Serious Mental Illness Flashcards
1
Q
How can you support women with serious mental illnesses?
A
- Acknowledge the woman’s role in caring for her baby and support her to do this in a non-judgmental and compassionate way.
- Involve the woman and, if she agrees, her partner, family or carer, in all decisions about her care and the care of her baby (NICE CG192, 2014).
2
Q
What is Bipolar Affective Disorder (BPAD)
A
- A recurrent mood disorder that includes episodes of mania or mixed episodes of mania and depression
- Affects 1.3 percent of all adults regardless of ethnicity or gender
- Mean age of onset is 21 years of age
- Men experience more manic episodes then women, are hospitalised more frequently and more likely to abuse drugs and alcohol
3
Q
Causes of BPAD
A
- No single factor pinpointed. Genetic predisposition exists (runs in families) in conjunction with other factors
- Imaging studies - abnormal cell death in parts of the brain that regulates emotions
- Mood stabilisers and antidepressants can promote cell survival and slow/stop accelerated cell death
4
Q
Symptoms of BPAD
A
- Extreme mood swings from euphoria to severe incapacitating depression.
5
Q
Describe the manic phase of BPAD
A
- Misperceived reality; delusions of indestructibility and over confidence, physically aggressive, oblivious to others needs
- Psychotic symptoms – hallucinations, delusions Easily distracted
Lack good judgement - Hyperactive and hyper-verbal and disturbed sleep patterns
6
Q
What is the depressive phase in BPAD
A
- Feelings worthlessness, helplessness, hopelessness Loss of interest in people/activities
Poor concentration
Fatigue - Complains of physical aches + pains (psychosomatic) Sleep disturbance
Suicidal thoughts and gestures/attempts
7
Q
BPAD Pharmacological Treatments
A
- Can be combined or monotherapies:
o Lithium
o Anticonvulsants: sodium valberate
o Antipsychotics
o Lithium – decreases the intensity and frequency of mood swings, but:
Use in first trimester associated with an increase risk of congenital heart disease (x7) including Ebstein’s anomaly, but no consistent evidence of increased risk of other congenital anomalies- anomaly scan at 20 weeks: a more thorough cardiac scan
However, use of lithium in 2nd and 3rd trimester associated with floppy baby syndrome, potential thyroid abnormalities and nephrogenic diabetes insipidus, and with a range of CV and CNS, hepatic and other complications at birth - Goal - Control symptoms allowing sufferer to return to functioning effectively in his/her daily life. Based on patients preference of medication, history of positive response, ease of administration, potential adverse effects and associated co-morbidities.
8
Q
Lithium and pregnancy
A
- Lithium crosses placenta at similar levels, regardless of mother’s serum levels, so dose should be kept at lower end of therapeutic range
- However, serum lithuim levels should be checked every 3 to 6 months in pregnancy and mother observed for signs of toxicity (nausea, vomiting, diarrhoea, tremor)
- Lithium present in high concentrations in breast milk, so generally not recommended when breast feeding due to the long half-life
9
Q
BPAD and other medications
A
- Antipsychotics, including olanzapine and clozapine are also sometimes used in the management of BPAD
- Clozapine should not be prescribed to pregnant women (because of increased risk of agranulocytosis in fetus)
- Olanzapine associated with an increased risk of gestational diabetes and weight gain
- Depot antipsychotics should not be used during pregnancy, as safety not established
10
Q
BPAD and pregnancy
A
- Pregnancy associated with increased rate of relapse and first presentation
- High risk of puerperal psychosis- virtually guaranteed
- High risk if family history
- Postnatal psychotic disorders may have more rapid onset with more severe symptoms than psychoses occurring at other times
- Risks associate with pregnant women stopping medication abruptly without an informed discussion
11
Q
What is Schizophrenia ?
A
- A psychiatric diagnosis that describes a mental disorder characterized by abnormalities in the perception or expression of reality.
- Most commonly manifests as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking with significant social or occupational dysfunction.
