When the bough breaks: Mental Illness in the Pregnant and Postpartum Woman

1. When the bough breaks: Mental Illness in the Pregnant and Postpartum Woman Dr.Mariam AlawadhiMD,FRCPC Assistant professor-Department of Psychiatry,KuwaitUniversity Head of consultation liaison unit-KCMH

2. Agenda • Review the epidemiology and clinical presentation of perinatal mood and anxiety disorders in perinatal women. • Understand the psychiatric, obstetricand pediatric implications of a mother’s untreated illness. • Discuss a bio-psychosocial approach to the management of these disorders.

3. Depression is “the most common complication of childbearing.” Wisner, 2002

4. 1 in 5 mothers will experience a mental health disorder during their pregnancy or the year after they deliver.

5. 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.

6. Challenging the myths... • Media images of pregnancy and motherhood • Pregnancy was planned, so why do I have the “blues”? • Work-life balance • Relationships (couple, extended family)

7. ...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

8. Perinatal mental health Pregnancy related • Antepartum Depression • Antepartum anxiety Postpartum related • Baby Blues • Postpartum Depression • Postpartum Psychosis • postpartum anxiety

9. 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 fetalneurobehavioral; pre-term labour (Steele et al., 1992) Depression vs. pregnancy? affect  cognition functional impairment

10. Antenatal Depression • Risk factors: • low self-esteem • low social support, low income • antenatal anxiety, hx of depression, hx of abuse • negative cognitive style • hxof miscarriage/pregnancy termination • pregnancy complications

11. 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

12. 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

13. 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 Perinatal anxiety disorders

14. Postpartum blues • Baby blues • Very common (50-80%) • Starts w/in 1 wk pp: peaks 3-5 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

15. 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)

16. 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)

17. 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

18. (Kendler, 1993; Wisner, 2002) Risk factors

19. 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) Postpartum psychosis • 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

20. Rare (1-2/1000 women) Most commonly 2-4 wks/pp Risk Factors Family hx of BAD Early onset depression History of PPD Postpartum psychosis

21. Agenda 2.Understand the psychiatric, obstetricand pediatric implications of a mother’s untreated illness.

22. 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) Economic & health care burden

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

24. Fetal Risks from A/PPD • Poorer maternal health practices • Elevated cortisol levels • Preterm delivery • Small for gestational age • Low birth weight Schmeelk1999, Lundy 1999, Hoffman 2000, Adewuya 2007, Hedgaard 1993

25. Adverse parenting outcomes Depressed mothers: • Perceive their infants as more bothersomeand 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 Whiffen1989, Cohn 1990, Chaffin 1996

26. Adverse parenting outcomes These effects are moderated by: • Timing of depressive episode • Age of children • SES of family Lovejoy, 2000

27. Attachment Definition : A strong emotional and social bond between infants and their caregivers

28. 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.

29. 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.

30. Bowlby (cont’d) • Believed quality of early attachment influences future relationships (friends, romantic partners, own children).

31. 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

32. 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.

33. 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.

34. 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

35. Four Stages of Attachment • Pre-attachment • Attachment-in-the- making • Clear-cut attachment • Formation Of Reciprocal Relationship

36. PREATTACHMENT PHASE Birth-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

37. 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

38. “CLEAR CUT” ATTACHMENT PHASE 6-8 Months to 18 Months -2 Years • The attachment to familiar caregiver becomes evident • Babies 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

39. 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

40. Attachment Just the mother? • No Attachment to the mother is usually the primary attachment, but can attach to fathers and other caretakers as well.

41. Mary Ainsworth • Ainsworth 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.

42. STRANGE SITUATION • Observer shows caregiver and infant into the experimental room and then leaves. ( 30 Seconds) • Caregiver sits and watches child play. (3 mins) • Stranger enters, silent at first, then talks to caregiver, then interacts with infant. Caregiver leaves the room. (3 mins) • First separation. Stranger tries to interact with infant. (3 mins) • First reunion. Caregiver comforts child, stranger leaves. Caregiver then leaves. (3 mins) • Second separation. Child alone. (3 mins) • Stranger enters and tries to interact with child • Second reunion. Caregiver comforts child, stranger leaves. • All episodes except 1 last for 3 mins unless the child becomes very upset

43. STRANGE SITUATION • Video • http://youtu.be/PnFKaaOSPmk

44. 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

45. STRANGE SITUATION • Findings Infants differ in quality or style of their attachment to their caregivers. • Most show one of four distinct patterns of attachment: • Secure attachment • Insecure/Avoidant attachment • Insecure/ambivalent attachment • Disorganized/Disorientated attachment

46. 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.

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

48. 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

49. Disorganized Attachment • 5-10% • Elements of both avoidant and ambivalent (confused)

50. Agenda • 3. Discuss a biopsychosocialapproach to the management of these disorders.