Psychiatric Morbidity And Psychiatric Morbidity And PregnancyPregnancy

Dr J RomainDr J Romain

EpidemiologyEpidemiology 15-30% new mothers suffer from mild 15-30% new mothers suffer from mild

depressiondepression 10% new mothers likely to suffer with major 10% new mothers likely to suffer with major

depressive illnessdepressive illness Between 1/3- ½ will have a severe depressive Between 1/3- ½ will have a severe depressive

illnessillness 2% women see a psychiatrist within first year 2% women see a psychiatrist within first year

after deliveryafter delivery 4 in 1000 admitted to psychiatric hospital, of 4 in 1000 admitted to psychiatric hospital, of

which 80% will be suffering from their first ever which 80% will be suffering from their first ever psychiatric illnesspsychiatric illness

Majority of women suffer mild depressive Majority of women suffer mild depressive illnessillness

Little evidence that this is more common Little evidence that this is more common than in the general populationthan in the general population

Risk of developing severe mental illness- Risk of developing severe mental illness- puerperal psychosis or severe depression puerperal psychosis or severe depression is increased by 16-fold, particularly in the is increased by 16-fold, particularly in the first 3 months post partumfirst 3 months post partum

Importance of PsychiatryImportance of Psychiatry

Substantial Morbidity- leading overall Substantial Morbidity- leading overall cause of maternal mortality in CEMACH’s cause of maternal mortality in CEMACH’s ‘Why Mothers Die’ 2000-2002‘Why Mothers Die’ 2000-2002

Effective treatmentEffective treatmentAdverse consequencesAdverse consequencesPredict riskPredict riskRegular medical contactRegular medical contactPreventionPrevention

Risk Factors for Mild DepressionRisk Factors for Mild DepressionTend to be psychosocialTend to be psychosocial Single (unsupported)Single (unsupported) YoungYoung Short IntervalShort Interval Early deprivationEarly deprivation Chronic life difficultiesChronic life difficulties Society adversity trendSociety adversity trend Past psychiatric hxPast psychiatric hx Prior social services involvementPrior social services involvement Life EventsLife Events

Risk Factors for Serious Mental Risk Factors for Serious Mental IllnessIllness

Often biologicalOften biological

Primiparity (especially if had a c-section)Primiparity (especially if had a c-section)Past psychiatric history (1 in 3-5 risk)Past psychiatric history (1 in 3-5 risk)Family psychiatric history (1 in 3 risk)Family psychiatric history (1 in 3 risk)

Baby ‘Blues’Baby ‘Blues’

Majority of women experience some Majority of women experience some alteration in their mental state between alteration in their mental state between days 3-10. Progesterone dropping.days 3-10. Progesterone dropping.

Commonly day 5Commonly day 5Low, tearful and labile mood, irritability, Low, tearful and labile mood, irritability,

insomnia.insomnia.Bouts of despair and catastrophizingBouts of despair and catastrophizingUsually only lasts 48hrsUsually only lasts 48hrsResponds to kindness and reassuranceResponds to kindness and reassurance

Mild Postnatal DepressionMild Postnatal Depression

At least 7% women meet the criteriaAt least 7% women meet the criteriaVulnerable ‘at risk’ womenVulnerable ‘at risk’ women Insidious onset in 1Insidious onset in 1stst week, present 3 week, present 3

months – year via health visitormonths – year via health visitorTearful, difficulty coping, unsatisfied with Tearful, difficulty coping, unsatisfied with

motherhood, anxiety, phobia’s, loneliness motherhood, anxiety, phobia’s, loneliness and isolationand isolation

Treatment with counselling (6 weekly) and Treatment with counselling (6 weekly) and social supportsocial support

Severe Major Postnatal Severe Major Postnatal DepresssionDepresssion

Affects between 3-5% of womenAffects between 3-5% of women Onset in first 2 weeks but can be up to 12 Onset in first 2 weeks but can be up to 12

weeks, peak between 2-4, 10-14weeks, peak between 2-4, 10-14 Biological symptoms; early morning wakening, Biological symptoms; early morning wakening,

impaired appetite, concentration and interests, impaired appetite, concentration and interests, anhedoniaanhedonia

Mood profoundly low, guilt and incompetentMood profoundly low, guilt and incompetent Treatment; antidepressants (SSRI’s, tricyclics) Treatment; antidepressants (SSRI’s, tricyclics)

need to be continued for 6 months after need to be continued for 6 months after recovery. Counselling. Good prognosisrecovery. Counselling. Good prognosis

Risk of relapse; 1 in 2 for future pregnancies Risk of relapse; 1 in 2 for future pregnancies outside childbirth risk of depression is lowoutside childbirth risk of depression is low

Puerperal PsychosisPuerperal Psychosis Abrupt onset 80% 3-14 days, rapidly Abrupt onset 80% 3-14 days, rapidly

deterioratesdeteriorates Likened to manic-depressive or bipolar affective Likened to manic-depressive or bipolar affective

disorderdisorder Restless agitation, perplexity, confusion, fear Restless agitation, perplexity, confusion, fear

and suspicion, delusions about themselves and and suspicion, delusions about themselves and their babytheir baby

Many experience first-rank schizophrenic Many experience first-rank schizophrenic hallucinations and delusionshallucinations and delusions

Treatment; urgent referral to psychiatrist +/- Treatment; urgent referral to psychiatrist +/- admission to mother and baby unit. If severe; admission to mother and baby unit. If severe; ECT.ECT.

Recovery 2-6wks, cont. meds for 6 months, Risk Recovery 2-6wks, cont. meds for 6 months, Risk of 1 in 2 during subsequent pregnancies. of 1 in 2 during subsequent pregnancies. Advised to delay 2 yrs for next babyAdvised to delay 2 yrs for next baby

Adverse Sequelae of PNDAdverse Sequelae of PND

Immediate- physical morbidityImmediate- physical morbidity

suicide/infanticidesuicide/infanticide

prolonged psychiatric prolonged psychiatric morbiditmorbidit

social bond mother-babysocial bond mother-baby

emotional developmentemotional developmentLater- social-cognitive affects childLater- social-cognitive affects child

psychiatric morbidity childpsychiatric morbidity child

marital breakdownmarital breakdown

PreventionPrevention

High risk patients (previous psychiatric High risk patients (previous psychiatric history, family history) picked up early in history, family history) picked up early in pregnancypregnancy

Monitored closely; seen in hospital clinics Monitored closely; seen in hospital clinics and by psychiatrist if necessary- and by psychiatrist if necessary- prophylactic medsprophylactic meds

Long term follow up postnatallyLong term follow up postnatally

Thankyou!Thankyou!