Perinatal Mental Health

1. Perinatal Mental Health Dr Cressida Manning Consultant Perinatal Psychiatrist Florence House Mother and Baby Unit

2. Contents of Presentation • Confidential Enquiry into maternal deaths. • Risks of untreated illness. • Risk factors for postnatal depression and psychosis. • Discussions around treatment. • Medication.

3. Recent Case Study Felicia Boots. 35 Mother of 2 ( 14 months and 10 weeks). Manslaughter on grounds of diminished responsibility. Stopped medication as breastfeeding.

4. Confidential Enquiry Centre for Maternal and Child Enquiries (CMACE) Most recent report ‘Saving Mothers Lives’ (2011) 2006-2008 29 suicides 1st 6 months 19 past psychiatric history 9 identified of which 4 had care plan

5. Saving Mothers Lives 38% Psychosis 21% Severe Depressive Illness

6. Recommendations - Back to Basics 1Saving Mothers Lives • Anxiety or depression • Review in 2 weeks • Consider psych referral if symptoms persist • Refer urgently where: Suicidal ideation, uncharacteristic symptoms/marked change from normal functioning, morbid fears, profound low mood, personal or family history of serious affective disorder, mental health deterioration, morbid fears, panic attacks and intrusive obsessional thoughts.

7. Effects of Untreated Illness Increased morbidity. Increased risks towards self and others. Links between maternal anxiety and fetal behaviour and heart rate Stress/anxiety during pregnancy can have long term effects on child

8. Associated with an increased incidence of: • Emotional problems - Anxiety/depression • Behavioural problems – ADHD, conduct disorder • Impaired cognitive development, esp language • Sleep problems in infants Sensitive early mothering important as what happens in utero for child outcome

9. Effects of antenatal and postnatal depression • Children of mothers depressed in perinatal period compared to children of well mothers: • Lower IQ scores • 12x more likely to have a statement of special needs • elevated risk of violence at 11 and 16 years • More likely to suffer separation anxiety at 11 and a diagnosis of depression at 16

10. Suicide • Majority of deaths secondary to postpartum psychosis or very severe depressive illness • Oates (2008) Suicide rate for ppp 2/1000 • Common profile; white, older, 2nd or subsequent pregnancy, married, comfortable circumstances • Likely to die violently

11. Infanticide • Similar profile • 1/3rd mental illness • Death extended suicide or occasionally altruistic based on delusional belief • Highest concern if delusion involves child e.g baby changed, not hers, possessed, evil.

12. Postpartum Psychosis 1st few weeks highest risk • Heron et al (2007) Greater than 80% 1st week • Link with BPAD

13. Bipolar Disorder • 52% relapse in 1st 40 weeks after stopping treatment • If pregnant and stable on antipsychotic and likely to relapse without medication continue • Up to 70% relapse if untreated in postnatal period • 50% psychotic symptoms day 1 - 3

14. Postpartum Psychosis – Risk Factors • 1st Baby • Single • C- Section • Older • Fertility Problems • Previous episode – 1 in 7 • Sleep Loss

15. Warning Signs • Early signs often non specific • Insomnia, agitation/anxious, perplexed and odd behaviour. Risk overlooked Can lead to rapid deterioration to Psychotic symptoms

16. Postnatal Depression • 10 -15% • Severe 3% • 1/3 to ½ continuation of antenatal anxiety and depression • Onset few days to 6 months • Increased risk in subsequent pregnancies – approx 25 – 50%

17. Postnatal Depression – Risk Factors • Antenatal anxiety or depression • Past history of psychiatric illness • Life events • Lack of or perceived lack of support • Low income • Domestic violence • FH of psychiatric illness • Childhood abuse

18. Risk Factors cont… • Obstetric factors • Sleep deprivation • Infant factors –irritability • Personality factors – control, interpersonal sensitivity, ‘neuroticism’ • Biological factors – inconsistent results

19. Early Detection • 1st contact; • Past or present mental illness • Previous psychiatric input, including admissions • Family history of severe mental illness

20. Treatment of pregnant and breast feeding women- NICE guidelines Importance of balancing risks and benefits Cautious Women requiring psychological treatment should be seen for treatment within 1 month of assessment and no longer than 3 months.

21. NICE • Discussion should include: • Risk of relapse and not treating disorder • Woman’s ability to cope with untreated symptoms • Severity of previous episodes and response to treatment • Woman’s preference • Possibility that stopping drug with teratogenic risk once pregnancy confirmed may not remove risk

22. NICE • Risks of stopping medication abruptly • Need for prompt treatment due to impact of illness on foetus/child • Increased risk of harm of specific drug treatments • Treatment option that would allow mother to breastfeed

23. NICE • Prescribing: • Drugs with lowest risk profile • Lowest effective dose • Monotherapy • Risks lower threshold for psychological treatment Important to put risks from drug treatment in context of the individual woman’s illness

24. Antidepressants SSRIs Paroxetine in 1st trimester increase in cardiac malformations (VSD) – planning pregnancy or unplanned advise to stop. Other SSRIs now implicated. SSRI’s taken after 20 weeks may be associated with an increased risk of persistent pulmonary hypertension of the new born Neonatal withdrawal- normally mild and self limiting

25. Symptoms include; • Irritability • Hypertonia • Jitteriness • Difficulties feeding • Tremor • Agitation • Seizures • Tachypnoea • Posturing

26. Tricyclics Tricyclics have lower known risks during pregnancy than other antidepressants Have higher fatal toxicity index CHD with clomipramine Withdrawal symptoms No effects on long term neurodevelopmental outcomes Imipramine

27. Other antidepressants Venlafaxine – Conflicting results for congenital malformations – data too limited to say safe. Possible increased neonatal withdrawal and increased risk of high blood pressure at higher doses. Theoretical risk of PPHN Mirtazapine – Possible association with increased rate of spontaneous abortion. No evidence to link to congenital malformations but data too limited to say safe. JAMA 13 – Metaanalysis – preterm birth 3 days - Apgar <0.5 - Weight 75g - Spontaneous abortion not significant.

28. Benzodiazepines • Raised risk of oral cleft (7 in 1000; x10) • Withdrawal syndrome – jitteriness, autonomic dysregulation, seizure, floppy baby syndrome • Consider gradually stopping in women who are pregnant • Short term use only for severe agitation and anxiety

29. Lithium – Ebsteinsanomoly (1 in 1000) General population 1 in 20000 Overall risk CHD 0.9-12% vs 0.5-1% general population. Floppy baby syndrome, thyroid dysfunction, nephrogenic diabetes insipidus. High quantities in breast milk.

30. Valproate • NTD 100 to 200 in 10000 • IUGR • Facial dysmorphias • Low IQ Do not routinely prescribe to women of child bearing age. If no option adequate contraception Discontinue if pregnant

31. Carbamazepinne • Increased risk congenital malformations -6.7% v 2.3% • Craniofacial, GIT, cardiac, urinary tract and digit anomalies • Advice as valproate • Lamotrigine • Cleft palate 8.9/1000

32. Atypical Antipsychotics • Olanzapine and Quetiapine • Limited data to base assessment of safety in pregnancy, but available data does not suggest a substantially increased risk of congenital malformations or spontaneous abortions • No pattern of malformations observed. • Withdrawal symptoms • Olanzapine – increased birth weight

33. What Clinicians need to do Do not assume it is always better to stop medication Provide prompt and Effective treatment of mental illness in pregnancy and postnatal period Understand, consider and communicate known risks (and how these will be managed) of medication Complete risk benefit analysis for individual patient.