[54] Post-Natal Depression Flashcards
What is postnatal depression defined as?
Non-psychotic illness occurring during the first postnatal year
What should the term ‘postnatal depression’ not be used as?
An umbrella term for all mental health problems following delivery
What are the different scenarios in which post-natal depression can occur?
- De novo
- Recurrence of depressive condition occurring prior to pregnancy
- Part of wider problem, e.g. bipolar disorder
How does the overall prevalence of PND compare to depression at other times?
Probably not significantly more common in the post-natal period than other times
What is the prevalence of PND in the developed world?
10-15%
What % of women with PND symptoms seek or obtain medical advice?
As few as 15%
What are the strongest risk factors for PND?
- Previous history of mental health problems
- Psychological disturbance during pregnancy
- Poor social support
- Poor relationship with partner
- Baby blues
- Recent major life events
What are the less strong risk factors for PND?
- Unplanned pregnancy
- Unemployment
- Not breast-feeding
- Antenatal parental stress
- Antenatal thyroid dysfunction
- Longer time to conception
- Depression in father of child
- Having 2 or more children
- Current, or history of, substance misuse
- Neonatal low birth weight or illness, stillbirth, or SIDS
What are the weakest risk factors for PND?
- Obstetric complications
- History of abuse
- Low family income
- Lower occupational status
How does PND present?
Same as depression in other circumstances, including;
- Low mood
- Low enjoyment and pleasure
- Anxiety
- Disturbed sleep
- Loss of appetite
- Poor concentration
- Low self-esteem
- Low energy levels
- Loss of libido
- Thoughts of death/suicidal thoughts
What needs to be considering when a patient presents with symptoms of PND?
Some of these symptoms can be normal in the early post-natal period, e.g. sleep disturbance, tiredness, anxiety about the baby
What should HCPs be aware of regarding the symptoms of PND?
Women may be unwilling to disclose symptoms of depression and other mental health problems
Why might new mothers be unwilling to disclose symptoms of depression and other mental health problems?
- Fear or stigma
- Fear the baby may be taken into care
- Concern they will be perceived as a poor mother
- Problems with alcohol or substance dependence
What can screening questions for PND be asked?
At booking at postnatal checks
What screening questions for PND can be asked at screening and postnatal checks?
- During the past month, have you often felt 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?
What should be done if the answer to the screening questions for PND is yes, or if there is clinical suspicion?
Further assessment is required
What can be used to help the assessment of a woman who answers yes to the screening questions for PND, or there is clinical concern?
Formal assessment tool, e.g. Edinburgh Postnatal Depression Scale
What are the general principles of the management of PND?
- Empowerment
- Communication
- Wider family environment
What is involved in empowerment in PND?
- Involve women in decisions about their care
- Reassure that postnatal depression is not uncommon
- Be optimistic about its resolution
What should be done if a mother with PND lacks capacity?
Follow Department of Health guidelines and code of practice accompanying the Mental Capacity Act
What communication is important in PND?
- The woman, her relatives, and carers should be given information in a form that is culturally appropriate
- Communication between all HCP involved is vital for integrated care
What needs to be considered in PND regarding the wider family environment?
Consider needs of other children, dependent adults, and the effect the illness may have on the relationships with partners
What always needs to be considered in the management of PND?
Welfare of the baby
What should the choice of treatment in PND be decided based on?
- Efficacy
- Previous response to treatment
- Incidence of side effects
- Likely compliance
- Patient preference
- Safety during breastfeeding
How should mild to moderate PND be managed?
Consider facilitated self-help strategies
How should mild to moderate depression be managed when there is a history of severe depression?
Consider anti-depressant
What are the management options for moderate to severe PND?
- High intensity psychological intervention
- Antidepressant treatment
- Combination of psychological therapy and antidepressants
Give an example of a high intensity psychological intervention
CBT
When should antidepressants be used in mild to moderate PND?
- Risks are understood and accepted
- Woman declines psychological therapy
- Psychological therapies have failed
How should severe PND with thoughts of suicide or harming the baby be managed?
- Immediate referral for urgent psychiatric assessment
- Child protection procedures may need to be invoked
Can antidepressants be used in breastfeeding women?
Evidence remains unclear about role and safety of antidepressants in breast-feeding women, and so decisions have to be made on an individual basis
What do the NICE guidelines say about antidepressants and breastfeeding?
Women should be encouraged to breastfeed, unless they are taking;
- Lithium
- Sodium valproate
- Carbamazepine
- Clozapine
How does the threshold for pharmacological therapy in the treatment of depression vary in pregnancy compared to other times?
It is higher
Describe the course of PND
Widely variable, and will depend on predisposing factors and response to treatment
By when do most cases of PND resolve?
3-6 months
What proportion of women will have symptoms of PND after 6 months?
1/4
What is untreated PND associated with?
Adverse effects on the infant
What adverse effects on the infant are associated with untreated PND?
Short-term and long-term poor cognitive, emotional, social, and behavioural development
When are the adverse effects of PND on the infant seen?
When the mother is unable to engage actively with the infant
What does NICE recommend for the prevention of PND?
Women are proactively screened for mental health problems, and high-risk patients identified
When should HCPs screen for depression and anxiety?
- Booking
- Postnatally at 4-6 weeks and 3-4 months
What questions should be asked to screen for depression and anxiety?
- Past or present severe mental illness
- Previous treatment by psychiatrist/specialist mental health team, including inpatient care
- Family history of severe perinatal mental illness in first-degree relative
What past or previous severe mental illness should be asked about when screening for PND?
- Schizophrenia
- Bipolar disorder
- Psychosis in postnatal period
- Severe depression
What should done when a woman is identified as high risk of developing severe depression, or with a history of severe mental illness?
Referral to secondary care mental health services
