When the bough breaks: Mental Illness in the

Pregnant and Postpartum Woman Dr.Mariam Alawadhi MD,FRCPC

Assistant professor-Department of Psychiatry,Kuwait University

Head of consultation liaison unit-KCMH

AgendaReview the epidemiology and clinical

presentation of perinatal mood and anxiety disorders in perinatal women.

Understand the psychiatric, obstetric and pediatric implications of a mother’s untreated illness.

Discuss a bio-psychosocial approach to the management of these disorders.

Depression is “the most common complication of childbearing.”

Wisner, 2002

1 in 5 mothers will experience a mental health disorder during their pregnancy or the year after they deliver.

Pregnancy and the transition to parenthood is considered to be one of life's major transitions.

Women are at an increased risk of developing mental health issues due to physiological and psychological risk factors.

Challenging the myths...

Media images of pregnancy and motherhoodPregnancy was planned, so why do I have the

“blues”?Work-life balanceRelationships (couple, extended family)

...and facing reality

Tired, home alone, lots of care for baby, no time for self, complete loss of control over time

Wide range of positive and negative emotions

Adjustment and adaptation to pregnancy and motherhood is dynamic

pregnancy alters a woman’s life irreversibly

Women need accurate information (e.g, pregnancy, labour, delivery) = power, control

Shame & stigma

Perinatal mental healthPregnancy related Antepartum Depression Antepartum anxiety

Postpartum related Baby Blues Postpartum Depression Postpartum Psychosis postpartum anxiety

Let’s define the terms first...Antepartum depression

Antepartum depression

Associated with: Poor prenatal care (e.g., nutrition; substance use) Changes in cortisol & HPA axis development Poor perinatal outcomes (e.g, abnormal fetal

neurobehavioral; pre-term labour (Steele et al., 1992)

Depression vs. pregnancy? affect cognition functional impairment

Antenatal Depression Risk factors:

low self-esteem

low social support, low income

antenatal anxiety, hx of depression, hx of abuse

negative cognitive style

hx of miscarriage/pregnancy termination

pregnancy complications

Confounds in diagnosing depression during pregnancy

Overlapping symptoms: Sleep disturbances Increased/decreased appetite Decreased energy Changes in concentration

Illnesses with similar symptoms: Anemia Thyroid dysfunction Gestational diabetes mellitus

Perinatal Anxiety

Generalized Anxiety Disorder = 4-8% Panic Attacks = 1-3% Obsessive Compulsive Disorder = 0.2-1.2% Posttraumatic stress Disorder = 6%; 40% in loss

Perinatal anxiety disorders

Effects of maternal stress & anxiety during pregnancy

– Altered fetal movement

– Lower gestational age

– Lower infant birth weight

– Lower APGAR scores

– Enduring changes in cortisol measures in offspring

Ross,2006

Postpartum blues

• Baby blues– Very common (50-80%)– Starts w/in 1 wk pp: peaks3-5 days post-delivery– Unrelated to environmental stressors– Unrelated to psychiatric history– Present in all cultures

Low-level symptoms:• Tearfulness• Irritability, reactivity• Insomnia• Anxiety• Poor appetite

Posited relationship between “Blues” and PPD

• During pregnancy:– Increase oestrogen, progesterone (placental production of

hormones); beta-endorphin & cortisol (cortisol peaks in late pregnancy - CRH), prolactin

– Oestrogen enhances neurotransmitter serotonin (increases synthesis & reduced breakdown)

• After delivery:– Drop in oestrogen/progesterone (removal of placenta at

delivery); drop in cortisol & b/e– Decrease estrogen decrease serotonin – Prolactin levels return to normal in non-lactating women w/in

weeks – Breastfeeding: prolactin levels remain high (induces release of

oxytocin)

Postpartum depression

Postpartum depression

Peaks at 3-6 mo pp Average PPD course is 7 mo

Related to psychiatric history and environmental stressors

DSM IV onset from within 4 wks. of delivery, “pp onset”Clinically, up to 1 y postpartum (DSM V to reflect this)

Postpartum depression

Added clinical features:

Obsessive traits (e.g., name of baby, harming baby)

Depressed, despondent, emotionally numb

Ambivalence toward baby (bonding)

Grief for loss of self

Feelings of inadequacy, guilt*

Feeling isolated/misunderstood

Suicidal ideation/Ego-dystonic thoughts of harming baby

Risk factors

(Kendler, 1993; Wisner, 2002)

