Psych Flashcards
Approach to treatment of mental health issues in pregnancy
- The potential benefits of psychological interventions and psychotropic medication
- The possible consequences of no treatment
- The possible harms associated with treatment
- What might happen if treatment is changed or stopped, particularly is medication is stopped abruptly
Definition of perinatal mental health
time from conception to one year postpartum
Routine screening/ RANZCOG recommenddations for mental health issues
Routine screening recommended at every AN and PN visit (with Edinburgh Postnatal Depression Scale)
Screen for psychosocial risk factors (ANRQ3)
Early intervention produces the best outcomes for mothers and their families
Awareness of systemic inadequacies
- Poor communication
- Lack of continuity of care
- Non-collaborative models of care
Give advice on lifestyle issues and sleep
Care should be culturally responsive and family-centred
Treatment offered should involve collaborative decision-making with the woman and her partner
Red flags for mental health assessment
Recent or rapidly changing significant alterations in mental state
Emergence of new symptoms
- Psychotic symptoms (delusions, hallucinations)
-Severe anxiety in relation to infant’s / children’s welfare
Psychotic symptoms that involve the infant
Acts of violent self-harm or suicide
New / persistent / non-reassurable ideas and expression of these ideas, where the woman believes she is incompetent / inadequate as a mother or feels estranged from her infant
Pervasive guilt and hopelessness
Deterioration in function as a consequence of symptoms, e.g. self-care, care of the infant, avoidance of the infant
Not eating
Severe insomnia
Psychomotor retardation
Indications for referral for maternal mental health
Current illness with psychosis, severe anxiety, severe depression, suicidality, self-neglect, harm to others or significant interference with daily function
Hx of BPAD or schizophrenia
Previous serious PP mental illness
Complex psychotropic medication regimens
Suicide
Risk is highest in:
- Late pregnancy and first 12/52 PP
- Those with early-onset serious mental illness
- Hx of previous mental illness
In those with puerperal psychosis, risk of suicide in 2 per 100
Methods of suicide in this period are more likely to be violent than outside this period
Anorexia nervosa and pregnancy
Highest mortality of all psychiatric conditions 6-fold increase in perinatal mortality Increased rate of fertility problems Common in young women Remission rates are high in pregnancy Support postpartum - Feeding difficulties are common
Incidence of perinatal mental health issues
Up to 80% of mothers experience the ‘baby blues’
10% of Australian women experience AN anxiety and/or depression
- 16% experience PN
10% of fathers affected
3-5% of women severely affected and require secondary care services
Baby blues / postnatal blues
3-5 days after giving birth (peaks day 5)
Transient, self-limiting
Usually dissipating within 10 days
Tearfulness, anxious, irritable
- Mild hypochondriasis
Affects primiparous and multiparous women equally
Cause - probably combination of psychosocial factors and hormonal factors
- Studies have found higher progesterone and oestrogen levels in women with PN blues, but cortisol levels similar
- Prolactin levels may be higher in women with PN blues
Sleep and rest improve symptoms of PN blues - discuss reducing visitors
Involve / inform family
Reassure and safety net - Screen women for resolution day 10-14 PN
Impact of depression on pregnancy
Detrimental effects on fetal and infant development and on mother infant attachment
Of women identified with AN or PN depression, 50-70% of those untreated remain depressed 6 months later
25% of women will develop a chronic illness
25% will develop recurrent depression
Aetiology / definition of PND (post-natal depression)
Any non-psychotic depressive illness occurring in the first PN year
Thought that 1/3 of those diagnosed have symptoms starting antenatally
Risk of relapse is higher in those who stop their medication
Pregnancy is not a protective factor in relapse from mental disorders
Gradual onset in first 2 weeks
2 peak presentations:
- 2-4 weeks PN
- 10-14 weeks PN
Prognosis is good
High risk of recurrence in future pregnancies (1 in 2 to 1 in 3)
Risk factors of PND
History of mental health problems FHx of PN depression Lack of support Previous trauma - physical, emotional or sexual abuse Isolation - physical, mental, cultural Stressful life events History of drug or alcohol abuse
Edinburgh Postnatal Depression Scale (EPDS)
10-item questionnaire AN and PN use Sensitivity 34-100% Specificity 44-100% Goal to identify women who require further assessment, not to diagnose depression
If EPDS 10-12, monitor and repeat 2-4 weeks later
If >12, arrange further assessment as it may suggest a crisis
PPV 57%, NPV 99%
Depression screening questions (Whooley questions)
- 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 during things?
