Perinatal Mental Health

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• Publisher: M&K Publishing
• Year: 2012
• Print ISBN: 9781905539499
• eBook ISBN: 9781907830495
• Topic: Medicine
• Subtopic: Nursing

The prospect of parenthood represents a milestone in anyone's life course and is often a period of stress and challenge. There are a number of significant mental health problems that can occur during the perinatal period, the consequences of which can be both enduring and, occasionally, life threatening. However, irrespective of the specifics of the clinical manifestation of a disturbance, the distress and misery that accompanies it has significant ramifications for the mother or mother-to-be and her partner and family.

Part One

Maternal mental health before and during pregnancy

Chapter 1Epidemiology of maternal mental health disorders
Jessica Gibson and Ron Gray

Chapter 2Major depressive disorder
Carol Henshaw

Chapter 3Anxiety
Amanda McGrandles and Tim Duffy

Chapter 4Personality disorders
Caroline J. Hollins Martin

Chapter 5Schizophrenia
Mick P. Fleming and Colin R. Martin

Chapter 6Bipolar affective disorder
Glenn R. Marland and Colin R. Martin

Chapter 7Eating disorders
Helen Fawkner

Chapter 8Sexual dysfunction
Olga B.A. van den Akker

Chapter 9Comorbid physical illnesses
Julie Jomeen and Colin R. Martin

Chapter 10Chronic fatigue syndrome
Yvonne Christley and Colin R. Martin

1	Epidemiology of maternal mental health disorders
	Jessica Gibson and Ron Gray

This chapter discusses the epidemiology of the antenatal period only (mental illness in the postnatal period is addressed later in this book). It considers the characteristics of the antenatal period to identify specific issues and risk factors associated with this stage. The discussion is confined to the pregnant woman, only referring to the fetus when it may be directly affected by maternal mental illness. Each diagnostic category is examined separately to consider whether pregnancy impinges on the course of mental illness in any way, but treatment in the antepartum period and the teratogenesis of psychotropic drugs are not discussed as they are beyond the scope of this chapter.

The perinatal period has been identified both as a risk factor for relapse of mental illness and a time of relative protection. It is timely, therefore, to investigate whether the antenatal period differs significantly from other times in a woman’s life in terms of developing a de novo mental illness or experiencing a relapse of a pre-existing disorder.

The peak age of onset for most severe mental illnesses occurs during the fertile years for women, that is between 15 and 45 years old. Up to 50 per cent of pregnancies in the UK are unplanned (Dex and Joshi, 2005) and this rate may be even higher among women with mental illness. Therefore, the possibility of pregnancy in all women with mental illness who are of reproductive age should be considered. Only by understanding how pregnancy affects mental illness and vice versa can we address how it might be detected and treated and what services need to be developed.

Review methodology

This literature review was informed by searching on Medline™, Embase™ and PsychInfo™ for the years 1998–2009. The terms ‘pregnancy’, ‘antenatal’, ‘prenatal’, ‘antepartum’, ‘obstetric’, ‘schizophrenia’, ‘psychosis’, ‘substance misuse’, ‘alcohol’, ‘bipolar’, ‘suicide’, ‘deliberate self-harm’, ‘obsessive–compulsive disorder’, ‘anxiety’, ‘post-traumatic stress disorder’, ‘tokophobia’, ‘depression’, ‘eating disorder’, ‘anorexia nervosa’ and ‘bulimia nervosa’ were used. Bibliographies were inspected and relevant citations examined.

What is special about the antenatal period with respect to mental health problems?

In the antenatal period there are two particular concerns: the mother and the developing child. The relationship between mother and the fetus is physiological, psychological and social. From a physiological perspective, virtually every substance that enters a woman’s body is transmitted to the fetus across the placenta. This is of particular relevance for medicinal or other drugs and alcohol, especially in the first trimester of pregnancy. At the same time, pregnancy has significant effects on the woman’s body. There are alterations in hormone levels, circulatory blood volume and blood pressure and on the immune system. Psychological changes during pregnancy are equally significant. Particularly in a first pregnancy, a woman needs to adapt to her changing role in society, her family structure and in her workplace. This may be a time when issues from childhood and the past may re-emerge. Difficulties in a relationship with parents are often re-awakened as a woman prepares for parenthood for the first time. Previous experiences of physical or sexual abuse may be recalled as she becomes increasingly aware of her evolving reproductive function (Austin, 2003). From a social perspective, pregnancy may entail additional financial costs and pressures about accommodation. Relationships between the woman and her partner, the father of the developing fetus, may be renegotiated in pregnancy, and this can change level of support and stability in her personal life.

