Psychiatric & Mental Disorders During Pregnancy Supervised by: Dr. Suresh
Why is it important ? • Women are at the greatest risk of developing a psychiatric disorder during childbearing age . • The psychiatric disorders with the highest prevalence in women are depressive and anxiety disorders up t o 20 % . • Women with histories of these disorders are at risk for relapse during pregnancy, particularly if they have experienced two or more relapses of the disorder. • Ideally, women with a history of any recurrent psychiatric disorder should obtain a pre pregnancy consultation to discuss the safest treatment approach as they try to conceive and during the pregnancy
pseudocyesis • It is generally estimated that false pregnancy is caused due to changes in the endocrine system of the body, leading to the secretion of hormones which translate into physical changes similar to those during pregnancy. • The underlying cause is often: MENTAL.
pseudocyesis • There are various explanations :Psychodynamic theories:- attribute the false pregnancy to emotional conflict. - intense desire to become pregnant, or an intense fear of becoming pregnant.- internal conflicts and changes in the endocrine system.
Signs & Symptoms: • similar to the symptoms of true pregnancy and are often hard to distinguish from it. • natural signs of pregnancy :amenorrhoea, morning sickness, tender breasts, and weight gain . • The most common symptom is: Abdominal distension(60-90%)*N.B: often resolve under general anesthesia and the woman's abdomen returns to its normal size. • The second most common physical sign ofpseudocyesis is menstrual irregularity(50–90%).* Women are also reported to experience the sensation of fetal movements known asquickening
Signs & Symptoms: • Other common signs and symptoms:-gastrointestinal symptoms.- breast changes or secretions. -labor pains (One percent of women eventually experience false labor.) -uterine enlargement- and softening of thecervix. **The hallmark sign of pseudocyesis that is common to all cases is that the affected patient is convinced that she is pregnant.
Puerperal mental disorders • During the postpartum period, up to 85% of women suffer from some type of mood disturbance. Most women, symptoms are transient and relatively mild (ie, postpartum blues). • 10-15% of women experience a more disabling and persistent form of mood disturbance (eg, postpartum depression, postpartum psychosis). • More recent evidence suggests that postpartum psychiatric illness is virtually indistinguishable from psychiatric disorders that occur at other times during a woman's life. • Types: • Postpartum blues. • Postpartum depression. • Postpartum psychosis.
Postpartum Blues: • Up to 85% of women experience postpartum affective instability. • Symptoms : * Rapidly fluctuating mood * tearfulness * Irritability * Poor concentration * Depression and anxiety * Sleep disturbance • Symptoms peak on the fourth or fifth day after delivery and last for several days. • Generally time-limited and self - limited with spontaneously remit within the first 2 postpartum weeks. • Symptoms do not interfere with a mother's ability to function and to care for her child.
PostPartum Depression (PPD): • Postpartum depression occurs in 10 -20 % of women in the general population with risk of recurrence 50 % . • postpartum depression develops insidiously over the first 3 postpartum months, more acute onset. • Postpartum depression is more persistent and debilitating than postpartum blues. • Suspect if the blues last beyond 2 weeks with : * Depressed mood * Tearfulness *Inability to enjoy pleasurable activities * Insomnia & Fatigue * Appetite disturbance * Suicidal thoughts *Recurrent thoughts of death. • Anxiety is prominent, including worries or obsessions about the infant's health and well-being • Postpartum depression often interferes with the mother's ability to care for herself or her child.
Postpartum Psychosis: • Postpartum psychosis is the most severe form of postpartum psychiatric illness. • 1-2 per 1000 women after childbirth. • Postpartum psychosis has a dramatic onset, emerging as early as the first 48-72 hours after delivery. In most women, symptoms develop within the first 2 postpartum weeks. • The condition resembles a rapidly evolving manic episode with symptoms include : * Hallucinations *Delusions . * Restlessness and insomnia * Rapidly shifting depressed or elated mood, and disorganized behavior. • Post partum psychosis is a psychiatric Emergency that typically requires inpatient treatment . • Risks for infanticide and suicide are high among women with this disorder.
