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Maternal mental illness and sleep
Overview of today
Postnatal depression
Features, causes, risk factors and treatment
Consequences for mother and child
Postnatal psychosis
Sleep problems
For mother and baby
Complementing your existing skills
Partnership between academic knowledge and professional practice
Interactive sessions
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Postnatal depression
Overview Contrast with baby blues Diagnosis Causes and risk factors Treatments
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Post-natal depression (PND)
Baby blues Two to four days after birth (quite normal – but not PND)
Emotional/liable to burst into tears, for no apparent reason
Difficult sleeping (even when baby permits) Loss of appetite Feeling anxious, sad, or guilty Questioning maternal skills
Effects up to 75% of mums May relate to changes in post-birth hormone levels
Or could be related to being in hospital Key is that this doesn't last long – usually only a few days
If it persists it may develop into PND
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Major depressive disorder (DSM-IV TR)
Low mood AND/OR … Markedly diminished interest/pleasure in ‘usual’ activities
PLUS four from: Significant weight loss/gain/changes in appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue/low energy Feelings of worthlessness or excessive/inappropriate
guilt Poor concentration/indecisiveness Recurrent thoughts of death/suicide
Symptoms must be ‘continually’ present for at least 2 weeks
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PND: Features
PND needs same DSM-IV diagnosis as major depressive disorder But relates specifically to the postpartum period
But within 4 weeks of birth (is that enough?) Additional features may also indicate presence
Sense of inadequacy, inability to cope Feeling guilty Being unusually irritable Being hostile/indifferent to husband/partner/baby Panic attacks Excessive unwarranted anxiety Obsessive fears about the baby's health or wellbeing
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Whooley questions
During the past month…
1. Have you often been bothered by feeling down, depressed or hopeless?
2. Have you often been bothered by having little interest or pleasure in doing things?
Consider a third question:
Is this something you feel you need or want help with?
Is this sufficient?
Is there more we can do?
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PND: Prevalence
PND affects about 10% of new mums Compare to baby blues (up to 75%)
Although DSM-IV states ‘must be within 4 weeks of birth’ Most clinicians/researchers extend this to several
months Vulnerable mums usually referred in ‘perinatal’ period
During pregnancy up until baby is 1 year Can come on gradually or all of a sudden Can range from being relatively mild to very hard-hitting About 50% PND women afraid to tell health visitors about
it Scared it will lead to social services taking child away Or that they would be seen as bad mothers
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PND: Causes
Causes of PND uncertain But there are a number of known risk factors
Having had depression before Especially PND
Not having a supportive partner Having a premature or sick baby Having lost your own mother as child Having had several recent life stresses
Bereavement, unemployment, housing or money problems
Poor sleep (we will talk about this later)
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PND: Causes
Some additional risk factors for PND Shock of becoming a mother
Women often unprepared for physical impact of childbirth
Plus new and daunting skills to learn New full time responsibility Helpless human being who cannot communicate
Other than cry (distressing in itself) Some mums get anxious when they don’t hear
crying! Lie awake listening out
Loss of freedom and independence Exhaustion and fatigue
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PND: Causes
Hormones
Oestrogen and progesterone affect emotions
Levels of progesterone are very high during pregnancy
PND maybe due to sudden drop progesterone after birth
Diet
Lack of certain nutrients during pregnancy may cause PND
Omega 3 oils (found in oily fish, seeds and nuts)
Magnesium (leafy green vegetables and seeds)
Zinc (seeds and nuts)
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PND Treatment
Antidepressants Huge amount of evidence of benefit in treating
depression First line choice in most adults BUT it is not that simple in PND
Some antidepressants serious side effects and interaction
Consider this if mum is breastfeeding Some antidepressants are not safe for infants
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Medication for PND – what is safe?
Tricyclic antidepressants Lower known risks than other antidepressants
But more dangerous in overdose SSRIs (after 20 weeks) greater risk hypertension in
neonate Fluoxetine fewer known risks of SSRIs Paroxetine (in 1st trimester) some risk foetal heart
defects Venlafaxine some risk high blood pressure (at high
doses) Most antidepressants pass into the breast milk
Imipramine, nortryptiline and sertraline - at relatively low levels
Citalopram and fluoxetine - at relatively high levels
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PND Treatment
Counselling and talking therapies (CBT etc.) very effective
Group or individual care
BUT rare - can take time to get into a programme
We need more Perinatal Mental Health teams!
Self-help strategies
Counselling (listening visits)
Brief cognitive behavioural therapy
Interpersonal psychotherapy
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Organisation of care
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Summary
PND often confused with baby blues PND more serious and longer lasting But less common
We need to understand risk factors Extend beyond Whooley questions
Group task Are Whooley questions enough? What are the risk factors? What signs should we watch out for? Why are mums reluctant to tell us about mental health
problems? How far should we pursue this?
