Perinatal Mental Health Dr Cressida Manning Consultant Perinatal Psychiatrist Florence House Mother and Baby Unit

Contents of Presentation Confidential Enquiry into maternal deaths. Risks of untreated illness. Risk factors for postnatal depression and psychosis. Discussions around treatment. Medication.

Recent 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

Confidential Enquiry Centre for Maternal and Child Enquiries (CMACE) Most recent report ‘Saving Mothers Lives’ (2011) 2006-2008 29 suicides 1st 6 months 19 past psychiatric history 9 identified of which 4 had care plan

Saving Mothers Lives 38% Psychosis 21% Severe Depressive Illness

Recommendations - Back to Basics 1 Saving Mothers Lives Anxiety or depression Review in 2 weeks Consider psych referral if symptoms persist Refer 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.

Effects of Untreated Illness Increased morbidity. Increased risks towards self and others. Links between maternal anxiety and fetal behaviour and heart rate Stress/anxiety during pregnancy can have long term effects on child Monk et al 2000 mental arithmetic fetal heart rate increases in anxious group. – no clear mech as cortisol takes 20 mins to increase

Associated with an increased incidence of: Emotional problems - Anxiety/depression Behavioural problems – ADHD, conduct disorder Impaired cognitive development, esp language Sleep problems in infants Sensitive early mothering important as what happens in utero for child outcome ALSPAC 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 10 -15% ( 50% genetic and lot of postnatal influence)

Effects of antenatal and postnatal depression Children of mothers depressed in perinatal period compared to children of well mothers: Lower IQ scores 12x more likely to have a statement of special needs elevated risk of violence at 11 and 16 years More likely to suffer separation anxiety at 11 and a diagnosis of depression at 16 SLCDS – south london child development study Longitudinal prospective study1986 -2012

Suicide Majority of deaths secondary to postpartum psychosis or very severe depressive illness Oates (2008) Suicide rate for ppp 2/1000 Common profile; white, older, 2nd or subsequent pregnancy, married, comfortable circumstances Likely to die violently 50% female non perinatal and 75% male die by violent means – 90% perinatal period

Infanticide Similar profile 1/3rd mental illness Death extended suicide or occasionally altruistic based on delusional belief Highest concern if delusion involves child e.g baby changed, not hers, possessed, evil.

Postpartum Psychosis 1st few weeks highest risk Heron et al (2007) Greater than 80% 1st week Link with BPAD

Bipolar Disorder 52% relapse in 1st 40 weeks after stopping treatment If pregnant and stable on antipsychotic and likely to relapse without medication continue Up to 70% relapse if untreated in postnatal period 50% psychotic symptoms day 1 - 3

Postpartum Psychosis – Risk Factors 1st Baby Single C- Section Older Fertility Problems Previous episode – 1 in 7 Sleep Loss

Warning Signs Early signs often non specific Insomnia, agitation/anxious, perplexed and odd behaviour. Risk overlooked Can lead to rapid deterioration to Psychotic symptoms

Postnatal Depression 10 -15% Severe 3% 1/3 to ½ continuation of antenatal anxiety and depression Onset few days to 6 months Increased risk in subsequent pregnancies – approx 25 – 50%

Postnatal Depression – Risk Factors Antenatal anxiety or depression Past history of psychiatric illness Life events Lack of or perceived lack of support Low income Domestic violence FH of psychiatric illness Childhood abuse

Risk Factors cont… Obstetric factors Sleep deprivation Infant factors –irritability Personality factors – control, interpersonal sensitivity, ‘neuroticism’ Biological factors – inconsistent results

Early Detection Past or present mental illness 1st contact; Past or present mental illness Previous psychiatric input, including admissions Family history of severe mental illness Monk et al 2000 mental arithmetic fetal heart rate increases in anxious group. – no clear much as cortisol takes 20 mins to increase

Treatment of pregnant and breast feeding women- NICE guidelines Importance of balancing risks and benefits Cautious Women requiring psychological treatment should be seen for treatment within 1 month of assessment and no longer than 3 months.

NICE Discussion should include: Risk of relapse and not treating disorder Woman’s ability to cope with untreated symptoms Severity of previous episodes and response to treatment Woman’s preference Possibility that stopping drug with teratogenic risk once pregnancy confirmed may not remove risk

NICE Risks of stopping medication abruptly Need for prompt treatment due to impact of illness on foetus/child Increased risk of harm of specific drug treatments Treatment option that would allow mother to breastfeed

NICE Prescribing: Drugs with lowest risk profile Lowest effective dose Monotherapy Risks lower threshold for psychological treatment Important to put risks from drug treatment in context of the individual woman’s illness

Antidepressants self limiting SSRIs Paroxetine in 1st trimester increase in cardiac malformations (VSD) – planning pregnancy or unplanned advise to stop. Other SSRIs now implicated. SSRI’s taken after 20 weeks may be associated with an increased risk of persistent pulmonary hypertension of the new born Neonatal withdrawal- normally mild and self limiting Are 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

Symptoms include; Irritability Hypertonia Jitteriness Difficulties feeding Tremor Agitation Seizures Tachypnoea Posturing Also association with decreased gestational age (1 week),, spontaneous abortion and decreased birth rate

Tricyclics Tricyclics have lower known risks during pregnancy than other antidepressants Have higher fatal toxicity index CHD with clomipramine Withdrawal symptoms No effects on long term neurodevelopmental outcomes Imipramine

Other 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 PPHN Mirtazapine – 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.

Benzodiazepines Raised risk of oral cleft (7 in 1000; x10) Withdrawal syndrome – jitteriness, autonomic dysregulation, seizure, floppy baby syndrome Consider gradually stopping in women who are pregnant Short term use only for severe agitation and anxiety

Lithium – Ebsteins anomoly (1 in 1000) General population 1 in 20000 Overall risk CHD 0.9-12% 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

Valproate NTD 100 to 200 in 10000 IUGR Facial dysmorphias Low IQ Do not routinely prescribe to women of child bearing age. If no option adequate contraception Discontinue if pregnant Limit dose 1g per day and 5mg folic acid

Carbamazepinne Lamotrigine Increased risk congenital malformations -6.7% v 2.3% Craniofacial, GIT, cardiac, urinary tract and digit anomalies Advice as valproate Lamotrigine Cleft palate 8.9/1000 Matalon 2002

Atypical Antipsychotics Olanzapine and Quetiapine Limited data to base assessment of safety in pregnancy, but available data does not suggest a substantially increased risk of congenital malformations or spontaneous abortions No pattern of malformations observed. Withdrawal symptoms Olanzapine – increased birth weight

What Clinicians need to do Do not assume it is always better to stop medication Provide prompt and Effective treatment of mental illness in pregnancy and postnatal period Understand, consider and communicate known risks (and how these will be managed) of medication Complete risk benefit analysis for individual patient.