Perinatal, Menstrual and Menopause Mental Health

Question 1

What factors can affect maternal mental health in the post partum period?

Answer 1

Delivery - especially concerning whether the mother felt she had control and whether things went according to how she expected and planned.

Question 2

What things do you need to ask about in a mental health history for a pregnant person?

Answer 2

Any previous pregnancies - miscarriage, stillbirth, terminations

Vulnerability - homelessness and accommodation

Question 3

What things do you need to ask about in a mental health history for a patient who is post partum?

Answer 3

Postnatal period = substantially inc risk of mental health deterioration

Explore the P’s experience of birth

Important to ask about suicidal thinking
Does the mother feel trapped, like running away, that the baby would be better with someone else?
Thoughts of harming the baby / children
Ever lost their temper with the baby

Question 4

Why is it important to detect mental health problems early in pregnancy and after birth?

Answer 4

The earlier you can diagnose and treat conditions, the better the outcomes are - especially psychosis.

Question 5

What is postpartum psychosis strongly linked to?

Answer 5

A personal or family Hx of bipolar disorder

Question 6

If someone with mental health issues is thinking about getting pregnant, what do you need to discuss with them?

Answer 6

Ideally want to start planning about mental health prior to conception

Think about the while picture of a person’s mental health

Think about the biopsychosocial model

Some meds can increase prolactin and affect fertility

Ideally see them together with their partner to plan their support and care
What support there will be when the baby is born. How able the P will be able to look after the baby themselves,
Any care plan should be developed collaboratively with culture and beliefs being taken into account.

Question 7

What can chronic stress, anxiety and depression in pregnancy lead to?

Answer 7

Increased levels of prematurity, intrauterine growth restriction and developmental problems in the child.

Theory = foetus is exposed to high levels of glucocorticoids as a result - affecting HPAA = affects foetal brain development.

Question 8

What types of mental health disorders can pregnant patients suffer from?

Answer 8

Anxiety disorders
Depressive disorders
Eating / Personality disorders
Substance misue
Psychotic illnesses

Question 9

What types of obstetric risk are pregnant patients with mental health problems more at risk of?

Answer 9

Smoking, high BMI and chronic stress all impact on pregnancy outcomes
Mental illness can make it more likely that Ps have a higher BMI and smoke.
Tangible translation of mental health problems into physical health problems.

Question 10

What does antenatal depression increase the risk of?

Answer 10

Post natal depression
Ps depressed in pregnancy are more likely to experience post-natal depression

Question 11

Overwhelmed and anxious feelings may be normal in pregnancy. How can you tell whether there is a depressive illness going on?

Answer 11

Think about key depressive features - hopelessness, worthlessness can be indicators of depression

Question 12

What are teenage pregnancies more at risk of?

Answer 12

PTSD

Question 13

Which organic cause in pregnancy can cause depressive symptoms?

Answer 13

Thyroid disease

Question 14

What is an extreme fear of pregnancy and childbirth called?

Answer 14

Tokaphobia

Question 15

What is the difference between primary and secondary tokaphobia?

Answer 15

Primary tokaphobia - affects first time mothers who have not experienced childbirth or pregnancy before.

Secondary = results from a previous traumatic birth experience

Question 16

What are the Sx of tokaphobia?

Answer 16

Sleep problems
Panic attacks
Anxiety

Question 17

Which Rx do Ps with tokaphobia often respond well to?

Answer 17

CBT

Question 18

What are the rates of OCD in Fs?

Answer 18

1 in 100 have OCD
Increases to 3 in 100 in the post partum period

Question 19

What are the Sx of OCD in the perinatal period?

Answer 19

Recurrent thoughts and images
Compulsive rituals
Impacts on daily life

Often arises around significant fear of harm coming to the baby - worries are often focused on accidentally or deliberately harming the child or the child becoming ill.

Can happen occasionally - can be very normal. But if so distressed that they are taking significant measures to prevent their thoughts coming true - is more perinatal OCD.

Question 20

What percentage of new mothers are likely to develop a depressive illness in the postnatal period?

Answer 20

15%!

Early postnatal period = high risk time for new episodes of mental health illness

Question 21

When do the baby blues often occur?

Answer 21

Within the first 10 days of giving birth = often around day 3-5

Question 22

What is the difference between PND and PPP?

Answer 22

Baby blues - within first 10 days after birth often in 3-5. Person is still able to care for the baby. Hopelessness and worthlessness arent prominent. Would not normally have suicidal thoughts.

