Post Natal Depression

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Post Natal Depression

• By
• Anju Narayanan

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Scale of the Problem

• 10-15 of new mothers 400-600 women in Tayside
• Approx 4500 women in Scotland annually
• 3-5 require Psych referral
• 0.4 require inpatient care
• 3 X common in teenage parents(HallElliman,2003)
• CEMDcauses of perinatal maternal deaths in
  2000-2002 and 2004found psychiatric illness as
  the leading cause

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Why Mothers Die ?
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CEMD Recommendations

• Local guidelines for mg of females at risk of
  perinatal mental illness in trusts providing
  maternity services
• Mother and baby units
• Routine screening for PHx at antenatal booking
• Communication of relevent psych history to
  secondary level at booking

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• Specialist assessment of females with serious
  psych history and agreed mg plans between all
  members involved in care
• Counselling and management plan for those at risk
• Knowledge of laws and issues relating to child
  protection
• Local training for screening

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Clinical Features

• Onset at 6-8w
• Varying severity
• Typically symptoms of depression at other times
  guilt inability to function
• Untreated,30 remain at one year
• Significant effects on development of child if
  untreated(Brockington, 2004)

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• Postnatal Blues
• Affects atleast 50 women
• Anxiety, lack of confidence,tearfulness
• Self limiting
• Puerperal Psychosis
• Onset in first 2 w
• More severe and rare illness
• Dramatic presentation95 affective,
  psychotic symptoms
• Good prognosis
• Upto 50 risk of recurrence

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Predictors of PND

• Past psychiatric history
• Psychological problems during pregnancy
• Poor marital relationships
• Lack of social support
• Stressful life events
• Psychosocial riskslow social status, previous
  miscarriage or termination,ambivalence about the
  baby, lack of female confidante,difficult
  pregnancy/delivery

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Detection

• Antenatally
• Screening questions
• Over the past 2w have you felt
  down,depressed or hopeless?
• Over the past 2w have you felt little
  interest/pleasure in doing
• things?
• can detect upto 95 of those experiencing
  depression(Peveler et al,2002)
• Discuss PND, assess risk, assess for substance
  misuse, domestic abuse, if ve involvement of
  relevent professional/agency/ICP

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• Postnatally
• Edinburgh Postnatal Depression Scale
• Most commonly used checklist in postnatal
  period
• Recommended in English speaking women
• Not a dignostic tool(clinical judgement
  SIGN, 2002)
• Validated for use at 6-8w and 6-9 months(Cox
  et al,1987)
• But suggested use at 12w postpartum as its
  the most prevalent time(SIGN 60,2002 CEMD,
  2004)

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EPDS
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Interpretation of EPDS

• Scores gt10-possible depression(SIGN 60)
• Reassess in 2w
• If clinical concern, involve relevent
  professional
• Positive score on item10 , assess/exlpore
  by primary care team/CMHS and or Child Protection
• Score of zero by no means excludes PND(Downie
  et al,2003)

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Management

• Good response to pharmacological and psychosocial
  interventions(SIGN,2002 Whitton et al,1996)
• Counselling Listening visits by
  HV,psychological therapy
• Evidence shows benefits from weekly
  nondirective counselling by trained professionals
  compared to routine care(Alder Truman,2002,Appleb
  y et al,1997,Whitton et al,1996)
• Family Focussed Interventions
  motherpartner/motherbaby(SIGN 60,2002)

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• CBT in mild to moderate depression found to be
  as effective as antidepressants
• Group Therapy treatments effective in emotional
  disorders
• Infant Massagesimproves relationship between
  mother and infant and maternal mood.
• Physical Exercise not much evidence in
  PND,positive effect on depression in general
  population.

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Pharmacological Intervention

• General Principles
• Use drugs with a better evidence base
• Treat with lowest effective dose
• Single dose regime for breastfeeding mothers
• Antidepressants not recommended for mild
  depression(NICE Guideline 23)
• Use previously effective drug for women with
  PHx
• of PND
• Women at risk of BAD/Puerperal psychosis
  should
• receive specialist review and consider
  continuing
• therapy

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• SSRIs
• In PregnancySSRIs except fluoxetine should
  not be used under 18yrs(CSM Feb 2005) and should
  be tapered slowly prior to delivery
• Sertraline preferable in women with no
  previous antidepressant tx history
• Babies born to mothers taking SSRIs should be
  monitored for withdrawal symptoms-breastfeeding
  encouraged.

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• Venlafaxine
• Should not be given to women under 18yrs of
  age
• Should be initiated by a psychiatrist(CSM
  2004)
• Infants should be monitored for withdrawal
  symptoms
• Avoid in breastfeeding.
• TCAs
• Avoid clomipramine in pregnancy
• Observe newborn for withdrawal effects
• No clinical indication to stop breastfeeding
  if a TCA is required

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• Mood Stabilisers
• Women on antiepileptics should be pxd Folic
  acid 5mgs daily during first trimester
• In women maintained on Lithium, continue ,
  monitor serum levels,offer detailed USScan
• Valproate carbamazepine avoid if possible
  in first trimester
• Infants of mums on valproate/carbamazepine
  should be observed for signs of toxicity.
• Alternatives St Johns Wort-no evidence
  available in pregnancy lactation.
• If already on ,no evidence to stop breastfeeding.
  

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Integrated Care Pathway

• Based on the recommendations of CEMD, SIGN 60 and
  other evidence
• Multidisciplinary approach to effective detection
  and management of perinatal mental illness
• NHS Tayside ICP

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Summary

• 10-15 new mothers experience PND
• Suicide is the leading cause of maternal death in
  the UK(CEMD,2004)
• Untreated,PND can impact on the cognitive,
  emotional, social behavioural development of
  the baby
• Good prognosis if treated and evidence shows best
  managed in an integrated way(SIGN 60,2002)

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• Thank you
• Any ?