Postpartum Depression And Postpartum Psychosis Flashcards
What is postnatal depression?
Postnatal depression (PND) refers to the development of a depressive illness following childbirth and may form part of a bipolar or, more usually, a unipolar illness.
The onset of a depressive episode within four weeks of childbirth can be recorded via the perinatal-onset specifier in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). There is evidence to suggest that the DSM-5 specifier is too narrow; therefore, most clinicians consider depressive episodes occurring within 6-12 months of delivery to be PND
What are the risk factors for PND?
The strongest risk factors appear to be:
- Previous history of mental health problems.
- Psychological disturbance during pregnancy.
- Poor social support.
- Poor relationship with partner.
- Baby blues.
- Recent major life events.•
Other risk factors include:
- Unplanned pregnancy.
- Unemployment.
- Not breastfeeding.
- Antenatal parental stress.
- Antenatal thyroid dysfunction.
- Longer time to conception.
- Depression in the father of the child.
- Having two or more children.
- Current, or history of, substance misuse.
- Neonatal low birth weight or illness, stillbirth and sudden infant death syndrome (SIDS).
What is the presentation of PND?
PND presents with the same symptoms as those of depression in other circumstances.
However, take into account that some of the symptoms associated with depression can be normal in the early postnatal period (sleep disturbance, tiredness, anxiety about the baby).
Symptoms of depression include:
- Low mood.
- Loss of enjoyment and pleasure.
- Anxiety.
- Disturbed sleep.
- Loss of appetite.
- Poor concentration.
- Low self-esteem.
- Worthlessness and inappropriate feelings of guilt.
- Low energy levels.
- Loss of libido.
- Thoughts of death/suicidal thoughts
Why are patients unwilling to disclose symptoms of PND?
NICE warns that health professionals should be aware that women may be unwilling to disclose symptoms of depression and other mental health problems or reluctant to engage.
This may be due to fear of stigma, fear the baby may be taken into care, concern that they will be perceived as a poor mother, the nature of the condition or problems with alcohol or substance dependence.
How is PND diagnosed?
At booking and at postnatal checks, all health professionals should consider mental health screening questions.
Consider asking the following questions to screen for depression:
- 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 interest or pleasure in doing things?
Consider asking the following two questions about anxiety:
- During the past month have you been feeling nervous, anxious, or on edge?
- During the past month have you not been able to stop or control worrying?
If the answer is “yes” to any of these questions, or if there is clinical concern, further assessment is required. This may be by the use of a formal assessment tool, such as the Patient Health Questionnaire (PHQ-9), the Edinburgh Postnatal Depression Scale or the Generalised Anxiety Disorder Scale (GAD-7).
How is PND assessed?
NICE advises that assessment of any mental health problem in either pregnancy or the postnatal period should include the following:
Past history or family history of any mental health problem. Also any current or past treatment for a mental health problem and response to any treatment.
Physical well-being and history of any physical health problem. Alcohol and drug misuse. The woman’s attitude to and experience of the pregnancy.
The mother-baby relationship.
Relationships and social networks. Living conditions and social isolation.
Domestic violence and abuse, sexual abuse, trauma, or childhood maltreatment. Housing, employment, and economic and immigration status.
Responsibilities as a carer for other children and young people or other adults.
What are the general principles of PND?
Empowerment.
- Involve women in decisions about their care. Partners, family and carers should also be involved if the woman agrees.
- Reassure the woman that PND is not uncommon, and be optimistic about its resolution. -Give her all the information she needs to make informed decisions about treatment, and acknowledge her central role in the decision-making process.
- Ensure adequate contact and support networks.
Communication.
- Good communication is important - the woman, her relatives and carers should be given information in a form that is culturally appropriate and takes account of any physical disabilities that present an obstacle to comprehension (eg, deafness). -Communication between all health professionals involved is vital for integrated care. Develop an integrated care plan.
The wider family environment.
-Consider the needs of other children, dependent adults, and the effect the illness may have on relationships with partners. The welfare of the baby must always be borne in mind.
What is the management of mild to moderate PND?
Consider facilitated self-help strategies (as per NICE guidelines on depression)
What is the management of mild to moderate PND with a hx of severe depression?
Consider an antidepressant.
What is the management of moderate to severe PND?
High-intensity psychological intervention such as cognitive behavioural therapy (CBT).
Antidepressant treatment if:
- Risks are understood and accepted, particularly if breastfeeding.
- The woman declines psychological therapy.
- Psychological therapies have failed.
- High-intensity psychological intervention in combination with antidepressant therapy.
Women who have ideas of either suicide or of harming the baby should be referred immediately for urgent psychiatric assessment. Child protection procedures may need to be invoked.
A few mothers have depression that is too severe to be managed solely in primary care and will require the involvement of a psychiatrist; sometimes needing compulsory admission using the Mental Health Act. Dedicated “mother and baby units” offer the ideal environment but are not available in all areas.
What are the complications of PND?
Postpartum depression has repercussions beyond physical harm to the child.
The condition also affects mother-infant bonding and often the child is treated inappropriately with a very negative attitude.
This can have a significant impact on the growth and development of the child.
Children born to mothers with postpartum depression have been found to exhibit marked changes in behaviour, altered cognitive development and early onset of depressive illness.
Negative influences of mothers’ depression are seen in their language skills and intelligence quotients (particularly in boys). However, these effects are not universal. It is only seen when the mother is unable to engage actively with the infant.
What is the prevention of PND?
Women should be proactively screened for mental health problems, and high-risk patients identified.
It is advised that when women present for booking and at the postnatal check, health professionals (including midwives, obstetricians, health visitors and GPs) should ask questions to screen for depression and anxiety.
At the first contact they should also ask about:
- Past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in the postnatal period and severe depression.
- Previous treatment by a psychiatrist/specialist mental health team including inpatient care.
- A family history of severe perinatal mental illness in a first-degree relative.
Women identified as at high risk of developing severe depression, or with a history of severe mental illness, should be referred to secondary care mental health services.
What is postpartum psychosis?
Postpartum psychosis is a severe mental illness that develops acutely in the early postnatal period, usually within the first month following delivery. Psychotic features are present. There is a close link with bipolar disorder.
It is a psychiatric emergency. Identifying women at risk allows the development of care plans to allow early detection and treatment. Management requires specialist care.
What is the aetiology of postpartum psychosis?
Women at high risk of postpartum psychosis include those with:
- A past history of postpartum psychosis.
- A past history of bipolar disorder.
- A family history of postpartum psychosis or bipolar disorder.
It is thought that postpartum psychosis may be a manifestation of underlying bipolar disorder. Possible contributing factors include sleep deprivation, hormonal changes, stress and genetic influences.
What is the presentation of postpartum psychosis?
Presentation is typically within the first postnatal month.
There can be a rapid transition between symptoms of mild anxiety to severe psychosis. As a result of this, the diagnosis can be easily missed.
All significant changes to the mental state in the postnatal period should be closely monitored and should trigger a referral to specialist services.
Symptoms may be depressive in nature (withdrawal, confusion, loss of competence, distraction, catatonia) or manic (elation, lability, agitation, rambling).
There may be delusions (paranoia, jealousy, persecution, grandiosity). There may be hallucinations which may be auditory, visual, olfactory or tactile. There may be odd beliefs about the baby.
