perinatal psychiatry · children of mothers who had had pnd were found to perform significantly...
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Perinatal PsychiatryDR LUCINDA DONALDSON, CONSULTANT PERINATAL PSYCHIATRIST
WHITTINGTON HOSPITAL
Relevance of the perinatal period to mental illness Risk of the development of mental illness
Risk of relapse of mental illness
Consideration of use of psychotropic drugs
Obstetric complications and outcomes for baby
Lifestyle factors
Safeguarding
Engagement
Risk management
Stigma
Rates of perinatal psychiatric disorders
Postpartum psychosis 2/1000
Chronic serious mental illness 2/1000
Severe depressive illness 30/1000
Mild-moderate depressive illness and anxiety states
100-150/1000
Post-traumatic stress disorder 30/1000
Adjustment disorders and distress 150-300/1000
Postpartum psychosis
Psychiatric emergency requiring immediate treatment
Typically occurs in the first few days following delivery 50% will have presented by day 7 90% will have presented by 3 months (Kendell et al, 1987)
Sudden onset, rapid deterioration, rapidly changing presentation
Risk factors
History of bipolar disorder 25-50% risk of severe postpartum recurrence (Jones and Craddock, 2001) Nearly 1 in 2 risk of any mood disorder postnatally (Di Florio, 2013)
Family history of postpartum psychosis Relapse rates as high as 74% in women with bipolar and with a family
history of post-partum psychosis… …compared with only 30% of bipolar women without any family history of
postpartum psychosis (Jones & Craddock, 2001) But 50% or more of women with postpartum psychosis have no history
that would have placed them at high risk (Robertson Blackmore et al, 2013)
Risk factorsPrimiparity (Robertson Blackmore et al, 2006)
Discontinuation of mood stabiliser during pregnancy (Viguera et al, 2000)
Obstetric complications (Robertson Blackmore et al, 2005)
Previous episode of post partum psychosis◦ 57% of women went on to experience another episode of PP (Robertson et al, 2005)
Perinatal depression
Clinically may be indistinguishable from depression at any other time
Compared to unipolar depression, perinatal illness may◦ Consist of more negative or intrusive thoughts heavily focussed
on the maternal role or the infant
◦ Present with more anxiety features (generalised anxiety; panic attacks; hypochondriasis; OCD)
◦ Take longer to respond to treatment
Postpartum depression
Most common postpartum psychiatric disorder
Around 50% of episodes start during pregnancy (Josefsson, 2002)
Presentation usually within first 3 months, with a second peak around 6-8 months
History of previous postpartum depression, 1 in 3 chance of recurrence in next pregnancy (Cooper et al, 1995)
Risk factors for perinatal depression
Anxiety and depression during pregnancy
Past history of psychiatric illness
Perceived low levels of social support
Life events
Domestic violence
Marital/family conflict
Migration status
Severe baby blues
Obstetric factors been shown not to have a significant association
The role of hormonal changes/HPA axis probably plays a part but the relationship is complex
Impact of perinatal depression and anxiety on foetus and neonate
Antenatal depression associated with increased risk of premature delivery (<37 weeks’ gestation) (Grigoriadis, 2013; Grote et al, 2010)
The findings regarding an association between depression and low birth weight were contradictory
Antenatal anxiety and adverse foetal outcomes – inconclusive◦ Some association with greater foetal activity, higher rates of preterm birth and perinatal complications
(Alder et al, 2007)
Impact of perinatal depression on mother and child
Children of mothers who had had PND were found to perform significantly less well on cognitive tasks at 18 months than children of well mothers (Murray et al, 1992; Murray et al, 1996)
Effect still obtained at 4-5 years old (Cogill et al, 1996; Sharp et al, 1995)
Higher rates of insecure attachment with antenatal depression (Hayes et al, 2013) and PND (Martins et al, 2000)
Children of mothers who suffered PND were 4 times more likely to suffer from a psychiatric disorder at 11 years old than children whose mothers did not have PND (Pawlby, 2008)
Suicides
◦ The care of 101 women who died by suicide in pregnancy or up to one year postpartum in 2009 to 2013 was analysed in detail
◦ One in eleven of the women who died during or up to six weeks after pregnancy died from mental health-related causes.
214 deaths due to direct and indirect causes among 2,373,213 maternities
- a maternal death rate of 9.02 per 100,000 maternities
- 1 in every 11,000 women giving birth
Characteristics of women (n=101) who died by suicide 2009-2013Median age 29 years
Majority were white, UK citizens
Most had one or two previous deliveries
Almost ¼ were known to social services
Only ¼ received the recommended level of care
¼ booked late for antenatal care
‘Red flag’ presentations which should prompt urgent senior psychiatric assessment
Recent significant change in mental state or emergence of new symptoms
New thoughts or acts of violent self-harm
New and persistent expressions of incompetency as a mother or estrangement from the infant
Perinatal Mental Health TeamsUCLH
Team manager: Jackie Hughes
Consultant Obstetrician: Seni Subair
Consultant Psychiatrist: Gina Waters
Consultant Psychologist: Lih-Mei Liao
Polly Smith, Lead Nurse for Safeguarding
Ann Lloyd, Liaison Health Visitor
Safeguarding midwives
WHITTINGTON
Consultant Psychiatrist: Lucinda Donaldson
Perinatal nurse specialist: Ola Ajala
What we offerAssessment of pregnant women with mental illness, signposting and onwards referral
Close liaison with other professionals/agencies
Birth plans
Organise MBU admissions
Differences:
Whittington sees postnatal women
UCLH offers therapy (Whittington refer on)
Meds advice (UCLH via phone; Whittington preconception/joint obstetric-psychiatric clinic)
Essential referralsDiagnosis of severe mental illness (schizophrenia, bipolar disorder, schizoaffective disorder
History of post-partum psychosis
History of severe depression
History of contact with mental health services
Family history of bipolar affective disorder or perinatal mental illness
Suicidal thoughts/self-harming behaviour
Active eating disorder
Advice on/review of psychotropic medication during pregnancy/breastfeeding
UCLH perinatal team web pageNewly revamped webpage
Info for referrers and service users
No generic counselling
NB currently antenatal only
https://www.uclh.nhs.uk/OurServices/ServiceA-Z/WH/PMHS/Pages/Home.aspx
Perinatal Mental Health Service
University College Hospital
Women's Health Division
2nd Floor North
250 Euston Road
London, NW1 2PG
Patient enquiries
Telephone: 020 3447 2697
Email: [email protected] GP enquiries
Telephone: 020 3447 2697
Fax: 020 3447 9775
Email: [email protected] Service manager - Jackie Hughes
Email: [email protected]
UCLH contact detailshttps://www.uclh.nhs.uk/OurServices/ServiceA-Z/WH/PMHS/Pages/Home.aspx
Perinatal Mental Health Service, University College Hospital, Women's Health Division, 2nd Floor North, 250 Euston Road
London, NW1 2PG
Email: [email protected] GP enquiries
Telephone: 020 3447 2697
Fax: 020 3447 9775
Email: [email protected]
•Whittington contact details
•Electronic referrals accepted from any health professional.
•Administrator 020 7561 4142
•Perinatal mobile 07774 629 071
Summary of perinatal mental illness
Mild and short-lived mood disturbance is common
Untreated perinatal depression can lead to poor outcomes for mother and baby
The risk of developing a severe mental illness is markedly elevated following childbirth (but only affects a minority of women) and has serious implications for the mother, infant and family
Suicide has previously been identified as the leading cause of maternal deaths
Prescribing in pregnancy and breastfeeding is complex and individualised
Effective communication, interfacing and sharing of information is vital