Perninatal psychiatry Flashcards
Psychiatric conditions in pregnancy
- How common are psychiatric conditions in pregnancy?
- Do pts with pre-existing psychiatric histories have an increase in episodes during pregnancy?
- Uncommon
- No
Is the same true for the puerperium period (After birth)?
-1 month following miscarriage what % of women have a diagnosable depressive disorder?
- No
- 50% (4x normal), with atypical features of bereavement
- No significant increase in the rates of mental illness following a termination of pregnancy, society is more excepting now
What need to be weighed up when medication is indicated?
- Which of the following medication is safe or teratogenic?
- Lithium
- Benzodiazepines
- TCAs
- SSRIs
- Antipsychotics
-Risk of relapse against teratogenic/adverse effects
Teratogenic medication includes
-Lithium
-Benzodiazepines
Safer
- TCAS
- SSRIs
- Antipsychotics; EP S.Es may ocur in the neonate
Puerperal Disorders
- IS this a high risk period?
- What 3 main conditions should be considered when evaluating a womens psychological symptoms?
-Yes for the relapse of pre-existing mental illness as well as the development of a new mental illness
- Postnatal blues
- Postnatal depression
- Postnatal psychosis
Postnatal Blues
- What % of women does this occur in?
- It occurs within how many days?
- What is it characterised by?
- How long does it take to peak?
- What is the cause?
- How is it managed?
- 50% postpartum women
- 1st 10 days post delivery
- Episodes of weeping
- Mild depression
- Emotional liability
- Anxiety
- Irritability
- Peaks between the 3rd and 5th day
- Biological; fall in progesterone post-delivery
- Its a self limiting condition, usually only requires reassurance
- An apparently bad case may actually be the onset of postnatal depression
Postnatal depression
-What factors are strongly implicated?
- A previous history of what is particularly important?
- What else is a risk factor?
- How important are biological factors?
Psychosocial factors
- Recent stressful life events
- Lack of a close confiding relationship
- Young maternal age
- Marital status
- A previous history of depression, especially PND or postnatal blues
- An obstetric complication during delivery is also a risk factor
- They are less important
What is the prevalence of postnatal depression?
- 10-15%
- No socioeconomic class or parity factors are implicated
Clinical features?
- Usually develops over that time period?
- How long does it last for?
- Symptoms?
-Within 3 mnths after delivery
-2 to 6 months
Symptoms are similar to normal depressive episodes, include;
-Low mood
-Loss of interest
-Fatiguability
-Suicidal ideation
-Anxious preoccupation with the babies health
-Reduced affection for the baby with impaired bonding
-Obsessional phenomena which may involve recurrent intrusive thoughts of harming the baby (important to ascertain if they are ego-dystonic thoughts or not - repulsive thoughts)
-Infanticide thoughts that are not experienced as repugnant (ego-syntonic) and may be seriously entertained, and involve a degree of planning
Management
- What is the treatment of choice in most cases?
- In more severe cases what may be needed?
- Counselling
- Medication and in very severe cases admission to a mother and baby unit
- ECT is highly effective when implicated and results in rapid improvement
- An assessment of the infants wellbeing is vital as part of a comprehensive psychosocial and risk assessment
What is the Prognosis?
- Most respond to treatment
- Should be followed up closely
- May need long term therapy
- Women who develop PND without pre-existing history of depression are at risk of future episodes of PND but not of non-puerperal depression
Puerperal Psychosis
- How fast is onset?
- How long after birth?
- What are the initial symptoms?
- What do they progress to?
- Rapid
- Usually between day 4 to 3 weeks post delivery, and almost always within 8 weeks
- Insomnia
- Restlessness
- Perplexity
- Suspiciousness
- Marked confusion with psychotic symptoms
- Can fluctuate dramatically over a short period of time
unclear whether the puerperal psychoses represent a; -Separate disease entity -Mood disorder with psychotic features -Schizophrenia episode -Organic psychosis Combination of these.
In 80% of cases the presentation resembles a mood disorder with delusions and hallucinations
What is its epidemiology?
What is the disorder most closely related to?
- Pts with puerperal psychosis are more likely to have a past psychiatric history of?
- How important are psychosocial factors?
- What is occasionally the cause?
- What are other risk factors?
-Occurs in around 1 in 500 births
- Bipolar affective disorder
- The relatives of these pts have a similar incidence of mood disorders as the relatives of pts with mood disorders
- A mood disorder or a family history of a mood disorder or mental illness
- They play less of a role in peurperal psychosis than in PND
- Medication and obstetric complications
- Primiparous mother (having 1st baby)
- Previous peurperal psychosis
- Delivery associated with caesarean section or perinatal death
Management
What is crucial to do on a mental state exam?
-What are the major concerning symptoms?
-Where is the pt invariable treated?
-Assessing the risk of infanticide and suicide
- Thoughts of or self harm
- Harm to the baby
- Severe depressive delusions
- Command hallucinations
- Hospital; mother and baby unit.
- Detention under the mental health act may be necessary
What pharmacological treatment can be given?
- Antipsychotics
- Antidepressants
- Lithium
- Benzodiazepines; used if severe behavioural disturbances
- Caution with medication if breast feeding
- ECT can be very useful in severe or treatment resistant cases
What is the prognosis?
- Most cases recover within 3 month
- 75% within 6 weeks
- 30% risk of recurrence with future pregnancies
- Women with both puerperal and non-puerperal depressive or manic episodes (an established mood disorder) have a 50-85% chance of future puerperal episodes