The above demonstrates some of the ways in which pregnancy impacts on a mother. We also know that the woman’s mental state and behaviours can have a direct effect on the fetus. Maternal stress can cause changes in the fetus’s hypothalamic–pituitary–adrenal axis and predispose the infant to behavioural disorders and depression in later life (Hubel et al., 2008; O’Connor et al., 2002). The harmful effects of substance misuse during pregnancy are also well documented and include fetal malformations, stillbirth and premature delivery. Specific problems that arise in the antenatal period may be exacerbated in multiple pregnancies and may also arise following stillbirth, miscarriage and termination of pregnancy. What is more, any disorder arising in pregnancy may continue into the postnatal period, and beyond.

Classification of mental disorders in the antenatal period

The commonly used classification systems for mental illness have no specific category for antenatal occurrence of mental disorders. While there is a qualifier to denote if onset is in the puerperium, there is no equivalent for the antenatal period. This may impede the accurate recording of information concerning the onset of women’s mental illness and it poses limitations to research that may require such data. This approach also suggests that a relapse or new-onset illness in a woman in the antenatal period is widely considered to be no different from psychopathology that occurs at any other time (Henshaw et al., 2009).

How do we detect mental disorders in the antenatal period?

The National Institute for Health and Clinical Excellence (NICE) guidelines define ‘detection’ of antenatal mental illness as ‘the identification of a current disorder’, while ‘prediction’ refers to ‘the identification of risk factors, current or past, which increase the probability of onset of a mental disorder at some point in the future’.

Detection normally occurs through self-report by women with a degree of insight or with a known mental illness. The process of screening could, in theory, detect ‘hidden’ mental health problems. However, accurate detection of antenatal mental illness requires validated screening tools, but few instruments are validated for use in this population. Successful screening also depends on communication between the population of interest and the healthcare services. Unfortunately, women with existing mental illness are among those who are least likely to be in touch with medical services (McNeil et al., 1984).

The aim of screening would be to detect cases of illness that could be treated, thus reducing the overall morbidity associated with pregnancy. It would be unethical to screen anyone without the adequate provision of resources to treat those with detected disorders (National Screening Committee, 2001). Screening is not a diagnostic activity; it needs to be followed by formal assessment and diagnosis. A systematic review of antenatal assessments by Austin et al. (2008) found that screening for antenatal mental illness may increase clinicians’ awareness of psychosocial risk, but there was insufficient evidence that routine screening will lead to improved mental health outcomes.

Is the antenatal period associated with an increased risk of developing a psychiatric disorder or relapse or an unusual presentation?

To answer this question it is helpful to consider each broad diagnostic category of mental illness individually in order to investigate any patterns or trends that exist in the antenatal period, from bipolar disorder, anxiety and depression to eating disorders and substance misuse.

Bipolar disorder

It is well documented that the postpartum period is a time of significantly increased risk of relapse for women with bipolar disorder. However, there is varying evidence about the risk of women relapsing or developing bipolar disorder de novo in the antenatal period. There is some research to suggest that pregnancy exerts a protective effect (Grof et al., 2000) but other recent studies indicate that pregnancy is a time of substantial risk. Women who are prescribed with mood stabilising medication may abruptly cease taking medication, especially if the treatment is known to have potentially teratogenic effects. Sudden cessation of this medication is known to increase the risk of a depressive or manic relapse. A prospective study by Viguera et al. (2007) suggests that pregnancy carries a significant risk of relapse. In women with a known bipolar disorder, in whom mood-stabilising medication is stopped, the risk of relapse is twice as likely as in women who continued with their medication. The latent period to recurrence of the illness was also four times shorter in those who came off their medication, and the illness lasted longer. The risk of relapse was even higher if there was abrupt cessation of medication. A total of 86 per cent of these women experienced a relapse of a mood disorder meeting the diagnostic criteria for SCID (Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders)). The incidence of relapse in women who continued on their medication remained high, with 37 per cent of the cohort experiencing at least one episode of illness. Unplanned pregnancy was a predictor of antenatal relapse in this group. Most relapses (79 per cent) were depressive or mixed in type, with mania or hypomania accounting for the remaining 21 per cent of cases.

