Perinatal Mental Health

Dr Cressida Manning

Consultant Perinatal Psychiatrist

Florence House Mother and Baby Unit

Contents of Presentation

Confidential Enquiry into maternal deaths.

Risks of untreated illness.

Risk factors for postnatal depression and psychosis.

Discussions around treatment.

Medication.

Recent Case Study

Felicia Boots. 35

Mother of 2 ( 14 months and 10 weeks).

Manslaughter on grounds of diminished responsibility.

Stopped medication as breastfeeding.

Confidential Enquiry

Centre for Maternal and Child Enquiries (CMACE)

Most recent report ‘Saving Mothers Lives’ (2011) 2006-2008

29 suicides 1st 6 months

19 past psychiatric history

9 identified of which 4 had care plan

Saving Mothers Lives

38% Psychosis

21% Severe Depressive Illness

Recommendations - Back to Basics 1Saving Mothers Lives

Anxiety or depression Review in 2 weeks

Consider psych referral if symptoms persist

Refer urgently where:

Suicidal ideation, uncharacteristic symptoms/marked change from normal functioning, morbid fears, profound low mood, personal or family history of serious affective disorder, mental health deterioration, morbid fears, panic attacks and intrusive obsessional thoughts.

Effects of Untreated Illness

Increased morbidity.

Increased risks towards self and others.

Links between maternal anxiety and fetal behaviour and heart rate

Stress/anxiety during pregnancy can have long term effects on child

Associated with an increased incidence of:

Emotional problems - Anxiety/depression

Behavioural problems – ADHD, conduct disorder

Impaired cognitive development, esp language

Sleep problems in infants

Sensitive early mothering important as what happens in utero for child outcome

Effects of antenatal and postnatal depression Children of mothers depressed in perinatal period compared to

children of well mothers:

Lower IQ scores

12x more likely to have a statement of special needs

elevated risk of violence at 11 and 16 years

More likely to suffer separation anxiety at 11 and a diagnosis of depression at 16

Suicide

Majority of deaths secondary to postpartum psychosis or very severe depressive illness

Oates (2008) Suicide rate for ppp 2/1000

Common profile; white, older, 2nd or subsequent pregnancy, married, comfortable circumstances

Likely to die violently

Infanticide

Similar profile

1/3rd mental illness

Death extended suicide or occasionally altruistic based on delusional belief

Highest concern if delusion involves child e.g baby changed, not hers, possessed, evil.

Postpartum Psychosis

1st few weeks highest risk Heron et al (2007) Greater than 80%

1st week Link with BPAD

Bipolar Disorder

52% relapse in 1st 40 weeks after stopping treatment

If pregnant and stable on antipsychotic and likely to relapse without medication continue

Up to 70% relapse if untreated in postnatal period 50% psychotic symptoms day 1 - 3

Postpartum Psychosis – Risk Factors

1st Baby

Single

C- Section

Older

Fertility Problems

Previous episode – 1 in 7

Sleep Loss

Warning Signs

Early signs often non specific

Insomnia, agitation/anxious, perplexed and odd behaviour. Risk overlooked

Can lead to rapid deterioration to Psychotic symptoms

Postnatal Depression

10 -15%

Severe 3%

1/3 to ½ continuation of antenatal anxiety and depression

Onset few days to 6 months

Increased risk in subsequent pregnancies – approx 25 – 50%

Postnatal Depression – Risk Factors

Antenatal anxiety or depression

Past history of psychiatric illness

Life events

Lack of or perceived lack of support

Low income

Domestic violence

FH of psychiatric illness

Childhood abuse

Risk Factors cont…

Obstetric factors

Sleep deprivation

Infant factors –irritability

Personality factors – control, interpersonal sensitivity, ‘neuroticism’

Biological factors – inconsistent results

Early Detection

1st contact;

Past or present mental illness

Previous psychiatric input, including admissions

Family history of severe mental illness

Treatment of pregnant and breast feeding women- NICE guidelines

Importance of balancing risks and benefits

Cautious

Women requiring psychological treatment should be seen for treatment within 1 month of assessment and no longer than 3 months.

NICE

Discussion should include:

Risk of relapse and not treating disorder

Woman’s ability to cope with untreated symptoms

Severity of previous episodes and response to treatment

Woman’s preference

Possibility that stopping drug with teratogenic risk once pregnancy confirmed may not remove risk

NICE

Risks of stopping medication abruptly

Need for prompt treatment due to impact of illness on foetus/child

Increased risk of harm of specific drug treatments

Treatment option that would allow mother to breastfeed

NICE

Prescribing:

Drugs with lowest risk profile

Lowest effective dose

Monotherapy

Risks lower threshold for psychological treatment

Important to put risks from drug treatment in context of the individual woman’s illness

Antidepressants

SSRIs Paroxetine in 1st trimester increase in cardiac malformations (VSD) – planning pregnancy or unplanned advise to stop. Other SSRIs now implicated.

SSRI’s taken after 20 weeks may be associated with an increased risk of persistent pulmonary hypertension of the new born Neonatal withdrawal- normally mild and self limiting

Symptoms include; Irritability Hypertonia Jitteriness Difficulties feeding Tremor Agitation Seizures Tachypnoea Posturing

Tricyclics

Tricyclics have lower known risks during pregnancy than other antidepressants

Have higher fatal toxicity index

CHD with clomipramine

Withdrawal symptoms

No effects on long term neurodevelopmental outcomes

Imipramine

Other antidepressants

Venlafaxine – Conflicting results for congenital malformations – data too limited to say safe. Possible increased neonatal withdrawal and increased risk of high blood pressure at higher doses. Theoretical risk of PPHN

Mirtazapine – Possible association with increased rate of spontaneous abortion. No evidence to link to congenital malformations but data too limited to say safe.

JAMA 13 – Metaanalysis – preterm birth 3 days

- Apgar <0.5

- Weight 75g

- Spontaneous abortion not significant.

Benzodiazepines

Raised risk of oral cleft (7 in 1000; x10)

Withdrawal syndrome – jitteriness, autonomic dysregulation, seizure, floppy baby syndrome

Consider gradually stopping in women who are pregnant

Short term use only for severe agitation and anxiety

Lithium – Ebsteins anomoly (1 in 1000) General population 1 in 20000

Overall risk CHD 0.9-12% vs 0.5-1% general population.

Floppy baby syndrome, thyroid dysfunction, nephrogenic diabetes insipidus.

High quantities in breast milk.

Valproate NTD 100 to 200 in 10000 IUGR Facial dysmorphias Low IQ

Do not routinely prescribe to women of child bearing age. If no option adequate contraception Discontinue if pregnant

Carbamazepinne

Increased risk congenital malformations -6.7% v 2.3%

Craniofacial, GIT, cardiac, urinary tract and digit anomalies

Advice as valproate

Lamotrigine

Cleft palate 8.9/1000

Atypical Antipsychotics

Olanzapine and Quetiapine

Limited data to base assessment of safety in pregnancy, but available data does not suggest a substantially increased risk of congenital malformations or spontaneous abortions

No pattern of malformations observed.

Withdrawal symptoms

Olanzapine – increased birth weight

What Clinicians need to do

Do not assume it is always better to stop medication

Provide prompt and Effective treatment of mental illness in pregnancy and postnatal period

Understand, consider and communicate known risks (and how these will be managed) of medication

Complete risk benefit analysis for individual patient.