Lecture 4-Antenatal and postnatal depression Flashcards
what are the symptoms of antenatal depression?
Symptoms Chronic anxiety Guilt Incessant crying Lack of energy Relationship worries Worrying their partner may leave once the baby is born Conflict with parents Isolation Fear to seek help
what are causes of antenatal depression?
Physical Body changes! Weight gain (only clothes that fit are tatty or were previous used for ‘painting’ etc.), swollen breasts, dizziness and nausea, bladder issues, exhaustion, heart rate, blood pressure, swollen ankles/wrists... Hormonal changes Nausea – morning sickness
For some mums-to-be these experiences (and/or perception of them) worse than for others
Emotional Mood swings First-time mum experience Change of identity Previous pregnancy difficulties Complications, difficult labour, miscarriage, stillbirth… Chronic anxiety Especially new mums
Social
Antenatal depression is NOT new
Mums just did not have chance to talk about it before
Family support
Families often lived closer together than they do now
Work and finance
Greater pressure for mum to work in modern age
Expectations
Media perceptions of perfect nursery/bedroom
Pressure to live to societal standard
Good enough mum
NOTE: Majority of cases of antenatal depression disappear at birth BUT - one third of these mums develop postnatal depression
what is post natal depression?
Baby blues (see O’Hara, 2009)
Two to four days after birth (quite normal – but not PND)
Emotional/liable to burst into tears, for no apparent reason
Difficult sleeping (even when baby permits)
Loss of appetite
Feeling anxious, sad, or guilty
Questioning maternal skills
Effects up to 75% of mums
May relate to changes in post-birth hormone levels
Key is that this doesn’t last long – usually only a few days
If it persists it may develop into PND
BUT PND often develops independently
what is PND defined as in the DSM 5
PND needs same DSM-5 diagnosis as major depressive disorder
But relates specifically to the peripartum period
Pregnancy and/or within 4 weeks of birth
Five (or more) of (but at least one of symptom 1 or 2)
Depressed mood (for most of day, nearly every day…)
Markedly diminished interest in all/almost all activities
Significant weight loss (not dieting) or decease/increase appetite
Insomnia or hypersomnia
Psychomotor agitation/retardation (observable)
Fatigue or loss of energy
Feelings of worthlessness or excessive/inappropriate guilt
Diminished ability to think/concentrate or indecisiveness
Recurrent thoughts of death… suicidal ideation/attempt/plan
what is the prevalence of PND?
PND affects about 10% of new mums
Compare to baby blues
Although DSM-5 states ‘must be within 4 weeks of birth’
Most commissioned services recognise this needs to be longer
Vulnerable mums referred in ‘perinatal’ period
(Usually) during pregnancy up until baby is 1 year
Can come on gradually or all of a sudden
Can range from being relatively mild to very hard-hitting
About 50% PND women afraid to tell health professionals about it
Scared it will lead to social services taking child away
Or that they would be seen as bad mothers
what are the causes of PND?
Causes of PND uncertain But there are a number of known risk factors (Kim, et al. 2008) Having had depression before Especially PND Not having a supportive partner Having a premature or sick baby Having lost own mother as child Having had several recent life stressors Bereavement, unemployment, housing money problems… Poor sleep Shock of becoming a mother Women often unprepared for physical impact of childbirth New skills to learn New full time responsibility ‘Helpless’ baby who cannot communicate Other than cry (distressing in itself) Some mums get anxious when they don’t hear crying! Lie awake listening out Loss of freedom and independence Exhaustion and fatigue
Hormones
Oestrogen and progesterone affect emotions
Levels of progesterone are very high during pregnancy
PND maybe due to sudden drop progesterone after birth
But, hormones not a major influence in PND
Unlike postpartum psychosis (see later)
Diet
Lack of nutrients during pregnancy may be related to PND
Omega 3 oils (found in oily fish, seeds and nuts)
Magnesium (leafy green vegetables and seeds)
Zinc (seeds and nuts)
Impacts of PND
PND associated with several negative outcomes
Increased marital stress
Disturbances in child’s emotional and cognitive development (Cogill et al 1986)
Children of depressed mothers more likely to be associated with:
Insecure attachment
Eating difficulties
Sleep disturbance
Being overly clinging
PND affects mum’s ability to cope with care of baby (Murray, et al., 2003)
BUT we MUST be careful how we communicate that
May cause further guilt, self-blame, stigma…
Impact on child development
Significant intellectual deficits found in children (aged 4) whose mothers had suffered with depression (Cogill, et al., 1986)
PND may be associated with later difficulties in child’s adjustment - problems when starting school
Anxiety in girls; conduct problems in boys
Affects child’s social and emotional development
Ability to form relationships
Attachment and PND
Why is attachment important between mother and infant?
