Perinatal and Forensic

Question 1

Perinatal - epidemiology

Perinatal = increased risk of de novo or relapse

Answer 1

15-30% PND; 10% major depressive episode
3-5% mod-severe depression (ADD needed)
2% referred psychiatry; 0.4% Ax, 0.2% psychosis

T1 > gen pop; mild and Rx-responsive; first onset rare; T3 anx/depp can continue as PND

Question 2

perinatal - types

Answer 2

pre-existing
onset in pregnancy
post-natal onset

‘the pinks’ normal; first 48h PP; no Rx
-euphoria, insomnia, talking/active;
‘the blues’; PND; PP

Question 3

baby blues

?Biological; not linked to life events

Answer 3

50-80%; hormones + exhaustion (phys/psych)
onset 3-10 days; peak d5; duration 48h
low risk , no Rx

labile, tearful, mild anxiety, irritable
mild, not pervasive (not affecting lots)

Question 4

post natal depression

psychosocial: complications, support, young, stressors

PMH 30% depp, PND 70-85%

Answer 4

15-30%; peaks 2-4 weeks (Second peak 3/12; mild)
2/3 resolve in 2-3 months with Rx
-6/12 if no Rx

50% recurrence risk in future PP if previous severe depression or PND

depp Sx + guilt/concern about parenting skill, affection/bonding
anxious preoccupation, obsession, dystonic harm thoughts

Question 5

puerperal psychosis - features

Answer 5

rapid onset: d4-w3, always

Question 6

puerperal psychosis - aetiology

Answer 6

biological: related to BAD and severe depression
-likely to have PPH/FHx for mood disorders
psychosocial less important

RF: primip, previous PP, previous c/s, previous perinatal death

Question 7

puerperal psychosis - stats

Answer 7

0. 2% (1in500); BAD = 50% risk; 99% risk if BAD or schizoaffective
   onset: 50% d7, 75% d16, 95% d90

80% resemble mood disorder + psychosis

Question 8

puerperal psychosis - management

Answer 8

risk assessment esp. infanticide and suicide

• RF: harm thoughts, severe delusions, command halls
• inpatient: mother and baby unit

bio: APD, ADD, lithium, BZD (behaviour), ECT
- beware BF

Question 9

puerperal psychosis - prognosis

Answer 9

ST good: most recover 3/12, 75% by 6/52
30% recurrence in future preggo; 50-85% if non-pueperal mood disorder

M/M risk, lots of intense IP care

Question 10

perinatal screening

Answer 10

booking in screening: PPH and FH
6 week check
contact details for presentation

Question 11

perinatal prevention

Answer 11

birth plan by 35/40
monitor MH after deliver
PPx meds if needed
?child protection
emergency contact details; liaison staff

Question 12

forensic - crime

Answer 12

ADD

Question 13

forensic - schizophrenia

Answer 13

associated with violence but minority

delusions and pre-emptive violence
command AH and passivity
poor insight

Question 14

forensic - substances

Answer 14

stronger link to violence than other MH

direct effects of intoxication, dependence, or long term use

indirect e.g. for funding

Question 15

forensic - PD

Answer 15

especially antisocial PD

impulsivity, lack of empathy/remorse, paranoia, anger management issues

often associated with substance abuse

Question 16

forensic - psychopathy

Answer 16

cognitive, affective, behavioural Sx:

• interpersonal: callous, superficial, manipulative
• affective: temper, no guilt or fear
• behaviour: impulsive, criminality-prone

strongly linked to violence

Question 17

forensic - sexual offenders

Answer 17

most have no MH (only 25-50% have PD)
associated with LD, hypomania, psychosis, brain damage

assess: PPH, psychosexual history, MSE, risk

Rx: CBT, cyproterone acetate, SSRI

Question 18

forensic -risk assessment

Answer 18

hazard = harm potential
risk = probability of harm

risks: DSH/SI, harm to others, substances, neglect, vulnerable/exploit, concordance,

Question 19

forensic - defences

require mental illness/brain abn affecting function

Answer 19

• fitness to plead: capacity (understand charge and evidence, instruct lawyer, challenge juror, plead)
• insanity: absence of understanding; acquittal
• diminshed responsibility: murder reduced to manslaughter; impaired responsibility
• automatism: absence of intent; unable to control physical acts
  e. g. delirium, hypoG, seizures, sleepwalking

Question 20

forensic - pre-sentencing

Answer 20

35: assess/report; 28d-12w; court + 1DR
36: Rx IP; 28d-12w; court + 2Dr
48: transfer for Rx; home office; 2Dr
49: restriction of movement; 1DR

Question 21

forensic - during sentencing

Answer 21

37: treatment; 6 months; court; 2DR
38: treat/test response (esp/ PD); 8-12/52; court
41: restriction; unlimited time; court +1DR

Question 22

forensic - post-sentencing

Answer 22

47: transfer to treat; HO + 2DR
49: restriction; HO

Question 23

PP assessment

Answer 23

onset

Question 24

PP/PND treatment

Answer 24

lithium/BZD = teratogenic/tox
TCA = ?safer
SSRI and APD ok but EPSE risk in neonates
-paroxetine teratogenic

ECT rapid and effective; severe and treatment-resistant

counselling commonest; ADD if severe PND/PP

Question 25

forensic - violence RF

Answer 25

• history: previous, substances, MH, PD
• clinical: dels/halls, thoughts, plans/threats, violent fantasy, impulsive, insight
• external: access to victims and weapons
• other: unemployment, gender, substances