Presentation on theme: "Perinatal Mental Health"— Presentation transcript:
1Perinatal Mental Health Dr Cressida ManningConsultant Perinatal PsychiatristFlorence House Mother and Baby Unit
2Contents of Presentation Confidential Enquiry into maternal deaths.Risks of untreated illness.Risk factors for postnatal depression and psychosis.Discussions around treatment.Medication.
3Recent Case Study Felicia Boots. 35 Mother of 2 ( 14 months and 10 weeks).Manslaughter on grounds of diminished responsibility.Stopped medication as breastfeeding.Husband found children lying side by side walk in wardrode. She had also tried to end her own life.High lights the ultimate tradgedy of untreated perinatal illness but also the importance of continuing treatment of women with existing illness and diagnosis and treatment of new episodes where required
4Confidential Enquiry Centre for Maternal and Child Enquiries (CMACE) Most recent report ‘Saving Mothers Lives’ (2011)29 suicides 1st 6 months19 past psychiatric history9 identified of which 4 had care plan
5Saving Mothers Lives38% Psychosis21% Severe Depressive Illness
6Recommendations - Back to Basics 1 Saving Mothers Lives Anxiety or depressionReview in 2 weeksConsider psych referral if symptoms persistRefer urgently where:Suicidal ideation, uncharacteristic symptoms/marked change from normal functioning, morbid fears, profound low mood, personal or family history of serious affective disorder, mental health deterioration, morbid fears, panic attacks and intrusive obsessional thoughts.
7Effects of Untreated Illness Increased morbidity.Increased risks towards self and others.Links between maternal anxiety and fetal behaviour and heart rateStress/anxiety during pregnancy can have long term effects on childMonk et al 2000 mental arithmetic fetal heart rate increases in anxious group. – no clear mech as cortisol takes 20 mins to increase
8Associated with an increased incidence of: Emotional problems - Anxiety/depressionBehavioural problems – ADHD, conduct disorderImpaired cognitive development, esp languageSleep problems in infantsSensitive early mothering important as what happens in utero for child outcomeALSPAC study effect of antenatal stress/anxiety on behav devel – mental health disorder in children exposed around double the risk. Attributable load due to antenatal stress/ anxiety is about % ( 50% genetic and lot of postnatal influence)
9Effects of antenatal and postnatal depression Children of mothers depressed in perinatal period compared to children of well mothers:Lower IQ scores12x more likely to have a statement of special needselevated risk of violence at 11 and 16 yearsMore likely to suffer separation anxiety at 11 and a diagnosis of depression at 16SLCDS – south london child development study Longitudinal prospective study
10SuicideMajority of deaths secondary to postpartum psychosis or very severe depressive illnessOates (2008) Suicide rate for ppp 2/1000Common profile; white, older, 2nd or subsequent pregnancy, married, comfortable circumstancesLikely to die violently50% female non perinatal and 75% male die by violent means – 90% perinatal period
11Infanticide Similar profile 1/3rd mental illness Death extended suicide or occasionally altruistic based on delusional beliefHighest concern if delusion involves child e.g baby changed, not hers, possessed, evil.
12Postpartum Psychosis1st few weeks highest riskHeron et al (2007) Greater than 80% 1st weekLink with BPAD
13Bipolar Disorder 52% relapse in 1st 40 weeks after stopping treatment If pregnant and stable on antipsychotic and likely to relapse without medication continueUp to 70% relapse if untreated in postnatal period50% psychotic symptoms day 1 - 3
14Postpartum Psychosis – Risk Factors 1st BabySingleC- SectionOlderFertility ProblemsPrevious episode – 1 in 7Sleep Loss
15Warning Signs Early signs often non specific Insomnia, agitation/anxious, perplexed and odd behaviour. Risk overlookedCan lead to rapid deterioration to Psychotic symptoms
16Postnatal Depression 10 -15% Severe 3% 1/3 to ½ continuation of antenatal anxiety and depressionOnset few days to 6 monthsIncreased risk in subsequent pregnancies – approx 25 – 50%
17Postnatal Depression – Risk Factors Antenatal anxiety or depressionPast history of psychiatric illnessLife eventsLack of or perceived lack of supportLow incomeDomestic violenceFH of psychiatric illnessChildhood abuse
19Early Detection Past or present mental illness 1st contact;Past or present mental illnessPrevious psychiatric input, including admissionsFamily history of severe mental illnessMonk et al 2000 mental arithmetic fetal heart rate increases in anxious group. – no clear much as cortisol takes 20 mins to increase
20Treatment of pregnant and breast feeding women- NICE guidelines Importance of balancing risks and benefitsCautiousWomen requiring psychological treatment should be seen for treatment within 1 month of assessment and no longer than 3 months.
