Presentation on theme: "Dr.Mariam Alawadhi MD,FRCPC"— Presentation transcript:
1When the bough breaks: Mental Illness in the Pregnant and Postpartum Woman Dr.Mariam Alawadhi MD,FRCPCAssistant professor-Department of Psychiatry,Kuwait UniversityHead of consultation liaison unit-KCMH
2AgendaReview 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.
3Depression is “the most common complication of childbearing.” Wisner, 2002
41 in 5 mothers will experience a mental health disorder during their pregnancy or the year after they deliver.
5Pregnancy 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.
6Challenging the myths... Media images of pregnancy and motherhood Pregnancy was planned, so why do I have the “blues”?Work-life balanceRelationships (couple, extended family)
7...and facing realityTired, home alone, lots of care for baby, no time for self, complete loss of control over timeWide range of positive and negative emotionsAdjustment and adaptation to pregnancy and motherhood is dynamicpregnancy alters a woman’s life irreversiblyWomen need accurate information (e.g, pregnancy, labour, delivery) = power, controlShame & stigma
9Let’s define the terms first... Antepartum depression Associated with:Poor prenatal care (e.g., nutrition; substance use)Changes in cortisol & HPA axis developmentPoor perinatal outcomes (e.g, abnormal fetal neurobehavioral; pre-term labour (Steele et al., 1992)Depression vs. pregnancy? affect cognition functional impairment
10Antenatal Depression Risk factors: low self-esteem low social support, low incomeantenatal anxiety, hx of depression, hx of abusenegative cognitive stylehx of miscarriage/pregnancy terminationpregnancy complications
11Confounds in diagnosing depression during pregnancy Overlapping symptoms:Sleep disturbancesIncreased/decreased appetiteDecreased energyChanges in concentrationIllnesses with similar symptoms:AnemiaThyroid dysfunctionGestational diabetes mellitus
13Perinatal anxiety disorders Effects of maternal stress & anxiety during pregnancyAltered fetal movementLower gestational ageLower infant birth weightLower APGAR scoresEnduring changes in cortisol measures in offspringRoss,2006
14Postpartum blues Baby blues Very common (50-80%) Starts w/in 1 wk pp: peaks3-5 days post-deliveryUnrelated to environmental stressorsUnrelated to psychiatric historyPresent in all culturesLow-level symptoms:TearfulnessIrritability, reactivityInsomniaAnxietyPoor appetite
15Posited relationship between “Blues” and PPD During pregnancy:Increase oestrogen, progesterone (placental production of hormones); beta-endorphin & cortisol (cortisol peaks in late pregnancy - CRH), prolactinOestrogen enhances neurotransmitter serotonin (increases synthesis & reduced breakdown)After delivery:Drop in oestrogen/progesterone (removal of placenta at delivery); drop in cortisol & b/eDecrease estrogen decrease serotoninProlactin levels return to normal in non-lactating women w/in weeksBreastfeeding: prolactin levels remain high (induces release of oxytocin)
16Postpartum depression Peaks at 3-6 mo ppAverage PPD course is 7 moRelated to psychiatric history and environmental stressorsDSM IV onset from within 4 wks. of delivery, “pp onset”Clinically, up to 1 y postpartum (DSM V to reflect this)
17Postpartum depression Added clinical features:Obsessive traits (e.g., name of baby, harming baby)Depressed, despondent, emotionally numbAmbivalence toward baby (bonding)Grief for loss of selfFeelings of inadequacy, guilt*Feeling isolated/misunderstoodSuicidal ideation/Ego-dystonic thoughts of harming baby
18Risk factors Biological Psychological Social Obstetric Family history of depression or affective disordersPrevious PPD or depressionThyroid dysfunctionHormonesAltered immune functionSleep disturbancesLow self-esteemagePerfectionist, neuroticism, high/unrealistic expectations of self/babyFeelings of inadequacyRole conflictAttitude toward pregnancy (ambivalence, unwanted)Trauma/abuseUnresolved grief (death of child)Lack/poor social supportRelationship problems (couple, extended family)Difficult baby (feeding, colic)Separation from babyStressful live events (move, job change, illness)Economic stressRecent lossChildcare stress (# of children at home)IVF (fertility drugs)Difficult deliveryMedical complications of pregnancyHealth problems of infantLack of readiness for hospital discharge(Kendler, 1993; Wisner, 2002)
19Postpartum psychosis Heterogeneous group of disorders BAD (35% with bipolar diathesis)MDD w/ psychotic featuresSZ-spectrum disordersMedical 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 & disorientationErratic behaviourinsomniaWaxing & waningRisk for suicide and infanticidePsychiatric emergency
20Postpartum psychosis Rare (1-2/1000 women) Most commonly 2-4 wks/pp Risk FactorsFamily hx of BADEarly onset depressionHistory of PPD
21Agenda2.Understand the psychiatric, obstetric and pediatric implications of a mother’s untreated illness.
