Postnatal depression

1. Postnatal depression Prepared by: Muna shinnawe Nora nasrallah Hamzh kharof

2. What is Postnatal Depression? Postnatal Depression is a depressive illness which affects between 10 to 15 in every 100 women having a baby. And it is a form of clinical depression which can affect women, and less frequently men, after childbirth

3. introduction • When does PND happen? • The timing varies. PND often starts within one or two months of giving birth. It can start several months after having a baby. About a third of women with PND have symptoms which started in pregnancy and continue after birth. • 14.5% in the first 3 months • 6.5-12.9% in the first year

4. introduction • Women are vulnerable to depression within the first postnatal year, not just first few postnatal weeks. • Around 14.5% of women may have a new episode of major or minor depression during the first three postnatal months, and the prevalence for major and minor depression during the first postnatal year is estimated as 6.5 – 12.9%. (Gaynes et al.,2005)

5. introduction • severe mental illness with a statistically small but exceptionally serious risk of suicide and infanticide in some severely depressed mothers

6. The Confidential Enquiry into Maternal Deaths (CEMD) in the U.K.

7. Depression is not just unhappiness 1-It is a potentially life-threatening disorder 2-It cause Destruction of family relationships Women’s depression may affect their: 1- partners : • Divorce([webster,2002] ,[Ballard et al.,1994],[Boath et al.,1998] and [Morgan et al.,1997] 2-their ability to cope with supporting the woman 3-caring for the new infant, or other children. ([C. Jane Morrell]\2006)

8. Depression is not just unhappiness 4-Increased risk of psychosocial disorders in children/partner • Depression • Child abuse/neglect • Social/emotional development in children

9. Do women with PND harm their babies? • Depressed mothers often worry that they might do this, but it is very rare to do this

10. The effect of PND on infants • PND affect the development of children ([cogill et al.,1986] and [caplan et al ., 1989]) • It affect the attachment between infant and his mother .(Murray,1992) • It affect the emotional, behavioural and cognitive development of the newborn.

11. The effect of PND on infants • newborns of women with postnatal depressionare more likely to have impairment in terms of socio-emotional and cognitive developments. ([C. Jane Morrell]\2006)

12. predictors of PND *No clear etiology *The strongest predictors of PND are related to • antenatal anxiety • depression • lack of social support • stressful life events. (Carter et al.,2006) • ([C.Jane Mmorrell]\2006)

13. Is there is a link between PND & C’s section ? • A link between caesarean section and PND has not been established. • (Carter et al.,2006)

14. Risk Factors • Women with a history of depression • Prior history of postpartum depression • recurrence risk ~ 50 % • Any history of depression • recurrence risk ~ 25 % Level of risk is related to severity and duration of previous depression

15. PND Risk Factors • Family psychiatric history • stressful life events. (Carter et al.,2006) • Marital conflict • Unplanned pregnancy • Previous miscarriage • Congenitally malformed infant during 12 months

16. PND Risk Factors • Lack of perceived social support. • Lack of emotional & financial support from partner. • Living without a partner.

17. PND risk factors • Intimate Partner Violence • Intimate partner violence is positively associated with postpartum depression among Canadian women. • ([Hind A. Beydoun PhDa, , , Ban Al-Sahab MSb, May A. Beydoun PhDc and Hala Tamim PhD]\2010])

18. S&S of PND • Parenting Stress. • hostile feelings towards their infant. • negative perceptions of their infant’s behaviour. • (cornish et al.,2006)

19. S&S of PND • The woman may get irritable or angry with her partner, baby or other children. • Women's with PND may also feel as if they are inadequate mothers, causing them to have feelings of guilt and embarrassment. • ([Dominic T.S.lee ] and [Tony K.H.Chung]\2006).

20. S&S of PND • depressed mood • tearfulness • lack of drive and enjoyment • social withdrawal • ([Dominic T.S.lee ] and [Tony K.H.Chung]\2006)

21. S&S of PND • Insomnia • poor appetite • impaired concentration • feelings of uselessness and helplessness • ([Dominic T.S.lee ] and [Tony K.H.Chung]\2006)

22. S&S of PND • Bodily symptoms such as: • wound pain • headache • back pain • She might have ideas about self-harm and suicidal plans. • forgetfulness and impaired concentration . • ([Dominic T.S.lee ] and [Tony K.H.Chung]\2006)

23. Psychological symptoms • Depressed mood • Decreased interest or pleasure in activities • Feeling worthless or guilty • Difficulty concentrating • Recurring thought of death or suicide

24. Physical symptoms • Change in appetite  weight gain or loss • Insomnia or excessively sleepy • agitation • Fatigue/loss of energy

25. Screening - Tools • They use the Edinburgh Postnatal Depression Scale(EPDS) • Beck’s Depression Inventory (PDI) • Postpartum Depression Screening Scale (PDSS)

26. Why the EPDS was established? • Because of the general problem with the detection of postnatal depression in primary care. • ([Cooper,2003] [Kumar and Robson,1984],[Richards,1990] and [Holden,1991])

27. Edinburgh Postnatal Depression Scale (EPDS) • the EPDS is one of the mood assessment instruments most widely used in clinical practice, (Green ,2005). • But it was not developed as a diagnostic test,(Leverton,2005) and cannot be used confirm PND without a clinical interview.

