17.1 Antenatal Psychiatric Disorders
EXPLANATION OF CONDITION
Childbirth is a significant life event resulting in profound and permanent changes in a woman’s role and responsibilities. It is a time when a woman is at greatest risk for developing a psychiatric disorder. This risk is further increased if she has previously suffered from a serious mental illness. Mental illness is one of the leading causes of maternal deaths1.
Pregnancy is not protective against mental illness2. In fact, mental health problems during pregnancy are at least as common as they are after childbirth and are increasingly recognised as important forerunners of postnatal illness3,4. Socio-cultural expectations often make it difficult for women to seek help for perinatal mental health problems.
Some degree of emotional lability and anxiety during pregnancy is normal. Sleep problems are also common. However, it is important to be able to differentiate these from the signs of mental illness. Early detection and treatment of mental illness is crucial5,6.
Any psychiatric disorder may present in pregnancy. The clinical issues to note are:
- New psychiatric disorders as well as relapses and recurrences of previous disorders may occur both during pregnancy and after chilbirth7
- Most first-onset conditions are mild depressive and anxiety disorders and the cause is commonly psychosocial6
- Relapses of the following disorders may occur: depressive and anxiety disorders, obsessive compulsive disorder, schizophrenia, bipolar disorder and substance misuse
- It is important to enquire for a previous history of serious mental illness at the booking visit, to be able to predict and possibly prevent a relapse
- Identifying women with a past or family history of bipolar disorder or puerperal psychosis is particularly important because of the high risk of postpartum relapse (one in two).
- Psychiatric medication should not automatically be discontinued once the woman becomes pregnant7. This is a frequent cause of relapse.
- Mild to moderate disorders may be managed in primary care. Past or current severe illness should be referred to specialist psychiatric services, preferably to a perinatal psychiatric service7,8
- Good communication between all health professionals both in primary and secondary services is crucial1
COMPLICATIONS
Antenatal psychiatric disorders may be associated with9–12:
- Poor attendance in antenatal clinic
- Smoking and substance misuse
- Poor general health and nutrition
- Deliberate self-harm and suicide
- Low birth weight and pre-term deliveries
- Problems with mother–infant attachment
- Neglect or harm to infant and other children; safeguarding issues
- Possible long-term developmental and behavioural problems in the child
- Mental health problems in the woman’s partner
NON-PREGNANCY TREATMENT AND CARE
Mild to moderate mental illness may be managed in primary care. Severe mental illness is managed by psychiatric services either in the community or in hospital.
Management of mental illness may include:
- Advice on lifestyle, exercise and coping with stress
- Psycho-education
- Talking therapies (psychotherapy)
- Psychotropic medication (e.g. antidepressants and antipsychotics)
- Rarely, electroconvulsive therapy (ECT)
PRE-CONCEPTION ISSUES AND CARE
Women with previous mental illness should receive advice about the following issues in a manner that is socially and culturally sensitive:
- Contraception
- Risk of recurrence of mental illness in perinatal period
- Risks and benefits of medication in pregnancy
- Some psychiatric medications reduce fertility and should be changed if pregnancy is planned
- Avoid certain drugs (especially sodium valproate) due to high rates of birth defects
- Fetal growth retardation
- Low birth weight
- Prematurity
- Long-term developmental and behavioural problems in the child
- Smoking
- Alcohol and substance misuse
- Poor dietary habits
- Lack of exercise
- Self-harming behaviour
- Lack of engagement with services
- Mild to moderate depressive and anxiety symptoms are the most frequent psychiatric problems in pregnancy and may be managed in primary care
- Psychological therapies such as cognitive behaviour therapy, interpersonal therapy or self-help strategies may be indicated
- Advice may be sought from specialist psychiatric services if needed, regarding continuing or commencing medication
