1. When the bough breaks: Mental Illness in the Pregnant and Postpartum Woman
Dr.Mariam Alawadhi MD,FRCPC
Assistant professor-Department of Psychiatry,Kuwait University
Head of consultation liaison unit-KCMH

2. Agenda
Review the epidemiology and clinical presentation of perinatal mood and anxiety disorders in perinatal women.
Understand the psychiatric, obstetric and pediatric implications of a mother’s untreated illness.
Discuss a bio-psychosocial approach to the management of these disorders.

3. Depression is “the most common complication of childbearing.”
Wisner, 2002

4. 1 in 5 mothers will experience a mental health disorder during their pregnancy or the year after they deliver.

5. Pregnancy and the transition to parenthood is considered to be one of life's major transitions.
Women are at an increased risk of developing mental health issues due to physiological and psychological risk factors.

6. Challenging the myths... Media images of pregnancy and motherhood
Pregnancy was planned, so why do I have the “blues”?
Work-life balance
Relationships (couple, extended family)

7. ...and facing reality
Tired, home alone, lots of care for baby, no time for self, complete loss of control over time
Wide range of positive and negative emotions
Adjustment and adaptation to pregnancy and motherhood is dynamic
pregnancy alters a woman’s life irreversibly
Women need accurate information (e.g, pregnancy, labour, delivery) = power, control
Shame & stigma

8. Perinatal mental health
Pregnancy related
Antepartum Depression
Antepartum anxiety
Postpartum related
Baby Blues
Postpartum Depression
Postpartum Psychosis
postpartum anxiety

9. Let’s define the terms first... Antepartum depression
Associated with:
Poor prenatal care (e.g., nutrition; substance use)
Changes in cortisol & HPA axis development
Poor perinatal outcomes (e.g, abnormal fetal neurobehavioral; pre-term labour (Steele et al., 1992)
Depression vs. pregnancy?  affect
 cognition  functional impairment

10. Antenatal Depression Risk factors: low self-esteem
low social support, low income
antenatal anxiety, hx of depression, hx of abuse
negative cognitive style
hx of miscarriage/pregnancy termination
pregnancy complications

11. Confounds in diagnosing depression during pregnancy
Overlapping symptoms:
Sleep disturbances
Increased/decreased appetite
Decreased energy
Changes in concentration
Illnesses with similar symptoms:
Anemia
Thyroid dysfunction
Gestational diabetes mellitus

12. Perinatal Anxiety Generalized Anxiety Disorder = 4-8%
Panic Attacks = 1-3%
Obsessive Compulsive Disorder = %
Posttraumatic stress Disorder = 6%;
40% in loss

13. Perinatal anxiety disorders
Effects of maternal stress & anxiety during pregnancy
Altered fetal movement
Lower gestational age
Lower infant birth weight
Lower APGAR scores
Enduring changes in cortisol measures in offspring
Ross,2006

14. Postpartum blues Baby blues Very common (50-80%)
Starts w/in 1 wk pp: peaks
3-5 days post-delivery
Unrelated to environmental stressors
Unrelated to psychiatric history
Present in all cultures
Low-level symptoms:
Tearfulness
Irritability, reactivity
Insomnia
Anxiety
Poor appetite

15. Posited relationship between “Blues” and PPD
During pregnancy:
Increase oestrogen, progesterone (placental production of hormones); beta-endorphin & cortisol (cortisol peaks in late pregnancy - CRH), prolactin
Oestrogen enhances neurotransmitter serotonin (increases synthesis & reduced breakdown)
After delivery:
Drop in oestrogen/progesterone (removal of placenta at delivery); drop in cortisol & b/e
Decrease estrogen decrease serotonin
Prolactin levels return to normal in non-lactating women w/in weeks
Breastfeeding: prolactin levels remain high (induces release of oxytocin)

16. Postpartum depression
Peaks at 3-6 mo pp
Average PPD course is 7 mo
Related to psychiatric history and environmental stressors
DSM IV  onset from within 4 wks. of delivery, “pp onset”
Clinically, up to 1 y postpartum (DSM V to reflect this)

17. Postpartum depression
Added clinical features:
Obsessive traits (e.g., name of baby, harming baby)
Depressed, despondent, emotionally numb
Ambivalence toward baby (bonding)
Grief for loss of self
Feelings of inadequacy, guilt*
Feeling isolated/misunderstood
Suicidal ideation/Ego-dystonic thoughts of harming baby

