Postnatal Depression

1. Postnatal Depression Dr Barbara Bavdaž International Conference on Women’s Health October 8th/10th 2009 Nablus, Palestine

2. Childbearing • One of the most complex events in human experience • Physical changes of childbirth • Psychological changes of childbirth • Increased vulnerability to general psychiatric disorders

3. Postnatal Depression (PND) or PPD • World-wide. Affects about 13% of women within the first year of childbirth • Cultural changes (stigma !). Greater awareness • Information. Prevention. Can escape diagnosis • Antenatal and postnatal “screening” • Early intervention • Multidisciplinary approach • Mother-infant relationship and (can affect) child growth and cognitive and emotional development of the baby

4. Postnatal Depression in the Developing World • Attention tends to focus on seemingly more pressing health problems • Recent studies show 25-30 % new mothers (prevalence almost double) • Mental health pays a central role in maintaining physical health and development of the community • Lower status relative to men, lack of autonomy, birth of a girl, poor housing, isolation, poverty

5. Postnatal Depression in the Developing World • Environment more hostile • More infection, less sanitation • Lot of pressure, unable to do all those things • Baby does not get all the nutrients; diarrhoea, losing vital nutrients • Does not respond appropriately to child’s illness, not taking the baby to be vaccinated

6. Postnatal Depression in the Developing World • In Ethiopia 10% die in their first year of life: 50-60% because they are malnourished and don’t have the strength to fight the illness • Projects asking local clinicians to use local and not Western standards to define mental disorder • In Pakistan: ‘Lady Health Workers’ since 1994 • About 96,000 LHW cover more than 80% of Pakistan’s rural population • Support through empathic listening and positive reinforcement • ‘We are working for optimal health of the child’ • ‘A healthy mother leads to a healthy child’

7. Old Classification Under Three Headings: • Maternity blues (30-75% 3-4 days after birth) • Post-partum ( post-natal ) depression • Post-partum ( puerperal ) psychosis

8. New classification * Four-part classification: • Psychosis • Mother-infant relationship disorders • Depression • Anxiety and stress-related disorders * I. Brockington

9. PND • Depressed • Irritable • Tired • Sleepless • Lack of Appetite • Anhedonia • Sexuality • Unable to cope • Guilty • Anxious

10. Postnatal Depression * • Non-psychoticdepressionwithanonsetwithin 1 yearofchildbirth, But… • A layterm ? • Weakepidemiologicalassociation ( p/d ) • Common in adult women ( lowerrates! ) • Heterogeneousgroup • Causalassociationssameasfordepressiongenerally *IanBrokington, Univ. of Birmingham, UK

11. Detection, Prevention, Treatment Interventions • Reduce stigma, allowpublicrecognition • E.I. / Promptdiagnosis and (prophylactic ?) treatment • Antenatalclinics ( riskfactors, history ) • Midwifes, (community) nurses, generalpractitioners, healthvisitors • Voluntaryagencies, groups • Involvementoffathers, family members • Impact on infantwell-being and development !

12. Risk factors • Unwanted pregnancy (single w., adolescents, over forty) • Young age (interruption of schooling and of personal growth, future poverty) • Having three or more children • Single m. status or poor marital relationship • Lower socioeconomic status (maternal education protective factor) • Low self esteem • Substance abuse

13. Risk factors continue… • Ante-natal depression or anxiety • Previous episode of postnatal depression • History of depression or bipolar disorder • Family history of PPD • Gender of child (!) • Recent stressful life events • Inadequate social support (child care stress) • Obstetric and pregnancy complications

14. Prevention and detection • General screening: -Use questionnaires e.g. EPDS ( “the whole gamut of post-partum psychiatric disorders” ) ! -Explore wider context e.g. mother’s life history, personality circumstances ! -Follow course of the pregnancy including parturition, puerperium ! -Assess quality and strength of relationships ! -Identify vulnerability and availability of support !

15. Prediction and Detection • Healthcare professionals: midwives, obstetricians, health visitors, GPs, community nurses, voluntary agencies, (peer) groups, • Pregnancy does not protect against depression • High relapse rates in those who discontinue medication

16. Treatment • Should integrate both psychosocial and biological modalities • Psychological support: hospital and community nurses, health visitors, counsellors ( groups and individual sessions, anxiety management…) • Social support: social workers, motherhood classes, o.t. (support workers), self help groups • Involvement of fathers • Pharmacological treatment

17. Risks of Not Treating PPD • Harm to the mother through • Poor self-care • Lack of obstetric care • Self-harm • Harm to the foetus or neonate ranging from • Neglect to • infanticide

18. Mild or Moderate Depression During Pregnancy or During Postnatal Period • Self-help strategies • Non-directive counselling • Brief cognitive-behavioural therapy or interpersonal psychotherapy

19. Treatment with Ad’s. The Maudsley Recommendations • Those who are already receiving AD • Those who develop a moderate or severe depressive illness • Psychological management • Ad - tricyclics (amitript., imipr., nortript.) - SSRIs (avoid paroxetine/first trimester/linked to cardiac malformations!) - fluoxetine has the lowest known risk • Continue breast-feeding and switch to mixed (breast/bottle) feeding • All AD carry the risk of withdrawal or toxicity

20. Resources and Services • Aims= prevention, early diagnosis, versatile intervention with minimal family disruption (community based…) • The multidisciplinary specialist team: psychiatrists, psychologists, nurses and nursery nurses, social workers (Ts) • Voluntary agencies, self-help groups, leaflets and booklets (RCPsych, MIND in U.K.)

