Maternal Mental Illness & Sleep An overview of the day

1. Maternal Mental Illness & SleepAn overview of the day Dr Andrew Mayers amayers@bournemouth.ac.uk

2. Maternal mental illness and sleep • Overview of today • Postnatal depression • Features, causes, risk factors and treatment • Consequences for mother and child • Postnatal psychosis • Sleep problems • For mother and baby • Complementing your existing skills • Partnership between academic knowledge and professional practice • Interactive sessions

3. Postnatal depressionFeatures, causes and treatment Dr Andrew Mayers amayers@bournemouth.ac.uk

4. Postnatal depression • Overview • Contrast with baby blues • Diagnosis • Causes and risk factors • Treatments

5. Post-natal depression (PND) • Baby blues • Two to four days after birth (quite normal – but not PND) • Emotional/liable to burst into tears, for no apparent reason • Difficult sleeping (even when baby permits) • Loss of appetite • Feeling anxious, sad, or guilty • Questioning maternal skills • Effects up to 75% of mums • May relate to changes in post-birth hormone levels • Or could be related to being in hospital • Key is that this doesn't last long – usually only a few days • If it persists it may develop into PND

6. Major depressive disorder (DSM-IV TR) • Low mood AND/OR … • Markedly diminished interest/pleasure in ‘usual’ activities • PLUS four from: • Significant weight loss/gain/changes in appetite • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue/low energy • Feelings of worthlessness or excessive/inappropriate guilt • Poor concentration/indecisiveness • Recurrent thoughts of death/suicide • Symptoms must be ‘continually’ present for at least 2 weeks

7. PND: Features • PND needs same DSM-IV diagnosis as major depressive disorder • But relates specifically to the postpartum period • But within 4 weeks of birth (is that enough?) • Additional features may also indicate presence • Sense of inadequacy, inability to cope • Feeling guilty • Being unusually irritable • Being hostile/indifferent to husband/partner/baby • Panic attacks • Excessive unwarranted anxiety • Obsessive fears about the baby's health or wellbeing

8. Whooley questions • During the past month… • Have you often been bothered by feeling down, depressed or hopeless? • Have you often been bothered by having little interest or pleasure in doing things? • Consider a third question: • Is this something you feel you need or want help with? • Is this sufficient? • Is there more we can do?

9. PND: Prevalence • PND affects about 10% of new mums • Compare to baby blues (up to 75%) • Although DSM-IV states ‘must be within 4 weeks of birth’ • Most clinicians/researchers extend this to several months • Vulnerable mums usually referred in ‘perinatal’ period • During pregnancy up until baby is 1 year • Can come on gradually or all of a sudden • Can range from being relatively mild to very hard-hitting • About 50% PND women afraid to tell health visitors about it • Scared it will lead to social services taking child away • Or that they would be seen as bad mothers

10. PND: Causes • Causes of PND uncertain • But there are a number of known risk factors • Having had depression before • Especially PND • Not having a supportive partner • Having a premature or sick baby • Having lost your own mother as child • Having had several recent life stresses • Bereavement, unemployment, housing or money problems • Poor sleep (we will talk about this later)

11. PND: Causes • Some additional risk factors for PND • Shock of becoming a mother • Women often unprepared for physical impact of childbirth • Plus new and daunting skills to learn • New full time responsibility • Helpless human being who cannot communicate • Other than cry (distressing in itself) • Some mums get anxious when they don’t hear crying! • Lie awake listening out • Loss of freedom and independence • Exhaustion and fatigue

12. PND: Causes • Hormones • Oestrogen and progesterone affect emotions • Levels of progesterone are very high during pregnancy • PND maybe due to sudden drop progesterone after birth • Diet • Lack of certain nutrients during pregnancy may cause PND • Omega 3 oils (found in oily fish, seeds and nuts) • Magnesium (leafy green vegetables and seeds) • Zinc (seeds and nuts)

13. PND Treatment • Antidepressants • Huge amount of evidence of benefit in treating depression • First line choice in most adults • BUT it is not that simple in PND • Some antidepressants  serious side effects and interaction • Consider this if mum is breastfeeding • Some antidepressants are not safe for infants

14. Medication for PND – what is safe? • Tricyclic antidepressants • Lower known risks than other antidepressants • But more dangerous in overdose • SSRIs (after 20 weeks)  greater risk hypertension in neonate • Fluoxetine fewer known risks of SSRIs • Paroxetine (in 1st trimester)  some risk foetal heart defects • Venlafaxine  some risk high blood pressure (at high doses) • Most antidepressants pass into the breast milk • Imipramine, nortryptiline and sertraline - at relatively low levels • Citalopram and fluoxetine - at relatively high levels

15. PND Treatment • Counselling and talking therapies (CBT etc.) very effective • Group or individual care • BUT rare - can take time to get into a programme • We need more Perinatal Mental Health teams! • Self-help strategies • Counselling (listening visits) • Brief cognitive behavioural therapy • Interpersonal psychotherapy

16. Organisation of care

17. Summary • PND often confused with baby blues • PND more serious and longer lasting • But less common • We need to understand risk factors • Extend beyond Whooley questions • Group task • Are Whooley questions enough? • What are the risk factors? • What signs should we watch out for? • Why are mums reluctant to tell us about mental health problems? • How far should we pursue this?