1. Maternal Perinatal Mental Health How can we help? Kareena Private Hospital Professional Education Evening 23 rd June 2008 Dr Ian Harrison Visiting Perinatal Psychiatrist, Karitane Residential Unit, Carramar drianharrison.com.au

2. Our 3 Domains of Influence BIOLOGICAL The mother and baby’s Physical development and well being

3. Our 3 Domains of Influence BIOLOGICAL PSYCHOLOGICAL The mother and baby’s Physical development and well being the mother’s Psychological health (and the father’s as well)

4. Our 3 Domains of Influence BIOLOGICAL PSYCHOLOGICAL ATTACHMENT The mother and baby’s Physical development and well being the mother’s Psychological health (and the father’s as well) The baby’s Attachment relationship with the mother and it’s unfolding Personality development

5. A Mother’s Attachment Relationship With Her Baby …begins well before birth. …begins before conception …begins in her relationship with her own mother.

6. Motherhood as a Developmental Crisis A developmental crisis: Has potential for growth or regression Is she/he: having a baby? becoming a mother/father? developing the personality of a new person?

7. What Prepares a Mother for this New Task? best predictor of a good attachment relationship is a good experience and a good relationship with their own mother, as a baby (herself) ….and as a child ….and now as an adult

8. Adjustment to Motherhood (and Fatherhood) 3 Questions 1.What will heighten the crisis for this mother? 2. What strengths does she bring to the process? 3. In what way can we facilitate the process? What do we bring?

9. We are Psychological and Attachment Midwives Developing a collaborative approach. It is helpful to be upfront about our focus. “Is there anything that might get in the way of you having a good experience, good outcome, successful transition, etc to motherhood and bonding with your new baby?”

10. Routine Antenatal Psychosocial Screening & History Taking The Important Questions to Ask 1. Have you had any difficulties with anxiety or depression in the past? 2. How were things for you when you were a baby? 3. How much support to do you have socially and from your partner to help you with this baby? 4. How are you going emotionally?

11. The Safe Start Model Lack of social or emotional support availability of practical and emotional support Recent Major Stressors (in the last 12 months) changes or losses e.g. financial stressors, migration issues, someone close dying etc Low self-esteem including low self- confidence, high anxiety and perfectionistic traits

12. The Safe Start Model History of anxiety, depression or other mental health problems, substance abuse Couple relationship problems or dysfunction Adverse childhood experiences Domestic Violence

13. Use of the Edinburgh Postnatal Depression Scale use it early, use it serially use it as a springboard for discussion. How has your mood been? (Might be good today – false negative) How is your bonding with the baby?

14. The Four P’s of Maternal (Paternal) Maladjustment ProtectivePerpetuatingPrecipitatingPredisposing Bio Psycho Social

15. Prior to pregnancy and/or During pregnancy Maternal age 35 Low socio economic status Lack of partner or other social support Drug or alcohol problems, including heavy smoking Recent bereavement Infertility or other obstetric difficulties Previous termination, miscarriages, still birth, neonatal deaths SIDS Pregnancy not wanted Late or poor attendance for antenatal care : Caring for the Family’s Future by Barnett, Fowler, and Glossop 2004.

16. Prior to pregnancy and/or During pregnancy Bleeding, hypertension, admission to hospital Past psychological problems or family history of mental illness Severe premenstrual syndrome Anxious perfectionistic personality Problems in relationship with partner, Domestic violence Poor relationship with mother Developmental disability Adverse childhood experiences e.g. physical or sexual abuse or neglect : Caring for the Family’s Future by Barnett, Fowler, and Glossop 2004.

17. At Delivery (in addition to any of the previous risks) No partner No partner or support person in attendance Unsupportive person in attendance Any complication in the mother or in the baby Labour and delivery not going to plan Premature or post mature baby Negative feelings regarding the baby : Caring for the Family’s Future by Barnett, Fowler, and Glossop 2004.

18. After the birth (in addition to any of the previous) Multiple birth Premature sick baby Abnormal appearance of the baby Not the expected baby Severe baby “blues”, “pinks” Breastfeeding problems Unsettled baby : Caring for the Family’s Future by Barnett, Fowler, and Glossop 2004.

19. Most potent risk factors for postnatal depression Any previous psychological disorder Anxious conscientious (perfectionistic) personality Problematic relationship with partner (poor communication through to criticism and hostility through to domestic abuse) Recent or otherwise significant bereavement or other loss History of physical or emotional or sexual abuse Recent migration, non-English speaking Aboriginal Torres Strait Islander background : Caring for the Family’s Future by Barnett, Fowler, and Glossop 2004.