21. State of Art in the World • Domiciliary assessment and home treatment • Day hospital ( putting women with similar problems in touch with each other ) • Mother and baby units, linked to obstetric units and paediatric units in UK, Australia, New Zealand, France, Germany, Belgium, The Netherlands • Italy: Trieste • Service evaluation/research need to be implemented

22. Psychological Intervention in High Risk Pregnancy • IRCCS Burlo Garofolo- Department of Obstetrics and Gynaecology Dr Viviana Ive, psychologist, psychotherapist • Centre for High Risk Pregnancy: pre-eclampsia, multiple pregnancy, previous pregnancy with intrauterine death or previous interruption caused by severe delay in foetal growth, elective medical abortion • Multidisciplinary integrated team to support women before pregnancy and monitor during pregnancy, in order to reduce at most the risks (for health) of mother and baby. Centred on physical health, emotional and psychological health • Coordinated by one Psychologist/Psychotherapist

23. Psychological Intervention in High Risk Pregnancy 2 • Referrals: from medical staff or midwife, who offer the possibility of psych. intervention), sometimes requested directly by the women. • Assessments: on ward if urgent, alternatively opa’s • Crisis intervention (on ward): intra-uterine death or peri-natal death communication of dubious or poor prognosis (after echography) emotional distress during pregnancy (panic attacks, phobias, mood disorders) traumatised by parturition post-natal emotional distress (difficulties in relating with newborn baby) • Intensive psychological intervention during hospital admission. Some women need further care and follow up in OPC. • Network intervention: the hospital social service and the community based services

24. Psychological Intervention in High Risk Pregnancy 3 • OPACounselling and psychotherapy,focussed on bereavement (with disfunctional features), emotional disturbance in pregnancy (anxiety, mood disorders) or post- natal depression, difficulties in relationship with baby or marital problems, PTSD • Network intervention: hospital social service, community based services (CMHTs, PCTs, Social Services, GPs, Alcohol and Substance Misuse Services) • Aimsof intervention: to provide care, support, containment and elaboration of pain caused by any pathological condition, foetal death, emotional distress; to allow sufficient or good care to new born baby in any circumstances

25. ‘Synergic Effects of Oxytocin andPsychotherapy in  Postpartum Depression’ 1 • A 3 year randomized controlled trialon 150 women; area of intervention is the province of Trieste • Financed by the Department of Reproductional and Developmental Science -Dr. Andrea Clarici - MD - Senior Lecturer at the University of Trieste Faculty of Medicine(IRCCS Paediatric Hospital Burlo Garofolo, Trieste).-Dr. Sandra Pellizzoni - Psychologist - Postgraduate student at theIRCCS Paediatric Hospital Burlo Garofolo Trieste

26. ‘Synergic Effects of Oxytocin andPsychotherapy in  Postpartum Depression’ 2 • Hypothalamic neuropeptide implicated in regulation of social, reproductive and stress-related functions • A key role in intimate attachment such as marital relationship and early interaction with offspring • Twofold effect: to strengthen attachment and reduce stress • Referrals from paediatricians, obstetricians and midwifes • Two random groups: psychotherapy and Oxytocin vs. psychotherapy and placebo

27. Depression, post-partum, violence1 • Trieste, IRCCS-Burlo G. – Psychology Dept. University of Trieste and University of California in San Francisco • Study on 352 women, mean age 32, September 2004 to March 2005 • Part 1: two questionnaires • (Common) violence acted by partner or family member • Leads to depression, anxiety, low self esteem, has negative impact on physical and mental health (well being) of both, mother and child

28. Depression, post-partum, violence2 • 8 months after giving birth 10% of women experience domestic violence (psychological, sexual, physical) • 5% high levels of psychophysical distress with depression • Incidence of depression x13 higher in those who experience intrafamilial violence (27,6% vs. 2,7%)

29. PPD and employment3 • 8 months later 32% not satisfied with current occupational situation GHQ-12* • No difference between those at home and those at work • Significant the congruence between reality and desired situation • Employment dissatisfaction negatively associated with woman’s health after childbirth

30. *General Health Questionnaire (GHQ-12) • General Health Questionnaire (GHQ-12) • We would like to know how your health has been in general, over the past few weeks. • Please answer the following questions by circling the number that best applies to you. • Have you recently…. • …much less than usual-same as usual-more than usual-much more than usual… • Been able to concentrate on whatever you are doing? Lost much sleep over worry? Felt that you were playing a useful part in things? Felt capable of making decisions about things? Felt constantly under strain? Felt that you couldn't overcome your difficulties? Been able to enjoy your normal day-to-day activities? Been able to face up to your problems? Been feeling unhappy and depressed? Been losing self-confidence in yourself? Been thinking of yourself as a worthless person? Been feeling reasonably happy, all things considered?

