Professionals Helping vulnerable families Antenatal and postnatal mental health Becoming a mother is a time of heightened emotions. For many women the dominant emotions are positive ones, but many pregnant women and new mothers experience temporary feelings of low mood including unhappiness, loneliness and anxiety. For some women these feelings may be severe enough to be a clinically diagnosable mental illness, and some women already have a history of diagnosed mental illness when they become pregnant. Out of the Blue Best Beginnings' Out of the Blue films project helps to raise awareness and reduce stigma around perinatal mental health issues. Video lectures - Kathleen Kendall-Tackett In May we were privileged to get Kathleen Kendall-Tackett to speak at a seminar we hosted in London. Kathleen is a leading authority on depression in mothers and on the relationship between breastfeeding and depression. We are pleased to let you know that the videos we made on the day are now available to view online. Please feel free to share these videos with your colleagues and through your networks. Terminology The terminology used by professionals to describe mental health problems can be problematic because: in the past there has been a tendency to overlook antenatal mental health problems in the past there has been a tendency to group together all postnatal mental health problems under the label of ‘postnatal depression’ as well as having a clinical meaning, words such as ‘stress’, ‘depression’, and ‘anxiety’ are used in ordinary conversation to describe mild and short-lived emotions. Mental health experts currently separate the following mental health issues: Normal mood changes – the ‘baby blues’ Mild to moderate anxiety and depression (both antenatal and postnatal) Severe anxiety and depression and psychosis (both antenatal and postnatal) Impact of mental health problems Impact on mothers As well as the specific distress caused by experiencing the symptoms of a mental health problem (discussed below), a woman may have feelings of: inadequacy anger, frustration and loss at the absence of hoped-for happiness and fulfilment shame and stigma guilt These feelings, and worries about consequences such as involvement of social services, may make a woman reluctant to give honest answers to a health professional’s questions about her mood. (MIND 2006, MIND 2010; Beck 2006) Impact on children Anxiety in pregnancy can reduce blood flow to the fetus and affect birthweight and future hypertension (Teixeira 1999). Depression undermines a mother’s ability to interact with her baby responsively, so that the baby is significantly less likely to form a secure attachment (Martins & Gaffen 2002). Children (especially boys) of mothers who have been postnatally depressed are at increased risk of cognitive delay (Murray & Cooper 1997, Sharp et al 1995) and behavioural problems by school age (Sinclair & Murray 2001; Hay et al 2003). Moderate to severe depression in mothers and fathers increases children’s risk of experiencing depression themselves, particularly in early adulthood (Weissman et al 2006). Untreated psychosis is associated with preterm birth and low birthweight (Nordentoft et al 1997; Howard 2001). Impact on fathers New fathers can find coping with their partner’s depression overwhelming, frustrating, and isolating (Davey et al 2006). New fathers are also at increased risk of depression (Huang & Warner 2005). Normal mood changes – the 'baby blues' What is it? A brief period of low mood, anxiety and tearfulness with symptoms peaking on the fifth day after birth (Stein 1980). PrevalenceMost new mothers (up to 85%) experience the baby blues (NICE 2006). What should a health professional do? Ensure the woman and her partner know what to expect. Give the woman support and reassurance that the mood will pass spontaneously (Beck 2006). Encourage the woman to take care of her own needs. NICE says that if the symptoms have not resolved by 10-14 days after birth, the woman should be assessed for postnatal depression (NICE 2006). Mild to moderate depression and anxiety What are they? Mild to moderate depression is experienced as tearfulness, irritability, feelings of loneliness, loss of confidence, and a lack of satisfaction with motherhood (MIND 2006). Mild anxiety is experienced as feelings of being overwhelmed by responsibilities and unable to cope.(MIND 2006) The causes of antenatal and postnatal depression are uncertain. Medical explanations suggest genetic and biochemical factors such as hormonal imbalance, while social explanations focus on the challenges of adapting to parenthood. Some women may prefer a medical understanding as it suggests an illness which is ‘not their fault’, while others may prefer a social understanding as it avoids a suggestion that they are ‘mentally ill’ (Beck 2006). Women are at increased risk of developing depression if they: live in poverty are very young lack social support have a partner who is unsupportive or abusive or depressed lost their own mothers as children have a sick or premature baby experience external stresses such as bereavement, moving house, losing a job or financial problems (Beck 1996, Beck 2001, MIND 2010). Prevalence 10-15% of new mothers are affected by mild postnatal depression, usually starting within the first three months after birth (Kumar & Robson 1984). Rates of antenatal depression are higher than the rates postnatally (Evans et al 2001), and many women who suffer from antenatal depression have experienced depression before pregnancy as well. Rates of anxiety are believed to be higher in pregnancy than in the postnatal period (Heron et al 2004). Anxiety and depression often occur together, before, during and after pregnancy, and each condition appears to worsen the symptoms of the other (NICE 2007). What should a health professional do? Ensure that all women and their partners know what the symptoms are, and what to do if they experience them. In particular it is important for the fathers to understand how their partners may be feeling and the importance of supporting them by sharing household tasks (Matthey et al 2004, RCP 2011). NICE recommends that at a woman’s first contact with primary care, at her booking visit and postnatally at 4-6 weeks and 3-4 months, primary healthcare professionals should ask all women two questions to identify possible depression: “During the past month, have you often been bothered by feeling down, depressed or hopeless?” “During the past month, have you often been bothered by having little interest or pleasure in doing