Perinatal and Forensic Flashcards
Perinatal - epidemiology
Perinatal = increased risk of de novo or relapse
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
perinatal - types
pre-existing
onset in pregnancy
post-natal onset
‘the pinks’ normal; first 48h PP; no Rx
-euphoria, insomnia, talking/active;
‘the blues’; PND; PP
baby blues
?Biological; not linked to life events
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)
post natal depression
psychosocial: complications, support, young, stressors
PMH 30% depp, PND 70-85%
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
puerperal psychosis - features
rapid onset: d4-w3, always
puerperal psychosis - aetiology
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
puerperal psychosis - stats
- 2% (1in500); BAD = 50% risk; 99% risk if BAD or schizoaffective
onset: 50% d7, 75% d16, 95% d90
80% resemble mood disorder + psychosis
puerperal psychosis - management
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
puerperal psychosis - prognosis
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
perinatal screening
booking in screening: PPH and FH
6 week check
contact details for presentation
perinatal prevention
birth plan by 35/40 monitor MH after deliver PPx meds if needed ?child protection emergency contact details; liaison staff
forensic - crime
ADD
forensic - schizophrenia
associated with violence but minority
delusions and pre-emptive violence
command AH and passivity
poor insight
forensic - substances
stronger link to violence than other MH
direct effects of intoxication, dependence, or long term use
indirect e.g. for funding
forensic - PD
especially antisocial PD
impulsivity, lack of empathy/remorse, paranoia, anger management issues
often associated with substance abuse
forensic - psychopathy
cognitive, affective, behavioural Sx:
- interpersonal: callous, superficial, manipulative
- affective: temper, no guilt or fear
- behaviour: impulsive, criminality-prone
strongly linked to violence
forensic - sexual offenders
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
forensic -risk assessment
hazard = harm potential risk = probability of harm
risks: DSH/SI, harm to others, substances, neglect, vulnerable/exploit, concordance,
forensic - defences
require mental illness/brain abn affecting function
- 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
forensic - pre-sentencing
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
forensic - during sentencing
37: treatment; 6 months; court; 2DR
38: treat/test response (esp/ PD); 8-12/52; court
41: restriction; unlimited time; court +1DR
forensic - post-sentencing
47: transfer to treat; HO + 2DR
49: restriction; HO
PP assessment
onset
PP/PND treatment
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
forensic - violence RF
- 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