Early mother–infant bond may have sig. impact on developing infant (e.g. Bowlby, 1953; Ainsworth, 1993)
Infant’s internal working model (IWM) is very important
Expectations about themselves in relation to others
Model of self and of other
If infant’s carer attends positively and responds to needs
Infant has positive IWM:
High self-worth, availability of others, resolution of crises
Infant’s carer inconsistent response and attention
Infant’s has negative IWM:
Low or ambivalent self-worth, unavailability of others, crises not resolved
May cause bonding issues
Bonding problems with maternal MI
Mum is distracted for whole manner of reasons Low mood Lack of motivation Fear and guilt Poor concentration Lack of self-worth Low self-esteem Effect of medication
My research (with Clinical Psychology Doctorate student – see Steadman et al. 2007)
We explored serious mental illness in mothers (vs. controls)
Including severe depression
Sample
6 ill mums; 12 healthy controls
Recruited within first 8 weeks after birth
We measured a number of key aspects
Cognitive functioning (computerised tests)
Memory, speed of functioning, attention
Perceptions of parenting skills and stress (questionnaire)
Observation of interaction with baby (video)
Quality, sensitivity, appropriateness, etc.
Mother/infant interaction research
Cognitive functioning Measured via computer program Word and picture recall and recognition Reaction time Rapid visual information processing Spatial and numeric working memory Power and continuity of attention Episodic memory Working memory Speed of memory
Observation of interaction with baby
Quality and appropriateness of interaction
Assessed using highly validated method:
Crittenden CARE Index
Pat Crittenden was a student of Mary Ainsworth
Ainsworth pioneered attachment styles
And was herself student of Bowlby
what are the aims of the crittenden care index
Mothers and infants rated on 7 aspects Facial expression Verbal expression Position and body contact Affection and sensitivity Turn-taking and co-operation Control Choice of activity
Mother infant interaction videos
assessed mother and child as they played together for warm or dysfunctional relationships.
baby played with mother with a mirror facing mum, so that her facial expressions as well as babies could be assessed
mother/infant interaction research
Results
Significant differences found for several measures
Mothers with serious mental illness (SMI) vs. controls
Poorer mother–infant interaction
Poorer perceived maternal competence
Poorer cognitive function
Mother–infant interaction and perceived maternal competence
SMI mums significantly less sensitive
Their infants were significantly less cooperative
Cognitive function
SMI mums sig poorer on speed of memory processing
PND treatment
Antidepressants
Huge amount of evidence of benefit in treating depression
First line choice in most adults
BUT it is not that simple in PND
But are they safe in pregnancy and breastfeeding?
Majority are (current evidence)
Risk of mum staying unwell less safe
BUT this should always be checked with GP/psychiatrist
Current ‘Special Issue’ for Human Psychopharmacology
Counselling and psychological therapies (CBT etc.) very effective
Group or individual care
BUT rare - can take time to get into a programme
We need more Perinatal Mental Health teams!
Self-help strategies
Counselling (listening visits)
Interpersonal psychotherapy
Mindfulness?