21NICE Discussion should include: Risk of relapse and not treating disorderWoman’s ability to cope with untreated symptomsSeverity of previous episodes and response to treatmentWoman’s preferencePossibility that stopping drug with teratogenic risk once pregnancy confirmed may not remove risk
22NICE Risks of stopping medication abruptly Need for prompt treatment due to impact of illness on foetus/childIncreased risk of harm of specific drug treatmentsTreatment option that would allow mother to breastfeed
23NICE Prescribing: Drugs with lowest risk profile Lowest effective dose MonotherapyRisks lower threshold for psychological treatmentImportant to put risks from drug treatment in context of the individual woman’s illness
24Antidepressants self limiting SSRIs Paroxetine in 1st trimester increase in cardiacmalformations (VSD) – planning pregnancy orunplanned advise to stop. Other SSRIs now implicated.SSRI’s taken after 20 weeks may be associatedwith an increased risk of persistent pulmonaryhypertension of the new bornNeonatal withdrawal- normally mild andself limitingAre SSRIs assoc with increase riskof congenital malformations. Conflicting but probably yes. 0.5 to 0.9. But implications of stopping increase 6 fold PND. PPH around 0.5 to 1 in 1000 reis et al chambers higher 6-12/1000
25Symptoms include; Irritability Hypertonia Jitteriness Difficulties feedingTremorAgitationSeizuresTachypnoeaPosturingAlso association with decreased gestational age (1 week),, spontaneous abortion and decreased birth rate
26TricyclicsTricyclics have lower known risks during pregnancy than other antidepressantsHave higher fatal toxicity indexCHD with clomipramineWithdrawal symptomsNo effects on long term neurodevelopmental outcomesImipramine
27Other antidepressants Venlafaxine – Conflicting results for congenital malformations – data too limited to say safe. Possible increased neonatal withdrawal and increased risk of high blood pressure at higher doses. Theoretical risk of PPHNMirtazapine – Possible association with increased rate of spontaneous abortion. No evidence to link to congenital malformations but data too limited to say safe.JAMA 13 – Metaanalysis – preterm birth 3 days- Apgar <0.5- Weight 75g- Spontaneous abortion not significant.
28Benzodiazepines Raised risk of oral cleft (7 in 1000; x10) Withdrawal syndrome – jitteriness, autonomic dysregulation, seizure, floppy baby syndromeConsider gradually stopping in women who are pregnantShort term use only for severe agitation and anxiety
29Lithium – Ebsteins anomoly (1 in 1000) General population 1 in 20000 Overall risk CHD % vs 0.5-1% general population.Floppy baby syndrome, thyroid dysfunction, nephrogenic diabetes insipidus.High quantities in breast milk.Ebstein anomaly- distorted and displaced tricuspid valve with abn of right atrium and ventricle
30Valproate NTD 100 to 200 in 10000 IUGR Facial dysmorphias Low IQ Do not routinely prescribe to women of childbearing age.If no option adequate contraceptionDiscontinue if pregnantLimit dose 1g per day and 5mg folic acid
31Carbamazepinne Lamotrigine Increased risk congenital malformations -6.7% v 2.3%Craniofacial, GIT, cardiac, urinary tract and digit anomaliesAdvice as valproateLamotrigineCleft palate 8.9/1000Matalon 2002
32Atypical Antipsychotics Olanzapine and QuetiapineLimited data to base assessment of safety in pregnancy, but available data does not suggest a substantially increased risk of congenital malformations or spontaneous abortionsNo pattern of malformations observed.Withdrawal symptomsOlanzapine – increased birth weight
33What Clinicians need to do Do not assume it is always better to stop medicationProvide prompt and Effective treatment of mental illness in pregnancy and postnatal periodUnderstand, consider and communicate known risks (and how these will be managed) of medicationComplete risk benefit analysis for individual patient.