new horizon mother and baby centre › uploads › 20160322134641.pdfnew horizon mother and baby...
TRANSCRIPT
New Horizon Mother and Baby Centre
Perinatal mental health service
Christine Munday
Speciality Doctor
Learning Outcomes
• Service organisation
• Importance of perinatal mental illness
• Ante natal depression
• Post natal depression
• Puerpural psychosis
New HorizonMother and Baby CentreSouthmead
Conference Room
Children’s Play area
The Lounge
A Bedroom
Staff
• Nurses
-Ward Manager
-Psychiatric nurses
-Nursery nurses
• Occupational Therapist
• Doctors- Consultant, Staff Grade
and junior doctor
Types of Treatments
• Psychological therapies
• Pharmacological treatment
• Social interventions
• Baby care and attachment
Who is admitted?
• Women with mental health disorder or distress
> 36 weeks pregnant
with baby < I year
• Women in high risk group for relapse for 2 weeks after birth
Admissions by diagnosis
Who do we see?
• Women with SMI planning pregnancy
• In pregnancy -past history SMI
-previous care mental health services
• Post natally -post natal depression
-puerpural psychosis
Who refers?
• Nationwide - mental health services
• Locally -community - GP
midwives
health visitors
social workers
mental health
hospital obstetric services
mental health services
NICE guidelines (2014)
• Women are unwilling to discuss mental health issues
– Stigma
– Fear of having baby removed
Recognising mental health problems
• During the past 1/12 have you been bothered by feeling down, depressed or hopeless?
• During the past month have you been bothered by having little interest or pleasure in doing things?
NICE 2014
Recognising mental health problems
• During the past month have you been feeling, anxious or on edge?
• During the past month have you not been able to stop or control worrying?
• Also use EPDS or PHQ-9
• Refer to GP or mental health services if severe problem suspected NICE 2014
Assessing mental health problems
• Previous mental health hx and response to treatment
• Physical health
• Alcohol/drug misuse
• Mother and baby interaction
• FH
• Social support
• Living conditions NICE 2014
Assessing mental health problems
• Risk
– Self neglect
– Self harm
– Suicidal thoughts
• Assess severity, arrange help, advise about seeking further help if needed
– Risk to others
• Consider safe-guarding if children at risk!
Pre-conception counselling
• New service
• Referrals from GP, mental health services
• 12 women seen each year
• Mostly with partners
• 80% with bipolar disorder
• Discussion of medication in pregnancy and breast feeding and risks of relapse
Preconception counselling
• Uncertainty of benefits, risks and harms of treating mental health problem
• Previous response to treatment
• Risk of harm of no treatment
• Sudden onset of illness post natally (first 2 weeks)
Case Study A
• 34 year old woman
• Unplanned pregnancy
• Already on fluoxetine
• What next ?
Intervention - prescribingNICE-2014
• Don’t necessarily stop medication
• Explore options, including risks
• Involve partner
• Monotherapy
• Lowest effective dose
• Previous response to treatment
• Dose adjustment in pregnancy
Pregnant women and therapy
• Pregnant women often stop taking medication
• Explore reasons why
• Alternative of psychological therapy
• Consider re-starting
• Change to alternative drug
• Ensure mother aware of risks
Antenatal depression
• Epidemiology
Rate depends on population and timing of study
• 9% O’Hara (1984)
used controls
showed AND predictor of PND
• 20% ALSPAC (EPDS at 32-weeks)
26
Antenatal depression
• Depressed Mood
– Tears– DSH– Seeking termination– Biological symptoms
• EMW• ↓ Appetite• ↓ Libido
• DVM
• Somatisation
– Worries over foetus– Anxiety symptoms
• Palpitations• Diarrhoea• Vomiting• Sweating• Tremor
Antenatal depression
• High rates of antenatal depression in community studies
• Impact on maternal and child health
–Placental abruption
–Premature labour
– Low APGAR scores and low BW
• Cohen et al 1989, Crandon 1979 & Istvan 86
28
Antenatal depression
• Poor antenatal care
• High rates of smoking, drug and alcohol use
• Deliberate self-harm / suicide
• Risk taking behaviour
• Poor bonding / attachment
• Longer term effects on child
Antenatal depression
Maternal childhood
maltreatment
Antenatal depression
Maltreatment of children
Antisocial behaviour
Risk factors for antenatal depression
• Woman who have experienced abuse
• Previous depression
• Young- under 22 years
• Relationship problems
• F.H. mental illness
Antenatal Liaison
• Adhoc telephone or email advice re: medication and management
• Women under care of recovery team– Advice about medication
– Pre-birth planning
– Planned admission if required
• Consider referral to PCLS
BMJ personal story
• March 2012
• Mood disorder in perinatal period
Mrs X had depression since teens
Bipolar disorder diagnosed early 20s
Admitted with mania
Then 18 months depression on lithium
Became pregnant
Referred to perinatal team
BMJ Personal story
• Overall thoughts
– Perinatal team helpful assessing women at risk and supporting them
• What helped?