things?” If the answer to both questions is “yes”, a third question should be asked: “Is this something you feel you need or want help with?” (NICE 2007) Because of the potential risks from medication during pregnancy and breastfeeding, NICE recommends that to treat mild to moderate depression: health professionals should first consider self-help strategies, e.g. guided self-help, computerised CBT and exercise ‘listening visits’ brief cognitive behavioural therapy (CBT) or interpersonal therapy. Antidepressant drugs should only be considered if the woman has a history of severe depression and her mild symptoms decline or do not improve, or the woman has moderate symptoms and has expressed an informed preference for antidepressant treatment. All psychological treatments should be started normally within one month of assessment, and no later than three months (NICE 2007). The Royal College of Psychiatrists recommends that health professionals should advise women to: talk about their feelings get support with practical tasks from family and friends try to catch up on sleep and get time away from the baby (RCP 2011). Saving Mothers Lives recommends that where a woman reports symptoms of depression and anxiety, health professionals should: Review the woman in two weeks Consider referral to mental health services of the symptoms persist (Saving Mothers Lives 2007) Other activities that may help women include: ‘Alternative therapies’ such as infant massage (Onozawa et al 2001). Attending groups that may help overcome social isolation and provide a break (MIND 2010). Exercise (MIND 2010) Receiving support from other women experiencing antenatal and postnatal depression and anxiety through dedicated internet chatrooms (NICE 2007). Severe depression, anxiety and psychosis What are they? Severe depression is experienced as low mood, impaired concentration, extreme tiredness, feelings of guilt, incompetence, hopelessness and despair, and morbid thoughts about oneself or the baby (MIND 2010). Severe anxiety is experienced as feelings of losing control and going mad, and terrifying panic attacks with palpitations and difficulties breathing so that the sufferer believes she is suffocating and dying (Dion 2002). Symptoms of psychosis include delusions, hallucinations, confusion, fear, suspicion, rapid mood swings, and disinhibited and uncharacteristic behaviour (Beck 2006, MIND 2006). Puerperal psychosis is the term for any psychotic episode experienced after childbirth. Postnatal Post Traumatic Stress Disorder (PSTD) is experienced as nightmares, flashbacks, anger, and difficulty concentrating and sleeping (Beck 2004). It may be a pre-existing condition or be triggered by a traumatic labour (NICE 2007). Prevalence 3-5% of new mothers develop moderate to severe postnatal depression, usually within the first four to six weeks after birth (O’Hara & Swain 1996). Two per thousand new mothers are admitted to hospital with severe depression (Oates 1996). There is no additional risk of developing a psychotic disorder during pregnancy. Women with pre-existing psychotic disorders may be at increased risk of experiencing a psychotic episode if they stop taking medication abruptly due to pregnancy (NICE 2007). Two per thousand women experience puerperal psychosis, many of whom have no history of mental illness (NICE 2007). A woman is 35 times more likely to develop psychosis during the first month after birth than at other times (Kendall et al 1987). A woman who has had a previous episode of serious mental illness (even many years before) has a 1 in 2 chance of it recurring after childbirth (Saving Mothers Lives 2011) What should a health professional do? The Clinical Negligence Scheme for Trusts requires that pregnant women must be asked about their previous psychiatric history and family history of mental illness as a routine part of antenatal care (MIND 2006). NICE recommends that these questions should be asked at first contact with services in both the antenatal and postnatal periods (NICE 2006). NICE recommends that where a woman is affected by serious mental illness or has a history of serious mental illness, health professionals should discuss with her the risks from stopping medication abruptly the risk of harm associated with drug treatments the risk of harm from the mental disorder if untreated treatment options that would enable the woman to breastfeed if she wants to (NICE 2007). NICE also gives detailed guidance on the safety of specific drugs (NICE 2007). Saving Mothers Lives recommends that health professionals should urgently refer a pregnant woman or new mother to psychiatric services in these circumstances: thoughts of suicide uncharacteristic symptoms/marked change from normal functioning mental health deteriorating persistent symptoms in late pregnancy and the first 6 weeks postpartum association with panic attacks and/or intrusive obsessional thoughts morbid fears that are difficult to reassure profound low mood/ideas of guilt and worthlessness/insomnia and weight loss personal or family history of serious affective disorder (Saving Mothers Lives 2011). Understanding the experiences of mothers with mental health problems Many mothers who experience mental health problems have the additional stress of not being taken seriously by family, friends and health professionals who deny the reality of their illness or are impatient with their inability to ‘snap out of it’.There are lots of insights into what mental illness feels like on the mutual support forums for women with antenatal and postnatal depression, e.g. on www.pni.org.uk/.A good blog by a mother with bipolar disorder (manic depression) includes ‘10 things not to say to a depressed person’ http://purplepersuasion.wordpress.com/2011/07/31/ten-things-not-to-say-to-a-depressed-person/ and ‘10 supportive things I’m glad someone said to me’ http://purplepersuasion.wordpress.com/2011/08/03/ten-supportive-things-im-glad-somebody-said-to-me/ Further information MIND (National Association for Mental Health)0845 766 0163, www.mind.org.uk SANE0845 767 8000, www.sane.org.uk Perinatal Illness UKwww.pni-uk.com/ PNI UKwww.pni.org.uk/ Association for Post-Natal Illness020 7368 0868, www.apni.org NHS Clinical Knowledge Summarieshttp://www.cks.nhs.uk/depression_antenatal_and_postnatal Royal College of Psychiatristshttp://www.rcpsych.ac.uk/mentalhealthinformation/mentalhealthproblems/postnatalmentalhealth.aspxMaternal Mental Health Alliancehttp://maternalmentalhealthalliance.org.uk/ References Beck CT. 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