28. (EPDS) • 10 item questionnaire • Each response scored 0 – 3, with total score of 30 possible • Scores > 12 or 13 identify most women with postpartum depression

31. Who can help? • health visitor ( talking therapy) • If your PND is severe, you may need care and treatment from a mental health service (medication)

32. Referrals • Consider Psychiatric referral if: • Poor response to therapy • Relapse • Major functional impairment • Suicidal or homicidal ideation

33. prevention • It is important to screen patients during • antepartum visits. • while in the hospital at postpartum . • well baby visits.

34. Length of Treatment • Based on patient history and severity of symptoms • Continue 12 months after full remission

35. Treatment of PND • postnatal depression is a major public health problem but the evidence base for its treatment remains limited Carol A. Henshaw \2004

36. treatments • Pharmacological treatment for depression • Psychological interventions • Home visiting (C.Jane Morrell\2006)

37. Pharmacological treatment for depression • There is not enough evidence from well controlled and reported trials about the costs and benefits of different interventions for depression. • Within the UK, depression in primary care is usually treated with antidepressants.(Wisner et al.,2002)

38. Pharmacological treatment for depression • Many people are uncertain about taking drugs for depression so the compliance was not good. • ([C. Jane Morrell]\2006)

39. Psychological interventions • Partly in response to concerns about antidepressants, (Hotopf et al.,1996) • over the past 25 years, there has been a move towards increasing the availability of psychological interventions.(Rowland et al.,2001)

40. Psychological interventions • In primary care, generic brief counselling(Harvey et al.,1998)or psychological interventions are equally, if not more effective than routine GP (general practitioner )care,([friedli et al.,1997],[Ward et al .,2000]and[Hemmings,1997])and as effective as antidepressants. (Chilvers et al .,2001)

41. Psychological interventions • Primary care patients may prefer brief psychotherapy to usual GP care (Chilvers et al .,2001) or prefer counselling over antidepressants. ([friedli et al.,1997],[Ward et al .,2000]and[Hemmings,1997]) • Therapies using CBT also appear to be cost-effective in primary care,(Churchill et al.,2001)and possibly helpful in preventing relapse.(Scott et al .,2003)

42. treatment • Traditionally, severe postnatal depression has been treated with medication or cognitive behavioural therapy and in mild to moderate postnatal depression non-directive counselling (‘the listening visit’), extra social and emotional support and group psychological therapies have been used.

43. treatment • Recently, the use of complementary therapies in the treatment of depression has been explored and it has been reported that the arts can have positive effects on patients with mental health problems • The study found that this programme created a relaxed, safe space which was experienced as supportive by women who participated in the sessions. Catherine Perrya, , , Miranda Thurstona, and Thelma Osbornb\2007

44. Health visitors detection and treatment of postnatal depression • Listening Visits in the UK • result was that 69% of the Intervention Group (IG) women (n = 18) recovered compared with 38% of the control group (CG) women (n = 9) who received routine care. • ([C.Jane Morrell]\2006)

45. Home visiting • One of the first systematic overviews of home visiting, indicated that there were positive outcomes for home visiting,( Ciliska,1994)but there are very few reports of UK-based research in health visiting.(Elkan et al .,2000).

46. Home visiting • The review of articles on the effectiveness of home visiting (Bull et al .,2004)confirmed the suggestion that health visiting can improve the management of PND.

47. The 57 Trial • 1. Antenatal Support Interventions (n = 2), • 2. Antenatal Prevention of Postnatal Depression (n = 10), • 3. Perinatal Support or Treatment to prevent Postnatal Depression (n = 14), • 4. Postnatal Support Interventions (n = 6), • 5. Postnatal Prevention of Postnatal Depression (n = 5), • 6. Postnatal Treatment of Postnatal Depression (n = 20).

48. . Antenatal Support Interventions (n = 2), • In one of the two UK-based trials, mothers found the support valuable, since it improved their subjective well-being. (Spencer et al.,1989) • In the other trial,(Oakley et al.,1990) the IG women were less likely to report feeling depressed, low or worried about the baby after the birth, than the CG

49. This study was not using standardised tools. • Because the samples were too small and objective assessments were not used, there was insufficient evidence from the trials to confirm the possibility of improved maternal psychosocial outcomes. (Hodnett,2002b)

50. Trials of antenatal prevention of postnatal depression • There was not enough evidence from antenatal targeted interventions provided for ‘at-risk women’.(Austin,2003). • that mean’s the women in the IG were just as likely to become depressed as those in the CG. • These antenatal studies do not provide sufficient evidence upon which to base care.