- All women with serious mental illness (past or current) should be referred to specialist services, preferably to a specialist perinatal psychiatry team7
- The risk–benefit ratio of psychotropic medication is assessed and decisions regarding medication during pregnancy are made after discussion with the woman
- For treatment guidance see Appendix 17.1
- At the booking visit, the midwife will screen for past or present serious mental illness in the woman and her family. If positive, refer to perinatal psychiatric services
- Establish a trusting relationship with the woman that is socially and culturally sensitive
- Advice regarding smoking cessation, diet and exercise, breast-feeding, birth preparation and support services
- There are no physical reasons why the birth should be managed differently
- Anxiety management techniques may be useful in anxious women
- Neonatologists should be contacted if the woman is currently receiving psychotropic medication
- Labour should be managed from a normal perspective
- Discuss methods of support for labour pain to reduce anxiety
- Support throughout labour is important
- Consent should be obtained throughout labour
- Advice regarding continuation or discontinuing psychotropic medication prior to labour should be entered in the pre-birth care plan
- Drugs should be used judiciously in view of possible effects on the baby
- Increased anxiety and agitation
- Low mood, excessive tearfulness or apathy
- Poor handling or attachment to baby
- Bizarre or unusual behaviour
- Delusions and hallucinations
- Thoughts or acts of harming herself or baby
- Specialist perinatal psychiatry team should be contacted if symptoms are severe
- Appropriate treatment takes precedence over breast-feeding. Many psychotropic drugs are safe in breast-feeding and need not be discontinued
- Transfer to a specialist psychiatric mother and baby unit may be indicated if the woman’s mental state deteriorates
- Observe mother and baby interaction
- Discuss rest, diet and self-care, assess how mother is coping
- Reassure if mood change is due to postnatal blues
- Observe baby if breast-feeding mother is on medication
- Assess risk to baby
- If symptoms indicate serious mental illness, liaise and refer to specialist perinatal psychiatric service
17.2 Postnatal Psychiatric Disorders
EXPLANATION OF CONDITION
Psychiatric disorders following childbirth are common, and include both new episodes specific to the postpartum period, as well as recurrences of previous illnesses1. Depression and puerperal psychosis will be described here.
Depression
The term ‘postnatal depression’ is often used inappropriately to describe all postnatal psychiatric disorders, and is best avoided2. The relative risk of depression in the postnatal period is five. The symptoms do not differ from depression outside of childbirth3–5. Severe depression occurs in 3–5% of postpartum women and commonly presents within 1–3 months postpartum. Normal emotional changes following childbirth may mask or be mistaken for depressive symptoms.
‘Postnatal blues’ are experienced by 50–80% of women. Symptoms are transient and occur between 3 and 7 days after delivery6,7, including irritability, tearfulness, low mood, euphoria and sleep disturbance. Symptoms resolve spontaneously and the woman and her family need reassurance and support.
General Symptoms
In the postnatal period depression may range from mild to severe. Prediction and early detection are important. The key features of depressions are:
- Low mood, loss of interest and enjoyment, and reduced energy
- Associated symptoms such as: reduced concentration and self-esteem, ideas of guilt, hopelessness, thoughts or acts of self-harm or suicide and sleep and appetite disturbance
At the booking visit and at all subsequent visits the midwife should screen for depression. Ask the following questions2:
- During the past month, have you often felt low, depressed or hopeless?
- During the past month, have you had little interest or pleasure in doing things?
Puerperal Psychosis
This is a severe mood disorder with delusions and hallucinations. The onset is sudden, usually within the first 2 days postpartum. The illness is closely related to bipolar disorder. Women with a personal history or family history of bipolar disorder are particularly at risk8. There is also an association with primiparity and association with obstetric complications9.
