Antenatal and Postnatal Mental Health

1. Antenatal and Postnatal Mental Health NICE Clinical Guideline 45: 2007 DTV VTS Sept 2016 Dr Rachel Lunney (& thanks to Dr Dinah Roy)

2. Objectives • Consider cases of mental health problems in pregnancy and the postnatal period • Revise NICE guidance on peri- & postnatal health problems • Consider how to identify postnatal depression in primary care • Discuss how to manage the spectrum of perinatal mental health disorders • Consider the diagnosis and management of Bipolar Affective Disorder in Primary Care (Part 2 after tea)

3. Session Plan • Discuss experiences of patients with mental disorders during pregnancy & postnatal period • Presentation NICE CG45 2014 • Inc Case examples: discussion • Tea • Presentation: NICE Bipolar Disorder

4. Experiences of dealing with Mental Disorder during pregnancy and postnatal period • Can you recall any memorable patients? • Roles in Primary Care teams • GP, Midwife, Health Visitor? • Perspectives from secondary care attachments • Paediatrics • Psychiatry • Obstetrics • Questions and learning needs?

5. Self test quiz 1: True or False? • Baby Blues occurs in the first 7 days after delivery • Baby Blues affects >30% of women • Postnatal Depression affects 10% of women • Postpartum psychosis affects women in 1 in 1000 deliveries • Women with Bipolar Disorder have a 1 in 4 risk of Postpartum psychosis • Suicide is the commonest cause of maternal death in the 1 year postpartum

6. Self test quiz 1: True or False? • Baby Blues occurs in the first 7 days after delivery T • Baby Blues affects >30% of women T • Postnatal Depression affects 10% of women T • Postpartum psychosis affects women in 1 in 1000 deliveries T • Women with Bipolar Disorder have a 1 in 4 risk of Postpartum psychosis F – worse: 1 in 2 & 40-70% relapse risk postnatally • Suicide is the commonest cause of maternal death in the 1 year postpartum T

7. Self test quiz 2: True or False? • Risk factors for maternal mental health disorders can be identified and acted on to affect outcomes • Psychological treatment of mild depression in pregnancy reduces progression to more severe illness • Tricyclic antidepressants are the safest drug choice in pregnancy • SSRIs are safe throughout pregnancy • Sertraline is the best choice for breast feeding mums • Midwives are the best people to identify MH problems

8. Self test quiz 2: True or False? • Risk factors for maternal mental health disorders can be identified and acted on to affect outcomes T • Psychological treatment of mild depression in pregnancy reduces progression to more severe illness T • Tricyclic antidepressants are the safest drug choice in pregnancy F – Safer, tho overdose risk high • SSRIs are safe throughout pregnancy F: Less safe >20wks • Sertraline is best choice for breast feeding mums T • Midwives are the best people to identify MH problems F – Family, GP if contact, MH team

9. NICE CG 192: 2014Antenatal and postnatal mental health: clinical management and service guidance • Predict those at risk • Detect those affected • Treat those who need it

11. Case 1 Liz • 26 yrs, 2 weeks post-partum full term normal delivery • Breast feeding her son Jack • Supportive partner • 5 year old daughter to previous partner • PMH moderate depression aged 20. Treated w antidepressants, discontinued when pregnant • Tearful, tired, poor appetite and sleep • Biospsyhosocial (BPS) Assessment? Issues? • Predict? Detect? Treat?

12. Case 2 Kelly • 27 yrs, 5 weeks postpartum full term normal delivery • PMH mod postnatal depression after first son 3y ago • Weepy, tired, angry and low • Tearful, agitated; no thought disorder, not suicidal • Lack of support, husband works away, no family locally. • Breast feeding • BPS Assessment? Issues? Predict? Detect? Treat?

13. Case 3 Gillian • 19 yrs, 7 months postpartum after NVD girl, Skye • Dad’s mother concerned– couldn’t see her grandchild. • PMH psychosis aged 17yrs, MH section • Met Skye’s Dad in psychiatric inpatient unit • Hallucinations, paranoia • Gillian’s mother obstructive? Mental health issues • BPS Assessment? Issues? Predict? Detect? Treat?

