Post natal depression

Question 1

what screening questions to ask for post natal depression (associated with hormonal changes in pregnancy

Answer 1

DEPRESSION
- During the past month, have you been bothered by feeling down, depressed or hopeless?
- During the past month, have you been bothered by little interest or pleasure in doing things?
ANXIETY
- During the past month have you been worrying a lot about everyday problems?
ALCOHOL AND DRUG PROBLEMS
- Have you used drugs or drunk more than you meant to in the last year?
- Have you felt that you wanted to cut down on your drinking or drug use in the past year?

• Edinburgh Postnatal Depression scale - done routinely at 6 weeks (4-8wks validity) - refer if any suicidality
• Psychosis screen
  Past psychiatric history - depression during pregnancy; previous depression/ manic episode (bipolar)
• Social - social supports at home. own relationship and suport with parents

Question 2

Differentials for postnatal depression

Answer 2

Baby blues: 70-80% of all new mothers
- Within 3-5 days of delivery, resolving spontaneously over 2 weeks. Self-limiting
- Emotional sensitivity, mood lability, irritability

Puerperal psychosis: sudden onset 1-2 weeks PP of pyschotic symptoms.
- Mania, mixed mania+depression abnormal behaviour or rapid speech may also be present

Depressive episode of bipolar disorder

• OCD
• Substance-induced
• Organic causes of fatigue
• eg. anaemia, infection, post partum thyroiditis, cardiomyopathy and exacerbation of pre-existing illness, fibromyalgia or chronic fatigue syndrome
  should order FBC, U&Es, TFTs, B12/folate etc.

Question 3

Presentation and the diagnostic criteria post natal depression

Answer 3

Presentation
- Tiredness.
- Poor concentration
- Prominent anxiety
Subtle changes in behaviour
- Feelings of guilt about inability to look after new infant/ overwhelmed.
- Irritability

Diagnostic criteria is same as MDD however it has the specifier with peripartum onset
with/ without psychotic features

Question 4

Management of post partum depression

Answer 4

Immediate Safety Concerns
- Admission to specialised mother/baby unit if risk of harming self/others
Red flags
- Suicide intent
- Rapidly evolving delusions or obsessions esp. about infant
- Confusion

Social
- Ensure no risk to child - Oranga Tamariki involvement as needed
- Psychoeducation of family/whanau
- Postnatal support groups/ webbased
- Lifestyle : exercise, time for pleasurable activities, sleep hygiene, diet and lifestyle, anti drinking/ drugs.

Psychological
- CBT : working with therapist to challenge negative beliefs
-Interpersonal T: Working with therapist to learn ways to improve relationships with other people.
- Psychodynamic, or nondirective counselling

Biological
- Antidepressant - for moderate/severe symptoms for 2 weeks, significant anxiety/ panic attacks, psychomotor change/ significant biological symptoms, previous response to antidepressants.

1. SSRI - Sertraline and paroxetine have least excetion into breastmilk - low to undectable serum infant conc.
   - fluoxetin has highest conc in breastmilk.
   - If pt already on antidepressant in pregnancy should continue

Question 5

What are the risks and benefits to antidepressant treatment of antenatal depression - post partum and during pregnancy
what should the neonate be monitored for

Answer 5

Risks
- small increased risk of congenital heart defects when SSRIs (particularly paroxetine) are taken during early pregnancy, although evidence iss conflicting.
- SSRIs taken after 20 weeks gestation slightly increase the risk of persistent pulmonary hypertension in the newborn.
- If in the weeks prior to delivery, small increased risk of postpartum haemorrhage and a risk of neonatal withdrawal symptoms.

The neonate should be monitored for withdrawal effects after birth, however these are usually mild and self-limiting. (colic, drowsiness, poor feeding, irritability)

Untreated depression in pregnancy may be associated with pre-term delivery, low birth-weight, poor breast-feeding, and can impact on mother-infant attachment and child development.

Question 6

explain post natal depression to mother

Answer 6

• You came here today because you were worried about your …lack of energy/feelings of sadness/ difficulty with stress
• It’s normal to have changes in mood right after your baby is born, but for 1 in 10 mums feel down for much longer, and those feelings may develop into postnatal depression which I think fits what you’re experiencing right now
• As with other types of depression, there’s no simple reason why some women are affected more than others. Things such as previous mental health struggles, recent stressful life events or reduced network of support can increase the likelihood of developing post natal depression.
• Depression is an illness – being depressed doesn’t mean you’ve failed as a parent, or as a person.
• Its important for you and your baby to get support. This can mean talking therapies or starting a medication as well as strengthening the support available to you in this time.
• Talking therapies like CBT help you to break the cycle between negative thoughts and actions which can make our mood worse .
• Medications help by balancing certain chemicals in the brain involved in regulating our emotions, it usually takes 1-2 weeks to start working. You may be on them until a few months after you’ve started feeling better. There are options which are safe in breastfeeding