– Good communication between professionals
• Compassionate midwife
• 2 week admission postnatally with daily visits from perinatal team
Alternatives to antidepressants
• Exercise
• Supportive counselling
• CBT
• Marital work
Resources
• CounsellingGreen House
Mothers for Mothers
• Couple work – Relate
• Psychological therapy – LIFT
• Bereavement – Cruise
• Befriending – Homestart
• Bluebell
Intervention
Mild depression
-Consider – withdraw medication & monitor
-Psychological therapies
Moderate/severe depression
-Pharmacological treatment
-Psychological therapy
Antidepressants in pregnancy
• Previous responses
• Reproductive safety
• Risk of discontinuation
• Past history severe depression
• Preference for medication
• Sleeping difficulties use Promethazine (NICE 2014)
Anti-depressants
• Tricyclics
– Amitriptyline
– Impramine
– Nortriptyline
• Advantages/disadvantages
– Safe in pregnancy
– Fatality in overdose
– Side effects
Avoid clomipramine in first trimester ? teratogenic
Antidepressants - SSRI
• Sertraline, Citalopram & Fluoxetine
• VSD when taken in 1st trimester
• Assc. With low Apgar scores Jensen 2013
• Persistent pulmonary hypertension (after 20 weeks)
• Autism risk with AD use in antenatal depression Rai 2013
• Neonatal withdrawal
Post-natal depression
• 70,000 women annually in UK
• First recognised 1968 – Brice Pitt 10 – 20%
13% - O’Hara, study 12,000 women
15% - Cox et al (’82)
20% - Paykel et al (’80)
Post-natal depression
Natural history
• First 3-months ↑
esp 4 – 6-weeks (Kumar, Cox)
• Then – many recover but
6/12 – ⅓ - ½ still depressed
1-year – 10% still depressed
• Can become chronic
Presentation
Depressed mood
– Tears, no enjoyment
– DSH, poor care
– Biological symptoms
– EMW
– ↓ Appt
– ↓ Libido
– DVM
Somatisation
– Worries over parenting, guilt
– Anxiety symptoms
– Palpitations
– Diarrhoea
– Vomiting
– Sweating
– Tremor*fleeting or intrusive thoughts of harming baby common (41% post-natally
depressed mothers)
Jennings KD et al. Thoughts of harming infants in depressed and non-depressed mothers 1999
Risk Factors
• Personal and F.H. depression
2x more likely to have PND if relative has PND- Forty et al 2006
• Losing mother before 11 years old
• Unsupported – no confidence
• No employment outside home
• 2 or more children at home under 5 years old
Risk Factors
• Previous depression & FH
• Marital conflict
• Poor socio-economic status
• Life events
• Older women
• Infertility
• Previous loss, bereavement, stillbirth
• Separation from father in childhood
Complications
• Suicide and DSH in mother
• Non-accidental injury
• Infanticide (1 in 50,000 deliveries)
• Cognitive and emotional development of child
• Marital discord
Treatment
• Support- practical, emotional
• Supportive counselling
• CBT
• Marital work
• Antidepressant therapy- sertraline
• Antipsychotics
• Short term anxiolytics
Medication
Risks in breast feeding
BABY
• All psychotropic drugs excreted in breast milk
• Long term effects not known
• Safety difficult to establish
• Monitor baby for weight gain and irritability
Minimising risks in breast feeding
• Breast feed before medication at night
• Consider drug half-life
• Using mixed feeding-formula overnight
Case study B
• 37 year old woman – 3/12 post partum
• Difficult pregnancy - abnormal scans
• Normal delivery - baby in special care
• At home - baby has apnoea needs admission
• Mother - tearful, anxious, feelings of failure
Case study B
• Thoughts about running away
• Worried about harming baby
• No sleep, poor appetite
Case study B
• Miscarriage 2011
• Teacher happily married to supportive husband
• Mother also has anxiety and depression
• Past history-previous depression due to work related stress
• Anti-depressants for 6/12
Case study B
• Diagnosis-post natal depression
• Treatment