18. Risk factors Biological Psychological Social Obstetric
Family history of depression or affective disorders
Previous PPD or depression
Thyroid dysfunction
Hormones
Altered immune function
Sleep disturbances
Low self-esteem
age
Perfectionist, neuroticism, high/unrealistic expectations of self/baby
Feelings of inadequacy
Role conflict
Attitude toward pregnancy (ambivalence, unwanted)
Trauma/abuse
Unresolved grief (death of child)
Lack/poor social support
Relationship problems (couple, extended family)
Difficult baby (feeding, colic)
Separation from baby
Stressful live events (move, job change, illness)
Economic stress
Recent loss
Childcare stress (# of children at home)
IVF (fertility drugs)
Difficult delivery
Medical complications of pregnancy
Health problems of infant
Lack of readiness for hospital discharge
(Kendler, 1993; Wisner, 2002)

19. Postpartum psychosis Heterogeneous group of disorders
BAD (35% with bipolar diathesis)
MDD w/ psychotic features
SZ-spectrum disorders
Medical conditions (e.g., thyroid, low B12)
Drugs (e.g., amphetamines)
Bizarre symptoms:
Delusions (e.g., baby possessed)
Hallucinations (e.g., seeing s/o else’s face)
Mood swings (more than non/pp psychosis)
Confusion & disorientation
Erratic behaviour
insomnia
Waxing & waning
Risk for suicide and infanticide
Psychiatric emergency

20. Postpartum psychosis Rare (1-2/1000 women) Most commonly 2-4 wks/pp
Risk Factors
Family hx of BAD
Early onset depression
History of PPD

21. Agenda
2.Understand the psychiatric, obstetric and pediatric implications of a mother’s untreated illness.

22. Economic & health care burden
Yearly estimated costs of depression $14.4 – 44 billion dollars annually (Greenberg, 1993; Stephens, 2001)
The rate of depression among Ontarians is about 4.8% (Statistics Canada, 2003), with women more than twice as likely as men to be depressed (Statistics Canada, ).
50% of OB/GYN patients have a significant emotional disturbance (Ballinger, 1977; Bryne, 1984; Worsley, 1977)
Women with PPD access more community services, make more frequent non-routine visits to the pediatrician; costs are higher for women with an extended duration of illness (Petrou, 2002; Chee, 2008)
Peak prevalence of ♀ psychiatric contact (in & outpatient) occurs in the first 3 months after childbirth (Kendall, 1987; Munk-Olsen, 2008)

23. Maternal Risks from A/PPD
Coronary artery disease
Cancer
Hypertension
Overactive bladder
urinary incontinence
Poorer maternal health practices
Complications after childbirth

24. Fetal Risks from A/PPD Poorer maternal health practices
Elevated cortisol levels
Preterm delivery
Small for gestational age
Low birth weight
Schmeelk 1999, Lundy 1999, Hoffman 2000, Adewuya 2007, Hedgaard 1993

25. Adverse parenting outcomes
Depressed mothers:
Perceive their infants as more bothersome and make harsher judgments of them
Are more irritable and spend less time looking, touching, and talking to their infants
Are more likely to neglect/abuse their children
Whiffen 1989, Cohn 1990, Chaffin 1996

26. Adverse parenting outcomes
These effects are moderated by:
Timing of depressive episode
Age of children
SES of family
Lovejoy, 2000

27. Attachment Definition :
A strong emotional and social bond between infants and their caregivers

28. JOHN BOWLBY (1907-1990) British Child Psychiatrist & Psychoanalyst.
He was the first attachment theorist
describing attachment as a "lasting psychological connectedness between human beings".
Bowlby believed that the earliest bonds formed by children with their caregivers have a tremendous impact that continues throughout life.
According to Bowlby, attachment also serves to keep the infant close to the mother, thus improving the child's chances of survival.

29. John Bowlby (1969)
Argued babies are born equipped with behaviors (crying, cooing, babbling, smiling, clinging, sucking, following) that help ensure that adults will love them, stay with them and meet their needs.

30. Bowlby (cont’d)
Believed quality of early attachment influences future relationships (friends, romantic partners, own children).

31. HARLOW & ZIMMERMAN
A famous experiment was conducted by Harlow and Zimmerman in 1959, Which showed that developing a close bond does not depend on hunger satisfaction.
They conducted the experiment where rhesus monkey babies were separated from their natural mothers and reared by surrogates- terry cloth covered and other was wire mesh.
Babies cling to terry cloth mothers even though wire mesh had bottle.
This shows 'contact comfort' is more important

32. Attachment 'FEEDING IS NOT THE BASIS FOR ATTACHMENT'
The central theme of attachment theory is that mothers who are available and responsive to their infant's needs establish a sense of security in their children.
The infant knows that the caregiver is dependable, which creates a secure base for the child to then explore the world.

