Puerperal psychiatry

Question 1

Baby blues:

a) Prevalence
b) Symptoms
c) Last how long?
d) Cause
e) Can baby blues lead to depression?

Answer 1

a) 80%
b) Tearful, anxious, emotional, irritable, moody, feeling down
c) Gradually pass within around 10 - 14 days
d) Oestrogen levels drop by around 100 times
e) It increases the risk of PND, but not commonly

Question 2

Postnatal depression (PND)

a) Define
b) Prevalence
c) Risk factors - bio, psycho, social
d) Protective factors
e) Physical causes of tiredness

Answer 2

a) Any non-psychotic depressive illness occurring during the first postnatal year
b) 10 - 15%

c) Bio: Prior mental health issues, antenatal thyroid disease, substance misuse
Psycho: baby blues, psychological problems during pregnancy
Social: poor social support, poor relationship with partner, unplanned pregnancy, unemployment

d) Breastfeeding, good social support
e) Anaemia, postpartum thyroiditis

Question 3

PND: presentation

a) Same as depression - A SAD FACES
b) But which depressive symptoms may be normal post-partum?
c) Screening: when? questions?
d) Tool to use

Answer 3

a) A SAD FACES:
Appetite/weight, 
Sleep, 
Anhedonia, 
Depressed mood, 
Fatigue, 
Agitation/retardation, 
Concentration poor, 
Emptiness/hopelessness/guilt, 
Suicidal ideas/self harm

b) Poor sleep, tiredness, appetite changes

c) Antenatal and postnatal checks - “over the past month,
- have you felt down/depressed/hopeless ?
- OR lost interest in things?

d) Edinburgh postnatal depression scale

Question 4

PND: management

a) Mild-moderate depression
b) Mild-moderate depression (with history of severe depression)
c) Moderate-severe depression
d) If mother already on antidepressant during pregnancy…?
e) Three main indications for psychiatry referral
f) If psychiatry admission required, ideal ward is…?

Answer 4

a) - Reassure, educate,
- facilitated self-help (IAPT),
- psychosocial (CBT, engage with social issues)

b) SSRI

c) 1st line: CBT or interpersonal psychotherapy
- 2nd line: SSRI (understand risks), or combined CBT + SSRI

d) - Continue same treatment post-partum but consider risks to baby if breastfeeding
e) Suicidal ideation, thoughts of harming baby, also psychosis
f) Mother and baby unit

Question 5

PND: antidepressants

a) Encourage breastfeeding unless taking…?
b) Which antidepressants have lowest levels in breastmilk and can be considered?
c) Which antidepressants should generally be avoided if breastfeeding?

Answer 5

a) Lithium, valproate, carbamazepine, clozapine
b) Sertraline, paroxetine, imipramine
c) Citalopram, fluoxetine

Question 6

PND: complications

a) Risks to mother
b) Risks to baby

Answer 6

a) Suicide, neglect
b) Homicide, neglect, poor stimulation and reduced bonding leading to poor cognitive, behavioural and emotional development (attachment theory)

Question 7

Post-partum psychosis:

a) Define
b) Risk factors

Answer 7

a) Acute psychosis that develops post-partum (usually within the first month).
- Psychiatric emergency!

b) - Previous post-partum psychosis
- History of mental illness (particularly bipolar and schizophrenia)
- Family history of post-partum psychosis and bipolar disorder

Question 8

Post-partum psychosis: presentation

a) Negative symptoms - main DDx
b) Positive symptoms - main DDx
c) Specific to the baby
d) What symptoms might precede psychosis?
e) Investigations for DDx

Answer 8

a) Depressive (withdrawal, confusion, loss of competence, distraction, catatonia)
- Main DDx - schizo, depressive psychosis

b) - Manic (elation, lability, agitation, rambling).
- Delusions (paranoia, jealousy, persecution, grandiosity).
- Hallucinations (auditory, visual, olfactory or tactile).

DDx: drug-induced psychosis, manic episode, psychotic depression, schizophrenia

c) - Odd beliefs about the baby (e.g. delusions that they are somehow connected to God or the Devil)
d) Anxiety

e) For organic causes:
- Urine: toxicology
- Bloods: FBC, CRP, UEs (sodium), glucose, TFTs, folate and B12, calcium.
- Possible CT/MRI head

Question 9

Post-partum psychosis: management

a) Referral to …?
b) Drug management
c) What drugs should be avoided in breastfeeding women? (if needed, breastfeeding should be discourage)
d) If resistant, what may be tried?
e) Who may need to be alerted?
f) Psychotherapy?
g) In future pregnancies

Answer 9

a) mother and baby unit
b) Antipsychotics (not clozapine unless severe/resistant) and/or a mood stabiliser (beware in breastfeeding)
c) Lithium, valproate, carbamazepine, clozapine
d) ECT
e) Child protection services
f) No role in acute management, but may help with long-term recovery
g) Vigilant monitoring, early referral to specialist services. Risk of recurrence ~ 50%