1. Maternal Mental Illness Antenatal and postnatal depression Dr Andrew Mayers amayers@bournemouth.ac.uk

2. 2 Maternal Mental Illness  Overview  What is maternal mental illness?  Consequences for child and the mother  Effect on relationship between them  Types of illness  Antenatal depression  Antenatal anxiety  Postnatal depression  We will look at these illnesses in this session  Serious illnesses (later session)  Postpartum psychosis  Maternal OCD

3. 3 Who am I? What am I doing here?  First worked in Hampshire perinatal MH unit in 2003  Co-ordinated research programme  Now associated with Dorset MBU in Bournemouth  Formerly, Director of PANDAS  National pre- and postnatal mental illness charity  Member of Maternal Mental Health Alliance  Member of Perinatal Mental Health Partnership  Commissioned by NHS in Hampshire and IOW to ‘train’ health profs  Presented at CPHVA conference, York (Oct 2013)  For more information:  http://www.andrewmayers.info/perinatal-mental-health.html http://www.andrewmayers.info/perinatal-mental-health.html  Follow me on Twitter @DrAndyMayers

4. 4 Postnatal period  Correlation between antenatal mental distress and postnatal maternal distress and antenatal attachment and postnatal attachment...PREVENTION!!  Change/transition Psychological distress (anxiety, stress, low mood) Stress, daily hassles of bring up an infant, change in identity, relationship changes, loss of control …

5. 5 Impact on developing child  Significant intellectual deficits found in children (aged 4) whose mothers had suffered with depression (Cogill, et al., 1986)  Postnatal depression may be associated with later difficulties in child’s adjustment-problems when starting school  Anxiety in girls; conduct problems in boys  Affects child’s social and emotional development  Ability to form relationships  Depression in fathers associated with emotional and behavioural outcomes in children aged 3½ years  Increased risk of conduct problems in boys  Effects remain after controlling for maternal postnatal depression (Ramchandani et al., 2005)

6. 6 Impact of postnatal depression  PND associated with several negative outcomes  Increased marital stress  Disturbances in child’s emotional and cognitive development (Cogill, et al., 1986)  Children of dep mums more likely to be associated with:  Insecure attachment  Eating difficulties  Sleep disturbance  Being overly clinging  PND affects mum’s ability to cope with care of baby  See Murray, et al., 2003

7. 7 Impact of maternal sensitivity

8. 8 The importance of attachment  Why is attachment important between mother and infant?  Early mother–infant bond may have sig. impact on developing infant (e.g. Bowlby, 1953; Ainsworth, 1993)  Infant’s internal working model (IWM) is very important  Expectations about themselves in relation to others  Model of self and of other  If infant’s carer attends positively and responds to needs   Infant has positive IWM:  High self-worth, availability of others, resolution of crises  Infant’s carer inconsistent response and attention   Infant’s has negative IWM:  Low or ambivalent self-worth, unavailable others, crises not resolved

9. 9 What can health visitors do?  Health visitors CAN play a crucial role in identifying mental health difficulties  Spotting signs and risk factors  Early intervention  Signposting to relevant services  For the well-being of mother  AND the developing infant  Important to:  Acknowledge distress  Offer an empathic response  Assess risk  But WHAT are we looking for?

10. 10 Antenatal depression  “At any one time during pregnancy one in every ten women will be depressed and around one in every thirty will be depressed in pregnancy and the postnatal period” Dr Vivette Glover  Symptoms  Chronic anxiety  Guilt  Incessant crying  Lack of energy  Relationship worries  Worrying their partner may leave once the baby is born  Conflict with parents  Isolation  Fear to seek help

11. 11 Causes of antenatal depression  Physical  Body changes!  Weight gain (only clothes that fit are tatty or were previous used for ‘painting’), swollen breasts, dizziness and nausea, bladder issues, exhaustion, heart rate, blood pressure, swollen ankles/wrists...  Hormonal changes  Nausea – morning sickness  For some mums-to-be these experiences (and/or perception of them) worse than for others

12. 12 Causes of antenatal/postnatal depression  Emotional causes  Mood swings  First-time mum experience  Change of identity  Previous pregnancy difficulties  Complications, difficult labour, miscarriage, stillbirth…  Chronic anxiety  Especially new mums  NEVER ‘dismiss’ anxiety - EMPATHISE

13. 13 Causes of antenatal depression  Social causes  Antenatal depression is NOT new (despite only being recognised relatively recently)  Mums just did not have chance to talk about it then  Family support  Families often lived closer together than they do now  Work and finance  Greater pressure for mum to work in modern age  Expectations  Media perceptions of perfect nursery/bedroom  Pressure to live to societal standard  Good enough mum  NOTE: Majority of cases of antenatal depression disappear at birth BUT - one third of these mums develop postnatal depression