- Is this something with which you would like help?
Diagnostic and Statistical Manual of Mental Disorders (DSM IV)
Women must exhibit >5 symptoms for >2 weeks with >1 symptom from the first two symptoms listed:
- Depressed mood
- Anhedonia
- Significant change in weight or appetite
- Markedly increased or decreased sleep
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or guilt
- Reduced concentration
- Recurrent thoughts of death or suicide
Must be accompanied by significant impairment capacity to engage and function in usual activities, e.g. parenting, occupational, social and other roles
Risks of untreated depression to fetus
- Some studies found associated with miscarriage, lower gestational age, lower infant birthweight
- Lower APGAR scores, PET, NICU admissions, breastfeeding initiation
Risk factors and incidence of PTSD from birth
Reported to occur in 2-3% of women after childbirth
- Those who have suffered previous trauma (DV, rape, childhood sexual abuse)
- Those with risk factors for perinatal mood disorder
- Those who perceived that their birth experience was traumatic
Tocophobia
Morbid dread and fear of pregnancy and the birthing process
Primary tocophobia - in those with no previous experience of pregnancy
Secondary tocophobia - develops after a traumatic obstetric event in a previous pregnancy
History of sexual assault may be associated with an aversion to routine obstetric care associated with primary tocophobia
General principles for treating mental health stuff
Consider risk-benefit analysis for both the woman and the fetus / infant
Psychological interventions should be maximised to avoid unnecessary drug exposure
Use psychotropic medication with the lowest drug-risk profile
Polypharmacy should be avoided
Some medications require dose adjustments owing to the physiological changes (e.g. increased plasma volume, increased renal excretion)
Pre-conception counselling for meds in pregnancy
Discuss reasons for stopping
- If high risk of relapse, abruptly stopping medication is usually unwise
Consider restarting or switching to another medication
Offer psychological interventions
Consider increasing the level of monitoring and support
Ensure she is aware of the risks of stopping medication to both herself and the fetus / infant
Stopping or switching the medication after pregnancy is confirmed may not remove the risk of fetal malformations if known teratogen
Offer screening
SSRI Neonatal Behavioural Syndrome - aka Newborn Adaption syndrome
Jitteriness and respiratory distress At wort persistent pulmonary HTN - Absolute risk very small (1.2-3 per 1000 for SSRI) GI Onset 1-2 days PP Lasting up to 10 days Usually mild
SSRI - examples, impact on pregnancy and breastfeeding
Sertraline, citalopram
? Small risk of cardiac defects - not consistent in studies. Don’t use paroxetine first line as small increased risk.
