Psychiatry - Perinatal psychiatry

Question 1

What are the postnatal blues?

Answer 1

Also known as the “baby blues”
It is a common psychological problem typically occurring around the third day post partum. It is NOT a psychiatric disorder and should not be considered abnormal; however, it must be distinguished from post natal depression.

Occurs between 1/2 to 2/3 of mothers

Question 2

Aetiology of postnatal blues

Answer 2

Biological - reduction of oestrogen and progesterones after delivery

Question 3

Risk factors for postnatal blues

Answer 3

Women who have previously suffered with premenstrual syndrome 
Primagravidae (first pregnancy)
Anxiety and depression during pregnancy
Fear of labour
Poor social adjustment 
Not associated with obstetric factors

Question 4

History of postnatal blues

Answer 4

Symptoms begin within the first 10 days post partum, typically from the third to fifth day. Lability of mood is particularly characteristic, with rapid alterations between euphoria and misery. Women may complain of feeling confused but cognitive function is normal. They are frequently tearful and feel tense and irritable.

Question 5

Management of post natal blues

Answer 5

Medication is not required.
Reassurance, explanation and family support are the key features. Antenatal education that provides warning for women and their partner is helpful.

It may upset early bonding and breast feeding.

Prognosis is excellent. Resolves spontaneously in a few days.

Question 6

What is the definition of post natal depression?

Answer 6

Also known as puerperal depression.
Depression arising in the months following childbirth. It is not qualitiatively different from depression occurring at other times in life.

Question 7

Aetiology of post natal depression

Answer 7

Psychological factors - e.g. lack of support
Biological theories - hormonal changes; sudden drop in oestrogen and progesterone levels

Affects 10-15% of mothers, usually within the first 3 months of childbirth

Question 8

What risk factors are associated with post natal depression?

Answer 8

Past psychiatric history, especially depression
Psychological problems during pregnancy
Family history of postnatal depression
Recent adverse life events

Question 9

What features in the history suggest post natal depression?

Answer 9

May have developed insidiously over several weeks or as an exacerbation of the baby blues. Similar features to general depressive illness.

Sleep disturbance, energy changes and low libido are less sensitive indicators as these can occur normally after birth.

Cognitive features are more sensitive indicators and they are usually based around motherhood - e.g. feels guilty for not coping as a mother, gains no pleasure from the child, feels angry with the child

Question 10

Diagnosing post natal depression

Answer 10

Consider mental health screening at pre and postnatal checks. Ask the following:

1) During the past month, have you often been bothered by feeling down, depressed or hopeless?
2) During the past month, have you been bothered by having little interest or pleasure in things?

If yes, further assessment using the PHQ9 or the Edinburgh Postnatal Depression Scale.

Question 11

Management of postnatal depression

Answer 11

Assess risk to mother and child
Most cases will be mild and do not require psychiatric intervention and respond to additional support and counselling
Moderate depression can usually be managed at home, although if severe, admit to a mother and baby unit
Multidisciplinary care - liaise with GP and midwife/ health visitor
Antidepressant medication - no clear guidance, SSRI, TCA or SNRI can be used but no definitive data on safety in pregnancy
Screening for depression should be incorporated into the 6 week check

As with the baby blues reassurance and support are important.

Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe - whilst they are secreted in breast milk it is not thought to be harmful to the infant

Question 12

What complications can arise as a result of post natal depression?

Answer 12

Bonding failure
Rejection/ neglect of the baby
Marital/ relationship problems 
Detrimental effect on the childs language skills, social and emotional development in the first year or life 
Insecure attachments at 18 months 
Maternal suicide 
Infanticide

Question 13

Prognosis of post natal depression

Answer 13

Untreated, 10% have a course lasting longer than 6 months. 90% of cases last less than 1 month with treatment, 4% are still depressed after 1 year

Question 14

What is puerperal psychosis?

Answer 14

A psychotic disorder arising after childbirth
The strong association with bipolar affective disorder implies genetic predisposition and there may be a specific familial risk for puerperal episodes in bipolar effective disorder.

Question 15

What risk factors are associated with puerperal psychosis?

Answer 15

Past history of puerperal psychosis
Existing bipolar effective disorder
FHx of bipolar effective disorder and puerperal psychosis
Primagravida

Question 16

What history suggests puerperal psychosis?

Answer 16

Usually arises within a month of delivery and not uncommonly within the first 2 days. The majority of cases are effective in nature. Typically there are rapid fluctuations in mood and an abrupt onset of disturbed behaviour.

Question 17

What examination findings suggest puerperal psychosis?

Answer 17

Usually marked restlessness and fear. Mixture of manic and depressive symptoms. Delusions and hallucinations based may be based around the baby, e.g. paranoid delusions that her baby has been swapped with someone else’s and auditory command hallucinations instructing her to kill the baby. There is marked perplexity but no cognitive impairment.

Investigations need to rule out delirium due to infection.

Question 18

How should puerperal psychosis be managed?

Answer 18

Risk assessment of the mother and child
Admit to hospital (if appropriate using MHA), preferably a mother and baby unit. Rarely can be managed at home with frequent reviews involving CPN
Medication as appropriate (antidepressants, mood stabilisers and antipsychotics)
ECT may be useful if medication has failed
Supportive psychotherapy may be helpful during recovery to help the woman come to terms with and understand the nature of the illness, and to allow her to eliminate any feelings of guilt or failure

Question 19

What is the prognosis of puerperal psychosis?

Answer 19

Most cases settle within 6 weeks and are fully recovered within 6 months. However, the recurrence rate is over 50% for subsequent non puerperal psychosis, and 25% for subsequent puerperal psychosis, although this is increased for those with previous psychiatric history or family history.