14. 14 Post-natal depression (PND)  Baby blues (see O’Hara, 2009)  Two to four days after birth (quite normal – but not PND)  Emotional/liable to burst into tears, for no apparent reason  Difficult sleeping (even when baby permits)  Loss of appetite  Feeling anxious, sad, or guilty  Questioning maternal skills  Effects up to 75% of mums  May relate to changes in post-birth hormone levels  Or could be related to being in hospital  Key is that this doesn't last long – usually only a few days  If it persists it may develop into PND

15. 15 PND: DSM-5 diagnosis  PND needs same DSM-5 diagnosis as major depressive disorder  But relates specifically to the peripartum period  Pregnancy and/or within 4 weeks of birth  Five (or more) of (but at least one of symptom 1 or 2) 1. Depressed mood (for most of day, nearly every day…) 2. Markedly diminished interest in all/almost all activities 3. Significant weight loss (not dieting) or decease/increase appetite 4. Insomnia or hypersomnia 5. Psychomotor agitation/retardation (observable) 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive/inappropriate guilt 8. Diminished ability to think/concentrate or indecisiveness 9. Recurrent thoughts of death… suicidal ideation/attempt/plan

16. 16 PND: Features  Additional features may also indicate presence  Sense of inadequacy, inability to cope  Feeling guilty  Being unusually irritable  Which makes the guilt worse  Being hostile/indifferent to husband/partner/baby  Losing interest in sex  Panic attacks  Excessive unwarranted anxiety  Such as being alone in the house  Obsessive fears about the baby's health or wellbeing

17. 17 PND: Prevalence  PND affects about 10% of new mums  Compare to baby blues (25-75%)  Although DSM-5 states ‘must be within 4 weeks of birth’  Most clinicians/researchers extend this to several months  Vulnerable mums usually referred in ‘perinatal’ period  During pregnancy up until baby is 1 year  Can come on gradually or all of a sudden  Can range from being relatively mild to very hard-hitting  About 50% PND women afraid to tell health professionals about it  Scared it will lead to social services taking child away  Or that they would be seen as bad mothers  See O’Hara (2009) for good overview of PND

18. 18 PND: Causes  Causes of PND uncertain  But there are a number of known risk factors (Kim, et al. 2008)  Having had depression before  Especially PND  Not having a supportive partner  Having a premature or sick baby  Having lost your own mother as child  Having had several recent life stresses  Bereavement, unemployment, housing or money problems  Poor sleep (see later)

19. 19 PND: Causes  Some additional risk factors for PND  Shock of becoming a mother  Women often unprepared for physical impact of childbirth  Plus new and daunting skills to learn  New full time responsibility  Helpless human being who cannot communicate  Other than cry (distressing in itself)  Some mums get anxious when they don’t hear crying!  Lie awake listening out  Loss of freedom and independence  Exhaustion and fatigue

20. 20 PND: Causes  Hormones  Oestrogen and progesterone affect emotions  Levels of progesterone are very high during pregnancy  PND maybe due to sudden drop progesterone after birth  In one study women given progesterone to try prevent PND  But it had the reverse effect and got worse  Oestrogen treatment via patch can be helpful  Otherwise, hormones not a major influence  Diet  Lack of certain nutrients during pregnancy may cause PND  Omega 3 oils (found in oily fish, seeds and nuts)  Magnesium (leafy green vegetables and seeds)  Zinc (seeds and nuts)

21. 21 PND Treatment  Antidepressants  Huge amount of evidence of benefit in treating depression  First line choice in most adults  BUT it is not that simple in PND  Some antidepressants  serious side effects and interaction  Consider this if mum is breastfeeding  Some antidepressants are not safe for infants

22. 22 Medication for PND – what is safe?  Tricyclic antidepressants  Lower known risks than other antidepressants  But more dangerous in overdose  SSRIs (after 20 weeks)  greater risk hypertension in neonate  Fluoxetine fewer known risks of SSRIs  Paroxetine (in 1 st trimester)  some risk foetal heart defects  Venlafaxine  some risk high blood pressure (at high doses)  Most antidepressants pass into the breast milk  Imipramine, nortryptiline and sertraline - at relatively low levels  Citalopram and fluoxetine - at relatively high levels

23. 23 PND Treatment  Counselling and talking therapies (CBT etc.) very effective  Group or individual care  BUT rare - can take time to get into a programme  We need more Perinatal Mental Health teams!  Self-help strategies  Counselling (listening visits)  Brief cognitive behavioural therapy  Interpersonal psychotherapy

24. 24 Whooley questions  During the past month… 1. Have you often been bothered by feeling down, depressed or hopeless? 2. Have you often been bothered by having little interest or pleasure in doing things?  Consider a third question:  Is this something you feel you need or want help with?

25. 25 What we have learned  We have examined several aspects of maternal mental illness  What is maternal mental illness?  Types of illness  Antenatal depression  Antenatal anxiety  Postnatal depression

26. 26 Exercise  Group task  Are Whooley questions enough?  What are the risk factors?  What signs should we watch out for?  Why are mums reluctant to tell us about mental health problems?  How far should we pursue this?