• Initial support at home and sertraline 50mg
• Admission to New Horizon
• Non directive, supportive counselling
• Psychological therapy – CBT, positive thinking, goal setting
• Couple work – meetings with husband
Case study B
• Support with baby care to enable sleep and rest
• Regular meals
• Activities such as gardening, cooking
• Nursery nurses advice regarding baby care
• Gradual return home
• Sertraline, Lorazepam & Zopiclone
Andrea’s Postpartum Psychosis Episode Out of the Blue
The fourth day after the birth of my first baby was the start of my meltdown. I had no history or mental health issues. Confusion, extreme anxiousness and terror mounted and I hadn’t slept for four days. It happened suddenly and severely, within hours. I was manic and couldn’t walk, talk or think. I held my phone but couldn’t work out how to call for help.
Over two weeks, I had delusions and scribbled notes franticly. My mind was spiralling yet I had moments of clarity. My thoughts raced so fast, I developed a stutter. I felt like a baby re-learning how to eat, walk and talk. It was exhausting. I couldn’t read or watch TV and was terrified by people moving or speaking too fast; I couldn’t process thoughts quickly enough to understand. I was learning how to care for my baby at the same time as trying to survive myself.
I was scared I’d be separated from my baby. I wanted information but nothing was explained to me as they thought I was crazy. Severe depression developed. I was numb and rarely left the house.
It took a year to bond with my baby and I was suicidal for three months. After two years I made a full recovery but chose not to have more children.
Puerperal Psychosis(or post natal affective psychosis, post partum psychosis)
• 1-2 per 1000 deliveries -Kendal 1987
• 80% in first post natal week
• 15% in second post natal week -Heron 2007
• Symptoms- mood- mania, hypomania
psychosis- delusions, hallucinations
fluctuating
perplexity
• Treatment- atypical antipsychotic ± antidepressant
admission
Who? (psychosis post natally)
• Past history bipolar disorder
• Previous puerperal psychosis
• Past history schizophrenia
• Previous psychotic episode
• Family history post natal disorder
Who?• Bipolar disorder- 250 per 1000 deliveries
& F.H 570 per 1000 deliveries
• Previous P.P- 550 per 1000 deliveries
• Schizophrenia/ - relative increased risk of admission one
schizoaffective month post partum 5x (but B.P 4x that)
• Childbirth- 20x risk of admission in first week
post natal
increased risk for 10 weeks-KENDAL ’87
• Approx ½ first onset approx ½ recurrence
Case study B
• 37 year old - 6 days post natal
• Concerns on post natal ward
• Thought baby was going to be removed
• At home - deterioration
• Seen in ED, admitted to New Horizon
• Really anxious
• 10 hours sleep since birth of baby
Case study B
• Overwhelmed
• Poor concentration
• Indecisive
• Not sure son is her baby
• Psychotic symptoms - thought TV referring to her
• Auditory hallucinations
• Suicidal thoughts of running under bus
• No thoughts of harming baby
Case Study B
• Family history mother had PND and treated with ECT
• Past history previous stress induced psychosis
• Treated in hospital under section MHA with olanzapine
• Husband unaware
Case Study B
• Admitted and detained under section MHA
Treatment
Medication antipsychotic – olanzapine 10mg
Antidepressant citalopram 20mg
Support with baby care to enable rest and sleep
Psychological therapy
Couple work
Nursery nurse advice
Sequelae of Serious Mental Illness
• Suicide and DSH in mother
• Infanticide (1 in 50,000 deliveries)
• Non accidental injury
• Cognitive and emotional development of child
• Marital discord
Mother and baby interactions in SMI
• Verbal interaction, emotional sensitivity, physical care
• Mother- over stimulating with toys, loud talk.