Biological Psychological

Social Obstetric

•Family history of depression or affective disorders•Previous PPD or depression•Thyroid dysfunction•Hormones•Altered immune function•Sleep disturbances

•Low self-esteem•age•Perfectionist, neuroticism, high/unrealistic expectations of self/baby•Feelings of inadequacy•Role conflict•Attitude toward pregnancy (ambivalence, unwanted)•Trauma/abuse•Unresolved grief (death of child)

•Lack/poor social support•Relationship problems (couple, extended family)•Difficult baby (feeding, colic)•Separation from baby•Stressful live events (move, job change, illness)•Economic stress•Recent loss•Childcare stress (# of children at home)

•IVF (fertility drugs)•Difficult delivery•Medical complications of pregnancy•Health problems of infant•Lack of readiness for hospital discharge

Postpartum psychosis

Heterogeneous group of disorders

BAD (35% with bipolar diathesis)

MDD w/ psychotic features

SZ-spectrum disorders

Medical conditions (e.g., thyroid, low B12)

Drugs (e.g., amphetamines)

Bizarre symptoms: • Delusions (e.g., baby

possessed)• Hallucinations (e.g.,

seeing s/o else’s face)• Mood swings (more

than non/pp psychosis)

• Confusion & disorientation

• Erratic behaviour• insomnia• Waxing & waning

Risk for suicide and infanticide

Psychiatric emergency

Postpartum psychosis

Rare (1-2/1000 women) Most commonly 2-4 wks/pp

Risk Factors

Family hx of BAD Early onset depression History of PPD

Agenda

2.Understand the psychiatric, obstetric and pediatric implications of a mother’s untreated illness.

Economic & health care burden

• Yearly estimated costs of depression $14.4 – 44 billion dollars annually (Greenberg, 1993; Stephens, 2001)

• The rate of depression among Ontarians is about 4.8% (Statistics Canada, 2003), with women more than twice as likely as men to be depressed (Statistics Canada, 1996-97).

• 50% of OB/GYN patients have a significant emotional disturbance (Ballinger, 1977; Bryne, 1984; Worsley, 1977)

• Women with PPD access more community services, make more frequent non-routine visits to the pediatrician; costs are higher for women with an extended duration of illness(Petrou, 2002; Chee, 2008)

• Peak prevalence of ♀ psychiatric contact (in & outpatient) occurs in the first 3 months after childbirth(Kendall, 1987; Munk-Olsen, 2008)

Maternal Risks from A/PPD Coronary artery disease Cancer Hypertension Overactive bladder urinary incontinence Poorer maternal health practices Complications after childbirth

Fetal Risks from A/PPD Poorer maternal health practices Elevated cortisol levels Preterm delivery Small for gestational age Low birth weight

Schmeelk 1999, Lundy 1999, Hoffman 2000, Adewuya 2007, Hedgaard 1993

Adverse parenting outcomes

Depressed mothers: Perceive their infants as more bothersome and

make harsher judgments of them Are more irritable and spend less time looking,

touching, and talking to their infants Are more likely to neglect/abuse their children

Whiffen 1989, Cohn 1990, Chaffin 1996

Adverse parenting outcomes

These effects are moderated by: Timing of depressive episode Age of children SES of family

Lovejoy, 2000

Attachment Definition :

A strong emotional and social bond between infants and their caregivers

JOHN BOWLBY (1907-1990)

British Child Psychiatrist & Psychoanalyst. He was the first attachment theorist describing attachment as a "lasting

psychological connectedness between human beings".

Bowlby believed that the earliest bonds formed by children with their caregivers have a tremendous impact that continues throughout life.

John Bowlby (1969)

Argued babies are born equipped with behaviors (crying, cooing, babbling, smiling, clinging, sucking, following) that help ensure that adults will love them, stay with them and meet their needs.

Bowlby (cont’d)

Believed quality of early attachment influences future relationships (friends, romantic partners, own children).

HARLOW & ZIMMERMAN A famous experiment was conducted by Harlow and

Zimmerman in 1959, Which showed that developing a close bond does not depend on hunger satisfaction.

They conducted the experiment where rhesus monkey babies were separated from their natural mothers and reared by surrogates- terry cloth covered and other was wire mesh.

