Focus on perinatal mental health
Welcome to Priory Bitesize. This month we spoke to Dr Jaya Gowrisunkur, Consultant Psychiatrist at Priory Hospital Altrincham, about some of the mental health challenges faced by women during and after pregnancy.
The word 'perinatal' refers to the period from when pregnancy begins to the first year after the baby is born. Pregnancy and the postnatal period can involve major psychological changes for a woman. It is well recognised that a woman’s mental state during this time can significantly influence:
- The mental and physical health and development of the baby
- The woman’s relationships including with her partner and family and within her working environment
- Obstetric outcomes
Fast and intensive changes for women during and after pregnancy can be psychological, physical and social. However, it is mental health that is reported to be the leading cause of maternal deaths in the UK. Over half of these deaths are known to be suicide and the majority of these take place in the 6-week pre-delivery and 12-week post-delivery period; postnatal depression affects approximately 10% of mothers.
The course and prognosis of mental illness in the perinatal period does not, apart from the case of bipolar disorder, differ from that of similar conditions in the general population.
However, the management of these conditions is more challenging, as clinicians need to take into account the impact of the woman’s illness and its treatments, on the developing foetus, the newborn infant, and other relationships.
This article discusses the importance of recognising and treating mental health issues during and after pregnancy. We also explore the most common adjustment disorders that women and their families may experience and the best treatment for them.
Pregnancy and the perinatal period are often characterised by high levels of anxiety and worry for expectant mothers. Such feelings can have an adaptive effect, helping women to ensure their baby’s survival. Women can also experience significant levels of obsessive compulsions which can also assist in the protection and care of the infant (within limits). However when these ‘mechanisms’ escalate, they can become serious clinical conditions, posing a threat to the survival of the mother and child, and affecting the mother’s ability to bond with her baby.
Women generally present to their GP for initial care when they become pregnant and this can be a crucial opportunity to consider any mental health issues. It is important that GPs look at any pre-existing or emerging conditions, which can include:
- Bipolar disorder
- Psychotic illnesses
- Obsessive compulsive disorder (OCD)
- Eating disorders
- Post-traumatic stress disorder (PTSD)
- Alcohol and drug dependence
PTSD can occur after childbirth, due to experiences including pain of childbirth, the birth not going according to plans made by the woman, adverse obstetric events and perceived risk to the infant or to the woman. These perceived and/or real threats can also be a result of a loss of control which can be difficult for the woman to manage, especially if she has perfectionistic traits.
Key practice points for GPs during this initial assessment include:
- Considering any mental illness that may require more active intervention because of the impact on the foetus and on the woman’s physical health
- Understanding that stopping psychotropic medication for pre-existing conditions abruptly can have severe consequences for the pregnant woman including relapse, which can affect the pregnancy and foetal development
- Considering the needs of the wider family, other children and partners, as well as the expectant mother
- Balancing the risks posed by the mental illness versus the impact of psychotropic drugs, on the developing foetus and on the mother
- Considering the needs of particular populations including adolescents, ethnic minority backgrounds, women who have suffered from previous trauma as well as women who have suffered from poor parenting themselves
- Looking out for symptoms such as irritability, lability of mood, sleep disruption and tearfulness which are common in postnatal conditions and ‘the baby blues’
- Remembering common adjustment disorders such as anxiety disorders may be short lived but can develop into severe anxiety states which can be disabling and interfere with the mother’s ability to care for her baby
- Being aware of the possibility of OCD as this can lead to rejection of the child and may have serious long-term consequences
- Being aware that postnatal psychosis is quite rare but can be florid and may have a serious impact on the woman, her baby and her family
- Considering biological influences including genetic, biochemical and endocrine factors, psychological and social factors. The bi-psycho social model is crucial in understanding perinatal health and in managing it
It is important that GPs and other clinicians share the right level of information with the mother, and where appropriate, the woman’s partner and other family members and carers should always be involved. Social support, often from partners, family and friends is crucial and sometimes underestimated by clinicians.
Following this, the clinician should discuss the full range of treatments available to any woman experiencing perinatal mental health difficulties. These include:
- Pharmacological treatments
- Psychological treatments
Clinicians in general practice also need to be aware that some issues may require a specialist approach. Some patients may benefit from discussing their mental health with a consultant psychiatrist who has specialist expertise and clinical experience in managing particularly complex groups of patients. They may assist the GP in formulating a comprehensive care plan, addressing the physical, psychological and social needs of the woman, her infant and her family.