceintes, des nouvelles accouchées et des nourrices’

NEED FOR PERINATAL PSYCHIATRY

Depression leading cause of world wide disability WHO Global burden of disease study

Suicide third leading cause of indirect maternal death CEMACE: Saving Mothers’ lives 2006 - 2008

Untreated perinatal disorders => morbidity / bonding / risk Pre-existing psychiatric disorders => increased relapse risk Bipolar disorder => Puerperal psychosis risk

Confidential Enquiry into Maternal Deaths in UK, Saving Mothers’ Lives 2006 – 2008, RCOG 2011

Lopez et al. Global and regional burden of disease and risk factors, 2001:systematic analysis of populationHealth data. Lancet 2006 367:1747-57

MEDIA SPOTLIGHT

ROLE OF PERINATAL PSYCHIATRY

Managing high risk women with previous postnatal episodes or complex circumstances

Treating antenatal moderate / severe anxiety and mood disorders

Managing pre-existing psychoses (eg. Bipolar disorder) during pregnancy

Pre-conceptual counselling

Advising on risks of medication during pregnancy and breastfeeding

CLINICAL PRESENTATION -IN CONTEXT-

ANTENATAL

Depression Generalised anxiety Panic disorder Pre-existing psychoses

(eg. Schizophrenia,

Bipolar disorder)

POSTNATAL

Baby blues Depression Postpartum (Puerperal)

psychosis

EFFECT OF CHILDBIRTH

Kendell RE et al 1987 Epidemiology of puerperal psychoses Br J Psych;150:662-73

NOSOLOGY

Wide variety of disorders occur in relation to parturition

Psychiatric illness may be precipitated by pregnancy and childbirth

New onsets or recurrence

Pregnancy can influence pre-existing psychiatric illness

Psychiatric disorders can influence obstetric course

ANTENATAL DEPRESSION

Estimated rates vary: 7-15% developed countries / 19-25% in developing countries

Poverty, lack of education, young age, poor social support, unplanned pregnancy associated with antenatal depression

50% postnatal depression starts during pregnancy

2/3 women with recurrent depression will relapse if discontinue antidepressants after conception

Association with low birth weight and IUGR, preterm delivery

Chung et al. 2001. Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes. Psychosom Med 63:830-4

CLINICAL PRESENTATION

Negativity towards pregnancy

Thoughts re termination of pregnancy

Worry about course and outcome of pregnancy - will I have a miscarriage? - will baby be healthy? - I won’t be able to cope with labour - I will be a bad mother

Ideas and acts of self harm

Relationship difficulties

TREATMENT OF ANTENATAL DEPRESSION

Treatment dependent on severity

Mild depression – psychological interventions counselling, CBT

Moderate depression – Risk benefit analysis - Antidepressant therapy (NICE) - CBT

Severe depression – Antidepressant therapy (NICE) CBT CMHT / Perinatal service follow up

PSYCHOSIS DURING PREGNANCY

Early referral to Perinatal Mental Health Service Regular community follow up by Perinatal Mental Health Service Maintenance antipsychotic therapy for high risk patients Schizophrenia, schizoaffective disorder, bipolar disorder with history

of relapse, residual symptoms or previous postnatal episodes Consider change to trifluoperazine Care coordinator CPA Planning meeting pre-childbirth Liaison with Children & Families / Social Services

POSTNATAL DISORDERS

Baby Blues

Postnatal Depression

Postpartum (Puerperal)Psychosis

BABY BLUES

Incidence per delivery: ~ 50%

Typical onset after delivery: Around 2 – 5 days

Symptoms: Depressed mood, irritability, lability of mood, crying

Prognosis: Transient. Increased risk of subsequent postnatal

depression

Treatment: Requires no intervention. Self limiting.

POSTNATAL DEPRESSION

Incidence per delivery: 10 – 15%

Typical onset: Within 6 months of delivery

Distinct from non-postpartum depression?

