Transcript - Integration of Psychiatry into Primary Health Care

When the bough breaks:
Mental Illness in the
Pregnant and
Postpartum
Woman
Dr.Mariam Alawadhi MD,FRCPC
Assistant professor-Department of Psychiatry,Kuwait
University
Head of consultation liaison unit-KCMH
Agenda
 Review the epidemiology and clinical presentation of
perinatal mood and anxiety disorders in perinatal
women.
 Understand the psychiatric, obstetric and pediatric
implications of a mother’s untreated illness.
 Discuss a bio-psychosocial approach to the
management of these disorders.
 Depression is “the most common complication of
childbearing.”
Wisner, 2002
 1 in 5 mothers will experience a mental health
disorder during their pregnancy or the year after they
deliver.
 Pregnancy and the transition to parenthood is
considered to be one of life's major transitions.
 Women are at an increased risk of developing
mental health issues due to physiological and
psychological risk factors.
Challenging the myths...
 Media images of pregnancy and motherhood
 Pregnancy was planned, so why do I have the
“blues”?
 Work-life balance
 Relationships (couple, extended family)
...and facing reality

Tired, home alone, lots of care for baby, no time for self, complete loss of control over time

Wide range of positive and negative emotions

Adjustment and adaptation to pregnancy and motherhood is dynamic

pregnancy alters a woman’s life irreversibly

Women need accurate information (e.g, pregnancy, labour, delivery) = power, control

Shame & stigma
Perinatal mental health
Pregnancy related
 Antepartum Depression
 Antepartum anxiety
Postpartum related
 Baby Blues
 Postpartum Depression
 Postpartum Psychosis
 postpartum anxiety
Let’s define the terms first...
Antepartum depression
Antepartum depression
Depression vs. pregnancy?
 affect
 cognition
 functional impairment
Associated with:
 Poor prenatal care (e.g., nutrition; substance use)
 Changes in cortisol & HPA axis development
 Poor perinatal outcomes (e.g, abnormal fetal neurobehavioral;
pre-term labour (Steele et al., 1992)
Antenatal Depression
Risk factors:
 low self-esteem
 low social support, low income
 antenatal anxiety, hx of depression, hx of abuse
 negative cognitive style
 hx of miscarriage/pregnancy termination
 pregnancy complications
Confounds in diagnosing
depression during pregnancy
Overlapping symptoms:
 Sleep disturbances
 Increased/decreased appetite
 Decreased energy
 Changes in concentration
Illnesses with similar symptoms:
 Anemia
 Thyroid dysfunction
 Gestational diabetes mellitus
Perinatal Anxiety
 Generalized Anxiety Disorder = 4-8%
 Panic Attacks = 1-3%
 Obsessive Compulsive Disorder = 0.2-1.2%
 Posttraumatic stress Disorder = 6%;
 40% in loss
Perinatal anxiety
disorders
Effects of maternal stress & anxiety
during pregnancy
– Altered fetal movement
– Lower gestational age
– Lower infant birth weight
– Lower APGAR scores
– Enduring changes in cortisol
measures in offspring
Postpartum blues
Low-level symptoms:
• Baby blues
– Very common (50-80%)
– Starts w/in 1 wk pp: peaks
• Tearfulness
• Irritability, reactivity
• Insomnia
• Anxiety
• Poor appetite
3-5 days post-delivery
– Unrelated to environmental stressors
– Unrelated to psychiatric history
– Present in all cultures
Posited relationship between
“Blues” and PPD
• During pregnancy:
– Increase oestrogen, progesterone (placental production of
hormones); beta-endorphin & cortisol (cortisol peaks in late pregnancy CRH), prolactin
– Oestrogen enhances neurotransmitter serotonin (increases synthesis
& reduced breakdown)
• After delivery:
– Drop in oestrogen/progesterone (removal of placenta at
delivery); drop in cortisol & b/e
– Decrease estrogen decrease serotonin
– Prolactin levels return to normal in non-lactating women w/in
weeks
– Breastfeeding: prolactin levels remain high (induces release of
oxytocin)
Postpartum depression
 Postpartum depression
DSM IV  onset from within 4
wks. of delivery, “pp onset”
Clinically, up to 1 y postpartum
(DSM V to reflect this)
 Peaks at 3-6 mo pp
 Average PPD course is 7 mo
 Related to psychiatric history and environmental stressors
Postpartum depression
Added clinical features:
 Obsessive traits (e.g., name of baby, harming baby)
 Depressed, despondent, emotionally numb
 Ambivalence toward baby (bonding)
 Grief for loss of self
 Feelings of inadequacy, guilt*
 Feeling isolated/misunderstood
 Suicidal ideation/Ego-dystonic thoughts of harming baby
Biological
history of
depression or
affective disorders
•Previous
PPD or
depression
•Low
self-esteem
•Lack/poor
•Perfectionist,
dysfunction
•Hormones
•Feelings
•Relationship
problems (couple,
extended family)
•Difficult
baby
(feeding, colic)
•Separation
function
•Role
•Stressful
•Sleep
•Attitude
immune
toward
pregnancy
(ambivalence,
unwanted)
(Kendler, 1993; Wisner, 2002)
disturbances
conflict
•Trauma/abuse
•Unresolved
grief
(death of child)
from
baby
live
events (move, job
change, illness)
•Economic
•Recent
Obstetric
•IVF
(fertility drugs)
•Difficult
of
inadequacy
•Altered
social
support
•age
neuroticism,
high/unrealistic
expectations of
self/baby
•Thyroid
Social
stress
loss
•Childcare
stress (#
of children at
home)
Risk factors
•Family
Psychological
delivery
•Medical
complications of
pregnancy
•Health
problems of
infant
•Lack
of readiness
for hospital
discharge
Postpartum psychosis
Heterogeneous group of disorders