20. Always assess Strengths and Goals Vulnerability and strength is always a fluid dynamic. One is never at the extremes but always oscillating somewhere between the two. Look for exceptions to the problem What would tell you that the problem was no longer present?

21. Aim for Prevention & Look for Reversibility Low incidence Low reversibility High Incidence High Reversibility “Others” who can still get into difficulty

22. Some Recent Trends Increased age of women having a baby Increased chance of having a past history of depression or anxiety Increased treatment of depression generally means more women presenting taking an antidepressant Increased detection via antenatal screening Increased research and concern re the effects of depression on babies/toddlers Increased use of atypicals antipsychotics and mood stabilisers and herbals (St John’s Wort)

23. Prenatal Maternal Psychiatric Illness Effects on Mother and foetus poor compliance with obstetric/medical care poor maternal health/nutrition abuse of alcohol and cigarettes abuse of other substances including over the counter remedies suicidality, self-harm, recklessness – reduced care of other children – marital disturbance

24. What about the direct effects of maternal psychiatric illness on the foetus? These are potential effects on the foetus via changes in maternal blood chemistry, hormones, catecholamines, immune function etc, What happens to the foetus in untreated maternal psychiatric illness?? What are the long term consequences of untreated maternal psychiatric illness (eg depression) for offspring into childhood, adolescence, etc

25. Potential Direct Effects of Maternal Depression/Anxiety/Stress. Effects on foetus – changes in the HPA axis especially with anxiety disorders – lower birth weight – prematurity – “behavioural teratogenicity” (experiments in pregnant rats)

26. What has been shown? Deleterious effect on obstetric outcome and later infant development. Severe Stress and Depression may: – impede foetal growth – smaller head circumference – increased rate of preterm delivery and other complications – long term behavioural problems eg aggression in boys

27. Effects of Antidepressants on Foetus. Miscarriage possible slight increase Malformations ? Increase VSD Intra-uterine deaths no increase Low birth weight slight increase Prematurity slight increase Withdrawal syndromes can occur Behavioural sequelae as yet unknown

28. Clinical Problem: Minimising Exposure. We focus on the issue of exposure. There are 2 exposures: 1. What will the foetus/baby be exposed to in terms of medication? (in utero & breastfeeding) 2. What will the foetus/baby be exposed to in terms of maternal psychiatric illness? (in utero & breastfeeding)

29. Clinical Problem: Minimising Exposure The foetus/baby will be exposed to something. “There is no such thing as non-exposure.” Z. Stowe. The foetus/baby will be exposed to medication or psychiatric illness or both. Our role is to help the mother and her partner decide which path of exposure is best for them.

30. The Risk/Benefit Ratio The risks associated with medication are fairly fixed even if some of them are as yet unknown. The risks associated with maternal psychiatric illness varies enormously for each individual. Hence we ask, “What is the risk-benefit ratio for this woman, given her current symptom pattern or what has happened in her previous episodes of illness?”

31. “Happy Milk” vs. “Sad Milk” Milk may be pure but unhappy Milk may be impure but happy At the beginning of feed infant takes in only the milk. Soon the baby takes in a milk-and-mother “combo” By the end of the feed the baby takes in only the mother.

32. Psychotherapeutic Management Supportive psychotherapy builds good will with the woman who is, for the time being, opposed to medication. Avoid the dichotomy, “Well if you don’t want to take medication, I can’t help you”. – or “…. I don’t want to see you.” Always keep the “door open”.

33. Postnatal Maternal Psychiatric Illness Effects on Mother and baby. deficits in mother-infant attachment Neuro-behavioural sequelae increased failure to breastfeed separations at home, possible psychiatric hospitalisation abuse, neglect, self harm, recklessness rarely, suicidality/infanticide

34. Maternal Psychiatric Illness Further Effects Effects on Family and Environment reduced care of other children emotional neglect of other children marital disturbance occupational deterioration reduced social network Etc, etc

35.  Protect me  Comfort me  Delight in me  Organize my feelings Circle of Security Parent Attending to the Child’s Needs I need you to Support My Exploration Welcome My Coming To You I need you to  Watch over me  Help me  Enjoy with me I need you to © 2000 - Cooper, Hoffman, Marvin & Powell

36. There Is Nothing Special About Birth! Birth is only ever a compromise. Mahler and the “12 month-pregnancy” Winnicott and “Primary Maternal Preoccupation.” Bruce Perry’s “Somatosensory Bath”

37. THE END Thank You and Good Luck!