PND and PPP - more likely to be associated with cognitive changes and suicidality

PPP - usually has onset quite soon following delivery and is usually very rapid - affective Sx as well as psychosis

Question 23

What are the RFs for PND?

Answer 23

Aetiology not well understood - probably involves an interaction between biological, psychological and social factors.

Risk of PND is x20 higher with previous Hx of a significant depressive episode

Evidence suggests there is a subset of women who are particularly sensitive to dramatic hormone fluctuations in the PP period. Are more likely to have depressive Sx around the time of menopause and severe PMS.

FHx = important - 42% with FHx will get PND compared to 15% without.

Question 24

If a P has had a previous significant depressive episode, what is the risk of PND for that P?

Answer 24

20x higher than a P without this Hx

Question 25

What red flags do you need to look for in patients who have just given birth?

Answer 25

Marked change from normal mental state, uncharacteristic behaviour - often v sudden. Red flag! Extreme anxiety or panic attacks can be a prodrome to mental health problems. Really important to look into this further. Overvalued ideas in the postnatal period - explore in line of psychotic Sx. What other ideas may exist as well. Self harm - not very common in pregnancy or PPP. If it does occur - need to take incredibly seriously, especially if new as there is a strong association with suicidal behaviour.

Question 26

What red flags for mental health do you need look out for in the perinatal period?

Answer 26

Question 27

What is the incidence of post partum psychosis?

Answer 27

1 in 1000

Question 28

How does post partum psychosis present?

Answer 28

Can be manic, severe depression or confusion Within days of delivery Can fluctuate rapidly Rarely can have catatonia

Question 29

Which mental illness is post partum psychosis most closely linked to?

Answer 29

Bipolar disorder (not schizophrenia) If a P has BPD - they have 25% chance of developing PPP If a P has previously had an episode of PPP - they have a 50% chance of developing it again with the next birth

Question 30

In cases of post partum psychosis - what do you need to exclude?

Answer 30

Any organic cause - make sure it is not delirium Rapid onset of thyroid problems is also possible - so investigate.

Question 31

How is PPP treated?

Answer 31

Try to minimise distress and agitation Supporting breastfeeding where possible - pumping if needed. Pumping at times when medication is at its lowest in the blood. Observation often 1:1 or 2:1 Important physical needs are met as they have recently given birth = bleeding and DVT risks Aps are first line Tx. If severe depression - can think about giving AD as well. Doing treat with AD alone = manic switch - from depression to mania very quickly. ECT may be necessary - if catatonic or not eating/drinking

Question 32

What are the long term effects of maternal ill mental health on an infant?

Answer 32

Can be long term effects on cognitive, social, emotional and behavioural development.

Question 33

What is the toxic trio of vulnerabilities of a patient?

Answer 33

Mental illness + substance misuse + domestic abuse

Question 34

What is the link between mental illness and domestic abuse?

Answer 34

Strong link - approx 60-70% of women accessing mental health services have experienced domestic abuse.

Question 35

What is the start of menstruation called?

Answer 35

Menarche

Question 36

How do hormones in the menstrual cycle affect the CNS?

Answer 36

The act on steroid receptors and affect GABA, 5HT, Dopa and Glutamate transmission. Oestrogen and P and metabolites affect mood, behaviour and cognitive abilities.

Question 37

What is menopause defined as?

Answer 37

An absence of 12m + of periods due to menopausal changes.

Question 38

When are most symptoms of menopause experienced?

Answer 38

During perimenopause

Question 39

When are depressive rates highest for women?

Answer 39

During their reproductive years - due to increased oestrogen?

Question 40

When does PMS occur in the cycle?

Answer 40

During the luteal phase

Question 41

How is PMS diagnosed?

Answer 41

They are repetitive, cyclical, physical and behavioural Sx that occur in the luteal phase of the menstrual cycle. They should interfere with some aspect of a woman's life. The should resolve at least a few days before or at the start of the period. They should not be due to another disorder

Question 42

What is PMDD?

Answer 42

Mood and anxiety symptoms during the luteal phase only, which are severe enough to cause functional impairment. More severe than PMS with mood Sx predominating There should be significant distress that impacts across areas of life (work, relationships etc) No blood test for this as circulating hormones are normal.

Question 43

What Sx present in both PMS and PMDD?

Answer 43

PMDD - may see Sx more consistent with a depressive picture

Question 44

What are the RF for PMDD?

Answer 44

Age 20-30 Comorbid psychiatric disorders Genetic Psychosocial stress Smoking Obesity

Question 45

How can you investigate whether a P has PMDD?

