20 Tips For The Psychological Management of Perinatal Depression and Anxiety. Presented at the Mental Health Professionals Network - Bankstown May 2011 Dr Ian Harrison Visiting Perinatal Psychiatrist, Karitane Residential Unit, Carramar drianharrison.com.au

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

1. Before You Start: Know Yourself. What do babies do to you?

2. Begin With a Positive Partnership. Let mothers start where they wish with their new babies.

3. Hear The Story of The Baby. Every mother and baby have a unique story. Help to ventilate the story of the baby.

4. Look for Past, Unresolved Traumas. Selma Fraiberg: The Ghosts in The Nursery.

5. In the history, look for risk factors, (for PND). Use risk factors as a basis for psychotherapy.

Risk Factors for Prenatal Depression 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.

Risk Factors for Prenatal Depression 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.

Risk Factors 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.

Risk Factors Postnatally (in addition to any of the previous risks) Multiple birth. Premature or 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.

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.

6. Always try to bring it back to the baby. Ask Questions Using an Attachment Perspective.

7. Look for Losses, Role Transitions, and Conflicts. Interpersonal Psychotherapy (IPT) suits the perinatal setting.

8. Motherhood often requires a new mindset. Motherhood can be the first “failure” for a competent woman.

9. Meet the New Mother’s Dependency Needs. Model a secure attachment relationship.

10. Avoid “Treatment” or “Non-Treatment” Always keep the door open.

11. Transference Exists. Take advantage of it. Mothers (caregivers) project all sorts of feelings onto their therapists.

12. Simply being present is important. Never underestimate the therapeutic value of the simple presence of the other.

13. Look to Create a Holding Environment. Help the mother to hold and contain powerful emotions.

14. Try To See Mothers and Babies Together..Never worry that the baby will be disruptive.

15. Avoid Over-reacting to Parental Distress. Be the voice of calm and reason.

16. Always ask about self harm or harm to baby. Clients rarely try to cover this up.

17. Promote a Wider Supportive Network. Every one has something to offer.

18. Promote the Role of Fathers. Many fathers can become more involved with permission, encouragement and instruction.

19. Educate Parents Regarding Attachment. Become an informal attachment educator of your clients.

20. Use Positive Suggestion. Always try to “predict” a positive future.

THE END Thank You and Good Luck!