Little evidence to support distinction

Lack of consistent data on hormonal aetiology

DEPRESSIVE EPISODE (ICD-10 F32)

Group A symptoms Depressed mood, loss of interest and enjoyment, decreased energy

Group B symptoms a) reduced concentration and attention b) reduced self-esteem and self-confidence c) ideas of guilt and worthlessness d) bleak and pessimistic outlook e) ideas of self harm and suicide f) disturbed sleep g) diminished appetite

Four, six or eight symptoms required for TWO weeks Mild, Moderate, severe

RISK FACTORS FOR POSTNATAL DEPRESSION

Antenatal depression or anxiety

Past history of depression

Past history other psychiatric illness

Recent stressful life events

Poor social support

Musters et al. 2008. Management of postnatal depression. BMJ, 37, 399 - 403

CLINICAL PRESENTATION

Persistent low mood and tearfulness Low confidence / self esteem (‘bad mother’) Difficulty coping with childcare Difficulty bonding Extreme anxiety about health of baby Overconcern about feeding / sleeping regime Odd / overvalued ideas - eg. ‘Cord still attached to baby’ ‘Baby’s eyes are eyes of the devil’ Physical anxiety symptoms / panic attacks Suicidal thoughts Infanticidal thoughts Relationship difficulties / conflict

ASSESSMENT OF RISK

History

- Feelings of worthlessness, hopelessness- History of attempted suicide or harm to baby- Situational or environmental factors affecting risk

- Mental state

- Thoughts of suicide or harm to baby- Psychotic symptoms, delusions / hallucinations re baby

SCREENING – THE WHOOLEY QUESTIONS

Recommended by NICE

If the answer to either of first two questions is positive, proceed to third question

During the past month have you often been bothered by feeling down, depressed or hopeless?

During the past month have you often been bothered by having little interest or pleasure in doing things?

Is this something you feel you need or want help with?

Whooley et al. 1997. Case-finding instruments for depression: two questions are as good as many. J Gen Intern Med, 12:439-45

EDINBURGH POSTNATAL DEPRESSION SCALE

Developed for diagnosis of Postnatal depression

Simple self-rating 10 item scale

Effective screening tool

0-3 scoring

13 and above => Depressive illness likely

Cox et al. 1987. Detection of postnatal depression: development of the 10-item Edinburgh PostnatalDepression Scale. Br J Psychiatry 150: 782-786

TREATMENT OF POSTNATAL DEPRESSION (I)

MILD to MODERATE DEPRESSION

Self help strategies Non-directive counselling Brief Cognitive behaviour therapy Interpersonal therapy Support groups / organisations eg. Surestart

TREATMENT OF POSTNATAL DEPRESSION (II)

MODERATE DEPRESSION

Psychological therapy Antidepressant therapy* - if psychological therapy declined - if psychological therapy ineffective / partial response - if history of severe depression - requested by patient

*Consider breastfeeding issue

TREATMENT OF POSTNATAL DEPRESSION (III)

MODERATE to SEVERE

Combination therapy Psychological + Pharmacological Referral to Secondary care / Specialist Perinatal service CMHT follow up – CC Clinical psychology / Psychotherapy Inpatient care – Mother – Baby Unit - if risk issues - if community care ineffective - ECT

POSTPARTUM (PUERPERAL) PSYCHOSIS

Incidence: 1-2 / 1000 deliveries

Typical onset: Acute within 2-4 weeks of delivery

Mean age of onset: 26.3 yr

Risk factors: Past history of PP Family history of PP History of Bipolar disorder

BIPOLAR WOMEN AND RISK OF POSTPARTUM (PUERPERAL) PSYCHOSIS

0

100

200

300

400

500

600

Pop BP PrevPP

Episodes of PPper 1000deliveries

Jones & Craddock,Am J Psych 2001

TYPES of PSYCHOSIS IN RELATION TO CHILDBIRTH

Chronic - Schizophrenia

Acute - Organic psychoses (becoming rarer) - Schizophrenia (rare) - Affective – manic / depressed / mixed / schizoaffective “Puerperal Psychosis”

CLINICAL FEATURES

ICD 10 F53.1

Severe mental and behavioural disorder associated with puerperium, not elsewhere classified

‘Kaleidoscopic’