Answer 45

Essential to get a good menstrual Hx Tell P to keep a diary of Sx for around 3m - daily record of both physiological and psychiatric Sx. Should be Sx free for at least one week of the cycle. Most Sx should be in the luteal phase. Rule out hypothyroidism and anaemia And depression rather than PMDD

Question 46

What are the treatments for mild & moderate PMS and severe PMS or PMDD?

Answer 46

Mild - lifestyle & CBT Moderate - SSRIs, combined pill, CBT Severe - as above and v poss - GnRH agonist or oophorectomy

Question 47

Why my SSRIs be used on a cyclical basis for PMS or PMDD?

Answer 47

SSRIs have more rapid impact in PMDD than Ps with a depressive disorder - SSRIs can be an effective Rx for PMDD & PMS - can potentially be taken only during luteal phase of the cycle

Question 48

What is the average of menopause in the UK?

Answer 48

45-55 - most common = 51-52

Question 49

Who can have oestrogen only HRT?

Answer 49

If a P has had a hysterectomy or a progesterone Mirena coil - then they can have oestrogen only HRT. Otherwise HRT is given as a combo of oestrogen and progesterone - to avoid proliferation of the endometrium.

Question 50

What are the risk of HRT?

Answer 50

Cancer, heart disease, thrombosis, CVD

Question 51

What is known about HRT and dementia?

Answer 51

May possibly be some cognitive benefit to women by taking HRT. Although may be improvements just because HRT can help with sleep Sx and improve lack of sleep!

Question 52

Postnatal depression is most strongly linked to - Progesterone levels - Psychosical factors - Obstetric complicatioons

Answer 52

Psychosocial factors

Question 53

Does psychiatric medication need increasing in the third trimester due to increased blood volume?

Answer 53

Yes

Question 54

Why are many women reluctant to admit they have mood Sx postpartum?

Answer 54

Due to fear of stigma, embarrassment or worries their child might be taken into care

Question 55

When should you worry about a major depressive episode in a P?

Answer 55

If it lasts longer than 2w, if there are severe Sx or if it is causing substantial impairment to the P.

Question 56

How can you differentiate between PND and postnatal blues?

Answer 56

Postnatal blues is a common and self-limiting episode of mood and anxiety symptoms which resolve within 2 weeks of delivery. Postnatal depression is a common and potentially serious episode of depression arising within 6 months of delivery

Question 57

What are the Sx of PMS?

Answer 57

Mental health symptoms include low mood, labile mood, irritability, concentration difficulties, anxiety and fatigue. Physical symptoms such as headache, abdominal bloating and breast tenderness are also fairly common. The timing of a given symptom relative to menstruation rather than its exact nature is what is diagnostically important.

Question 58

How can you tell the difference between PMS and PMDD?

Answer 58

ICD-11 describes premenstrual dysphoric disorder (PMDD), which in essence are the mental health symptoms of PMS combined with significant distress or functional impairment.

Question 59

How does NICE classify PMS?

Answer 59

Classifies PMS as mild, moderate or severe depending on its impact on personal, social or professional life. Mild PMS does not interfere with normal functioning in these domains, moderate PMS causes interference, and severe PMS causes withdrawal from these domains.

Question 60

Which hormone is thought to be primarily responsible for PMS?

Answer 60

The principal theory of causation is that the rise in progesterone during the luteal phase is responsible for symptoms of PMS.

Question 61

What psychosocial stressors is menopause associated with?

Answer 61

Children leaving home and a growing awareness of ageing.

Question 62

Where should women with a major mental illness who are pregnant or planning a pregnancy be referred?

Answer 62

Perinatal psychiatry services

Question 63

Which SSRIs are best for breastfeeding?

Answer 63

Sertraline and paroxetine Paroxetine and sertraline: very small amounts excreted in breast milk; short half-life fluoxetine and citalopram are excreted in relatively larger (but still small) amounts. Fluoxetine has a long half-life and thus may accumulate

Question 64

Can mood stabilisers be given in pregnancy?

Answer 64

No - All are associated with teratogenicity. Valproate and carbamazepine increase the risk for neural tube defects and should be avoided in pregnancy. Valproate also increases the risk for developmental disorders (30%–40% of babies). Lithium increases the risk for cardiac defects but may be taken during pregnancy. Avoid in breastfeeding as well if possible

Question 65

Can APs be given in pregnancy?

