We believe in physical and emotional health and wellbeing in all its dimensions for all women in Australia throughout their lives.

Postnatal depression and anxiety:

new ways of understanding & responding effectively to risks

A webcast for health professionalsOctober 2016

Learning Objectives

• Recognise modifiable risks for perinatal depressive, anxiety and adjustment disorders;

• Implement evidence-informed strategies using e-mental health resources, to build skills and promote health adjustment among new parents.

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CPD Points

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Panel speakers

Professor Jane FisherAcademic clinical psychologist

Dr Deidre BentleyGeneral Practitioner

Ms Jan O’Connell Maternal and Child Health Nurse

Early parenthoodThe birth of an infant demands dramatic adaptationWomen:

• relinquish autonomy and personal liberty• occupational identity and capacity to generate an income • social and leisure activities in service of infant care• multiplication of the unpaid workload, and • for some, harm to bodily integrity through unexpected adverse

reproductive events

Common Mental Disorders (CMDs)• Non-psychotic mental health conditions identifiable in primary

health care; o Include depressive, anxiety and adjustment disorders, which

compromise day-to-day functioning (Goldberg and Huxley, 1992)• Lifetime prevalence of

o Major Depression 1.6 to 2.6 times higher among women than men (Kessler, 2003)

o Generalised Anxiety Disorder; Panic Disorder and Simple Phobias 2 to 3 ties higher in women than men (Kadri and Alami, 2009)

Postnatal CMDsDepression, Anxiety, Adjustment Disorders

• Patients who score above threshold on screening questionnaires or meetcriteria for major depression are heterogenous: their illnesses include avariety of anxiety, obsessional and post-traumatic stress disorders,together with depression associated with adversity, and primarydepression linked to bipolar disorder

Brockington, 2004

Prevalence of perinatal common mental disorders in high-income countries• Self-report measures yield symptom scores rather than diagnoses;• Variation in sampling, measures, cut-off scores, period of ascertainment and

whether point or interval prevalence ascertained;• Limited precision and comparability;

Women:Pregnancy

Depression: 7.4% (T1), 12.8% (T2), 12.0% (T3) (Bennett et al, 2004)Anxiety: 10.4% - 16.2% (Matthey et al, 2003)

Postpartum:Depression: 6.8% (Woolhouse et al, 2012) to 20.7% (Webster et al, 2001)Anxiety: ≈ 10% in the first six months postpartum (Fisher et al, 2010)

Summary• All women have heightened psychological needs after giving birth;• Some experience disabling symptoms of low mood, sadness,

irritability or anxiety;• These are rarely attributable to one factor, but rather to past and

recent experiences, some of which can be modified;• Every woman benefits from psychologically-informed primary care;• It is a phase of life when learning needs are high and therefore

there is potential to assist people to acquire new knowledge andskills to optimize mental health.

Young Parents - considerations• Relationship – stability & communication skills• Fewer life skills e.g. managing a household, decision making• Interrupted education, social experiences, career building• Economic - low disposable income - higher risk of poverty• Important brain developmental stages still occurring• Limited social and practical support networks• Unresolved issues – previous abuse, neglect, addiction, support• Remember the child’s physical, emotional, development needs

Fathers and PND

• Daunting sense of responsibility• Highly protective of their partner and baby• Concern about financial responsibilities, especially if in insecure or casual employment

• Uncertainty about providing infant care

MenPregnancy:

Depression: 4.6% (Condon et al, 2004)Anxiety: 4.4% - 9.7% (Matthey et al, 2003)Excessive alcohol use: 27.5% (Condon et al, 2004)

Postpartum:Depression: 1.5% - 4.7% (Matthey et al, 2000; Condon et al, 2004)Depression and / or Anxiety: 6.3% - 11.5% (Matthey et al, 2003) Excessive alcohol use: 23.9 - 25% (Condon et al, 2004)

Prevalence of perinatal common mental disorders in high-income countries• Much less evidence about men than women;• Couples are not independent of each other;

Assessment toolsEdinburgh (Postnatal) Depression Scale:• 10 fixed response option items (scored 0 to 3);• No assessment of somatic symptoms: appetite, weight change

or sleep disturbance;• Cut-off scores formally established in validation against gold-

standard diagnostic interviews;• Cut off scores for community (>9) and clinical (>12) indicators

Assessment toolsWhooley Questions were introduced by the National Institute for Clinical Excellence (NICE 2007) to their guidelines for Antenatal and Postnatal Mental Health

oDuring the past month have you often been bothered by feeling down, depressed or hopeless? Yes | No

oDuring the past month have you often been bothered by little interest or pleasure in doing things? Yes | No

• A third question should be considered if a woman answers “yes” to either of the initial questions.o Is this something you feels you need or want help with?