33. Attachment When does it form?
Usually within the first six months of the infant’s life
Shows up in second six months through wariness of strangers, fear of separation from caregiver, etc.

34. Attachment
Babies are born equipped with behavior like crying, cooing, babbling and smiling to ensure adult attention & adults are biologically programmed to respond to infant signals.
Bowlby viewed the First 3 years are very sensitive period for attachment

35. Four Stages of Attachment
Pre-attachment
Attachment-in-the- making
Clear-cut attachment
Formation Of Reciprocal Relationship
(3-4 yrs onwards): understand caregiver’s schedule. Separation protests decline.

36. PREATTACHMENT PHASE Birth-6weeks
Baby’s innate signals attract caregiver (Grasping, crying, smiling and gazing into the adult’s eyes) Caregivers remain close by when the baby responds positively
The infants encourage the adults to remain close as the the closeness comforts them
Babies recognize the mother’s smell, voice and face.
They are not yet attached to the mother, they don’t mind being left with unfamiliar adults.
They have No fear of strangers

37. ATTACHMENT IN MAKING 6 Weeks – 6 to 8 Months
Infant responds differently to familiar caregiver than to strangers.
The baby would babble and smile more to the mother and quiets more quickly when the mother picks him.
The infant learns that her actions affect the behavior of those around
begin to develop “Sense of Trust” where they expect that the caregiver will respond when signaled
The infant still does not protest when separated from the caregiver

38. “CLEAR CUT” ATTACHMENT PHASE
6-8 Months to 18 Months -2 Years
The attachment to familiar caregiver becomes evident
Babies display “Separation Anxiety”, where they become upset when an adult whom they have come to rely leaves
Although Separation anxiety increases between months of age its occurrence depends on infant temperament, context and adult behavior
The child would show distress when the mother leaves but if the caregiver is supportive and sensitive then this anxiety could be short- lived

39. FORMATION OF RECIPROCAL RELATIONSHIP
18 Months / 2 Years and on
With rapid growth in representation and language by 2 years the toddler is able to understand some of the factors that influence parent’s coming and going and to predict their return.
separation protests decline.
The child could negotiate with the caregiver, using requests and persuasion to alter her goals
With age the child depends less on the caregiver , more confidence that the caregiver will be accessible and responsive in times of need.

40. Attachment Just the mother?
No Attachment to the mother is usually the primary attachment, but can attach to fathers and other caretakers as well.

41. Mary Ainsworth
Ainsworth came up with a special experimental design to measure the attachment of an infant to the caretaker
The Strange Situation Test – procedure in which a caregiver leaves a child alone with a stranger for several minutes and then returns.

42. STRANGE SITUATION
Observer shows caregiver and infant into the experimental room and then leaves. ( 30 Seconds)
Caregiver sits and watches child play. (3 mins)
Stranger enters, silent at first, then talks to caregiver, then interacts with infant. Caregiver leaves the room. (3 mins)
First separation. Stranger tries to interact with infant. (3 mins)
First reunion. Caregiver comforts child, stranger leaves. Caregiver then leaves. (3 mins)
Second separation. Child alone. (3 mins)
Stranger enters and tries to interact with child
Second reunion. Caregiver comforts child, stranger leaves. •
All episodes except 1 last for 3 mins unless the child becomes very upset

43. STRANGE SITUATION
Video

44. Four Key Observations
Exploration : to what extent does the child explore their environment
Reaction to departure : what is the child’s response when the caregiver leaves
The stranger anxiety : how does the child respond to the stranger alone
Reunion : how does the child respond to the caregiver upon returning

45. STRANGE SITUATION
Findings Infants differ in quality or style of their attachment to their caregivers.
Most show one of four distinct patterns of attachment:
Secure attachment
Insecure/Avoidant attachment
Insecure/ambivalent attachment
Disorganized/Disorientated attachment

46. Secure Attachment Most infants (65-70% of 1 yr olds)
Freely explore new environments, touching base with caregiver periodically for security.
May or may not cry when separated, when returned, crying ceases quickly.

47. Avoidant Attachment 15% Don’t cry when separated
React to stranger similar to their caregiver
When returned, avoids her or slow to greet her.

