Postnatal Depression

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Postnatal Depression. Dr Barbara Bavda ž International Conference on Women’s Health October 8th/10th 2009 Nablus, Palestine. Childbearing. One of the most complex events in human experience Physical changes of childbirth Psychological changes of childbirth - PowerPoint PPT Presentation

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  • Postnatal DepressionDr Barbara BavdaInternational Conference on Womens HealthOctober 8th/10th 2009Nablus, Palestine

  • ChildbearingOne of the most complex events in human experiencePhysical changes of childbirthPsychological changes of childbirthIncreased vulnerability to general psychiatric disorders

  • Postnatal Depression (PND) or PPDWorld-wide. Affects about 13% of women within the first year of childbirthCultural changes (stigma !). Greater awarenessInformation. Prevention. Can escape diagnosisAntenatal and postnatal screeningEarly interventionMultidisciplinary approachMother-infant relationship and (can affect) child growth and cognitive and emotional development of the baby

  • Postnatal Depression in the Developing WorldAttention tends to focus on seemingly more pressing health problemsRecent studies show 25-30 % new mothers (prevalence almost double)Mental health pays a central role in maintaining physical health and development of the communityLower status relative to men, lack of autonomy, birth of a girl, poor housing, isolation, poverty

  • Postnatal Depression in the Developing WorldEnvironment more hostileMore infection, less sanitationLot of pressure, unable to do all those thingsBaby does not get all the nutrients; diarrhoea, losing vital nutrientsDoes not respond appropriately to childs illness, not taking the baby to be vaccinated

  • Postnatal Depression in the Developing WorldIn Ethiopia 10% die in their first year of life: 50-60% because they are malnourished and dont have the strength to fight the illnessProjects asking local clinicians to use local and not Western standards to define mental disorderIn Pakistan: Lady Health Workers since 1994 About 96,000 LHW cover more than 80% of Pakistans rural populationSupport through empathic listening and positive reinforcementWe are working for optimal health of the childA healthy mother leads to a healthy child

  • Old ClassificationUnder Three Headings:Maternity blues (30-75% 3-4 days after birth)Post-partum ( post-natal ) depressionPost-partum ( puerperal ) psychosis

  • New classification *Four-part classification:PsychosisMother-infant relationship disordersDepressionAnxiety and stress-related disorders

    * I. Brockington

  • PNDDepressedIrritableTiredSleeplessLack of AppetiteAnhedoniaSexualityUnable to copeGuiltyAnxious

  • Postnatal Depression *Non-psychotic depression with an onset within 1 year of childbirth,ButA lay term ?Weak epidemiological association ( p/d )Common in adult women ( lower rates! )Heterogeneous groupCausal associations same as for depression generally

    * Ian Brokington, Univ. of Birmingham, UK

  • Detection, Prevention, Treatment InterventionsReduce stigma, allow public recognition E.I. / Prompt diagnosis and (prophylactic ?) treatmentAntenatal clinics ( risk factors, history )Midwifes, (community) nurses, general practitioners, health visitors Voluntary agencies, groupsInvolvement of fathers, family membersImpact on infant well-being and development !

  • Risk factorsUnwanted pregnancy (single w., adolescents, over forty)Young age (interruption of schooling and of personal growth, future poverty)Having three or more childrenSingle m. status or poor marital relationshipLower socioeconomic status (maternal education protective factor)Low self esteemSubstance abuse

  • Risk factors continueAnte-natal depression or anxietyPrevious episode of postnatal depressionHistory of depression or bipolar disorderFamily history of PPDGender of child (!)Recent stressful life eventsInadequate social support (child care stress)Obstetric and pregnancy complications

  • Prevention and detectionGeneral screening:-Use questionnaires e.g. EPDS ( the whole gamut of post-partum psychiatric disorders ) !-Explore wider context e.g. mothers life history, personality circumstances !-Follow course of the pregnancy including parturition, puerperium !-Assess quality and strength of relationships !-Identify vulnerability and availability of support !