The clinical picture includes:
- Mood changes: elation, depression or irritability
- Perplexity and confusion
- Agitation and abnormal behaviour
- Delusions and hallucinations
- Thoughts or acts of harm to self or others
- Difficulty in caring for self and baby
COMPLICATIONS
Complications include:
- Self-harm and suicide3
- Neglect of baby and rarely, infanticide
- Problems with mother–infant attachment and interaction8,10,11
- Long-term emotional, behavioral and cognitive problems in the child12
- Relationship problems and family breakdown
- Social, occupational and financial complications
- Depression in the partner13
NON-PREGNANCY TREATMENT AND CARE
Depression in the non-pregnant population is managed in primary care if it is mild to moderate, and referred to psychiatric services if severe2. The following management options are available:
- Advice on lifestyle, exercise and coping with stress
- Talking therapies, e.g. cognitive behaviour therapy
- Antidepressant medication
- Mood stabilisers, e.g. lithium
- Electroconvulsive therapy (ECT)
PRE-CONCEPTION ISSUES AND CARE
Women with a past history of severe depression or puerperal psychosis should be counselled regarding relapse rates (about 50%) in future pregnancies. Medication should not be discontinued abruptly. Many psychiatric drugs are safe in pregnancy. The risk–benefit ratio should be assessed to decide whether or not to continue medication14,15.
Some drugs are associated with birth defects and should be avoided. Sodium valproate (an anti-epileptic drug that is used as a mood stabiliser) should not be prescribed to childbearing women because of the high risk of birth defects. Issues that may be associated with depression are as follows and require further advice and support:
- Poor diet and nutritional status
- Smoking
- Substance/alcohol abuse
- Self-harming behaviour
- Relationship problems
- Past history of severe depression
- Past or family history of bipolar disorder or puerperal psychosis
- Lack of social support
- Recent stressful life events
- Longstanding difficulties in coping
- Sexual abuse
- Domestic violence
- Antenatal depression may be treated either with talking therapies or antidepressants
- Psychotropic medication need not be discontinued
- For treatment guidance see Appendix 17.1
- Women at risk should have access to a specialist perinatal psychiatry service for advice or assessment if needed
- Communication with other professionals is important
- Refer to obstetrician
- Refer to perinatal service
- A trusting relationship should be established that is socially and culturally sensitive
- General advice on smoking cessation, diet and exercise, breast-feeding, birth preparation and support services
- If there is an identified risk to the baby, safeguarding referral and pre-birth multi-professional meeting is held
- There are no physical reasons why the birth should be managed differently
- Obstetric complications may increase the risk for developing postnatal psychiatric disorders
- Specialist perinatal psychiatric team may need to be contacted for advice or assessment
- Neonatologists should be contacted if the mother is on psychotropic medication
- Psychotropic medication may be indicated in women with past or present psychiatric illness
- Drugs should be used judiciously during labour in view of possible effects on the baby
- Discuss all carefully with the woman and birth partner
- Ensure that any plan has the woman’s full consent
- Psychological and physical support is important throughout labour
- Avoid unnecessary interventions
- Encourage skin to skin contact between mother and baby
- Breast-feeding to be encouraged if not pharmacologically contraindicated
- Postnatal blues and normal emotional changes should be distinguished from depression
- Depression usually presents within the first 12 weeks postpartum; one-third to one-half of these are severe and tend to present early, usually by 4–6 weeks postpartum
- Puerperal psychosis presents acutely, usually within 2 days postpartum
- Severe depression and puerperal psychosis needs referral to specialist perinatal psychiatric services
- Suicide is one of the leading causes of maternal mortality; hence early detection and treatment of mental illness are crucial
- Specialist perinatal psychiatry team should be contacted if there are symptoms of serious mental illness
- Risk assessment and safeguarding issues are important
- Psychotropic medication may be indicated. Medication that is safe in breast-feeding can be prescribed
- Admission to a specialist psychiatric mother and baby unit may be indicated if the mother is severely ill
- Observe mother and baby interaction
- Discuss sleep, diet and self-care, and how she is coping
- Reassure if mood change is due to postnatal blues
- Observe baby if breast-feeding mother is using medication
- Ask screening questions for depression; scales, e.g. EPDS16 may be used but only as part of a thorough clinical assessment2
- Communicate with specialist services and refer if needed
- Refer to Social Services if there are safeguarding issues
17.3 Eating Disorders
EXPLANATION OF CONDITION
Eating disorders (ED) are characterised by severe disturbances in eating behaviour1. The two main diagnostic categories are anorexia nervosa (AN) and bulimia nervosa (BN).
