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POSTNATAL DEPRESSION
DR MEENA PATEL
ASSOCIATE SPECIALIST
COOMBE WOOD PERINATAL MENTAL HEALTH SERVICE
6th March 2013
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INTRODUCTION TO PERINATAL
MENTAL HEALTH
• Psychiatric conditions complicating pregnancy and first
year post-natal
• New onset disorders e.g. PND, Puerperal psychosis
• UK-Sub speciality of adult psychiatry; now a section of
RCPsych
• Considerable psychiatric morbidity
• Serious consequences for mother foetus, infant
• Specialist management: medical & psycho social
management of mother, foetus/infant
• Multi agency- mental health, obstetrics, neonatal
paediatrics, children social services, GP, health visitors
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The Ideal!
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The Reality for some Mothers!
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BABY BLUES
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50-70% newly delivered mothers
4 to 10 days post partum, last 1-2 days
Disturbed sleep, vivid dreams
Fluctuating mood
Headache
No treatment required
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PUERPERAL PSYCHOSIS
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1-2/1000 newly delivered mothers
Within hours to first few weeks
Past/family history of BAD, PP
Rapid deterioration of mood-lability
Confusion, insomnia, agitation, over activity
Delusions, hallucinations
Risks involved
Need urgent psychiatric treatment
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ANTENATAL DEPRESSION
• Traditionally not recognised/treated
• Symptoms of depression, overlap
symptoms of pregnancy
• Tearfulness/irritability attributed to
hormone
• Often persist into post partum period
• 10-15% pregnant women experience
depression and anxiety
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POSTNATAL DEPRESSION
• 10-15% women experience PND
following birth
• On set within days upto one year of
delivery
• More insidious onset
• Untreated, may persist for one to two
years
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SYMPTOMS OF PND
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For at least two weeks
Persistent low, irritable, anxious mood
Sleep disturbance
Impaired appetite
Lack of energy, loss of interest
Poor memory and concentration
Inability to cope with daily chores
Guilt feeling
Anxiety of harming baby
Suicidal thoughts
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NEWS FLASH
By Martin Evans, Crime Correspondent –Daily Telegraph
11:45AM GMT 30 Oct 2012
• Felicia Boots, 35, suffocated 9-week-old Mason and 14month-old Lily-Skye just two weeks after the family, who are
originally from Canada moved into a new £1.4 million home
in south west London.
• The judge in the case Mr Justice Fulford described her as a
loving mother who has been suffering from a depressive
disorder and whose judgement "was simply not functioning".
• On the morning of the tragedy Mrs Boots had become
"fixated and deluded" that her children were going to be
taken away, the judge said.
• The court heard how she had suffered post natal depression
following the birth of her first child, Lily-Skye in March 2011.
• She was prescribed anti-depressants and had begun to feel
much better, the court heard.
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NEWS FLASH continued
• But when she became pregnant with her
son she became concerned about the
effects the medication might have on
him.
• The court heard how Mrs Boots had
stopped taking her medication because
she was breast feeding and she was
"irrationally worried about the
consequences for him".
• She made an attempt on her own life
after killing her children.
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WHY DOES IT HAPPEN?
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Don’t know enough
Probably multiple stresses
Large number of risk factors researched
Strongest to emerge:
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Previous history /family history of depression
Antenatal depression
Lack of support from partner, domestic violence
Life events- moving house, bereavement, loss of job,
money worries
Can occur even with no risk factors
hormones: no conclusive evidence
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RISKS OF UNTREATED PND
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Mothers: protracted suffering, suicide
Practical parenting difficulties
Attachment difficulties- less responsive
Fathers: increased rate of depression and
general health problems, if mother
depressed
• Both parents depressed-impact on infant
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RISKS OF UNTREATED PND continued
• Infant: attachment difficulties
• Short/long term cognitive behavioural
emotional social developmental difficulties
• Risk of neglect, rejection
• Infant’s temperament and resilience modify
negative outcomes
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MANAGEMENT
• Detection
• Guidelines and protocols in primary care and
maternity services
• NICE: all pregnant women to be asked
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Past/current mental health problem
Past/current psychiatric treatment
Family history of mental health problems
Last month feeling low or hopeless
Loss of interest, pleasure
Need for help
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MONITORING MOOD
• Mid wives to monitor mood at all antenatal
appointments
• Postnatally: HVs and GPs screen for PND at
6 weeks, 3 months, 6 months
• Use EPDS and GHQ for screening
• Assess further if high score
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PREVENTION
• Don’t know enough about PND to prevent it
• Sensible tips during pregnancy:
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Don’t try to be super woman
Don’t move house
Friends with other expecting couples
Antenatal classes with partner
Identify someone to confide in
If previous history, discuss with GP +HV
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PREVENTION continued
• After delivery:
– Rest, accept/ask for help
– Healthy diet, exercise
– Build in leisure
– Don’t blame yourself/partner
– Never too late to have treatment
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TREATMENT OF PND
• Diagnosis of PND helps:
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Common,
anyone can experience it
Will get better
Not her fault, not a bad mother
• Involve partner:
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Relieved by diagnosis
Guidance for what to do
Practical help with baby
Patience, being positive
Time together
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PHARMACOLOGICAL TREATMENT
• Hormonal therapy: considerable debate
and research
• Little reliable evidence for effectiveness
• Concerns about side effects
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ANTIDEPRESSANTS
• Not in mild depression
• Risk: benefit ratio important before
prescribing
• ADs not tranquilisers/pep pill
• Not addictive
• Take two or more weeks to work
• Need not stop breast feeding
• Need to continue for 6 months to reduce risk
of relapse
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TALKING THERAPIES
• Guidelines suggest easy and quick access
• Evidence for equal effectiveness for:
– Non directive counselling (supportive
listening), 6 to 8 sessions by trained HVs
– CBT: structured therapy to solve problems b y
changing unhelpful thoughts, beliefs,
behaviours
– Interpersonal therapy: focus on mothers past
and present relationships
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SOCIAL SUPPORT
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Social circumstances, cultural issues
Home start, family support worker, befriending
Mother and baby groups, NCT
Children centres/Sure Start
Family focused interventions:
Couples-individual or groups focused on parenting help
to improve depression and general health
• Mother infant therapy help to improve attachment
• Infant massage: Significant positive effect on mother
infant relationship and depressive symptoms
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RESOURCES
• Books: Coping with PND-Fiona Marshall 1993
Overcoming PND-Williams, Cantwell Robertson 2009
• Understanding PND : MIND
• Postnatal depression : Factsheet: RCPsych
Support Organisations:
Association of Postnatal Illness:
020 7386 0868
Meet-a-Mum Association (MAMA)
0845 120 3746
National Childbirth Trust:
0870 444 8707
NETMUMS : www.netmums.com
HOMESTART UK :
0800 068 6368
FAMILY WELFARE ASSOCIATION:
020 7254 6251
CRY-sis
08451 228 669
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