Parent Story #1 Petra and Chris• Petra is 34 years with 3 children

o4, 2 and 3 month old Amy; all caesarean• Chris reports Petra is

oexhausted, irritable and angry or cryingowonders what she does all day

• Amy is breast fed; only settles for short periods during the day with feeding wakes 3-4 times p/n

• Little family support • History of anxiety and PND; antidepressants

Medication • Would be guided by

oEPDS scoreoClinical impression /gut feeling oKnowledge of oral resources – GO TO

PEOPLEoOwn experience/scope of practice oReferral to or advice from MH

specialists if not comfortable • Exclude harm /psychosis• Consider risk/ benefit

• SSRIo Sertraline o Paroxetine– (Category D in first

trimester)o Citalopram/escitalopramo NOT FLUOXETINE in breastfeeding

• TCAo Amitriptylineo Nortriptylineo NOT DOXEPIN in lactation

Risks for perinatal common mental disordersMultifactorial, systematic reviews of evidence conclude:Non-modifiable• Past personal experiences of anxiety, depression, substance abuse or eating

disorder;• Coincidental adverse or stressful life events; • Unintended or unwanted pregnancy; Longer time to pregnancy;• Aspects of personality style;

(Scottish Intercollegiate Guidelines for the Management of Perinatal Mood Disorders, 2012)

• Experiences of maltreatment or neglect as a child;

Risks for perinatal common mental disorders

Potentially modifiable• Quality of relationship with the intimate partner: protective and

potential to increase risk; • Domestic violence;• Insufficient social support;

(Scottish Intercollegiate Guidelines for the Management of Perinatal Mood Disorders, 2012)

Occupational health and safetyOccupational fatigue:Prolonged work hours Irregular work hoursCircadian disturbanceParticular kinds of work “Shift work sleep disorder”

Alternate response to anxiety & distress• Listen actively – verbal and non-verbal communication• Identify issues creating the anxiety and distress• EPDS to further understand areas and level of distress• Provide relevant knowledge and normalise experience• Acknowledge her strengths and reassure• Organise additional visits/contact for building skills and

emotional support• Link into local services, parent groups, counselling (GP referral)

Parent Story #2 Kate, Lee and Molly

• Molly: first child born 5 weeks early • Special Care Nursery for 3 weeks• Breast feeding difficulties initially• At 7wks, change in feeding & sleeping patterns• Minimal parenting support• Lee works long hours and travels interstate• Relationship stresses and strains

What Were We Thinking! A new way of thinking

• Gender-informed understanding of women’s postpartum psychological health

• Addressing relevant social determinants directly• Views caring for a baby and running a household in which a

baby lives as tasks which require high-level knowledge and skills• Life-stage specific learning needs which can influence confidence

and competence• Psychiatric language and conceptual frameworks constitute a barrier

to participation, and are not essential to providing psychologically-informed care

Which factors does WWWT address?Two risks that are neglected in existing programs

1. Unsettled infant behaviour 2. Adjustments to the partner relationship

Preventive intervention involving mothers, fathers and their first newborns: Routine care from a WWWT trained MCH nurse Seminar in the early postnatal period Adult learning approaches in small groups

Understanding and disrupting gender stereotypes to improve mental health

Where do you stand?

Mothering is

instinctive

Mothering is

learned

Six months postpartum Any WWWT compared to usual care group

Mild to moderate anxiety 43% lower*

Fair or poor health 64% lower*

How do we know WWWT works?

Fisher et al., 2016

Six months postpartum Full WWWT program compared to usual care group

Any depressive, anxiety, or adjustment disorders prior 30 days 64% lower

Fewer critical and controlling behaviours from partners; Greater use of effective soothing and settling strategies No adverse outcomes

Support for Kate, Lee and Molly

Support for Kate, Lee and Molly• The role of parenting requires that we gain new knowledge and

set of skills to assist raising our children• Changes to the parents’ relationship requires patience, respect

and communication• Expectations about what having a child will be like can differ

from the reality, in particular the support needed and received• Timely parental information and support can improve mental

and physical health and relationships

Support for Petra and Chris

A New Reality InThisTogether Crying, Settling, Sleeping

Your Needs Every Baby is Different

Growth and Development

The Birth Not Long to Go Your Tired Baby Setting Limits Labelling Your Baby When Your Baby is Awake

How is it Now? What You Need to Know Settling Your Baby Being Firm Creating a Family Routine More about Feed-Play-Sleep

What am I Missing? Our New Family Helping Your Baby Sleep Taking a Breath Worrying Too Much The Help You Need

More About Losses and Gains

Everyone Needs Sleep Crying, Crying, Crying What to do if There is Not Enough Help

Supporting Your Baby’s Development

Sleeping Update

What Have you been Doing all Day?

Keeping it Nice Understanding Crying Having Mixed Feelings Your Baby is Growing

Worrying About Your Baby Teamwork More About Baby’s Sleep Leaving Your Baby with Someone Else

Your 4 Month Old

More About Keeping it Nice More About Settling Your Baby

Routine and Your Baby’s Carers

Keeping Your Baby Safe

The Family You Grew Up In

Feed-Play-Sleep Going it Alone Helping Babies to have Structure in their Lives

Your New Family Resettling Your Baby Games That Babies Enjoy w their Parents

* Interactive Worksheets Not All Crying is the Same

App Index

E-resources support and materials

• Free to order and download for your practice

Find out more• E-resources and ordering materials

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