In anorexia there is a deliberate attempt to lose weight whereas bulimia is characterised by repeated episodes of binge eating followed by compensatory behaviours (self-induced vomiting or purging)2. Atypical anorexia and bulimia do not fully meet the diagnostic criteria, but present with some of these symptoms3. Eating disorders are associated with complex psychological and medical complications4.
Eating disorders affect menstruation and fertility5. Pregnancy is a particularly difficult time for women with eating disorders because of the associated changes in body shape and weight6–8. Eating disorders are associated with antenatal and postnatal complications for the woman and baby and management in pregnancy is challenging. Close liaison between maternity and eating disorders services is needed.
Both biological and psychosocial factors are involved. Genetic factors are important, and eating disorders have a higher prevalence in some families9,10. Psychosocial factors include stressful life events, personality traits, cultural factors and social pressures that link attractiveness to being thin11–14.
Anorexia Nervosa
In AN, women restrict their weight and perceive themselves as being overweight in spite of evidence to the contrary. The diagnostic criteria are as follows:
- Body weight maintained at least 15% below that expected, or BMI less than 17.5 (BMI is outlined in Appendix 13.1.1)
- Weight loss, self-induced vomiting, purging, excessive exercise, appetite suppressants/diuretics
- Body-image distortion; dread of fatness
- Widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis causing amenorrhoea
- If onset is pre-pubertal, puberty is delayed or even arrested
Associated clinical features:
- Amenorrhoea, infertility, loss of sexual interest
- Lethargy, weakness, anaemia
- Hypotension, peripheral oedema, cardiac arrhythmias
- Constipation, abdominal pain, enlarged salivary glands
- Dry skin, alopecia, lanugo hair, brittle nails, osteoporosis
- Tooth decay, erosion of dental enamel
Onset of AN typically occurs between 14 and 18 years and may follow a stressful life event. Personality problems are common. Depression, self-harming behaviour and suicide may also occur. The course of the disorder is variable. Some women recover completely; others relapse or recover partially. Severe medical complications can be fatal and early diagnosis and treatment are crucial15.
Antenatal visits provide a good opportunity to check for eating disorders. Thorough physical examination and relevant tests are needed to detect medical complications. A referral to a psychiatric eating disorders service should be made as early in pregnancy as possible so that treatment can be commenced.
Bulimia Nervosa
BN is characterised by repeated bouts of overeating and excessive preoccupation with control of body weight leading to extreme measures to counteract effects of overeating (such as self-induced vomiting or purging). The preoccupations in bulimia are similar to those seen in anorexia.
Diagnostic criteria are:
- Persistent preoccupation with eating; craving for food; eating large quantities of food within a short time period.
- Counteracting the fattening effects of food by self-induced vomiting, purgative abuse, periods of starvation, or use of drugs (e.g. appetite suppressants/diuretics)
- Morbid dread of fatness
- Inappropriately low target weight
- Often, but not always, an earlier episode of AN
Onset of bulimia usually occurs in late adolescence. Most women are within normal weight range. Impulsivity, self-harming behaviour and alcohol or drug misuse are often associated. Depression may also occur. The course may be chronic or intermittent.
Associated clinical features:
- Irregular periods; amenorrhoea
- Dependence on laxatives, diarrhoea; constipation
- Dehydration, fluid and electrolyte disturbances
- Tooth erosion; loss of dental enamel
- Enlarged salivary glands
NON-PREGNANCY TREATMENT AND CARE16–19
- Psychotherapies:
- Cognitive behaviour therapy
- Interpersonal therapy
- Psychodynamic psychotherapy
- Cognitive behaviour therapy
- Medication – antidepressants
- Assess and treat medical and psychiatric complications
- Admission to a specialist eating disorder inpatient unit if needed
PRE-CONCEPTION ISSUES AND CARE
- Counselling and support: regarding amenorrhoea and infertility; discuss complications related to pregnancy
- Dietary and nutritional assessment and advice
- Polycystic ovaries more common in BN
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