BAD (35% with bipolar diathesis)
MDD w/ psychotic features
SZ-spectrum disorders
Medical conditions (e.g., thyroid, low B12)
Drugs (e.g., amphetamines)
Bizarre symptoms:
• Delusions (e.g., baby
possessed)
• Hallucinations (e.g.,
seeing s/o else’s face)
• Mood swings (more
than non/pp psychosis)
• Confusion &
disorientation
• Erratic behaviour
• insomnia
•Waxing & waning
Risk for suicide and
infanticide
Psychiatric emergency
Postpartum psychosis

Rare (1-2/1000 women)

Most commonly 2-4 wks/pp
Risk Factors
 Family hx of BAD
 Early onset depression
 History of PPD
Agenda
2.Understand the psychiatric, obstetric and pediatric
implications of a mother’s untreated illness.
Economic & health
care burden
•
Yearly estimated costs of depression $14.4 – 44 billion dollars
annually (Greenberg, 1993; Stephens, 2001)
•
The rate of depression among Ontarians is about 4.8% (Statistics Canada,
2003), with women more than twice as likely as men to be depressed
(Statistics Canada, 1996-97).
•
50% of OB/GYN patients have a significant emotional disturbance
•
Women with PPD access more community services, make more
frequent non-routine visits to the pediatrician; costs are higher for
women with an extended duration of illness
(Ballinger, 1977; Bryne, 1984; Worsley, 1977)
(Petrou, 2002; Chee, 2008)
•
Peak prevalence of ♀ psychiatric contact (in & outpatient) occurs in
the first 3 months after childbirth
(Kendall, 1987; Munk-Olsen, 2008)
Maternal Risks from A/PPD
 Coronary artery disease
 Cancer
 Hypertension
 Overactive bladder
 urinary incontinence
 Poorer maternal health practices
 Complications after childbirth
Fetal Risks from A/PPD
 Poorer maternal health practices
 Elevated cortisol levels
 Preterm delivery
 Small for gestational age