  • Prediction and DetectionHealthcare professionals: midwives, obstetricians, health visitors, GPs, community nurses, voluntary agencies, (peer) groups,Pregnancy does not protect against depressionHigh relapse rates in those who discontinue medication

  • TreatmentShould integrate both psychosocial and biological modalities

    Psychological support: hospital and community nurses, health visitors, counsellors ( groups and individual sessions, anxiety management) Social support: social workers, motherhood classes, o.t. (support workers), self help groups Involvement of fathers

    Pharmacological treatment

  • Risks of Not Treating PPDHarm to the mother throughPoor self-careLack of obstetric careSelf-harm

    Harm to the foetus or neonate ranging fromNeglect toinfanticide

  • Mild or Moderate Depression During Pregnancy or During Postnatal PeriodSelf-help strategiesNon-directive counsellingBrief cognitive-behavioural therapy or interpersonal psychotherapy

  • Treatment with Ads. The Maudsley RecommendationsThose who are already receiving ADThose who develop a moderate or severe depressive illnessPsychological managementAd - tricyclics (amitript., imipr., nortript.) - SSRIs (avoid paroxetine/first trimester/linked to cardiac malformations!) - fluoxetine has the lowest known riskContinue breast-feeding and switch to mixed (breast/bottle) feedingAll AD carry the risk of withdrawal or toxicity

  • Resources and ServicesAims= prevention, early diagnosis, versatile intervention with minimal family disruption (community based)The multidisciplinary specialist team: psychiatrists, psychologists, nurses and nursery nurses, social workers (Ts)Voluntary agencies, self-help groups, leaflets and booklets (RCPsych, MIND in U.K.)

  • State of Art in the WorldDomiciliary assessment and home treatmentDay hospital ( putting women with similar problems in touch with each other )Mother and baby units, linked to obstetric units and paediatric units in UK, Australia, New Zealand, France, Germany, Belgium, The NetherlandsItaly: Trieste Service evaluation/research need to be implemented

  • Psychological Intervention in High Risk Pregnancy

    IRCCS Burlo Garofolo- Department of Obstetrics and Gynaecology Dr Viviana Ive, psychologist, psychotherapist

    Centre for High Risk Pregnancy: pre-eclampsia, multiple pregnancy, previous pregnancy with intrauterine death or previous interruption caused by severe delay in foetal growth, elective medical abortion Multidisciplinary integrated team to support women before pregnancy and monitor during pregnancy, in order to reduce at most the risks (for health) of mother and baby. Centred on physical health, emotional and psychological health

    Coordinated by one Psychologist/Psychotherapist

  • Psychological Intervention in High Risk Pregnancy 2Referrals: from medical staff or midwife, who offer the possibility of psych. intervention), sometimes requested directly by the women.Assessments: on ward if urgent, alternatively opas Crisis intervention (on ward): intra-uterine death or peri-natal death communication of dubious or poor prognosis (after echography) emotional distress during pregnancy (panic attacks, phobias, mood disorders) traumatised by parturition post-natal emotional distress (difficulties in relating with newborn baby)Intensive psychological intervention during hospital admission. Some women need further care and follow up in OPC.Network intervention: the hospital social service and the community based services

  • Psychological Intervention in High Risk Pregnancy 3OPA Counselling and psychotherapy, focussed on bereavement (with disfunctional features), emotional disturbance in pregnancy (anxiety, mood disorders) or post- natal depression, difficulties in relationship with baby or marital problems, PTSD

    Network intervention: hospital social service, community based services (CMHTs, PCTs, Social Services, GPs, Alcohol and Substance Misuse Services)

    Aims of intervention: to provide care, support, containment and elaboration of pain caused by any pathological condition, foetal death, emotional distress; to allow sufficient or good care to new born baby in any circumstances

  • Synergic Effects of Oxytocin andPsychotherapy in Postpartum Depression 1

    A 3 year randomized controlled trial on 150 women; area of intervention is the province of Trieste

    Financed by the Department of Reproductional and Developmental Science

    -Dr. Andrea Clarici - MD - Senior Lecturer at the University of Trieste Faculty of Medicine (IRCCS Paediatric Hospital Burlo Garofolo, Trieste). -Dr. Sandra Pellizzoni - Psychologist - Postgraduate student at the IRCCS Paediatric Hospital Burlo Garofolo Trieste

  • Synergic Effects of Oxytocin andPsychotherapy in Postpartum Depression 2Hypothalamic neuropeptide implicated in regulation of social, reproductive and stress-related functionsA key role in intimate attachment such as marital relationship and early interaction with offspringTwofold effect: to strengthen attachment and reduce stressReferrals from paediatricians, obstetricians and midwifesTwo random groups: psychotherapy and Oxytocin vs. psychotherapy and placebo

  • Depression, post-partum, violence 1Trieste, IRCCS-Burlo G. Psychology Dept. University of Trieste and University of California in San FranciscoStudy on 352 women, mean age 32, September 2004 to March 2005Part 1: two questionnaires(Common) vi