Psychiatry Following Childbirth

Question 1

Postnatal depression management

Answer 1

Same as depression but take care with drugs used in breastfeeding mothers
- Antidepressants can be secreted in breast milk, therefore certain medications are avoided and others are preferred
- Recommended SSRIs are sertraline and paroxetine
- Low-dose amitriptyline is probably safe
- Lithium should be avoided if possible
- Sodium Valproate definitely avoided

Hospital admission should be considered if depression is severe with suicidal or
infanticidal ideation
- Mother and Baby Unit (MBU) is the optimal setting under these circumstances
- Separation should be avoided if possible

Most women respond well to treatment within a month

Use of CBT/IPT has been proven to reduce postnatal depression

Early and effective treatment of PND is important because it can affect the baby’s
attachment and have lasting effects on development and personality

Also important to factor in ongoing social support for the mother, baby and family

Health visitor visits in the follow-up period to monitor the progress of the mother and baby

Question 2

Puerperal psychosis

Answer 2

Depending on the presentation, antipsychotics, antidepressants, or lithium may be needed

Benzodiazepines may be needed for agitation

In severe cases, ECT may be lifesaving (women tend to respond well)

Admission is usually required, preferably to a mother and baby unit

Most patients recover within 6-12 weeks

Highest risk within 1st year after pregnancy
- Risk to the baby can be through neglect or violence
- Watch out for depressive delusions (e.g. the baby is evil, possessed or abnormal)

Question 3

Bipolar disorder in pregnancy

Answer 3

Do not offer lithium or sodium valproate to women who are planning a pregnancy or pregnant, unless antipsychotic medication has not been effective

If a woman taking lithium becomes pregnant, consider stopping the drug gradually
over 4 weeks
- Consider switching to an antipsychotic
- Antipsychotics are safe in pregnancy and breastfeeding (except clozapine)

Monitoring (more frequent)
- Every 4 weeks
- Weekly from the 36th week

Ensure that the woman gives birth in a hospital

Important: antipsychotic use can make it difficult to get pregnant because of
hyperprolactinaemia

Question 4

Bipolar disorder in pregnancy risks

Answer 4

Foetal heart malformations (Ebstein’s anomaly) but the magnitude of the risk of
uncertain

Important to weigh up benefits of treating mothers BPAD vs. risk of congenital
malformations

Lithium may be highly expressed in breast milk

Question 5

Learning disability psychological therapy

Answer 5

May include counselling, group therapy and modified CBT

Behavioural therapy - helps improve unhelpful behaviour patterns

ABC approach
- Antecedents
- Behaviour
- Consequences

Management involves:
- Avoiding antecedents
- Reinforcing positive behaviours
- Preventing reinforcement of negative behaviours (e.g. using distraction techniques)
- Helping people understand the consequences of their actions