Perinatal mental health

Question 1

what is the leading cause of death in women in the first postnatal year

Answer 1

suicide

Question 2

what to consider in a risk assessment

Answer 2

Risk to self (suicide or DSH)
Risk to others 
Risk from others (Domestic Violence)
Drugs, Alcohol & Smoking
Compliance/ engagement
Physical Disabilities/ Cognitive impairments

Question 3

what are baby blues

Answer 3

mood swings, tearfulness, irritable, low and anxious, over-react to things at times. usually stops when baby is 10 days old

Question 4

features of post natal depression

Answer 4

depressive symptoms >2w

Question 5

features of post natal anxiety

Answer 5

anxiety symptoms >2w

Question 6

features of post partum psychosis

Answer 6

severe mental illness, normally occurs within 1 month after birth, symptoms fluctuate hour-hour and day-day

Question 7

confounding factors for post partum psychosis

Answer 7

PMH: bipolar affective disorder, schizoaffective disorder, schizophrenia or PPP

Fhx

traumatic birth or pregnancy

Question 8

what are the 3 Whooley screening questions

Answer 8

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 pleasure or interest in doing things?

If yes to either question, is this something you feel you need or want help with?

Question 9

symptoms to look for in post natal depression

Answer 9

Look for low mood, inability to enjoy/take
pleasure, guilt, hopelessness, suicidal thoughts, anxiety may be first symptom, Women may express negative/ ambivalent feelings towards infant and have doubts or concerns about ability to care for infant/ children

As severity increases level of function decreases

Suicidal and infanticidal thoughts may emerge

Emotions
unhappy, tearful, anhedonia, feeling restless, irritable, loss of self-confidence, feeling useless, worthless, hopeless and thoughts of suicide.
Thoughts
negative thinking, finding it hard to make even simple decisions and difficulty in concentrating.
Physical
losing appetite and weight, insomnia, fatigue, constipation, loss of libido
Behavior
difficulty in starting or completing things – even everyday chores, crying and avoiding contact with other people.

Question 10

RFs for antenatal depression

Answer 10

Past history of depression
Marital discord/ dissatisfaction
Inadequate social support
Recent adverse life events
Lower socio-economic status
Unwanted pregnancy 
< 16years old
Describes self as nervy, a worrier, angry, shy/self-conscious
Perfectionist
Family History
Major health problems
Baby of non-desired sex
For one third of women who get depressed in pregnancy, this is first episode of major depression

Question 11

define psychosis

Answer 11

losing touch with reality

Question 12

clinical features of psychosis

Answer 12

Delusions & Hallucinations
Mania - grandiose delusions, on an important mission or have special powers and abilities.
Depression – guilty delusions, that you are worse than anybody else, done something wrong, or don’t exist or body rotting.

Question 13

treatment for PND/ anxiety

Answer 13

Education on diagnosis- Acceptance
Psychosocial stressors
Psychological talking therapies
Medication
HTT/ Admission (Informal)

High Risk, not consenting to treatment/ lacks capacity- MHA
Admission (Section 2 or 3)
MBU/ General Adult ward/ PICU
ECT

Question 14

psychological therapy in PND/ anxiety treatment

Answer 14

Short term evidence based therapies such as CBT or CAT
Longer term mother-infant psychotherapy
Family therapy
Group Therapy

Question 15

pre-conception/ pregnancy advice

Answer 15

Healthy Lifestyle Advice
400mcg Folic Acid 3/12 before conception and 3/12 after
5mg Folic Acid (Medication that has teratogenic potential)
GP/Perinatal MH Service/ CMHT
Continue on Medication? Risk vs benefits
Do not stop medication suddenly
Problems conceiving check prolactin levels (?antipsychotic medication)

Question 16

risks of not taking medicine

Answer 16

Mother neglecting her health
Not attending appointments, missing out on antenatal care
Alcohol and drug use
If relapse may require a higher dose of medication or several medications and admission. More risky for baby than if remained on standard dose of medication
Unwell - difficult to care for baby and bond
Some research studies have found pre eclampsia more likely and low birth weight, premature, SIDS if their mother has untreated depression.
Untreated mental illness can also affect a baby’s development later on.

