Perinatal Mental illness

Please tell me

she’s not pregnant!

Dr Sharon Beattie Consultant Psychiatrist

Durham and Darlington Perinatal Mental Health Team

November 2019

Why should perinatal mental illness be on your radar?

• It’s common – up to 20% of women experience mental heath problems at some point during their pregnancy/first post-natal year.

• Maternal suicide is the leading cause of death within a year after the end of pregnancy, with a mortality rate of 2.8 per 100 000 maternities (95% CI 2.2-3.5)

• Teratogenic and other adverse effects of medication on foetal development

• ‘if I cannot breast feed her then I a not a mother’ • ‘I do not deserve to be her mum’ • ‘if I hadn’t him then everything would have been fine’ • ‘I can’t call her by her name’ • ‘I am nothing special to her, I am a drain and they would be better off without me’ • ‘what does he want from me’ • ’sometimes I feel angry about his neediness’

Key points around risk & prevalence of perinatal depression and anxiety

Depression • Prevalence of depression during

pregnancy is similar to prevalence post-partum (about 12%)

• Past history of depression risk factor for post-natal depression

• Depressed or anxious mood during pregnancy predict postpartum depression & is associated with increased reporting of somatic symptoms during pregnancy

• Around half of postnatally depressed mothers experience intrusive obsessional thoughts that are frequently aggressive in nature and are directed toward their infant

Anxiety Disorders • Anxiety disorder is probably more

common than depression after delivery & possibly more prevalent during pregnancy

• Anxiety Disorder in 3rd trimester predicts high scores on EPDS postpartum, independently of the presence of major depression during pregnancy

• OCD may occur for first time during pregnancy or after delivery – between 25-70% of parous women with OCD reported first onset occurring during pregnancy of after delivery, or that it was exacerbated by childbirth

• Post-partum onset OCD can recur after later pregnancies

A note about woman with Bipolar Affective Disorder

• High risk of recurrence related to childbirth: up to 67% experiencing an episode in the immediate postpartum period

• Risk of recurrence same in both bipolar I & II, more likely in those who have had more than 4 episodes

• Relapse postpartum particularly likely if maintenance medication has been discontinued

• Risk of episode of illness not lower during pregnancy : 1/3 experiencing worsening of symptoms; 32% having pregnancy or post partum episodes; 50% experiencing symptoms when pregnant

• If mood stabilisers discontinued then pregnant women relapse as frequently as not pregnant women 57% vs 52%. The time to relapse is shorter, with a rapid (within 2 weeks) rather than slower discontinuation.

• Cohen et al (1995) estimated the relative risk of recurrence for women who did not receive maintenance medication as 8.6 times that of women who did

• 50% of UK pregnancies are unplanned – Pregnancies usually detected 6-8 weeks post conception

– Most sensitive period for teratogenic effects has passed

• Comprehensive risk/benefit assessment for each woman – based on her history and current mental state, as well as other risk factors for poor obstetric outcome (smoking, alcohol, substance misuse) and how these might change if she were to relapse/remain untreated

Least harmful approach

• The least harmful way (for baby) of treating maternal mental illness is through psychological interventions…….but only if they are accessible & effective

• Throughout the rest of this presentation – where I talk about use of medication - there is an assumption that this approach (for whatever reason) is not adequate to treat alone

• When making referrals for pregnant/post-natal woman ensure that you highlight this as they are prioritised for access to treatment

But what if/when you need to prescribe?

• The BNF and pregnancy – ‘all SSRIs: manufacturers advise avoid during pregnancy unless the potential benefit outweighs the risk’.

• Sertraline SPC – ‘Sertraline is not recommended in pregnancy, unless the clinical condition of the woman is such that the benefit of treatment is expected to outweigh the potential risk’

• Maternal suicide is the 3rd largest cause of direct maternal death occurring during or within 42 days of the end of pregnancy

• Maternal suicide is the leading cause of death within a year after the end of pregnancy, with a mortality rate of 2.8 per 100 000 maternities (95% CI 2.2-3.5)

• A woman died violently in her third trimester. She had a previous history of anxiety and depression, with depression in a previous post-natal period. She had been prescribed venlafaxine prior to the pregnancy with good effect, but it had been stopped on discovering the pregnancy, either by the woman herself or her GP. No alternative was suggested and there does not appear to have been any specialist service within her area.

• She developed worsening anxiety, and then depression, with a range of physical complaints, poor coping and suicidal ideation. She returned to her GP asking to restart her previously effective venlafaxine.

• It is clear from the consultation notes that the GP was very reluctant to prescribe and placed responsibility for the decision entirely on the woman, documenting an explanation of the risks but not the benefits, of taking medication. She died a week later on the day she was due to undergo a mental health act assessment

• MRRACE-UK writers considered there to be 3 main messages for health professionals

• The first – it is essential for doctors, midwifes and allied health professionals to challenge assumptions, both their own and those of others. Including a default assumption that stopping medication is appropriate in pregnancy without considering the benefits and risks to the mother.

• Second was about continuity of care. Third was need for training of non-specialist services.

• Key action from the report was ‘decisions on continuing, stopping or changing medication in pregnancy should only be made after careful review of the benefits and risks of doing so, to both mother and infant’

Risk of Discontinuing Medication

• Some studies have reported that woman who discontinue antidepressants, or taken them in the 2 years prior to conception and stopped, are more likely to report depressive symptoms during pregnancy, more likely to experience suicidal ideation or need admission

• Cohen et al (2004) followed up 32 women with histories of depression who were euthymic before discontinuing medication around the time of conception. ¾ relapsed, most in the 1st trimester. Similar finding in a follow-up of 201 from specialist centres: 26% of those who remained on medication relapsed, compared with 68% who did not.