- Onset of symptoms typically occurs in young adulthood
12
Q
Schizophrenia and pregnancy
A
- Women with tightly defined schizophrenia and on antipsychotic medication are less likely to relapse after delivery that women with BPAD or those with more broadly defined schizophrenia
- However, a substantial minority do relapse (21.72%)
- Women with schizophrenia more like to be socially disadvantaged, use illicit drugs, drink alcohol and smoke, and less likely to attend antenatal clinics and often receive poor quality antenatal care
- Women with schizophrenia at higher risk of obstetric complications, especially placental abruption and APH
- Also, at higher risk of poor outcomes, including miscarriage, IUD, low birth weight babies pre-term births and SIDS
- More likely to be separated from their children and at high risk of suicide
13
Q
Management of schizophrenia
A
- Medications with less risks include low-dose typical antipsychotics such as chlorpromazine, haloperidol or trifluoperazine
- Antipsychotic medication (with exception of clozapine) confers either no risk or a small non-specific risk for congenital malformations
- For severe relapses (including puerperal psychosis) rapid tranquillisation may be necessary, with either an antipsychotic or a benzodiazepine
14
Q
Postpartum psychosis
A
- Postpartum psychosis is a severe mental illness with a dramatic onset shortly after childbirth.
- All women should be screened antenatally for the known risk factors. Prevalence in UK is 1-2 per 1000 births (for those with no known risk factors)
- Women with bipolar disorder have at least a 1 in 4 risk, and need close contact and review during the perinatal period even if they are well (Florio et al, 2013).
15
Q
Key features of PP
A
- Sudden onset
- Rapid deterioration
- Most episodes within 2 weeks of delivery, with over 50% of symptom onsets occurring on days 1-3
- Clinical picture often changes rapidly, with wide fluctuations in intensity of symptoms and severe swings of mood
16
Q
Differential diagnoses of PP
A
- Primary cerebral or systemic disease (e.g. eclampsia or infection)
- Exogenous toxic substances or hormones
- Other psychiatric disorders e.g. depression, anxiety, personality disorder
17
Q
Prevention of acute psychiatric episodes
A
- Women with a history of SMI should have a care plan that includes prevention of acute psychotic episodes
- Medications likely to include mood stabilisers (e.g. Lithium) and an antipsychotic, such as olanzapine
- Care in labour should include input from a familiar mental healthcare professional
18
Q
Signs and symptoms of PP
A
- Excited, elated or ‘high’
- Depressed, anxious or confused
- Excessively irritable or labile in mood
- Plus one or more of the following: o Delusions o Hallucinations o Mania o Severe confusion
19
Q
Common symptoms of developing PP:
A
- Being more talkative, on the phone a lot Having a busy mind/racing thoughts Feeling very energetic, agitated, restless
- Insomnia, or not feeling the need to sleep
- Behaving out of character
- Feeling paranoid or suspicious of peoples motives
- Feeling things are connected in a special way or have a personal meaning
- Feeling that the baby is connected to God or the devil in some way
20
Q
Management and treatment of PP
A
- PP is a true psychiatric emergency and it is vital that it is recognised early and treated aggressively
- Therefore early assessment by psychiatrist vital
- Psychopharmacologic treatments: mood stabilizers (e.g. lithium), benzodiazipines and atypical antipsychotics (e.g. olanzapine)
21
Q
Care and support of women with PP (1)
A
- Sit beside woman, rather than in front – more comforting and less confrontational
- Talk to her in a reassuring, comforting way, even if she doesn’t respond
- Keep things quiet and calm (no TV or radio)
- Try to limit mobile phone use
- Validate what she thinks is real Don’t take things personally
- Call for help (2222 or 999) if you are concerned for safety of mother, baby or others (e.g. partner)
22
Q
Care and support of women with PP
A
- Usually require admission to hospital, ideally a mother and baby unit
- Some can be managed at home if they have access to crisis resolution or home treatment teams, and have a strong, supportive family/social network
- May require involuntary treatment under the Mental Health Act (‘sectioning’).
23
Q
What should you always be thinking about?
A
- SBAR
- MDT
- DOCUMENTATION
- ONGOING PLAN
