Perinatal psychiatry

Question 1

Which periods surrounding child-birth and pregnancy are most associated with psychiatric illness?

Answer 1

Pregnancy is generally a time of mental well-being and the development of mental disorders is unusual.

The more risky period is the puerperium period (after birth).

Question 2

Which psychiatric medications are thought to be more safe in pregnancy?

Answer 2

1) TCAs
2) SSRIs
3) Antipsychotics although extra-pyramidal side effects may occur in neonates

Question 3

Which psychiatric medications are thought NOT to be safe in pregnancy?

Answer 3

1) lithium and 2) benzodiazepines are probably teratogenic

Question 4

What are the main puerperal (after birth) disorders?

Answer 4

1) Postnatal blues
2) Postnatal depression
3) Puerperal psychosis

Question 5

What % of women experience the postnatal blues?

Answer 5

50%

Question 6

What period do the postnatal blues occur?

Answer 6

Within the first 10 days after delivery

Question 7

What are the symptoms of the post natal blues?

Answer 7

1) Episodes (that peak between the 3rd and 5th day) of weepiness associated with:
2) mild depression or
3) emotional lability
4) anxiety
5) irritability

Question 8

What is the aetiology of the post-natal blues thought to be? (and why)

Answer 8

Biological (The lack of a link between postnatal blues and life events, demographic factors or obstetric events)

Question 9

What generally is the treatment required for the postnatal blues?

Answer 9

Reassurance (but may precede postnatal depression)

Question 10

What are the risk factors for developing postnatal depression? (PND)

Answer 10

1) Mainly psychological ones (e.g. stressful life events, lack of a confiding relationship, etc.)
2) Obstetric complication
3) Biological risk factors are limited

Question 11

What is the prevalence of PND?

Answer 11

10% (1 in 8 women, this is roughly the same as in the general population)

Question 12

Within how long post-partum does PND usually develop?

Answer 12

Within 3 months

Question 13

How long does PND usually last?

Answer 13

2-6 months

Question 14

What additional symptoms occur in PND that are less common in normal depression?

Answer 14

1) Anxious preocupation about babies health
2) Reduced affection for the baby -> which may impair bonding
3) Obsessional phenomena which may be infanticidal

Question 15

Can antidepressants be used whilst breast-feeding?

Answer 15

Yes, despite antidepressants having the ability to pass to through breat milk. This is not an ideal situation though.

Question 16

Describe the course of puerperal psychosis.

Answer 16

Episodes typically

1) have a rapid onset
2) usually between day 4 to 21 days (3wks) post delivery and almost always within 8 weeks

Question 17

What psychiatric condition is puerperal psychosis (in 80%) similar to?

Answer 17

80% of cases the presentation resembles a mood disorder with delusions and hallucinations

Question 18

What are the common symptoms in puerperal psychosis?

Answer 18

1) insomnia
2) restlessness
3) perplexity
later progressing to:
4) suspiciousness
5) marked confusion with psychotic symptoms

Question 19

How common is puerperal psychosis?

Answer 19

Occurs in around 1 in 500 births

Question 20

How can puerperal psychosis be treated with medication?

Answer 20

May include antipsychotics, antidepressants and lithium.

Benzodiazepines can also be used with severe behavioural disturbances.

Question 21

What is the prognosis for puerperal psychosis?

Answer 21

Most cases recover within 3 months (75% within 6 weeks)

Question 22

What is the risk of recurrance of puerperal psychosis with future pregnancies?

Answer 22

30%

Question 23

Are TCAs safe in breast feeding?

Answer 23

The amount transmitted in breast milk is too small to be harmful.
Low dose amitriptyline appears to be safe

Question 24

Are SSRIs safe in breast feeding?

Answer 24

Limited information available but the manufacturers advise caution.
Fluoxetine is excreted in very small amounts but has a long half-life so may accumulate

Question 25

Is Lithium safe in breast feeding?

Answer 25

Risk of neonatal lithium toxicity as breast milk contains 40% of maternal lithium concentration

Question 26

Are antipsychotics safe in breast feeding?

Answer 26

Only small amounts are excreted but there is a possible effect on developing nervous systems.

Avoid high doses due to risk of lethargy in infants.

Only use when benefits outweigh risks.

Question 27

Are benzodiazepines and other hypnotics safe in breast feeding?

Answer 27

No. May cause lethargy.

Question 28

If there are thoughts of infanticide what must you ascertain?

Answer 28

ascertain if these are repulsive thoughts to the patient or not

as if they are not repulsive they may be seriously entertained.

Question 29

What can thoughts of infanticide worryingly involve?

Answer 29

a degree of planning

Question 30

Do symptoms of puerperal psychosis fluctuate or remain constant?

Answer 30

They can fluctuate dramatically in their nature

and intensity

over a relatively short period of time