14. Talking about depression in the postnatal period • http://www.nhs.uk/conditions/postnataldepression/pages/introduction.aspx • - A Perinatal Psychiatrist & several women share perspectives

15. NICE CG45:General principles of care • Be culturally sensitive • Build trust • Elicit ideas, concerns and expectations • Be aware of stigma re mental disorders (MD) • BJGP2019:60; 829 – Postnatal depression: women feel shame, & fear of appearing “not to cope” • Ensure continuity of care • Consider the impact on partner and children

16. Impact on partner and children JAMA 19 May 2010 • Postnatal depression is common: 10-13% of women BUT • 10% fathers suffer depression 1st trimester - 1st yr of life • Most are affected between 3-6 months post-partum • Other family members – children? Wider family? • Be alert to symptoms in women, partners and others

18. Which mental disorders may affectpregnancy and the postnatal period? Severe mental illness • Schizophrenia • Bipolar disorder Depression • Mild, moderate or severe Anxiety disorders • Panic disorder • Generalised anxiety disorder • Obsessive–compulsive disorder (OCD) • Post-traumatic stress disorder (PTSD) Eating disorders

19. How do MH problems present? • A range: adjustment reaction...mild...mod...severe • Severe mental illness: may be rapid & an emergency • Women with all mental disorders have babies! • Pregnancy, birth, childcare may precipitate problems • Women may seek help then for ongoing problems • Mental disorders increase the risks of pregnancy • Mental disorders affect maternal, foetal & infant health & well being

20. NB Mental disorders/labels • ‘Postnatal depression’ is not used in NICE 45: Why? Misused, to cover all mental disorders • Specific guidance in NICE CG45 for most MDs • NICE guidance for each condition also exists • ICD10 and DSM- IV inform the guideline • NB SIGN guidance uses ‘Postnatal depression’ • SIGN 127, March 2012 ‘Management of perinatal mood disorders’ http://sign.ac.uk/pdf/PAT127.pdf

21. Why the need for this guideline: 1? • Psychological health as important as physical health • Some MDs are unaffected by maternal period (see on*) • Risk if meds stopped abruptly in mental disorders (MD) vs • Medication risks to foetus and newborn baby vs • Risks to mother & baby if MD undetected or untreated: • Bonding, infant cognitive & emotional development • Maternal suicide risk and rarely infanticide

22. Why the need for this guideline 2? • Increased risk of relapse / first presentation of bipolar disorder* • More rapid onset of postnatal psychotic disorders* • Urgent intervention may be required (PsycEmerg’y) • Need for careful use of psychotropic drugs • Need for prompt and effective psychological interventions • Effects on the extended family

24. Care starts Pre Conception “Discuss contraception and the risks of pregnancy (including relapse, risks associated with stopping or changing medication, and risk to the foetus) with all women of child-bearing potential who have a mental disorder and/or who are taking psychotropic medication. Encourage them to discuss pregnancy plans.” Also applies to breast feeding

25. Discussing risks with pts with Mental Disorders (MD) – Secondary Care • Absolute and relative risk of treating MD vs not treating • Foetal risks to those with no MD vs those with one on Rx • Decision aids • Personalised view of risk • Written material • Needs of adolescents

26. Risks of specific drugs Antipsychotics Lithium • Raised prolactin levels: some • Gestational diabetes and weight gain: olanzapine • Agranulocytosis: clozapine Specific guidance in NICE 45 • Foetal heart defects (up from 8 in 1000 to 60 in 1000) • Ebstein’s anomaly (up from 1 in 20,000 to 10 in 20,000) • High levels in breast milk Specific guidance in NICE 45

27. Risks of specific drugs Benzodiazepines Carbamazepine, Lamotrigine, Valproate • Cleft palate and other foetal malformations • Floppy baby syndrome • Avoid routine use except in extreme agitation • Withdraw slowly Specific guidance in NICE 45 • Carb: Neural tube defects (up from 6 in 10,000 to 20-50 in 10,000). Other major foetal malformations including GI tract and cardiac abnormalities • Lamot: oral cleft (risk approx 9 in 1000), Stevens–Johnson syndrome in breastfed babies • Valp: Neural tube defects up from 6 in 10,000 to 100–200 in 10,000 Specific guidance in NICE 45

28. Primary care - Predict:Prediction of Mental Disorders At first contact with services in the antenatal and postnatal period, predict those at increased risk. Ask about : • Past or present severe mental illness (Schiz’a, Bipolar, Postnatal Psychosis, Severe Depression) • Previous treatment by psychiatrist/specialist mental health team • Family history of perinatal mental illness • Audit of records at booking appointment w GP/MW • SIGN: PH Postpartum psychosis or Bipolar: Refer.

