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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 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
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?