48. Ambivalent Attachment
10%
Seeks contact with their caregiver before separation
After she leaves and returns, they first seek her, then resist or reject offers of comfort

49. Disorganized Attachment
5-10%
Elements of both avoidant and ambivalent (confused)

50. Agenda
3. Discuss a biopsychosocial approach to the management of these disorders.

51. Detecting perinatal depression: why screen?
High prevalence rate
Risks of untreated symptoms
Availability of effective treatment
Availability of validated screening tools

52. Edinburgh Postnatal Depression Scale (EPDS)
10-item self-report
Adv: easy to score, designed for peripartum use, validated ante- and pp, cross-culturally validated
Disadv: not linked to DSM-IV-TR criteria, validation studies do not provide definitive answer about optimal cut-off scores
Guidelines: score 9-12 pp risk, 12> high risk (cut-off scores above 12 not sensitive in some studies)
(Cox & Holden, 2003)

53. Detecting Perinatal Depression
Why Screen??
PKU
A/PPD
Prevalence
1 in babies
1 in 5 mothers
Outcome
Mod-severe MR
Serious and lasting effects on mother/child health and family functioning
Predictive Screen 
Cost to Screen
$50/baby
free
Effective Rx
Cost-effective Rx
Gestational diabetes: 3-10% pregnancies
Gestational hypertension: 2-3% pregnancies

54. Educate about self-care
NESTS
Proper Nutrition
Exercise
Rest (Sleep protocol)
Time for yourself
Circles of Support

55. Educate about self-care
Sleep
SLEEP PROTOCOL: 5h of uninterrupted sleep per night
Breaks from baby
Enjoyable activities
Decrease isolation
Spend time with friends, family, other mothers
Protect yourself and your energy
Limit visitors, lighten chores

56. Treatment Screening and invesigations Check for other diseases
Thyroid disease
Anemia
Diabetes
Vitamin deficiencies

57. Treatment Therapy Cognitive Behavioral Therapy
Interpersonal Psychotherapy
Couple therapy
Group therapy

58. Medications Risks of medication 1) to mother 2) to fetus 3) to newborn
Risks of disease
1) to mother 2) to fetus 3) to child
4) to family
Suicide and homicide

59. l Principles of perinatal psychopharmacology
-Is there an increase risk of spontaneous abortion/miscarriage? -Is there an increase in the risk of congenital Malformation? -Is there an increase in the risk of adverse outcomes for the neonate? -Is there an increase in the risk of adverse outcomes from breastfeeding?

60. Effects of pregnancy on pharmacokinetics
Delayed gastric emptying
Decreased gastrointestinal motility
Increased volume of distribution
Decreased protein binding capacity
Increased hepatic metabolism

61. SSRIs Absolute risk of exposure in pregnancy is small.
• Paxil Health Advisory
• Poor Neonatal Adaptation Syndrome
• Persistent Pulmonary Hypertension
• Current U.S. Lawsuits
Louik 2007, Einarson 2008, Alwan 2008, Greene 2007, Hallberg 2005, Wogelius 2006, Oberlander, Levinson-Castiel 2006, Chambers 2006, 2009, Kallen 2008, Andrade 2009

62. Mood stabilizers
High risk for relapse into bipolar depression with discontinuation
Lithium may be the safest alternative
Valproic acid: teratogenicity neurobehavioral toxicity • CBZ and LTG lower risk than VPA
Folic acid supplementation
Li non-responders: consider LTG +/- antipsychotic vs. atypical across pregnancy
Wyszynski 2005, Morrow 2006, Cunnington 2007, Meador 2006, Holmes 2004, Cohen 2007

63. Breastfeeding
“It is when the socioeconomic situation is the worst that breastfeeding has the greatest benefit.” Dr. Jack Newman
Nutritional advantages
Infection, allergy, Ca, diabetes protection
Bonding, developmental benefits
Postpartum recovery, Ca (breast, ovarian), osteoporosis
Free and easy!

64. Mother’s bias
Women receiving chronic therapy tend to initiate breastfeeding much less often
If they do initiate, they discontinue it much earlier
• Continuation of breastfeeding correlates with cumulative amount of reassuring counseling advice women receive from health professionals
Moretti et al, 1995, 1998 From Koren 2007

65. Breastfeeding
Generally, excretion rates < 10% into breast milk are considered safe by the American Academy of Pediatrics.
[milk]/[plasma]:
Molecular size, protein-binding, acidity,lipophilicity
• Nursing infant: absorption from GI tract ability to detoxify, ability to excrete .

68. Nothing trumps maternal euthymia

69. Thank you!