Low birth weight
Schmeelk 1999, Lundy 1999, Hoffman 2000, Adewuya 2007, Hedgaard
1993
Adverse parenting outcomes
Depressed mothers:
 Perceive their infants as more bothersome and make
harsher judgments of them
 Are more irritable and spend less time looking,
touching, and talking to their infants
 Are more likely to neglect/abuse their children
Whiffen 1989, Cohn 1990, Chaffin 1996
Adverse parenting
outcomes
These effects are moderated by:
 Timing of depressive episode
 Age of children
 SES of family
Lovejoy, 2000
Attachment
Definition :
A strong emotional and social bond between infants and
their caregivers
JOHN BOWLBY (1907-1990)
 British Child Psychiatrist & Psychoanalyst.
 He was the first attachment theorist
 describing attachment as a "lasting psychological
connectedness between human beings".
 Bowlby believed that the earliest bonds formed by
children with their caregivers have a tremendous
impact that continues throughout life.
John Bowlby (1969)
 Argued babies are born equipped with behaviors
(crying, cooing, babbling, smiling, clinging, sucking,
following) that help ensure that adults will love them,
stay with them and meet their needs.
Bowlby (cont’d)
 Believed quality of early attachment influences future
relationships (friends, romantic partners, own children).
HARLOW & ZIMMERMAN
 A famous experiment was conducted by Harlow and
Zimmerman in 1959, Which showed that developing a close
bond does not depend on hunger satisfaction.
 They conducted the experiment where rhesus monkey
babies were separated from their natural mothers and
reared by surrogates- terry cloth covered and other was wire
mesh.
 Babies cling to terry cloth mothers even though wire mesh
had bottle.
 This shows 'contact comfort' is more important
Attachment
 'FEEDING IS NOT THE BASIS FOR ATTACHMENT'
 The central theme of attachment theory is that mothers
who are available and responsive to their infant's needs
establish a sense of security in their children.
 The infant knows that the caregiver is dependable,
which creates a secure base for the child to then
explore the world.
Attachment
When does it form?
 Usually within the first six months of the infant’s life
 Shows up in second six months through wariness of
strangers, fear of separation from caregiver, etc.
Attachment
 Babies are born equipped with behavior like crying,
cooing, babbling and smiling to ensure adult attention &
adults are biologically programmed to respond to infant
signals.
 Bowlby viewed the First 3 years are very sensitive
period for attachment
Four Stages of Attachment
 Pre-attachment
 Attachment-in-the- making
 Clear-cut attachment
 Formation Of Reciprocal Relationship
PREATTACHMENT PHASE
Birth-6weeks
 Baby’s innate signals attract caregiver (Grasping, crying,
smiling and gazing into the adult’s eyes) Caregivers remain
close by when the baby responds positively
 The infants encourage the adults to remain close as the the
closeness comforts them
 Babies recognize the mother’s smell, voice and face.
 They are not yet attached to the mother, they don’t mind
being left with unfamiliar adults.
 They have No fear of strangers
ATTACHMENT IN MAKING
6 Weeks – 6 to 8 Months

Infant responds differently to familiar caregiver than to strangers.
 The baby would babble and smile more to the mother and quiets more
quickly when the mother picks him.

The infant learns that her actions affect the behavior of those around

begin to develop “Sense of Trust” where they expect that the caregiver
will respond when signaled

The infant still does not protest when separated from the caregiver
“CLEAR CUT” ATTACHMENT
PHASE
6-8 Months to 18 Months -2 Years
 The attachment to familiar caregiver becomes evident
 Babies display “Separation Anxiety”, where they become
upset when an adult whom they have come to rely leaves
 Although Separation anxiety increases between 6 -15
months of age its occurrence depends on infant
temperament, context and adult behavior
FORMATION OF RECIPROCAL
RELATIONSHIP
18 Months / 2 Years and on
 With rapid growth in representation and language by 2
years the toddler is able to understand some of the
factors that influence parent’s coming and going and to
predict their return.
 separation protests decline.
 The child could negotiate with the caregiver, using
requests and persuasion to alter her goals
Attachment
Just the mother?
 No Attachment to the mother is usually the primary
attachment, but can attach to fathers and other
caretakers as well.
Mary Ainsworth
 Ainsworth came up with a special experimental design
to measure the attachment of an infant to the caretaker
 The Strange Situation Test – procedure in which a
caregiver leaves a child alone with a stranger for
several minutes and then returns.
STRANGE SITUATION
1.
2.
Observer shows caregiver and infant into the experimental room and then leaves. ( 30
Seconds)
Caregiver sits and watches child play. (3 mins)
3.
Stranger enters, silent at first, then talks to caregiver, then interacts with infant. Caregiver
leaves the room. (3 mins)
4.
First separation. Stranger tries to interact with infant. (3 mins)
5.
First reunion. Caregiver comforts child, stranger leaves. Caregiver then leaves. (3 mins)
6.
Second separation. Child alone. (3 mins)
7.
Stranger enters and tries to interact with child
8.
Second reunion. Caregiver comforts child, stranger leaves. •
All episodes except 1 last for 3 mins unless the child becomes very upset
STRANGE SITUATION
 Video
 http://youtu.be/PnFKaaOSPmk
Four Key Observations
 Exploration : to what extent does the child explore
their environment
 Reaction to departure : what is the child’s response
when the caregiver leaves
 The stranger anxiety : how does the child respond to
the stranger alone
 Reunion : how does the child respond to the caregiver
upon returning
STRANGE SITUATION
 Findings Infants differ in quality or style of their
attachment to their caregivers.
 Most show one of four distinct patterns of attachment:
1. Secure attachment
2. Insecure/Avoidant attachment
3. Insecure/ambivalent attachment
4. Disorganized/Disorientated attachment
Secure Attachment
 Most infants (65-70% of 1 yr olds)
 Freely explore new environments, touching base with
caregiver periodically for security.
 May or may not cry when separated, when returned,
crying ceases quickly.
Avoidant Attachment
 15%
 Don’t cry when separated
 React to stranger similar to their caregiver
 When returned, avoids her or slow to greet her.
Ambivalent Attachment
 10%
 Seeks contact with their caregiver before separation
 After she leaves and returns, they first seek her, then
resist or reject offers of comfort
Disorganized Attachment
 5-10%
 Elements of both avoidant and ambivalent (confused)
Agenda
 3. Discuss a biopsychosocial approach to the
management of these disorders.
Detecting perinatal depression:
why screen?
 High prevalence rate
 Risks of untreated symptoms
 Availability of effective treatment
 Availability of validated screening tools
Edinburgh Postnatal Depression
Scale (EPDS)
 10-item self-report
 Adv: easy to score, designed for peripartum use, validated
ante- and pp, cross-culturally validated
 Disadv: not linked to DSM-IV-TR criteria, validation studies
do not provide definitive answer about optimal cut-off
scores
 Guidelines: score 9-12 pp risk, 12> high risk (cut-off scores
above 12 not sensitive in some studies)
(Cox & Holden, 2003)
Detecting Perinatal Depression
Why Screen??
PKU
A/PPD
1 in 12 000 babies
1 in 5 mothers
Mod-severe MR
Serious and lasting effects on
mother/child health and family
functioning