29. Detect: Detection of Depression Identify possible depression • Use the ‘Whooley’ questions at first contact with primary care, at the booking visit, and postnatally (4-6wk & 3-4mths) • Positive screening? At risk? Concern? Used Edinburgh Postnatal Depression scale (Consider GAD-7 for Anxiety) • Other conditions? Psychosis?

30. The ‘Whooley’ questions • During the past month, have you often been bothered by feeling down, depressed or hopeless? • During the past month, 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?

31. Subthreshold or Mild Symptoms Depression and/or anxiety that do not meet diagnostic criteria but significantly affect personal and social functioning: Previous depression or anxiety? • 4–6 sessions of brief psychological treatment such as interpersonal therapy (IPT) or cognitive behavioural therapy (CBT) No previous depression or anxiety ? • Social support e.g. regular informal individual or group-based support Psychological treatments • Provide treatment within 1 month of initial assessment, where appropriate – risks/benefits of meds change so start earlier

32. Treat:Management of Mild to Moderate Depression • Pregnancy & Postnatal, consider: • Self-help strategies • Counselling (listening visits) • Brief Cognitive Behavioural Therapy • Interpersonal psychotherapy • Moderate to severe? Balance risks & benefits of meds

33. Treat: Prescribing antidepressants: Moderate-Severe Depression Tricyclics (TCAs) have lower known risks during pregnancy than other antidepressants. May be more dangerous if taken in overdose SSRIs taken after 20 weeks’ gestation may be associated with an increased risk of persistent pulmonary hypertension in the neonate Fluoxetine has lowest known risks during pregnancy vs other SSRIs Paroxetine taken in the first trimester may be associated with fetal heart defects Venlafaxine may be associated with increased risk of high blood pressure at high doses, toxicity in overdose compared with other drugs and increased difficulty in withdrawal Most antidepressants pass into the breast milk. All antidepressants carry the risk of withdrawal or toxicity symptoms in neonates

34. Treat: Severe: Referral and initial care • Severe mental illness suspected? (Schizophrenia or bipolar ). Refer to specialist mental health service • If appropriate refer to a perinatal mental health service • Ask about mental health at all subsequent contacts • Current or past history of severe mental illness? Develop a written care plan: pregnancy, delivery and postnatal. Share the information • Increase contact with mental health services • Inpatient care for a mental disorder within 12 months of childbirth? Use a specialist mother and baby unit

35. Talking about postnatal mental health problems: MIND • https://www.youtube.com/watch?v=w0aaM9XzwTA • MIND – 3 women share their experiences (6 mins)

36. Treat: Mother and Baby Unit, Morpeth • Purpose-built 6 bed unit; en-suite double bedrooms • For women experiencing mental health problems at 34+ weeks pregnant or with babies </=12 months old • Takes referrals via Psychiatry from northern region & beyond • Homely atmosphere fosters bonding between mother & child • Access to range of psychiatric treatments and services • Partner & family encouraged to help care for mother & baby • Address:Beadnell Ward, St George's Park, Morpeth, NE61 2NU. Telephone number: 01670 501869.

37. Severe Depression...can lead to tragedy Sept 2013, Swindon – The Daily Mail Wife of Army major threw herself to death in front of 100mph train 'while suffering severe post-natal depression‘ Emma Cadywould, 32y, University researcher, found it 'hard to cope' with six-month-old son Inquest heard she was supported by husband, Major Steve Cadywould Baby Harrison would wake 20 times a night Family say Emma had expressed suicidal thoughts but talked of 'normal domestic' matters on day of her death

38. Severe Depression • ‘Since we lost Emma we have become aware of some astonishing and desperately sad statistics. In the UK, one mother a week will be totally overwhelmed by post natal depression and will tragically be lost to a loving family. Post-natal depression is a silent killer.’ Emma Cadywould’s sister NICE aims to predict, detect & treat mental illness in women like EmmaRead more: http://www.dailymail.co.uk/news/article-2424496/Post-natal-depression-Wife-Army-major-threw-train.html#ixzz3lr5P4OO5