Babies cling to terry cloth mothers even though wire mesh had bottle.

This shows 'contact comfort' is more important

Attachment 'FEEDING IS NOT THE BASIS FOR

ATTACHMENT' The central theme of attachment theory is that

mothers who are available and responsive to their infant's needs establish a sense of security in their children.

The infant knows that the caregiver is dependable, which creates a secure base for the child to then explore the world.

Attachment When does it form? Usually within the first six months of the

infant’s life Shows up in second six months through

wariness of strangers, fear of separation from caregiver, etc.

Attachment Babies are born equipped with behavior like

crying, cooing, babbling and smiling to ensure adult attention & adults are biologically programmed to respond to infant signals.

Bowlby viewed the First 3 years are very sensitive period for attachment

Four Stages of Attachment

Pre-attachment Attachment-in-the- making Clear-cut attachment Formation Of Reciprocal Relationship

PREATTACHMENT PHASEBirth-6weeks

Baby’s innate signals attract caregiver (Grasping, crying, smiling and gazing into the adult’s eyes) Caregivers remain close by when the baby responds positively

The infants encourage the adults to remain close as the the closeness comforts them

Babies recognize the mother’s smell, voice and face. They are not yet attached to the mother, they don’t

mind being left with unfamiliar adults. They have No fear of strangers

ATTACHMENT IN MAKING 6 Weeks – 6 to 8 Months Infant responds differently to familiar caregiver than to strangers. The baby would babble and smile more to the mother and quiets

more quickly when the mother picks him. The infant learns that her actions affect the behavior of those

around begin to develop “Sense of Trust” where they expect that the

caregiver will respond when signaled The infant still does not protest when separated from the caregiver

“CLEAR CUT” ATTACHMENT PHASE

6-8 Months to 18 Months -2 Years

The attachment to familiar caregiver becomes evidentBabies display “Separation Anxiety”, where they become

upset when an adult whom they have come to rely leaves

Although Separation anxiety increases between 6 -15 months of age its occurrence depends on infant temperament, context and adult behavior

FORMATION OF RECIPROCAL RELATIONSHIP

18 Months / 2 Years and on

With rapid growth in representation and language by 2 years the toddler is able to understand some of the factors that influence parent’s coming and going and to predict their return.

separation protests decline. The child could negotiate with the caregiver,

using requests and persuasion to alter her goals

Attachment Just the mother? No Attachment to the mother is usually the

primary attachment, but can attach to fathers and other caretakers as well.

Mary AinsworthAinsworth came up with a special experimental

design to measure the attachment of an infant to the caretaker

The Strange Situation Test – procedure in which a caregiver leaves a child alone with a stranger for several minutes and then returns.

STRANGE SITUATION 1. Observer shows caregiver and infant into the experimental room and

then leaves. ( 30 Seconds)

2. Caregiver sits and watches child play. (3 mins)

3. Stranger enters, silent at first, then talks to caregiver, then interacts with infant. Caregiver leaves the room. (3 mins)

4. First separation. Stranger tries to interact with infant. (3 mins)

5. First reunion. Caregiver comforts child, stranger leaves. Caregiver then leaves. (3 mins)

6. Second separation. Child alone. (3 mins)

7. Stranger enters and tries to interact with child

8. Second reunion. Caregiver comforts child, stranger leaves. •

All episodes except 1 last for 3 mins unless the child becomes very upset

STRANGE SITUATION Videohttp://youtu.be/PnFKaaOSPmk

Four Key Observations Exploration : to what extent does the child

explore their environment Reaction to departure : what is the child’s

response when the caregiver leaves The stranger anxiety : how does the child

respond to the stranger alone Reunion : how does the child respond to the

caregiver upon returning

STRANGE SITUATION Findings Infants differ in quality or style of their

attachment to their caregivers. Most show one of four distinct patterns of

attachment:1. Secure attachment

2. Insecure/Avoidant attachment

3. Insecure/ambivalent attachment

4. Disorganized/Disorientated attachment

Secure Attachment

Most infants (65-70% of 1 yr olds) Freely explore new environments, touching base

with caregiver periodically for security. May or may not cry when separated, when

returned, crying ceases quickly.

Avoidant Attachment

15% Don’t cry when separated React to stranger similar to their caregiver When returned, avoids her or slow to greet her.

