Suicide in Perinatal Period

FATEMEH HADI, MD

ASSISTANT PROFESSOR OF PSYCHIATRYIRAN UNIVERSITY OF MEDICAL SCIENCES

Women’s suicide in the worldSuicide is the second leading cause of death among 15–29-year-olds.

According to the Global Burden of Disease study, suicide is the fourth leading cause of death for women aged 15–49 years worldwide, and has been identified as one of the major killers of young women in low-income and middle-income countries.

Road traffic accidents and suicide are among the ten leading causes of death among adult women in middle-income and high-income countries.

Maternal deathApplication of the tenth revision of the International Classification of Diseases (ICD) to deaths during pregnancy, childbirth, and the puerperium divides maternal deaths into:

Direct obstetric deaths (ie, deaths resulting from the obstetric complications of pregnancy, interventions, omissions, incorrect treatment, or a chain of events resulting from any of the above)

and

Indirect obstetric deaths (ie, deaths resulting from a previous existing disease, or disease that developed during pregnancy that was not due to direct obstetric causes, but was aggravated by physiological effects of pregnancy.

Maternal death in ICD-MMIn ICD-MM, maternal deaths related to psychiatric illness are classified as direct rather than indirect or fortuitous.

This step was taken because psychiatric illness in general, and suicides in particular, remain taboo in many countries and are likely to have been grossly under-reported. Although postpartum psychosis can be grouped as a direct cause, many suicides and other psychiatric deaths occur in women with underlying psychiatric conditions, and are therefore indirectly related to the pregnancy. In this way, ICD-MM deviates from the initial pathophysiological basis for classifying deaths as direct or indirect, and causes confusion.

classification of psychiatric deaths into a separate group is important to raise their visibility.

Maternal death

Suicide is an important cause of death during pregnancy and the first postnatal year, accounting for about 5–20% of maternal deaths in high-income countries, and 1–5% in low-income and middle-income countries.

The proportion of maternal deaths attributable to suicide in most studies ranged from roughly less than 1% to 5% in low-income and middle-income countries (Fuhr DC, et al, 2014) and from 3% to 13% in high-income countries (as reported in studies from Europe, North America, and Australia).

Suicide in LMICsThe proportion of pregnancy-related deaths attributable to suicide in low-income and middle-income countries is unknown.

This gap in knowledge is mainly because suicide deaths along with other coincidental causes of death have conventionally not been included in the WHO definition of maternal mortality, which includes direct and indirect obstetric causes of death only.

By contrast, the definition of pregnancy-related mortality includes all maternal mortality causes in addition to coincidental causes of deaths such as injuries. However, some maternal mortality studies recognise suicide as a cause of maternal mortality, arguing that it can be a fatal outcome of perinatal or postpartum mental illness and have advocated that it should therefore be deemed as an indirect cause of maternal death.

The WHO, in its revision of the causes of maternal mortality for the new ICD-11, proposed that all antepartum and postpartum suicide deaths should be included as direct obstetric deaths.

Perinatal suicide in Ontario, Canada: a 15-yearpopulation-based study

The perinatal suicide rate was 2.58 per 100 000 live births, with suicide accounting for 51 (5.3%) of 966 perinatal deaths.

Most suicides occurred during the final quarter of the first postpartum year, with highest rates in rural and remote regions.

Perinatal women were more likely to die from hanging (33.3%) or jumping or falling (19.6%) than women who died by suicide non-perinatally.

Only 39.2% had mental health contact within the 30 days before death, similar to the rate among those who died by suicide non-perinatally (47.7%).

The protective effect of maternity?Psychiatric disorder, and suicide in particular, is the leading cause of maternal death.

While suicide deaths and attempts are lower during pregnancy and the postpartum than in the general population of women, when deaths do occur, suicides account for up to 20% of postpartum deaths.

Women also died from other complications of psychiatric disorder and a significant minority from substance misuse.

It is likely that the suicide rate following delivery is not significantly different to other times in women's lives and for the first 42 days following delivery may be elevated. This calls into question the so-called ‘protective effect of maternity’.

Mental illness in the perinatal period Mental health among women, and more specifically during pregnancy, 15-20 % of pregnant women present a mental disorder (NICE, 2014)

Mental illness in the perinatal period has a distinct clinical presentation:

Women are more likely to stop medication in the perinatal period than at other times, and are more likely to have abrupt onset, rapidly deteriorating psychosis in the postnatal period.

Although most women have increased contact with health service during pregnancy, some might avoid services because of fear of stigma or child custody loss.

Suicide trends Drawing on maternal suicide statistics from 1997 up to 2005, these researchers identified some trends, including the following:

•Most of the women committing suicide had a previous history of mental illness.