• Yonkers et all (2011), who carried out a community-based study, reported that discontinuing antidepressants made no different to relapse rates, unless there had been an episode in the 6 months before conception or there was a history of 4+ episodes prior to pregnancy.

Impact of stopping medication on mum

• Relapse/deterioration – subsequent need for higher doses?

• Self-medicating/maladaptive coping mechanisms - drugs, alcohol, smoking

• Self-neglect – engagement in maternity care

• Poor functioning – relationships

• Post-natal relapse

• Bonding with infant – starts with antenatal brain changes

Wider risks of untreated illness

• Evidence suggests that perinatal mental illness is associated with adverse effects in the health and development of children, and that early life experiences may influence the health of an individual across their lifespan (Hogg, 2013)

• Perinatal mental illness often occurs in the context of a multiplicity of adverse psychosocial factors, and determining which of these also contribute to child outcome, and to what extent, is complex

• Although perinatal mental illness can be associated with adverse outcomes for the child, this is not always the case

Risk of untreated illness during pregnancy

Depression and anxiety associated with poor pregnancy outcomes: • pre-eclampsia, elective C-

section & epidural analgesia during labour

• Admission of infant to neonatal care

• Placental abruption • Decreased breastfeeding

initiation

• Depression in the year prior to

delivery is an independent risk factor for sudden infant death syndrome

• Depression and anxiety are associated with reduced adherence to vitamins, increased use of hypnotics & nicotine

• Anxiety during pregnancy identified as an independent predictor of childhood behavioural and emotional problems

• Schizophrenia and bipolar disorder are at increased risk of antepartum haemorrhage, preeclampsia, preterm delivery, babies with high/low birth weight, increased risk of still birth & neonatal death

• Antenatal depression has been shown to increase the risk of preterm delivery, low birth weight and intrauterine growth retardation.

• Antenatal anxiety is associated with greater levels of foetal activity, higher rates of preterm birth and low birth weight

Foetal experiences in utero

• How do these influence later in life?

• Taste? Sound?

• Level of movements of baby of a stressed mum

Foetal experiences in utero

• One of most widely explored maternal psychological state in relation to foetal experience is maternal stress.

• Significant body of evidence describing adverse outcomes of maternal stress in terms of pregnancy complications – pre-eclampsia, preterm delivery, miscarriage and foetal distress.

• Evidence to suggest maternal stress associated with adverse physical and mental health outcomes for foetus, infant and throughout life (Talge et al 2007)

• Evidence also to suggest adverse temperamental and behavioural effects on the infant: increased risk of ADHD, anxiety, and cognitive and language problems

• Evidence suggests that effects are mediated through a process of foetal programming via the hypothalamic-pituitary adrenal axis and cortisol (Knackstedt et al 2005)

Lasting impact of experiences in utero?

• Prenatal anxiety is related to difficult infant temperament postnatally independent of any effect of postnatal depression

• Both antenatal anxiety and postnatal depression predict child emotional and behavioural problems, but do so independently of each other

• Study suggested internalising behaviours in 4-5 year old children (depression, anxiety and withdrawal) not associated with psychotropic medications being used in pregnancy but are linked to impaired maternal mood. Misri et al 2006

• Some evidence to suggest that children exposed to antidepressants do better on behavioural outcomes (hyperactivity/inattentiveness, conduct problems, peer problems, emotional symptoms) that children of untreated mothers Grzeskowiak et al 2015

• Study showed that depression in pregnancy significantly predicted violence in adolescence , even after controlling for family environment, mothers smoking and drinking in pregnancy, exposure to postnatal depression and parents antisocial behaviour.

Risk of untreated illness in post-partum period

• The relationship between parent and child is the context in which the child develops a sense of themselves and what happens in relationships (Winnicott, Bowlby, Stern)

• Anna Freud described the importance of a mother recognising and responding sensitively to her infant in relation to the child’s further psychological development.

• Although there is research exploring father and infant attachment, there may be differences in attachment behaviour.

• Perinatal mental illness may pose a threat to attachment by impairing or limiting the extent of the relationship and bonding

• Being insecurely attached to both parents has been reported to increase risk of behavioural problems in childhood. Being attached to one parent is protective.

Other potential impacts of postnatal depression

• Children of parents with mental illness are at increased risk of abuse and neglect. The mechanisms underpinning this association are complex

• There is some evidence that compromised or poor interaction between mother and child, as in the case of perinatal mental illness, is associated with poor physical health outcomes for children

• Maternal depression is a risk factor for child cognitive and language delays

• Maternal postnatal depression is associated with increased risk of the child developing depression by the age of 16 years

Impacts of medication on baby

• Description of risks in pregnancy available through www.uktis.org and in lactation www.ncbi.nlm.nih.gov

• Patient information leaflets www.choiceandmedication.org and www.medicinesinpregnancy.org

Principles when prescribing

• Individualised risk-benefit assessment considering all aspects of maternal and foetal wellbeing

• Avoid first trimester exposure if at all possible • Use lowest effective dose for the shortest time (but

remember that pregnancy physiology may change pharmacokinetics – metabolism and volume of distribution increase during pregnancy)

• We now have more published data on SSRIs than TCA • TCAs are toxic in overdose • As far as possible, treat the woman with a drug she has

responded to in the past • Avoid polypharmacy if at all possible, whether concurrently

or sequentially

Key Messages

• Not getting on top of significant depression or anxiety in pregnancy leads to risk of further deterioration in post-natal period

• There is increasing evidence on the risks to baby of untreated anxiety and depression in pregnancy

• Decisions about methods of treating mental illness in pregnancy must consider not just potential risks of medication but also the risks of not treating the illness