Quickly changing from one thing to another

CLINICAL FEATURES

Mood symptoms - Depressed mood, lability, elation, rambling speech, overactivity

Psychotic symptoms - Delusions – fleeting not fixed, systemetisation not usual - re baby, mood incongruent, persecutory, reference, jealous, grandiose - Hallucinations – Auditory, visual, olfactory

Perplexity and confusion

Sit et al. 2006. A review of postpartum psychosis. J Women’s Health, 15, 4: 352-68

SUICIDE AND INFANTICIDE

CEMACH: Saving Mothers Lives 2003 – 2005 - Suicide second leading cause of indirect deaths

1000 women with PP => 2 suicides

More likely to be violent means eg. Hanging, self incineration, jumping from height

More likely to express homicidal ideation though homicidal behaviour rare

Confidential enquiry into Maternal deaths, Saving Mothers Lives 2003 – 2005, RCOG 2007

Sit et al. 2006. A review of postpartum psychosis. J Women’s Health, 15, 4: 352-68

TREATMENT OF POSTPARTUM (PUERPERAL) PSYCHOSIS

1) Inpatient (M-B) Unit admission – under MHA if necessary

2) Symptom focussed pharmacotherapy - Atypical antipsychotic - Antidepressant 3) Lithium - bottle feeding v breast feeding - Regular level checks – neonatal toxicity risk - Prophylaxis if past history of PP

4) - Valproate, Carbamazepine, Lamotrigine

TREATMENT OF POSTPARTUM (PUERPERAL) PSYCHOSIS

5) ECT - Deteriorating self care - Suicidality - physical risk

6) Maintenance pharmacotherapy / follow up

7) Consider past treatment response / side effects profile / acuity of illness as guide

STEPPED CARE MODEL

GPs, obstetricians, midwives, health visitors,

practice nurses

General healthcare services (maternity and primary care)

Detection of history ofand current mental

illness; referral

GPs, obstetricians, psychological

therapists, PCMHWs

Primary care mental health services

Assessment and referral; treatment of

mild to moderate illness

CMHT (psychiatrists, psychologists, nurses

social workers)

Specialist mental health services

Assessment; treatment; referral to specialist services;

inpatient care

Specialist perinatal mental health

services

Psychiatrists, nurses,nursery nurses, psychologists

Prevention, management& treatment of moderate/severe

illness; specialist advice and consultation to primary care

Personnel Service Core functions

PRINCIPLES OF PRESCRIBING PSYCHOTROPIC MEDICATION

Careful risk-benefit assessment If mild to moderate severity, use non-pharmacological intervention Avoid first trimester exposure if at all possible Choose drugs with lower risk profiles for mother / foetus / infant Start lowest effective dose and increase slowly Tricyclic antidepressants (amitryptiline, imipramine, nortripyline)

lowest known risks in pregnancy but dangerous in overdose SSRI’s: Relatively safe, fluoxetine lowest risk, Sertraline (breast

feeding) Trifluoperazine, haloperidol antipsychotics of choice Avoid polypharmacy if at all possible

RISK-BENEFIT ANALYSIS

RISK OF DRUGS

Risk of teratogenicity Risk of neonatal withdrawal Risk of longer-term

neurobehavioural / cognitive problems

Risks in breastfeeding

RISK OF ILLNESS

Untreated illness may affect birth weight and gestational age at delivery

Possible detrimental effect of sress in pregnancy on foetus

May impact on mother-infant attachment and later infant development

ANTIDEPRESSANTS IN PREGNANCY

Tricyclic antidepressants (amitryptiline, imipramine, nortriptyline) lowest known risks in pregnancy but more dangerous in overdose

SSRI’s: Fluoxetine lowest risk; Sertraline, citalopram Association with Persistent pulmonary hypertension, septal heart

defect (Tuccori et al, 2009; Pedersen et al, 2009) though absolute risk small

Neonatal withdrawal symptoms possible with antidepressants - taper if clinically appropriate prior to delivery