•These women typically had an abrupt onset of symptoms and rapid deterioration.

•There is usually an early onset of symptoms, with deaths typically occurring within the first three months of giving birth.

•There is often poor communication between the mother and her various health and psychiatric care providers and a lack of adaptation of psychiatric services to the maternity context.

Risk factors Most women who die by suicide in the perinatal period have a known history of mental illness.

Few studies examined risk factors for maternal suicides. Reported risk factors included:

1. Mental illness (present in 30–70% of maternal suicides)

2. Substance misuse

3. Intimate partner violence

4. Neonatal complications (particularly perinatal death)

5. Medical comorbidity

Associations with age and socioeconomic status differed by setting and timing of suicide, with teenagers reported to have a higher risk of pregnancy suicide than women of other ages, especially in low-income and middle-income countries.

Risk factors for suicide attempt in pregnancy and the post-partum period in women

with serious mental illnesses(Gressier, 2016)

History of mental illness is a major risk factor for suicide in perinatal period.

Suicide attempts in pregnancy was related to:

1. alcohol use

2. smoking during pregnancy

3. history of miscarriage

Suicide attempts in the post-partum period was associated with:

1. major depressive episode

2. recurrent depression

3. younger age

Depression Self-harm ideation is more common than attempts or deaths, with thoughts of self-harm during pregnancy and the postpartum ranging from 5 to 14%.

The risk for suicidality is significantly elevated among depressed women during the perinatal period, and suicide has been found to be the second or leading cause of death in this depressed population.

In the study” Perinatal depression in a cohort study on Iranian women”(2010)

The prevalence of depression in last trimester of pregnancy, was 22.8%

Rate of depression between 6 to 8 weeks after delivery, was 26.3%

Suicide Relative to suicide rates in the general female population, pregnant women have lower suicide rates.

When suicide does occur, the use of violent methods of suicide among pregnant women suggests high levels of intent and may be related to higher levels of psychopathology in these women.

Consistent with suicide in pregnancy, suicide methods in the postpartum are violent and indicate high intent.

The majority of the suicides died violently, mainly by hanging or jumping.

Minority of women died from an overdose of medication.

Contrasting with the usual finding that women are more likely to die from an overdose of medication.

Among the pregnant women who die by suicide, teenagers were reported to be at greater risk (Appleby, 1991), as were women in cultures that stigmatize motherhood among unmarried women.

WHOMental health problems during pregnancy and afterchildbirth are common.

Mental health problems such as depression andanxiety are very common during pregnancy and afterchildbirth in all parts of the world.

One in three to one in five women in developingcountries, and about one in ten in developedcountries, have a significant mental health problemduring pregnancy and after childbirth.

WHOThe risk factors for mental health problems are gender-specific.

Social determinants are an important cause of mental health problems in pregnant women and mothers.

Women, especially those living in developing countries are more exposed to risk factors, which increase their susceptibility to develop mental health problems.

Some of these include poor socioeconomic status, less valued social roles and status, unintended pregnancy and gender-based violence.

Rates of mental health problems are at least 3 to 5 times higher in women exposed to intimate partner violence.

Pre-existing psychological disturbances often surface as depression, substance abuse or attempts at suicide, particularly when combined with a pregnancy that is unwanted.

Screening oNone of the women who died had been admitted at any time to a Mother and Baby Unit and their psychiatric care had been undertaken by General Adult Services.

oNone of the women who died had had a previous episode correctly identified and none had had adequate plans for their proactive care.

oThere is a need for both Psychiatry and Obstetrics to acknowledge the substantial risk that women with a previous psychiatric history of serious mental illness face following delivery.

oThese findings led to the recommendation that all women should be asked early in their pregnancy about a previous history of serious psychiatric disorder and that management plans should be in place with regard to the high risk of recurrence following delivery.

Recommendations

Women with a history of significant mental health problems should be offered a mental health assessment antenatally and be counselled about pharmacological and other treatments during pregnancy.

Psychosocial screening, with ongoing mental health monitoring and clear referral pathways (where appropriate), should be made available to all women in the maternity setting.

Continuing professional development programs for general practitioners, midwives, child and family health nurses, and other community health practitioners should include education about perinatal morbidity and mortality from mental illness up to a year after birth.

Members of the mental health profession should be engaged in developing a standard instrument for investigating maternal deaths from psychiatric illness.

A culture of audit should be developed among mental health professionals regarding maternal deaths. The proposed standard instrument could be applied in investigations of deaths in which suicide is suspected.

You can find me at:

Hadi.f@iums.ac.ir

Thanks for your attention!