Question 17

medication for PND

Answer 17

1st line – Sertraline, Escitalopram (SSRI) & Mirtazapine (NASSAs)
Combination Antipsychotics (Olanzapine or Quetiapine)
Lamotrigine

Other antidepressants or mood stabilisers (risks vs benefits)

Question 18

side effects of SSRIs

Answer 18

First 2 weeks- nausea and more anxiety. Indigestion, which settles with food. They may interfere with sexual function. Rarely been reports of aggression.
However, most people get a small number of mild side-effects (if any).
The side-effects usually wear off over a couple of weeks as your body gets used to the medication.
More serious (but rare) – urinary retention, memory loss, confusion.

Question 19

Sife effects of SNRIs

Answer 19

Similar to the SSRIs, although Venlafaxine can also increase blood pressure

Question 20

side effects of NASSAs

Answer 20

Similar to SSRIs. But can cause drowsiness, and cause weight gain, but they cause less sexual problems.

Question 21

side effects of tricyclics

Answer 21

These commonly cause a dry mouth, a slight tremor, fast heartbeat, constipation, sleepiness, and weight gain.
In older people, they may cause confusion, slowness in starting and stopping when passing water, hypotension- syncope and falls. Avoid if heart trouble.
Interfere with sexual function
Tricyclic antidepressants are dangerous in overdos

Question 22

how long do mothers need to take antidepressants for?

Answer 22

at least 6 months after they start feeling better

Consider what the triggers are and ways to minimise them.
If had two or more attacks of depression then treatment should be continued for at least two years.

Question 23

risks of antidepressants during pregnancy- sertraline and escitalopram

Answer 23

No clear link with an increased risk of major malformations, miscarriage, stillbirth or baby being premature
7-9 months risk of high blood pressure
Birth “persistent pulmonary hypertension in the newborn” (or PPHN). The risk is very low: about 3/1000 compared to about 1/1000 if they did not. This can be treated.
Discontinuation symptoms - irritable, crying, shivering, or problems eating and sleeping. Usually mild, and go away in a few days without treatment. They can be helped if take medication whilst breastfeeding

Question 24

risks of antidepressants during breast feeding- sertraline and escitalopram

Answer 24

Breastfeeding a little more difficult to get started
They get into breast milk in very small amounts but not usually enough to affect the baby, unless the baby is premature.
The best ways to reduce the risks are:
Take once daily
Take straight after a main feed in the morning
Use expressed milk or formula feeds when levels of medicine in your body are likely to be highest

Question 25

risk of antipychotics in pregnancy- olanzapine and quetiapine

Answer 25

No clear link with increased risk of malformations, miscarriage or prematurity.
2nd & 3rd Trimester may reduce infants birth weight
Olanzapine be increase risk of pre-eclampsia, weight gain in mother- regular monitoring glucose, weight gain and blood pressure. Uncertain if Quetiapine has same effect.
May need higher doses of Quetiapine last 3months.
Birth discontinuation symptoms irritable, crying or problems eating or sleeping. Normally mild, go away in a few days without treatment.

Question 26

risk of antipsychotics in breast feeding- olanzapine and quetiapine

Answer 26

Gets in to milk usually very small amounts and not usually enough to affect baby, unless premature.
Best ways to reduce risks are;
Take OD
Take straight after main feed.
Use expressed milk or formula feeds when levels likely to be highest.

Question 27

monitoring for lithium

Answer 27

Routine serum-lithium monitoring should be performed weekly after initiation and after each dose change until concentrations are stable. Then every 3 months
Monitor BMI, U&Es, calcium and thyroid function every 6 months
Cardiac function before initiation and annually
Additional serum-lithium measurements should be made if a patient develops significant intercurrent disease or if there is a significant change in a patient’s sodium or fluid intake.

Question 28

signs of lithium toxicity

Answer 28

Feel very thirsty
Bad diarrhoea or vomiting
Hyperreflexia
Fasciculation
Confusion
Renal failure, dehydration, circulatory collapse (may need haemodialysis).
 Hypokalaemia.
 Death

Question 29

effects of lithium on baby

Answer 29

Lithium increases the rate of fetal heart defects to around 60 in 1000, compared with the risk of 8 in 1000 in the general population.

It is estimated that lithium increases the risk of Ebstein’s anomaly (a major cardiac malformation) from 1 in 20,000 to 10 in 20,000.

Question 30

monitoring of lithium DURING PREGNANCY

Answer 30

If a woman continues taking lithium during pregnancy, serum lithium levels should be checked every 4 weeks, then weekly from the 36th week, and less than 24 hours after childbirth;

the dose should be adjusted to keep serum levels towards the lower end of the therapeutic range, and the woman should maintain adequate fluid intake.