Tuccori et al. 2009. Safety concerns associated with the use of Serotonin Reuptake inhibitors and other Serotonergic/Noradrenergic antidepressants during pregnancy: a review. Clinical Therapeutics 31:1426-1453Pedersen et al. 2009. Selective serotonin reuptake inhibitors in pregnancy and congenital malformations:Population based cohort study. BMJ 339, 3569-3575

ANTIDEPRESSANTS AND BREASTFEEDING

Antidepressants transfer readily into human milk though often at levels far below clinical range

Certain considered safer than others though in general long term outcomes for exposure unknown

Low levels in breast milk: Imipramine, nortripyline, sertraline

Higher levels in breast milk: fluoxetine, citalopram

Other SSRI’s / SNRI’s / newer antidepressants should be avoided until more data available

BENZODIAZEPINES

Associated with cleft palate, neonatal withdrawal and floppy baby syndrome

Only for short-term treatment of extreme anxiety and agitation

Consider gradually stopping in pregnant women

If prescribed, keep to lowest possible dose for shortest possible time

Avoid if possible or decrease in late pregnancy

Dolovich et al. 1998. Benzodiazepine use in pregnancy and major malformations or oral cleft: meta-analysis of cohort and case-control studies. BMJ, 317, 839-43

LITHIUM

Ebstein’s anomaly risk raised from 1 in 20,000 to 10 in 20,000

Do not prescribe routinely esp 1st trimester or breastfeeding

Well and LOW RISK => stop gradually over 4 weeks

Not well and HIGH RISK=> switch gradually to antipsychotic

stop & restart 2nd trimester

continue if high risk

monthly level monitoring

National Institute for Health and Clinical Excellence. Antenatal and postnatal mental health: clinicalmanagement and service guidance. Clinical guideline 45

VALPROATE

Neural tube defects risk raised from 6 in 10,000 to 100 -200 in 10,000

Developmental problems / Autistic spectrum disorder

‘Foetal valproate syndrome’

Do not routinely prescribe to women of childbearing potential

Explain risks

Consider alternative in bipolar (eg. Antipsychotic)

If no alternative, limit to maximum 1g daily in divided doses and slow release form, with 5mg folic acid

Kini, U 2006. Fetal valproate syndrome: a review. Ped & Perinatal Drug Ther 7(3) 123 - 30

ANTIPSYCHOTICS

Trifluoperazine : safest in pregnancy and breastfeeding

Risperidone, amisulpiride: raised prolactin levels

Olanzapine: weight gain, gestational diabetes

Clozapine: Do not routinely prescribe but some case reports of its successful use

Avoid depot medication

Current evidence not suggestive that antipsychotics are major teratogens. Possibly small risk of cardiovascular malformation

(1-1.5%) though no specific drug implicated

Reis & Kallen 2008. Maternal use of antipsychotics in early pregnancy and delivery outcome. J Clin Psychopharmacol 28(3):279-88

EXPLAINING RISKS

Before making treatment decisions discuss absolute and relative risks associated with treating and not treating the mental disorder during pregnancy and postnatal period

Acknowledge uncertainty surrounding risks Explain background risk of fetal malformations for pregnant women

without mental disorder (2-4%) Describe risks using natural frequencies (1 in 10 vs 10%) Use decision aids Written material Audiotaped records of consultation if possible

PSYCHOLOGICAL TREATMENTS

Women requiring psychological treatment during pregnancy should have rapid access to it

Should be seen normally within 1 month and no longer than 3 months afterwards

Lower threshold for access due to time-limited nature of pregnancy and changing risk-benefit ratio for psychotropic medication

Counselling

Cognitive behaviour therapy (CBT)

Interpersonal therapy

Psychodynamic therapy

SOCIAL INTERVENTIONS

Housing

Employment

Benefits

Support network (Surestart, postnatal groups)

Children & Families (Social Services) liaison

SUMMARY

Role for Perinatal Psychiatry in recognition and management of mental disorders during pregnancy and child birth

Antenatal & postnatal depression, baby blues common may be managed in primary care

Puerperal psychosis needs secondary care / perinatal service

Special consideration of risk / benefit issues in pregnancy & breastfeeding

Outcomes after treatment of most perinatal disorders good