Perinatal Mental Health

A Sourcebook for Health Professionals

Riley Diana

• Publisher: CRC Press
• Year: 2018
• eBook ISBN:
  9781315343822
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

APPRAISAL AND REVALIDATION SERIES The new Appraisal and Revalidation Series helps doctors demonstrate their competence to the standard expected by the General Medical Council and to the standard expected if they are recognised as having 'special clinical interests'. It helps doctors gather evidence of their performance for appraisal and revalidation portfolios. This fifth book in the series examines the practical ways to identify learning and service needs within the areas of substance abuse palliative care musculoskeletal conditions and prescribing practice. It also provides guidance on how to collect data to demonstrate learning competence performance and service delivery standards. All general practitioners and those with special clinical interests and primary care organisation leads will find this book essential reading. For more information on other titles in this series please click here

1 Pregnancy

There is a popular image of the pregnant woman as ‘blooming’, with improved physical and emotional health. This is often far from the truth. A particularly notable finding is that women vary enormously in their response to pregnancy, and there is a similar variation with each stage of pregnancy, so that professionals need to be sensitive to women’s differing needs for emotional support at any particular time.

There is evidence that some pregnancies may be related to neurotic symptoms. A study of students found that those who became pregnant had a higher incidence of previous consultations for psychiatric problems¹. Pregnancy may be entered into as an attempt to gain attention, as an escape from an unwelcome situation, to mend a failing relationship, or to provide a love object. Worst of all, and most likely to fail, is the expectation that the child will provide the love and care that the woman has lacked in her life so far.

Joan Raphael-Leff² has identified three groups of ‘problem pregnancies’. These are:

• conflicted, where the pregnancy is unplanned, untimely, or wrong. This can be as a result of a transient or unhappy relationship, sometimes even as a result of rape or incest. The timing can be wrong, as in the woman who is resentful about the interruption of her career, or a pregnancy too soon after a stillbirth or neonatal death, whilst she is still grieving. A frequent pattern is a pregnancy soon after a termination or miscarriage in an attempt to ‘replace’ the lost child.
• complicated, by physical or socio-economic problems, or adverse life events. Pregnancies complicated by antepartum haemorrhage or pregnancy induced hypertension, which require the mother to rest in bed for long periods can be tedious and worrying. Where there are serious practical problems with housing, finance, or lack of support from friends or family, the mother will feel insecure and anxious. The ‘new house, new baby’ is a case in point. Bereavement, perhaps the loss of a parent, during the pregnancy will complicate the mother’s feelings, and often leads to postponement of the grieving process until after the birth.
• emotionally sensitized, in which the pregnancy is over- or undervalued because of the previous experience of the woman or her close family members, or due to her own neurotic traits. A previous history of infertility, for example, may mean that the mother overvalues the pregnancy, having unreal expectations about how wonderful it will be, yet being unprepared for the responsibility of a child. Previous pregnancy loss may lead to her withholding attachment to the baby until after the birth.

Psychiatric Problems in Pregnancy

There is a surprising incidence of measurable psychiatric morbidity, even during an apparently ‘normal’ pregnancy. A prospective study in a London antenatal clinic using the General Health Questionnaire (GHQ) showed that 16% of women were ‘cases’ of depression at 12-14 weeks into the pregnancy, and that this severity of depression correlated with previous psychological problems, ambivalence about the pregnancy, previous termination and marital tension³. A similar Australian survey found an even higher incidence (40%) at 33-34 weeks⁴. Another survey of 179 women at a booking clinic showed that 35% were high scorers on the GHQ, and 29% were confirmed as ‘cases’ at interview⁵. This is no artefact of questionnaire response. When the women studied are those with ‘high risk’ pregnancies in terms of physical complications, 66% are found to have a clear psychiatric diagnosis⁶.

This degree of morbidity in pregnant women does not seem to be given sufficient recognition by professional carers, perhaps because the emotional condition is thought to be as self-limiting as the physical state, but more likely, because it is not identified or is attributed to a ‘normal’ overemotional state in pregnancy (see Case Study 1.1).

It may, however, have relevance to the outcome of pregnancy. For example, late booking or poor attendance at the antenatal clinic is one way in which the mother’s emotional state may influence fetal health. There is also some evidence that physical complications are more frequent in emotionally disturbed women. One study⁷ has shown anxiety in pregnancy to correlate with pregnancy induced hypertension, and another⁸ that anxious women are more likely to opt for elective induction of labour. Research also shows that women with significant adverse life events (and hence increased stress) in the year preceding delivery are more likely to suffer premature labour⁹.

A special case is that of pregnant women who have suffered from previous psychotic illness. Careful follow-up studies show that in general they also vary in their reactions to pregnancy. About 30% report some improvement in their mental health, most of these being in the older age group, and with previous depressive or manic-depressive illness. Negative effects were associated with lack of social support, situational problems and interpersonal difficulties¹⁰. Psychotic episodes can, and do, occur during pregnancy but are relatively rare compared with their serious increase in frequency and severity postpartum.

