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Maternal Mental Illness & Sleep An overview of the day. Dr Andrew Mayers [email protected] Maternal mental illness and sleep. Overview of today Postnatal depression Features, causes, risk factors and treatment Consequences for mother and child Postnatal psychosis Sleep problems

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Maternal mental illness sleep an overview of the day

Maternal Mental Illness & SleepAn overview of the day

Dr Andrew Mayers

[email protected]

Maternal mental illness and sleep
Maternal mental illness and sleep

  • Overview of today

    • Postnatal depression

      • Features, causes, risk factors and treatment

      • Consequences for mother and child

    • Postnatal psychosis

    • Sleep problems

      • For mother and baby

  • Complementing your existing skills

  • Partnership between academic knowledge and professional practice

  • Interactive sessions

Postnatal depression features causes and treatment

Postnatal depressionFeatures, causes and treatment

Dr Andrew Mayers

[email protected]

Postnatal depression
Postnatal depression

  • Overview

    • Contrast with baby blues

    • Diagnosis

    • Causes and risk factors

    • Treatments

Post natal depression pnd
Post-natal depression (PND)

  • Baby blues

    • Two to four days after birth (quite normal – but not PND)

      • Emotional/liable to burst into tears, for no apparent reason

      • Difficult sleeping (even when baby permits)

      • Loss of appetite

      • Feeling anxious, sad, or guilty

      • Questioning maternal skills

    • Effects up to 75% of mums

    • May relate to changes in post-birth hormone levels

      • Or could be related to being in hospital

    • Key is that this doesn't last long – usually only a few days

      • If it persists it may develop into PND

Major depressive disorder dsm iv tr
Major depressive disorder (DSM-IV TR)

  • Low mood AND/OR …

  • Markedly diminished interest/pleasure in ‘usual’ activities

  • PLUS four from:

    • Significant weight loss/gain/changes in appetite

    • Insomnia or hypersomnia

    • Psychomotor agitation or retardation

    • Fatigue/low energy

    • Feelings of worthlessness or excessive/inappropriate guilt

    • Poor concentration/indecisiveness

    • Recurrent thoughts of death/suicide

  • Symptoms must be ‘continually’ present for at least 2 weeks

Pnd features
PND: Features

  • PND needs same DSM-IV diagnosis as major depressive disorder

    • But relates specifically to the postpartum period

      • But within 4 weeks of birth (is that enough?)

    • Additional features may also indicate presence

      • Sense of inadequacy, inability to cope

      • Feeling guilty

      • Being unusually irritable

      • Being hostile/indifferent to husband/partner/baby

      • Panic attacks

      • Excessive unwarranted anxiety

      • Obsessive fears about the baby's health or wellbeing

Whooley questions
Whooley questions

  • During the past month…

    • Have you often been bothered by feeling down, depressed or hopeless?

    • Have you often been bothered by having little interest or pleasure in doing things?

  • Consider a third question:

    • Is this something you feel you need or want help with?

  • Is this sufficient?

  • Is there more we can do?

Pnd prevalence
PND: Prevalence

  • PND affects about 10% of new mums

    • Compare to baby blues (up to 75%)

  • Although DSM-IV states ‘must be within 4 weeks of birth’

    • Most clinicians/researchers extend this to several months

  • Vulnerable mums usually referred in ‘perinatal’ period

    • During pregnancy up until baby is 1 year

  • Can come on gradually or all of a sudden

  • Can range from being relatively mild to very hard-hitting

  • About 50% PND women afraid to tell health visitors about it

    • Scared it will lead to social services taking child away

    • Or that they would be seen as bad mothers

Pnd causes
PND: Causes

  • Causes of PND uncertain

    • But there are a number of known risk factors

      • Having had depression before

        • Especially PND

      • Not having a supportive partner

      • Having a premature or sick baby

      • Having lost your own mother as child

      • Having had several recent life stresses

        • Bereavement, unemployment, housing or money problems

      • Poor sleep (we will talk about this later)

Pnd causes1
PND: Causes

  • Some additional risk factors for PND

    • Shock of becoming a mother

      • Women often unprepared for physical impact of childbirth

      • Plus new and daunting skills to learn

      • New full time responsibility

      • Helpless human being who cannot communicate

        • Other than cry (distressing in itself)

      • Some mums get anxious when they don’t hear crying!

        • Lie awake listening out

      • Loss of freedom and independence

      • Exhaustion and fatigue

Pnd causes2
PND: Causes

  • Hormones

    • Oestrogen and progesterone affect emotions

      • Levels of progesterone are very high during pregnancy

        • PND maybe due to sudden drop progesterone after birth

  • Diet

    • Lack of certain nutrients during pregnancy may cause PND

      • Omega 3 oils (found in oily fish, seeds and nuts)

      • Magnesium (leafy green vegetables and seeds)

      • Zinc (seeds and nuts)

Pnd treatment
PND Treatment

  • Antidepressants

    • Huge amount of evidence of benefit in treating depression

      • First line choice in most adults

      • BUT it is not that simple in PND

    • Some antidepressants  serious side effects and interaction

      • Consider this if mum is breastfeeding

        • Some antidepressants are not safe for infants

Medication for pnd what is safe
Medication for PND – what is safe?

  • Tricyclic antidepressants

    • Lower known risks than other antidepressants

      • But more dangerous in overdose

  • SSRIs (after 20 weeks)  greater risk hypertension in neonate

    • Fluoxetine fewer known risks of SSRIs

    • Paroxetine (in 1st trimester)  some risk foetal heart defects

    • Venlafaxine  some risk high blood pressure (at high doses)

  • Most antidepressants pass into the breast milk

    • Imipramine, nortryptiline and sertraline - at relatively low levels

    • Citalopram and fluoxetine - at relatively high levels

Pnd treatment1
PND Treatment

  • Counselling and talking therapies (CBT etc.) very effective

    • Group or individual care

    • BUT rare - can take time to get into a programme

      • We need more Perinatal Mental Health teams!

    • Self-help strategies

      • Counselling (listening visits)

      • Brief cognitive behavioural therapy

      • Interpersonal psychotherapy


  • PND often confused with baby blues

    • PND more serious and longer lasting

    • But less common

  • We need to understand risk factors

    • Extend beyond Whooley questions

  • Group task

    • Are Whooley questions enough?

    • What are the risk factors?

    • What signs should we watch out for?

    • Why are mums reluctant to tell us about mental health problems?

    • How far should we pursue this?