Answer 65

Most antipsychotics have no established teratogenic effects but may cause self-limiting extrapyramidal side-effects in neonates. Olanzapine increases risk for gestational diabetes. Avoid high doses in breastfeeding mums as can cause lethargy in an infant

Question 66

Can benzodiazepines be given in pregnancy?

Answer 66

Best not - Associated with floppy infant syndrome (hypotonia, breathing and feeding difficulties) and neonatal withdrawal syndrome. Breastfeeding - choose drugs with short half lives (e.g. lorazepam) if necessary as may cause lethargy in infants

Question 67

Can SSRIs be given in pregnancy?

Answer 67

Yes = Can be associated with withdrawal symptoms in neonates, which are generally mild and self-limiting. Rarely associated with persistent pulmonary hypertension when given after first trimester.

Question 68

What are the general principles of prescribing in pregnancy?

Answer 68

* * use the drug with the lowest known risk to mother and foetus * * use the lowest effective dose * * use a single drug rather than multiple drugs, if possible and be aware that doses may need adjusted due to physiological consequences of pregnancy

Question 69

When does PND develop?

Answer 69

Postnatal depression usually develops within 3 months of delivery (and can start during pregnancy), with peak time of onset at 3–4 weeks. A depressive episode arising more than 6 months after delivery is not generally viewed as postnatal depression.

Question 70

What are the Sx of PND?

Answer 70

The symptoms are similar to a nonpuerperal depressive episode: low mood, loss of interest or pleasure, fatigability and suicidal ideation (although suicide is rare). Note that sleeping difficulties, weight loss and decreased libido can be normal for the first few months following delivery. Additional features of postnatal depression may include: * * Anxious preoccupation with the baby’s health, often associated with feelings of guilt and inadequacy * * Reduced affection for the baby with possible impaired bonding * * Obsessional phenomena, typically involving recurrent and intrusive thoughts of harming the baby (it is crucial to ascertain whether these are regarded as distressing (ego-dystonic), as obsessions usually are, or whether they pose a potential risk). * * Infanticidal thoughts (thoughts of killing the baby) require urgent psychiatric assessment. True infanticidal thoughts are different from obsessions in that they are not experienced as distressing (ego-syntonic as opposed to ego-dystonic), and (worryingly) may involve active planning.

Question 71

If a woman is on an AD during pregnancy - should you change after delivery to a different AD that is "better for breastfeeding?"

Answer 71

If a woman has been on an antidepressant during pregnancy, do not change after delivery to a different antidepressant that is ‘better for breastfeeding’. Doing this means the child is exposed to two medications, instead of one. The foetus is exposed to far greater levels of antidepressant in utero than levels transmitted in breast milk, so if they are healthy at delivery they are unlikely to be harmed by further, lower, exposure.

Question 72

What is the prognosis for PND?

Answer 72

Most women respond to standard treatment and episodes resolve within 3–6 months; however, some patients have a protracted illness and may require long-term treatment and follow-up. Woman who develop postnatal depression have around a 40% increased risk for developing a similar illness following childbirth in the future.

Question 73

What percentage of PP psychosis begins in the first 3 days?

Answer 73

50% Vast majority will develop within the first two weeks

Question 74

How do episodes of postpartum psychosis typically begin?

Answer 74

Episodes typically begin with insomnia, restlessness and perplexity, later progressing to suspiciousness and marked psychotic symptoms (often with content related to the baby). The symptoms can be polymorphic, and frequently fluctuate dramatically in their nature and intensity over a short space of time. Mood symptoms are prominent, and can comprise elation, depression or both (mixed affective state). Patients often retain a degree of insight, and may not disclose certain bizarre delusions or suicidal/homicidal thoughts.

Question 75

What is the treatment for PPP?

Answer 75

Depending on presentation, antipsychotics, antidepressants and mood-stabilizing medications are indicated. Benzodiazepines may be needed in cases of severe behavioural disturbance. All psychotropic drugs should be used with caution in breastfeeding mothers, but many women are too unwell to breastfeed in any case. Electroconvulsive therapy can be particularly effective in severe or treatment-resistant cases. Psychosocial interventions are similar to those for other psychotic episodes, but also include providing support for the father.

Question 76

What is the prognosis of PPP?

Answer 76

Most cases of puerperal psychosis will have recovered by 3 months (75% within 6 weeks). Around one in six women who have a first episode of mood disorder following delivery will go on to develop bipolar disorder. There is about a 50% chance of experiencing a recurrence of postpartum psychosis after future childbirths, which can be reduced by prophylactic therapy.