No clear increased risk of significant PTB (3 days), IUGR (75g)
No increased risk of miscarriage, HTN
Untreated depression and anxiety is a/w poor outcomes
Risks - neonatal withdrawal
Safe in breastfeeding
<5% of maternal level, often undetectable
SNRI - examples, impact on pregnancy and breastfeeding
Category B2
No increased risk of congenital malformations
Increased risk of PPH
Venlafaxine may increase risk of PET and PPH
Same as SSRI
Data inconsistent
Any risks are probably small
Appear to be safe to use in breastfeeding, but infant exposure appears to be greater with venlafaxine than for other anti-depressants
Tricyclic anti-depressants - examples, impact on pregnancy and breastfeeding
Category C
Amitriptyline, desipramine, imipramine, nortriptyline
Have not been shown to be clearly associated with miscarriage or congenital malformations
Level in breastmilk appears low
Nortriptyline favoured if TCA started during lactation due to safety record
Benzodiazepines
Primary concern = withdrawal
Sedation
If required, low dose of drugs with short half-life and no active metabolites
Risk of PNAS
Consider for moderate to severe anxiety which awaiting onset of SSRI or TCA
Lithium
Risks
monitoring
Increased risk of Ebstein's anomaly - Magnitude of risk remains contentious - Congenital heart defect - septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle Absolute risk is still low Increased risk of PNAS
Don’t offer if planning pregnancy or pregnant
Increased risk of relapse if drug stopped during pregnancy, especially if abruptly
Therapeutic range is narrow and regular monitoring is required (changing plasma volumes)
Measure every 4 weeks, then weekly from 36/40
Signs of lithium toxicity
Toxicity if >1.2 mmol/l
- N/v, cramping, diarrhoea
- Neuromuscular signs - tremulousness, dystonia, hyperreflexia, ataxia
- Cardiac dysrhythmias (rare)
- ECG: T wave flattening
Lithium intrapartum and postpartum
Withhold during labour and childbirth due to higher placental transfer rates –> adverse fetal outcomes (low Apgar, longer hospital admissions, higher rates of CNS and neuromuscular complications)
Check levels 12h postdose post delivery
High levels excreted in breast milk therefore not advised
Antipsychotics - two groups
First generation - Chlorpromazine, haloperidol
- Not selective and block dopamine receptors along several neural pathways –> unwanted side effects
Second generation - Clozapine, risperidone, olanzapine, quetiapine
- More selective dopamine antagonists and have serotonergic properties
- In general, associated with fewer side effects
Antipsychotics - maternal and fetal effects
Maternal adverse effects
- Sedation, weight gain, metabolic syndrome (including GDM and hyperprolactinaemia)
- Prolactin levels should be measured if taking a prolactin-raising antipsychotic medication (risperidone) and planning a pregnancy
○ Raised levels reduce chances of conception
- Extrapyramidal side effects - akathisia, dystonism, parkinsonism, tremor
Fetal adverse effects
- Limited dated
- May be increased risk of congenital malformations
- Some studies found increased risk of SGA, GDM, PTB, CS
- Neonatal adaptation syndrome is commonly observed
Define and incidence of puerperal psychosis
Definition: an episode with an acute onset characterised by mania with psychotic symptoms that occurs in the early postpartum period
Psychiatric emergency
1 in 1000 women
Risk factors for puerperal psychosis
Close family member with the condition Hx of BPAD - 1 in 5 (20-30%) chance of developing puerperal psychosis 75% risk of develop PP psychosis if FHx of the condition in first degree relative and Hx of BPAD Previous episode of PP psychosis (>50% risk) Schizoaffective disorder Discontinuation of mood stabiliser FHx of BPAD Mother or sister who had PP psychosis Primiparity Obstetric complications Sleep deprivation Increased environmental stress Lack of partner support
Signs and Symptoms of postpartum psychosis
First signs can be nonspecific - Insomnia, agitation, odd behaviour
Progression is often rapid (within hours) - kaleidoscopic presentation
Hallucinations, delusions, fear, perplexity, confusion, agitation
- Up to 78% have delusional ideas about their infant
More likely to have manic symptoms
- Mood lability, pressure speech, distractibility
Onset - first 2-4 weeks - 50% by day 7 Symptoms may begin in labour Management with 1:1 care while awaiting psychiatric assessment if suspected Risk of infanticide and suicide
Treatment - postpartum psychosis
1:1 care - risk of suicide 2 in 100
Urgent (within 4h) assessment by senior psychiatrist
Hospital admission
Consider wellbeing of infant and other children at home
Mood stabilising medications and antipsychotic medications
Breastfeeding avoided in those on lithium
ECT is well tolerated and rapidly effective
Prognosis - postpartum psychosis
With the correct treatment, the short-term prognosis is generally good
High risk of recurrence - up to 50%
35-65% will develop BPAD
Offer prophylactic admission to mother and baby unit in next pregnancy
BPAD
Affects ~1% of the population
Mean age of onset 17-22 years
Relapse more likely following childbirth
- 50% chance of mood episode in PN period, including depression
- Sleep loss may be a contributor to the development of manic episodes
Particularly high risk of suicide in the first year postnatal
Have a clear postnatal plan to minimise risk of relapse
Minimise sleep deprivation
Avoid breastfeeding if on lithium