22Economic & 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)
23Maternal Risks from A/PPD Coronary artery diseaseCancerHypertensionOveractive bladderurinary incontinencePoorer maternal health practicesComplications after childbirth
24Fetal Risks from A/PPD Poorer maternal health practices Elevated cortisol levelsPreterm deliverySmall for gestational ageLow birth weightSchmeelk 1999, Lundy 1999, Hoffman 2000, Adewuya 2007, Hedgaard 1993
25Adverse parenting outcomes Depressed mothers:Perceive their infants as more bothersome and make harsher judgments of themAre more irritable and spend less time looking, touching, and talking to their infantsAre more likely to neglect/abuse their childrenWhiffen 1989, Cohn 1990, Chaffin 1996
26Adverse parenting outcomes These effects are moderated by:Timing of depressive episodeAge of childrenSES of familyLovejoy, 2000
27Attachment Definition : A strong emotional and social bond between infants and their caregivers
28JOHN BOWLBY (1907-1990) British Child Psychiatrist & Psychoanalyst. He was the first attachment theoristdescribing 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.
29John 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.
30Bowlby (cont’d)Believed quality of early attachment influences future relationships (friends, romantic partners, own children).
31HARLOW & ZIMMERMANA 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
32Attachment '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.
33Attachment When does it form? Usually within the first six months of the infant’s lifeShows up in second six months through wariness of strangers, fear of separation from caregiver, etc.
34AttachmentBabies 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
35Four Stages of Attachment Pre-attachmentAttachment-in-the- makingClear-cut attachmentFormation Of Reciprocal Relationship(3-4 yrs onwards): understand caregiver’s schedule. Separation protests decline.
36PREATTACHMENT 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 positivelyThe infants encourage the adults to remain close as the the closeness comforts themBabies 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
37ATTACHMENT 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 aroundbegin to develop “Sense of Trust” where they expect that the caregiver will respond when signaledThe infant still does not protest when separated from the caregiver
38“CLEAR CUT” ATTACHMENT PHASE 6-8 Months to 18 Months -2 YearsThe attachment to familiar caregiver becomes evidentBabies display “Separation Anxiety”, where they become upset when an adult whom they have come to rely leavesAlthough Separation anxiety increases between months of age its occurrence depends on infant temperament, context and adult behaviorThe child would show distress when the mother leaves but if the caregiver is supportive and sensitive then this anxiety could be short- lived
39FORMATION OF RECIPROCAL RELATIONSHIP 18 Months / 2 Years and onWith 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 goalsWith age the child depends less on the caregiver , more confidence that the caregiver will be accessible and responsive in times of need.
40Attachment Just the mother? No Attachment to the mother is usually the primary attachment, but can attach to fathers and other caretakers as well.
41Mary AinsworthAinsworth came up with a special experimental design to measure the attachment of an infant to the caretakerThe Strange Situation Test – procedure in which a caregiver leaves a child alone with a stranger for several minutes and then returns.
42STRANGE SITUATIONObserver 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 childSecond reunion. Caregiver comforts child, stranger leaves. •All episodes except 1 last for 3 mins unless the child becomes very upset
44Four Key ObservationsExploration : to what extent does the child explore their environmentReaction to departure : what is the child’s response when the caregiver leavesThe stranger anxiety : how does the child respond to the stranger aloneReunion : how does the child respond to the caregiver upon returning
45STRANGE SITUATIONFindings Infants differ in quality or style of their attachment to their caregivers.Most show one of four distinct patterns of attachment:Secure attachmentInsecure/Avoidant attachmentInsecure/ambivalent attachmentDisorganized/Disorientated attachment
46Secure 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.