Ambivalent Attachment

10% Seeks contact with their caregiver before

separation After she leaves and returns, they first seek her,

then resist or reject offers of comfort

Disorganized Attachment

5-10% Elements of both avoidant and ambivalent

(confused)

Agenda

3. Discuss a biopsychosocial approach to the management of these disorders.

Detecting perinatal depression: why screen?

High prevalence rateRisks of untreated symptomsAvailability of effective treatmentAvailability of validated screening tools

Edinburgh Postnatal Depression Scale (EPDS)10-item self-reportAdv: easy to score, designed for peripartum use,

validated ante- and pp, cross-culturally validatedDisadv: not linked to DSM-IV-TR criteria, validation

studies do not provide definitive answer about optimal cut-off scores

Guidelines: score 9-12 pp risk, 12> high risk (cut-off scores above 12 not sensitive in some studies)

(Cox & Holden, 2003)

Detecting Perinatal DepressionWhy Screen??

PKU A/PPDPrevalence 1 in 12 000

babies1 in 5 mothers

Outcome Mod-severe MR Serious and lasting effects on mother/child health and

family functioning

Predictive Screen

Cost to Screen $50/baby freeEffective Rx Cost-effective Rx

Gestational diabetes: 3-10% pregnanciesGestational hypertension: 2-3% pregnancies

Educate about self-care

NESTS Proper Nutrition Exercise Rest (Sleep protocol) Time for yourself Circles of Support

Educate about self-careSleepSLEEP PROTOCOL: 5h of uninterrupted sleep per nightBreaks from babyEnjoyable activitiesDecrease isolation

Spend time with friends, family, other mothersProtect yourself and your energy

Limit visitors, lighten chores

TreatmentScreening and invesigations

Check for other diseasesThyroid diseaseAnemiaDiabetesVitamin deficiencies

Treatment Therapy

Cognitive Behavioral Therapy Interpersonal Psychotherapy Couple therapy Group therapy

Medications

Risks of medication

1) to mother 2) to fetus 3) to newborn

Risks of disease

1) to mother2) to fetus3) to child 4) to family

Suicide and homicide

l

Principles of perinatal psychopharmacology

-Is there an increase risk of spontaneous

abortion/miscarriage?

-Is there an increase in the risk of congenital

Malformation?

-Is there an increase in the risk of adverse

outcomes for the neonate?

-Is there an increase in the risk of adverse outcomes from breastfeeding?

Effects of pregnancy on pharmacokinetics

Delayed gastric emptying Decreased gastrointestinal motility Increased volume of distribution Decreased protein binding capacity Increased hepatic metabolism

SSRIsAbsolute risk of exposure in pregnancy is small. • Paxil Health Advisory• Poor Neonatal Adaptation Syndrome • Persistent Pulmonary Hypertension • Current U.S. LawsuitsLouik 2007, Einarson 2008, Alwan 2008, Greene 2007, Hallberg 2005, Wogelius 2006, Oberlander, Levinson-Castiel 2006, Chambers 2006, 2009, Kallen 2008, Andrade 2009

Mood stabilizers High risk for relapse into bipolar depression with discontinuation Lithium may be the safest alternative Valproic acid: teratogenicity neurobehavioral toxicity

• CBZ and LTG lower risk than VPA Folic acid supplementation Li non-responders: consider LTG +/- antipsychotic vs. atypical

across pregnancy

Wyszynski 2005, Morrow 2006, Cunnington 2007, Meador 2006, Holmes 2004, Cohen 2007

Breastfeeding“It is when the socioeconomic situation is the worst

that breastfeeding has the greatest benefit.” Dr. Jack Newman

Nutritional advantages Infection, allergy, Ca, diabetes protection Bonding, developmental benefits Postpartum recovery, Ca (breast, ovarian),

osteoporosis Free and easy!

Mother’s biasWomen receiving chronic therapy tend to initiate

breastfeeding much less often If they do initiate, they discontinue it much earlier • Continuation of breastfeeding correlates with cumulative amount of reassuring counseling advice women receive from health professionals

Moretti et al, 1995, 1998 From Koren 2007

BreastfeedingGenerally, excretion rates < 10% into breast

milk are considered safe by the American Academy of Pediatrics.

[milk]/[plasma]:Molecular size, protein-binding,

acidity,lipophilicity • Nursing infant: absorption from GI tract ability to detoxify, ability to excrete .

Nothing trumps maternal euthymia

Thank you!