$50/baby
free
Effective Rx


Cost-effective Rx


Prevalence
Outcome
Predictive Screen
Cost to Screen
Gestational diabetes: 3-10% pregnancies
Gestational hypertension: 2-3% pregnancies
Educate about self-care
NESTS





Proper Nutrition
Exercise
Rest (Sleep protocol)
Time for yourself
Circles of Support
Educate about self-care
 Sleep
SLEEP PROTOCOL: 5h of uninterrupted sleep per night
 Breaks from baby
 Enjoyable activities
 Decrease isolation
Spend time with friends, family, other mothers
 Protect yourself and your energy
Limit visitors, lighten chores
Treatment
Screening and invesigations
 Check for other diseases
 Thyroid disease
 Anemia
 Diabetes
 Vitamin deficiencies
Treatment
Therapy
 Cognitive Behavioral Therapy
 Interpersonal Psychotherapy
 Couple therapy
 Group therapy
Medications
Risks of medication
1) to mother
2) to fetus
3) to newborn
Risks of disease
1) to mother
2) to fetus
3) to child
4) to family
 Suicide and homicide
-Is there an increase risk of spontaneous
abortion/miscarriage?
-Is there an increase in the risk of congenital
Malformation?
-Is there an increase in the risk of adverse
outcomes for the neonate?
-Is there an increase in the risk of adverse outcomes from
breastfeeding?
Effects of pregnancy on
pharmacokinetics
 Delayed gastric emptying
 Decreased gastrointestinal motility
 Increased volume of distribution
 Decreased protein binding capacity
 Increased hepatic metabolism
SSRIs
 Absolute risk of exposure in pregnancy is small.
• Paxil Health Advisory
• Poor Neonatal Adaptation Syndrome
• Persistent Pulmonary Hypertension
• Current U.S. Lawsuits
Louik 2007, Einarson 2008, Alwan 2008, Greene 2007, Hallberg 2005, Wogelius
2006, Oberlander, Levinson-Castiel 2006, Chambers 2006, 2009, Kallen 2008,
Andrade 2009
Mood stabilizers
 High risk for relapse into bipolar depression with discontinuation
 Lithium may be the safest alternative
 Valproic acid: teratogenicity neurobehavioral toxicity
• CBZ and LTG lower risk than VPA
 Folic acid supplementation
 Li non-responders: consider LTG +/- antipsychotic vs. atypical across
pregnancy

Wyszynski 2005, Morrow 2006, Cunnington 2007, Meador 2006, Holmes 2004,
Cohen 2007
Breastfeeding
 “It is when the socioeconomic situation is the worst that
breastfeeding has the greatest benefit.” Dr. Jack
Newman
 Nutritional advantages
 Infection, allergy, Ca, diabetes protection
 Bonding, developmental benefits
 Postpartum recovery, Ca (breast, ovarian),
osteoporosis
 Free and easy!
Mother’s bias
 Women receiving chronic therapy tend to initiate
breastfeeding much less often
 If they do initiate, they discontinue it much earlier
• Continuation of breastfeeding correlates with cumulative
amount of reassuring counseling advice women receive
from health professionals
Moretti et al, 1995, 1998 From Koren 2007
Breastfeeding
 Generally, excretion rates < 10% into breast milk are
considered safe by the American Academy of
Pediatrics.
[milk]/[plasma]:
 Molecular size, protein-binding, acidity,lipophilicity
• Nursing infant: absorption from GI tract ability to detoxify,
ability to excrete .
Nothing trumps maternal euthymia
Thank you!