47Avoidant Attachment 15% Don’t cry when separated React to stranger similar to their caregiverWhen returned, avoids her or slow to greet her.
48Ambivalent Attachment 10%Seeks contact with their caregiver before separationAfter she leaves and returns, they first seek her, then resist or reject offers of comfort
49Disorganized Attachment 5-10%Elements of both avoidant and ambivalent (confused)
50Agenda3. Discuss a biopsychosocial approach to the management of these disorders.
51Detecting perinatal depression: why screen? High prevalence rateRisks of untreated symptomsAvailability of effective treatmentAvailability of validated screening tools
52Edinburgh Postnatal Depression Scale (EPDS) 10-item self-reportAdv: easy to score, designed for peripartum use, validated ante- and pp, cross-culturally validatedDisadv: not linked to DSM-IV-TR criteria, validation studies do not provide definitive answer about optimal cut-off scoresGuidelines: score 9-12 pp risk, 12> high risk (cut-off scores above 12 not sensitive in some studies)(Cox & Holden, 2003)
53Detecting Perinatal Depression Why Screen??PKUA/PPDPrevalence1 in babies1 in 5 mothersOutcomeMod-severe MRSerious and lasting effects on mother/child health and family functioningPredictive ScreenCost to Screen$50/babyfreeEffective RxCost-effective RxGestational diabetes: 3-10% pregnanciesGestational hypertension: 2-3% pregnancies
54Educate about self-care NESTSProper NutritionExerciseRest (Sleep protocol)Time for yourselfCircles of Support
55Educate about self-care SleepSLEEP PROTOCOL: 5h of uninterrupted sleep per nightBreaks from babyEnjoyable activitiesDecrease isolationSpend time with friends, family, other mothersProtect yourself and your energyLimit visitors, lighten chores
56Treatment Screening and invesigations Check for other diseases Thyroid diseaseAnemiaDiabetesVitamin deficiencies
58Medications Risks of medication 1) to mother 2) to fetus 3) to newborn Risks of disease1) to mother 2) to fetus 3) to child4) to familySuicide and homicide
59l 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?
60Effects of pregnancy on pharmacokinetics Delayed gastric emptyingDecreased gastrointestinal motilityIncreased volume of distributionDecreased protein binding capacityIncreased hepatic metabolism
61SSRIs Absolute risk of exposure in pregnancy is small. • Paxil Health Advisory• Poor Neonatal Adaptation Syndrome• Persistent Pulmonary Hypertension• Current U.S. LawsuitsLouik 2007, Einarson 2008, Alwan 2008, Greene 2007, Hallberg 2005, Wogelius 2006, Oberlander, Levinson-Castiel 2006, Chambers 2006, 2009, Kallen 2008, Andrade 2009
62Mood stabilizersHigh risk for relapse into bipolar depression with discontinuationLithium may be the safest alternativeValproic acid: teratogenicity neurobehavioral toxicity • CBZ and LTG lower risk than VPAFolic acid supplementationLi non-responders: consider LTG +/- antipsychotic vs. atypical across pregnancyWyszynski 2005, Morrow 2006, Cunnington 2007, Meador 2006, Holmes 2004, Cohen 2007
63Breastfeeding“It is when the socioeconomic situation is the worst that breastfeeding has the greatest benefit.” Dr. Jack NewmanNutritional advantagesInfection, allergy, Ca, diabetes protectionBonding, developmental benefitsPostpartum recovery, Ca (breast, ovarian), osteoporosisFree and easy!
64Mother’s biasWomen receiving chronic therapy tend to initiate breastfeeding much less oftenIf they do initiate, they discontinue it much earlier• Continuation of breastfeeding correlates with cumulative amount of reassuring counseling advice women receive from health professionalsMoretti et al, 1995, 1998 From Koren 2007
65BreastfeedingGenerally, 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 .