Serious Mental Illness

Question 1

How can you support women with serious mental illnesses?

Answer 1

• 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).

Question 2

What is Bipolar Affective Disorder (BPAD)

Answer 2

• 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

Question 3

Causes of BPAD

Answer 3

• 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

Question 4

Symptoms of BPAD

Answer 4

• Extreme mood swings from euphoria to severe incapacitating depression.

Question 5

Describe the manic phase of BPAD

Answer 5

• 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

Question 6

What is the depressive phase in BPAD

Answer 6

• 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

Question 7

BPAD Pharmacological Treatments

Answer 7

• 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.

Question 8

Lithium and pregnancy

Answer 8

• 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

Question 9

BPAD and other medications

Answer 9

• 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

Question 10

BPAD and pregnancy

Answer 10

• 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

Question 11

What is Schizophrenia ?

Answer 11

• 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

Question 12

Schizophrenia and pregnancy

Answer 12

• 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

Question 13

Management of schizophrenia

Answer 13

• 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

Question 14

Postpartum psychosis

Answer 14

• 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).

Question 15

Key features of PP

Answer 15

• 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

Question 16

Differential diagnoses of PP

Answer 16

• Primary cerebral or systemic disease (e.g. eclampsia or infection)
• Exogenous toxic substances or hormones
• Other psychiatric disorders e.g. depression, anxiety, personality disorder

Question 17

Prevention of acute psychiatric episodes

Answer 17

• 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

Question 18

Signs and symptoms of PP

Answer 18

• 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

Question 19

Common symptoms of developing PP:

Answer 19

• 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

Question 20

Management and treatment of PP

Answer 20

• 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)

Question 21

Care and support of women with PP (1)

Answer 21

• 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)

Question 22

Care and support of women with PP

Answer 22

• 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’).

Question 23

What should you always be thinking about?

Answer 23

• SBAR
• MDT
• DOCUMENTATION
• ONGOING PLAN