Previous neurotic illness has been examined less closely, but there is some evidence to show that panic disorder and obsessive-compulsive symptoms actually improve during pregnancy, only to worsen again after delivery. Women with previous anorexia often react badly to the changing body shape associated with pregnancy, and will be preoccupied with weight and diet.

On the positive side, the incidence of suicide in pregnancy is extremely low. Over a 12-year period, 14 suicides were reported, mostly in the second trimester, whereas the expected number was 281; thus, pregnant women have only 5% of the expected risk of suicide. The numbers were highest in the 15-29 age groups¹¹.

Society seems to assume that all women will feel equally happy and fulfilled as soon as the pregnancy is established, but even the most stable and mature mother will have times of self- doubt and trepidation, and will need support for herself in order to deal with the demands of her new and unfamiliar role. Some of the ‘normal’ positive and negative responses are summarized in Tables 1.1, 1.2. Most women will fluctuate between these positive and negative feelings at different stages of the pregnancy depending on their own personality, past experience, and socio-cultural setting.

Table 1.1 Positive changes in pregnancy

Contributory Factors to Psychological Problems in Pregnancy

A woman’s reaction to the confirmation of pregnancy varies with her socio-cultural milieu. For example, the status of pregnancy in society is different in some ethnic and religious groups, and will also vary with time, the size of the existing family, and perhaps even the sex of the existing children.

Support from the partner has been shown in many studies to be an important factor in emotional health during pregnancy. Those experiencing depression commonly report relationship problems, and there is clearly a need in pregnancy, above all other times, for emotional as well as domestic and financial security. It has also been shown that women are more sensitive at this time to adverse life events such as health problems, losses, crises or domestic difficulties.

Table 1.2 Negative aspects of pregnancy

Anxieties about the normality of the pregnancy will be increased if there have been previous pregnancy disasters, if there is a family history of birth trauma or abnormality, or if there is doubt about the results of any of the antenatal predictive tests. Concern about the baby’s size on the scan, persistent vaginal bleeding, or raised blood pressure will affect psychological well-being and cause anxiety, self-blame and even resentment towards the fetus.

Prospective studies have shown that women who have frequent doubts about their ability to handle the demands of pregnancy and parenthood exhibit the most severe depressive symptoms in pregnancy. However, this may have a positive effect postpartum, as the woman ‘rehearses’ antenatally some of the negative aspects of motherhood. Other contributory personality factors may include over-dependency on partner or parents, and an over-sensitive, anxious or pessimistic personality.

Depression may accompany all physical symptoms, and the minor physical problems of pregnancy, such as nausea, heartburn, varicose veins and backache, will contribute to a lowering of mood. Of particular importance for emotional well-being is the reduction of Stage IV (the deepest level) sleep which occurs commonly in late pregnancy¹².

There is little factual information about the direct effect of the changed hormone levels in pregnancy on mood. It is thought that raised oestrogen levels give rise to nausea and emotional lability, whilst increased progesterone may cause sedation and lethargy. Thyroid hormone levels are raised in pregnancy¹³ and may contribute to anxiety symptoms; raised Cortisol levels, which also occur in pregnancy, are also known to correlate with depression.

Treatment of Psychological Problems in Pregnancy

Very simple interventions can often be most helpful in improving depressed mood or anxiety. The first requirement is to listen and to validate the feelings of the pregnant woman by giving her time and attention.

Practical Intervention

Simple advice-giving about having sufficient rest, particularly in the later stages of pregnancy, and avoiding major life changes, can be useful. The health visitor and the general practitioner are in an ideal position to identify antenatal anxieties and to offer reassurance and support. Women new to the area are particularly vulnerable; they lack a support network, and they may benefit from being introduced to other mothers at prenatal classes or mother and toddler groups.

Social workers can provide help with financial matters, and support for housing applications. They can also recommend the provision of practical support in terms of home help, or attendance at Social Services’ family centres. Playgroups or child-minding for older children can provide welcome relief, particularly for the socially disadvantaged mother.

Psychotherapy

Where there are more specific psychological issues to be addressed, counselling or psychotherapy can be of benefit. This can be on an individual basis, or can also include the partner. Group therapy is less suitable because of the inevitable exit from the group at delivery, although mothers in a postnatal support group will often continue to attend through a subsequent pregnancy.

Some therapists are reluctant to embark on analytical psychotherapy during pregnancy because of the many ‘real-life’ changes going on at the same time, but some find it more advantageous because the women are highly motivated, and have a sense of urgency to change before the birth.

Brief cognitive behavioural therapy may be both more practical and acceptable than analytical psycho...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword
• Introduction
• 1 Pregnancy
• 2 Labour
• 3 The Early Puerperium
• 4 Postnatal Depression
• 5 What Causes Postnatal Depression?
• 6 Puerperal Psychosis
• 7 Other Relevant Psychiatric Problems
• 8 Psychotropic Drugs
• 9 Fathers
• 10 Service Provision
• 11 Resources
• Index