Pathophysiology • Hormonal factors • Levels of estrogen, progesterone, and cortisol fall dramatically within 48 hours after delivery. • Psychosocial factors • Inadequate social supports • marital discord or dissatisfaction, or recent negative life events are more likely to experience postpartum depression. • Biologic vulnerability _ prior history of depression or family history of a mood disorder are at increased risk for postpartum depression. • Women with a prior history of postpartum depression or psychosis have up to 90% risk of recurrence.
Screening for postpartum Mood disorders: • Predicting who is at risk for postpartum depression is difficult. Individuals at great risk often have some of this risk factors : • Prior history of postpartum depression. • Personal or family history of mood disorder • Depression during a current pregnancy. • Inadequate social supports. • Marital dissatisfaction or discord • Recent negative life events such as a death in the family, financial difficulties, or loss of employment. • Screening of all mothers during the postpartum period is indicated. • The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-rated questionnaire used extensively for detection of postpartum depression.
Postpartum blues treatment • Postpartum blues typically is mild in severity and resolves spontaneously. • No specific treatment is required, other than support and reassurance. • Further evaluation is necessary if symptoms persist more than 2 weeks.
Postpartum depression treatment • Exclude medical causes for mood disturbance (eg, thyroid dysfunction, anemia). • Milder forms may respond to supportive psychotherapy. More severe may require pharmacological treatment. • Nonpharmacological treatment for women with mild-to-moderate symptoms. These modalities may be especially useful for mothers who are nursing and who wish to avoid taking medications. • Psychoeducational groups may be helpful. Individual or group psychotherapy (cognitive-behavioral and interpersonal therapy) are effective. • Pharmacological strategies are indicated for moderate-to-severe depressive symptoms or when a woman fails to respond to nonpharmacological treatment.
Pharmacological Treatment Cont, • Selective serotonin reuptake inhibitors (SSRIs) : are first-line agents and are effective in women with postpartum depression. eg, fluoxetine and sertraline • Serotonin-norepinephrine reuptake inhibitors (SNRIs) or Tricyclic antidepressants : may be useful for women with sleep disturbance eg , Nortriptyline and venlafaxine. • Anxiolytic agents : such as lorazepam and clonazepam may be useful as adjunctive treatment in patients with anxiety and sleep disturbance. • Preliminary data suggest that estrogen, alone or in combination with an antidepressant, may be beneficial; however, antidepressants remain the first line of treatment.
Special concern (PPD) • First episode of depression, 6-12 months of treatment is recommended. For women with recurrent major depression, long-term maintenance treatment with an antidepressant is indicated. • Inadequate treatment increases the risk of morbidity in both mother and infant. • Earlier initiation of treatment is associated with better prognosis. • Inpatient hospitalization may be necessary for severe postpartum depression. • Electroconvulsive therapy (ECT) is rapid, safe, and effective with severe postpartum depression, especially those with active suicidal idea.
Puerperal psychosis treatment • Puerperal psychosis is a psychiatric emergency requires inpatient treatment. • Most patients with puerperal psychosis suffer from bipolar disorder. Acute treatment includes a mood stabilizer (eg, lithium, valproic acid, carbamazepine) in combination with antipsychotic medications and benzodiazepines. • ECT (often bilateral) is tolerated well and rapidly effective. • Risk of suicide is significant in this population. • Rates of infanticide associated with untreated puerperal psychosis are as high as 4%.
Special concerns: • Breastfeeding and psychotropic medications : • All psychotropic medications, including antidepressants, are secreted into breast milk. Concentrations in breast milk vary widely. • Tricyclic antidepressants during breastfeeding are encouraging. Reports of toxicity in nursing infants are rare, although the long-term effects of exposure to trace amounts of medication are not known. • Avoid breastfeeding in women treated with lithium because this agent is secreted at high levels in breast milk and may cause significant toxicity in the infant. • Avoid breastfeeding in premature infants or in those with hepatic insufficiency who may have difficulty metabolizing medications present in breast milk.
Special concerns:(con’t) • Impact of postpartum depression on child development : • Postpartum depression may negatively affect these mother-infant interactions. • Mothers with postpartum depression are more likely to express negative attitudes about their infant and to view their infant as more demanding or difficult. • Children of mothers with postpartum depression are more likely than children of nondepressed mothers to exhibit behavioral problems . * sleep and eating difficulties * temper tantrums * hyperactivity * delays in cognitive development * emotional and social dysregulation * early onset of depressive illness.