- rough handling
- irritable
- angry
• Baby- distressed
-withdrawn
Personal storiesCIRCUS by Sarah Spring
Roll up, roll up, I am the ringmaster. Marvel at my commands and ready wit, Beast and man dumb before me, lapping my pronouncements like poisoned condensed milk. No question who is in charge. I am taller than the tent pole, Wider than the tent. Roll up, roll up, and see the shocking show.
Roll up, roll up, I am the strongman, Wondrous strength, both arms raised with bagfuls of books. Tearing and ripping furnishings, Withstanding the brute force of 40-plus stone of sinew bonehouse. Barracading myself from the enemy, I am invincible. Roll up, roll up, and see the shocking show.
Roll up, roll up, I am the caged oddity, Psychic savant, possessing the meaning of life. Soul soars, while body stoops and mouth dribbles. Eyes stare with defiance and burn with knowledge beyond vision. Who dares challenge the seer? Watch me hug to death the pulse from my secret. Roll up, roll up, and see the shocking show.
8th CMACE “Saving mother’s lives”
Total deaths 11.39 per 100,000 deliveries
Diagnosis of women who died from suicide
Diagnosis n %
Psychosis 11 38
Severe depression 6 21
Adjustment/ grief 3 10
Drug dependency 9 31
TOTAL 29 100
Suicide–past psychiatric history
Past Psychiatric history n %
No history, first illness 10 34
Past psychiatric history 19 66
Past psychiatric history identified 9 47
Past psychiatric history appropriately managed 4 21
Total 29 100
Women who died by suicide
76% married
76% employed
41% educated
90% white
2-3 per 1000 post partum psychosis
But in substance misuse- young, single, unemployed
Case study - C• 25 years
separated, 2nd baby
died 9th week post partum on railway line
Historybipolar disorder- well 5 years
4 previous admissions
at onset of pregnancy stopped valproate
discharged
requested termination
midwives not aware of history
“unwell” 3/7 post partum
2 weeks sees GP
9 weeks family concerned- contact HV
dies following day
Case study - D• 02/04
30s married teacher, 2nd baby
died by hanging at 6 days post natal
History
4 years ago depressive psychosis
ECT after birth of first child
- 2nd pregnancy. P.H “depression”
- day 4 midwife contacts CMHT
- day 6 dies
Craig’s story
Summary
• NICE guidelines highlight the importance of:-
– Early recognition
• Including those with previous mental health hx and awareness of risk factors
– Assessment
• Including of risk and safeguarding issues
– Intervention (incl. referral to PCLS and New Horizon)
References• Saving Mothers Lives
CMACE 2011 (deaths 2006-2008)
• NICE guidelines 2014Ante natal and Post natal Mental Health
• APP- action post partum psychosis
www.app-network.org
• National Teratology Service
0191 260 6181
• West Midlands Medical Information0121 424 7298
Learning Outcomes
• Service organisation
• Importance of perinatal mental illness
• Ante natal depression
• Post natal depression
• Puerpural psychosis