Psychiatric Illness in Pregnancy and the Postnatal Year

1. Psychiatric Illness in Pregnancy and the Postnatal Year Dr Alison Wenzerul Consultant Perinatal Psychiatrist alison.wenzerul@dhft.nhs.uk

2. Objectives for Today • To learn about how severe mental illness impacts on women in the perinatal period. • Issues around physical treatments for pregnant women and those who are breast feeding. • Safeguarding Issues • The impact on the infant and family. • How individual management plans are developed for at risk women • Communication options between the maternity and mental health services

3. Severe mental illness Schizophrenia Bipolar Affective Disorder Depression Mild, Moderate, Severe Anxiety disorders Panic Disorder OCD GAD PTSD Eating Disorders Mental Disorders During Pregnancy and the Postnatal Period

4. Parental Severe Mental Illness • 25%+ of women with severe mental illness have dependant children • Same mental health needs as non mothers with SMI • Normal fertility but more: • Unwanted pregnancies • Pregnancies from sexual assault • Terminations • Sexual partners • Without current partner

5. The Effects of Severe Mental Illness on Foetus and Infant: • Babies small for dates • Preterm delivery • Low birth weight • Severity of maternal mental illness is a good predictor of obstetric complications and later outcome • Increased incidence of neurological abnormalities in the newborn baby • Developmental delay: emotional, social, motor, cognitive and intellectual • Failure to thrive and reduced growth

6. In Pregnancy and the Postnatal Period Women are more likely to: • Stop medication abruptly • Have a relapse or first episode of bipolar disorder • Need an urgent intervention • Have a more rapid onset of a psychotic postnatal disorder

7. Following Childbirth: • The risk of a women suffering from a serious mental illness is greater in the three months following childbirth than at any other time in her life. • Over 10% of mothers will suffer an episode of depressive illness. Approximately 3% will have a moderate to severe depressive illness • 0.2% of mothers will suffer from a puerperal psychosis. • Suicide is a leading cause of maternal death in the postnatal period. • Mothers who suffer an episode of severe mental illness post partum have a 40% chance of a recurrence with any future pregnancy.

8. Why Mothers Die Saving Mothers’ Lives Key themes when mothers died: • Poor identification of past history (50%) • Poor identification of risk (50% of above) • Poor communication of both by psychiatric services, GPs, maternity • Misattribution of physical illness to psychiatric causes (32%) • All but 2 did not receive specialist care • Use of Illicit Substances

9. Risks to Children • Maternal mental ill health has significant consequences for children. • There are typically 750 – 800 homicides a year in England and Wales, of these, 25% are of children mainly by their parents. • Parental mental illness has been identified as a cause in a third of these case, 40% of these being schizophrenia. In addition to this, • Approximately one third of mental illness homicides are by women and 85% involve their children. • Every year approximately 20 children are killed by their mentally ill mothers – many of these are babies.

10. At first contact with maternity services, ask specific questions about: Past or present severe mental illness Previous treatment by psychiatrist/specialist mental health team Family history of perinatal mental illness Prediction

11. The Whooley Questions • Can be used at first contact with primary care, at the booking visit and postnatally: • During the past month, have you often been bothered by feeling down, depressed or hopeless? • During the past month, have you been bothered by having little interest or pleasure in doing things? • If the answer is ‘yes’ to either of these questions, please ask; • Is this something you feel you need or want help with?

12. Management of depression Mild or moderate depression • Self-help strategies • Counselling (listening visits) • Brief cognitive behavioural therapy • Interpersonal psychotherapy • Antidepressants

13. Puerperal Psychosis and Bipolar Affective Disorder • Puerperal psychosis 0.5-1.0 per 1000 deliveries; risk rises to 1 in 7 if has had a past episode. • Link between Bipolar Affective Disorder and Postpartum Psychosis • Women with Bipolar Affective Disorder have a high risk of recurrence related to childbirth, with approx 70% experiencing an episode in the immediate postpartum period

14. PRE BIRTH PLANNING MEETINGS • To clarify the treatment package. • To flag up any areas that may be a potential concern either within the remainder of the pregnancy, during or following childbirth • To provide a multi - disciplinary seamless approach and improve communication. • To identify each professionals’ individual roles in the provision of care • To share relapse signatures • To produce an emergency plan and share contact details.

15. Physical Treatments in Pregnancy • A careful risk-benefit assessment • If possible use non pharmacological interventions • Avoid first trimester exposure when possible • Use the lowest effective dose for the shortest time • Avoid polypharmacy

16. Pregnancy Pharmacokinetics • Delayed gastric emptying and longer intestinal transit times: Increased absorption • Reduced blood flow to legs in late pregnancy: Reduced absorption of IM drugs • Increased plasma volume: Dilution effect on psychotropics • Increased body fat: Serum lipids may compete for protein-binding sites and alter unbound drug concentrations • Increased metabolism: lower serum levels of psychotropics • Increased CP450 and CYP3A4, reduced CYP1A2 activity • Increased constipation and lower blood pressure can potentiate side effects

17. Factors Affecting Drug Concentration in Breast Milk • Maternal plasma level • Drug half-life • Lipid solubility, breast milk is fatty and concentrates lipophilic drugs including psychotropics • Protein binding: free drugs transfer into breast milk • Time since delivery: in early post partum there are larger gaps between alveolar cells in the breast, increasing the amount of drug that passes from maternal blood. After 4 days this reduces • Fat content of milk: lipophilic drugs will show increased transfer in hind milk rather than fore milk

18. Factors Affecting Infant Plasma Drug Levels • Amount of drug ingested • Infant metabolism: neonates have a reduced capacity to metabolise drugs for at least the first 2 weeks, this could increase with a preterm or ill infant • Infant excretion: the neonatal kidney is less efficient than an adult and only reaches that level at 2-5 months • CNS exposure: the blood brain barrier of a neonate is immature

19. National Guidance to Improve Care Recommends a specialist multi-disciplinary service (MDT) within a managed clinical network for every maternity locality, which provides: • Direct services • Consultation and advice to maternity services, other mental health services and community services • Access to specialist expert advice on the risks and benefits of psychotropic medication during pregnancy and breastfeeding • Clear referral and management protocols for services across all levels of the existing stepped care frameworks for mental disorders to ensure effective transfer of information and continuity of care • Pathways of care for service users with defined roles and competencies for all professional groups involved

20. References • Henshaw C, Cox J & Barton J: Modern Management of Perinatal Psychiatric Disorders • Lewis G (2007) Saving Mother’s Lives • Lewis G & Drife J (2004) Why Mothers Die 2000-2002 • McLennan J & Ganguli R (1999) Family Planning and Parenthood needs of Women with Severe Mental Illness • The National Teratology Information Service (NTIS) (http://www.nyrdtc.nhs.uk/Services/teratology/teratology.html)

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