31. NHS- Mother & Baby Unit (Thumbswood)1 • Hertfordshire, Welwyn G.C., QE II Hospital • Purpose-built, self-contained unit • Provide specialist assessmnet, care and treatment for mothers suffering from mental illnesses associated with childbirth (as early as possible) • Support to families and carers

32. NHS- Mother & Baby Unit (Thumbswood)2 • Provide a joint service between health and social care professionals • Ensure comprehensive follow-up care • Sensitive to cultural differences in parenting practices • Sustain and facilitate the developing relationship between mother and baby and other family members • MDT, liaison with Health Visitors, GPs, and Community Services

33. NHS- Mother & Baby Unit (Thumbswood)3 • Referrals from any area but exclusively from GP, consultant psychiatrist, maternity within QE II Hospital • Treatment: education, O.T., psychotherapy, postnatal groups, baby massage sessions, cooking, practical guidance, empowerment and ventilation of feelings, fathers’ group, weekly review; on-site support from midwives, obstetricians, gynaecologists, paediatricians

34. NHS- Mother & Baby Units • November 27th 2008 1st annual forum for the Quality Network for Perinatal Mental Health Services • 13 mother and baby units from across the country • Emergency admissions, admissions in late pregnancy, involvement of specialised community teams, safety and formal physical assessment of infants • Mind.org.uk; Perinatal.nhs.uk; Cemach.org.uk

35. Community Based ServiceASS1 Trieste and ‘Percorso Nascita’ since 1997-2002 • Based in Consultorio Familiare (Family Planning Clinics) in each Health District • Support in non problematic (physiologic) pregnancy • Antenatal classes, postnatal classes, advice through breastfeeding; vaccinations • Cervical screening; menopause clinics; breast cancer prevention-self examination • Direct access; privacy and confidentiality for under 18; teen pregnancy • (Illegal) immigrant women and the most vulnerable situations

36. Percorso Nascita • Midwife has a central and independent role (max. autonomy!), collaborating (when necessary) with gynaecologist • 3 groups monthly, each with 20 participants. Increasing number. • Assessments, referrals, home visits when needed, visits to mother and baby after discharge from hospital • Network with other community based services • High users’ satisfaction : continuity, accessibility; multidisciplinary, positive, constructive, optimistic approach, users’ centred, shaped on needs • Connected with other health and social services (e.g.DSM) • Baby blues, no PND recalled by the staff; is that prevention? Services network? Accessibility?

37. Primary Health Care - Now More than Ever (WHO) • 44 year discrepancy between industrialized and developing countries • 58 million on 136 mothers of new born babies without sanitary assistance • Public health costs p.p./ per year vary between 20 and more than 6 thousand U.S.dollars

38. Primary Health Care - Now More than Ever (WHO) • Infant mortality rate (IMR) under 5y. varies even within same city (Nairobi) from 1,5 to 25,4 per cent • Lack of drinkable water, vaccination, nutrition • Primary health care • Integrated community services • Holistic approach

39. Primary Health Care - Now More than Ever (WHO) • Prevention as important as cure • GPs at the core • Equity, accessibility, efficiency • Guidelines to develop health systems: -available to everyone -person centred -integrated approach -political leadership

40. Immigrants and PND • In Italy, 50% are women • Isolation, lack of social support, poor knowledge of language and culture, stress, housing problems, young age, victims of genital mutilation • Specific approach and service provision • ‘Dakar-Fann School’ meet under the village tree (patient, carers, friends, professionals...)

41. Illegal Immigrant Pregnant Women • The most vulnerable group of immigrants • Often mother of other children (one or more) • In Italy has the right to health care in pregnancy • STP (foreigner, temporarily in Italy) • Interpreter for small groups

42. Traditional Communities in Africa • During pregnancy and after birth care and support to mother • Whole village involved • Minimum rates of PPD • Urbanization brings consequences as reduced solidarity and isolation • Increased rates of PPD

43. ‘A Very Positive Impact’ • Successful athletes, politicians, writers, intellectuals after giving birth or breastfeeding • Cultural and social circumstances • Postpartum wellness, joy, positive feelings, physical energies • When pregnancy is a planned choice and based on a strong relationship

44. ‘A world that is unequal as regards health provisions, is unstable and unsafe.’ BAN KI-MOON WHO Secretary General Thank you

45. Thanks to dr Daniela Gerin, gynaecologist and coordinator of the project Salute Donna ASS1 Trieste • Claudia Massopust, senior midwife, District 4, ASS1 Trieste and her very kind colleague Chiara Menegolli • Special thanks to Ms Martina Kalc mother of Filip born on September 4th 2009 and who lost her first baby during pregnancy in 2007