39. Postpartum Psychosis • https://www.youtube.com/watch?v=BcaubXpQiFI • BBC Newsnight special report: 25mins, for those who want to learn more

40. Organisation of care • Effective detection • Effective assessment and referral to appropriate services • Timely, appropriate management and treatment • Accurate information about the disorder and the benefits and risks associated with interventions • Provision of care in the most appropriate setting • Appropriate communication about care with other services as required, taking into account confidentiality • Choice • NB Midwife shortages nationally; little GP input into maternity care – a challenge!

41. Summary NICE CG45 • Consider MH in all pregnant women or those planning a pregnancy: ask if they are • Destigmatise , build trust and continuity of care • Consider impact on partner and family • Balance and discuss risks of MD & meds to mum/baby • Primary care has a “window of opportunity” to recognise, support and treat MH problems: Ask at booking app, postnatal 6 wk check, and 3-4 months

42. Summary NICE CG45 • Predictthose at risk: PMH (maternity), severe MD • Detect those affected: screening questions, be aware • Treat: Psychological Rx if mild/subthreshold symptoms • Meds if severe and risks<benefits. SSRI usually • Urgent referral for those with severe MD eg psychosis • Specialist & Perinatal services: involve them early

43. Revisiting the case examplesApplying NICE CG45

44. Case 1 Liz • 26 yrs, 2 weeks post-partum full term normal delivery • Breast feeding her son Jack • Supportive partner • 5 year old daughter to previous partner • PMH moderate depression aged 20. Treated w antidepressants, discontinued when pregnant • Tearful, tired, poor appetite and sleep • BPS Assessment? Issues? Predict? Detect? Treat?

45. Case 1 Liz Learning points • Baby Blues’ – timing of symptoms vs depression • Prediction of depression/ at risk: PMH is key • Assessment and follow up • Partner support, and impact on him • ‘Listening visits’ from Health Visitor • Antidepressants during pregnancy – when to stop?

46. Case 2 Kelly • 27 yrs, 5 weeks postpartum full term normal delivery • PMH mod postnatal depression after first son 3yr ago • Weepy, tired, angry and low • Tearful, agitated; no thought disorder, not suicidal • Lack of support, husband works away, no family locally. • Breast feeding • BPS Assessment? Issues? Predict? Detect? Treat?

47. Case 2 Kelly Learning points • Prediction of depression/ at risk mother? • Detection of depression in postnatal period • Treatments – psychological / medical • Antidepressants in breastfeeding women • Team working – who else to involve?

48. Case 3 Gillian • 19 yrs, 7 months postpartum after NVD girl, Skye • Dad’s mother concerned– couldn’t see her grandchild. • PMH psychosis aged 17yrs, MH section • Met Skye’s Dad in psychiatric inpatient unit • Hallucinations, paranoia • Gillian’s mother obstructive? Mental health issues • BPS Assessment? Issues? Predict? Detect? Treat?

49. Case 3 Gillian Learning points • Role of extended family and impact of relationships / FH mental illness • Serious mental illness – prediction, vigilance, • Referral to secondary care • Mother and Baby (perinatal mental health) Unit • Confidentiality vs best interests & capacity • Child protection issues

50. Resources • www.patient.co.uk • www.nice.org.uk • http://www.nice.org.uk/nicemedia/live/11004/30432/30432.pdf • SIGN 127, March 2012 ‘Management of perinatal mood disorders’ http://sign.ac.uk/pdf/PAT127.pdf • http://www.rcgp-curriculum.org.uk/PDF/curr_13_Mental_Health.pdf • http://www.rcpsych.ac.uk/quality/quality,accreditationaudit/perinatalqualitynetwork.aspx • http://www.sign.ac.uk/pdf/PAT127.pdf - Patient booklet: Mood disorders during pregnancy and after the birth of your baby • http://www.pandasfoundation.org.uk/help-and-information/support-services/mother-and-baby-unit/beadnell-ward-morpeth.html • http://apni.org/ Association for Post Natal Illness