Schizophrenia

The peak age of onset of schizophrenia in women is in the mid- to late 20s, with a second smaller peak in women in their late 40s. This is later than in men and, as such, women are more likely to have completed their education, entered employment and started having children by the time of their diagnosis. While there is evidence of lower fertility rates in women with schizophrenia, the majority of women with psychotic disorders still have children (Howard et al., 2005). The impact of schizophrenia on the pregnancy is well documented; the mothers use more alcohol, tobacco and illicit drugs compared to women without schizophrenia and their nutritional status and attendance for antenatal care are poor. These factors may partly account for the increased rate of preterm delivery, intrauterine growth restriction, low birthweight, low Apgar scores and possibly stillbirth in their child (Altshuler et al., 1996; Howard, 2005).

However, it is not clear whether pregnancy has any effect on the course of pre-existing schizophrenia. One prospective study (McNeil et al., 1984) found higher rates of ‘active mental disturbance’ in pregnant women with a history of non-organic psychosis than in matched controls. Only one-third of these women were in contact with a psychiatrist during this time. The apparent avoidance of antenatal and mental health services by women with psychotic disorders means that it is difficult to gather accurate data in this area. There is no evidence that pregnancy increases the risk of developing schizophrenia de novo.

Depression

Antenatal depression has been relatively neglected, in terms of research, compared with postnatal depression. While diagnostic classification systems provide operational criteria by which to make a diagnosis, the ‘lay’ use of the term depression tends to be broader. Primary-care practitioners may also make less specific diagnoses, so data from primary care may relate to a greater range of psychological difficulties. Often a woman’s inability to cope or heightened anxiety and adjustment disorders find themselves included in the concept of ‘depression’. Therefore, data from research studies must be interpreted with caution paying close attention to the definition of ‘depression’ that is being used.

There is increasing evidence that rates of depression are at least as high, if not higher, during pregnancy than the postnatal period (Heron et al., 2004). The prevalence of antenatal depression is estimated at 10–20 per cent (Evans et al., 2001) which is similar to the prevalence of depression in the non-gravid population. Indeed, there is little evidence to suggest that there is a categorical difference between depression in the perinatal period and at other times.

Pregnancy may affect the course of a depressive disorder in several ways. Firstly, the pregnancy itself may act as a trigger because it is a major life event and all major life events are associated with an increased risk of relapse in affective disorders (Paykel, 2003). There are also significant biological changes in pregnancy that affect mood state. These include raised levels of female sex steroids that act at the mood regulation area of the brain (O’Keane, 2006). Discontinuation of antidepressant medication is another contributing factor (Cohen et al., 2006). In terms of relapse of pre-existing depression during pregnancy, Cohen et al. (2006) report that 43 per cent of women with a history of depression undergo a relapse during pregnancy. If their medications were decreased or stopped, the rate of relapse was 68 per cent. In those who continued antidepressant treatment throughout their pregnancy, 26 per cent experienced a relapse. Those who stopped or decreased their medication were found to have a five-fold greater risk of relapse than those who continued it. Of these occurrences, over half were within the first trimester, with the risk decreasing throughout the pregnancy. Other risk factors for antenatal depression include a history of depression of over five years, the occurrence of more than four previous episodes...

Table of contents

• Cover Page
• Title Page
• Copyright
• Dedication
• Contents
• Foreword
• Acknowledgements
• Partum Queens
• About the Editor
• About the Contributors
• Introduction
• Part One: Maternal mental health before and during pregnancy
• Part Two: Labour and the postnatal period
• Part Three: Mental health of the partner
• Part Four: Support, social care and healthcare delivery
• Part Five: Maternal assessment, counselling and therapy
• Part Six: Contemporary issues
• Part Seven: Child health, child care and child development
• Index