Depressive illness: the most common major complication of maternity - - PowerPoint PPT Presentation

Depressive illness: the most common major complication of maternity

Global Burden of Disease: DALYs (life years lost through death or illness) for women aged 15–44

WHO, 2008

Depressive illness: past history predicts high risk

l Women with past history depression, on no an9depressants: up to 60% relapse postnatally

(Wisner, 1994, 1998, 2004)

l 3-5% on an9depressants at start of pregnancy l Stopping an9depressants: 70% relapse in pregnancy (Cohen et al, 1999)

Childhood maltreatment: the most important predictor of antenatal depression (x10)

Plant et al, 2013

Low$childhood$abuse$ High$childhood$abuse$

Highest ever risk of psychosis

Birth

Puerperal psychosis: more rapid onset, more severe, and higher risk than at any other time (Oates, 1996; Appleby et al 1998)

10 20 30 40 50 60 70 80 90 100 % Remaining well after stopping Lithium Pregnancy (Weeks 1–40) Non pregnant Pregnant

Postnatal (weeks 41–64)

Highest ever risk of bipolar relapse

FEELINGS/ MOOD THOUGHTS/ BELIEFS BEHAVIOUR

DEPRESSION Low Anxious numb Negative about self, situation, life, past, present and future Slow, inactive, withdrawn, suicidal OCD Anxious Intrusive (obsessional) thoughts Compulsions, avoidance POSTPARTUM PSYCHOSIS Muddled, high or low Confused, bizarre, suspicious, hopeless, ‘irrational’ Changeable, strange, agitated, withdrawn, suicidal PTSD and C-PTSD Rapidly changeable, extreme, mixed; numb Lack of trust, suspicious, wary, self loathing, detached Rapidly changeable, extreme, dismissive, self harm

• Acute psychosis (2/1000), Severe/complex (2/1000);

• Services: Mother and Baby Units (2.5-3 beds/10,000

• Commissioning: na9onal (England)

Severe, high risk

• Severe illness (30/1000)
• Services: Specialist Perinatal Community Teams

• Commissioning: CCGs: Mental Health; + maternity

Admission vulnerable

• Mild/Moderate illnesses 10%
• Services: Treatment Primary Care/IAPT;

• Commissioning: CCGs and LAs

Mild/moderate

• Mild illness and severe distress -

• Services: Time and skills in

• Commissioning: CCGs and LAs

Mild illness and severe distress

• Good psychological care

• Services: Knowledge &

Maternal-child health and wellbeing

• Peer support
• Parent-infant

attachment services (‘Infant MH’)

• Thoughts of accidentally harming baby = 100%1
• Thoughts of deliberate harm = 50%1
• Frequent and repeated thoughts: OCD = 2%2
• As an indicator of risk of doing so = 0

What is ‘normal’?

• 40% would not

be able to get ANY specialist perinatal mental health care or even advice

• Only 25% could

access care that complies with NICE Guidelines issued 9 years ago

If the women who died by suicide became ill today:

1 in 4 deaths between 6 and 52 weeks after birth were psychiatric 1 in 7 deaths of women were by suicide

Suffering so terrible that death seems the best

• ption: suicide and maternity in the UK today

The Fetal Brain “Under Construc9on”

• 3mm long neural tube: 100 billion

neurons and 100 trillion connections

• 250,000 neurons/minute formed

through pregnancy

• Proliferation, migration, differentiation,

synaptogenesis continue for 18+months

• Neural pruning til puberty…

Children depressed at 16 all had mothers who were depressed, mainly during pregnancy No maternal depression à No children depressed at 16

When mother first depressed

Independent risk factors for adverse emo@onal/behavioural child outcome at 4 years: approximate risk

Prenatal severe anxiety x2 Maternal depression at 33 months x2 Housing problems x2

But not: Smoking in pregnancy; Life events in

pregnancy; Maternal age; Maternal educa9on; Social class; Financial difficul9es

Mothers’ childhood maltreatment has an impact on their children

SDQ: childhood emo9onal and behavioural problems Collishaw et al 2007

Transgenerational emotional adversity and poor mental health

Generation 2 Childhood trauma + Maternal antenatal depression

Generation 3 Childhood trauma + Maternal antenatal depression

Generation Childhood tra + Maternal ante depression

The adult effects of childhood emotional adversity

• Lack of trust, suspiciousness (from tendency-

pervasive); reject help

• Hypervigilance, fear; beliefs that negative

events could occur unpredictably at any time

• Minor events precipitate rapid and extreme

changes in mood, thinking and behaviour

• Self preservation through detachment from

current anguish: dissociation, non-psychotic voices, somatisation

• Self blame and self harm

The adult effects of childhood emotional adversity

• A lijle bit in most of us
• Complex Post Trauma9c Stress

Disorder

• Developmental Trauma Disorder
• Childhood Heroes
• Borderline personality disorder
• Emo9onally unstable personality

disorder

The path to complex PTSD

• What is neglect and what does it do to us (6mins. Harvard

clip): hjp://developingchild.harvard.edu/resources/ mul9media/videos/inbrief_series/inbrief_neglect/

• Impact of stress in pregnancy on foetus (2mins.Harvard clip):

hjp://developingchild.harvard.edu/index.php/resources/ mul9media/videos/three_core_concepts/toxic_stress/

• More detail on what childhood maltreatment does to brains
• f adults (15 mins Harvard lecture): hjps://

www.youtube.com/watch?v=dxv3hareoQ8

• Drama@c impact of childhood maltreatment on life@me

physical health (TED 15 mins.): hjps://www.youtube.com/ watch?v=95ovIJ3dsNk

Enhancing perinatal mental health

• Society: value parents and children;

understand the critical importance of attachment and the 1st 1000 days; positive attitudes to mental health and constructive attitudes to mental illness; paternity and maternity leave; massive shift in engagement of fathers/partners

• Individuals: above + actively provide

support

What makes ‘support’ effec9ve?

• Products: emo9onal AND prac9cal
• Components: individuals and networks
• Individuals: responsivity, trust, closeness,

shared history

• Networks: size, variety, interconnectedness

Professional help

• All of the above
• Identify women at high risk for extra

support/prevention (past mental illness; childhood adversity)

• Information, advice and support
• Don’t stop antidepressants without

careful consideration

• Psychological therapies and medications

Perinatal period: the most efficient time for detection of depression in women

yrs 11-16 5% no exposure 34% yrs 1-4 12% yr 1 pp 14% pregnancy 34% yrs 4-11 1%

(Sharpe et al 2006)

Routine detection: primary care and maternity services (NICE)

• At first pregnancy contact
• At 4-6 weeks PN (♯hiddenhalf)
• At 3-4 months PN

Treatment

• Exercise (pram pushing): occupy mind and

body and increase social contact

• Computerised CBT

– livinglifetothefull.com – moodgym.anu.edu.au

• Mindfulness apps: eg Headspace
• Cognitive Behaviour Therapy (CBT) - ‘IAPT’ in

England

• Antidepressants and antipsychotics
• Specialist perinatal MH care for severe illness

Unacceptable postnatal depression care

40% 24% 10% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Prevalent PND Cases Recognized Clinically Any Treatment Adequate Treatment

Economic costs (LSE, 2014)

Cost if we don’t act

£8.1bn£337m

Can we afford it?

• UK maternity care = £2800/woman
• Specialist perinatal mental health care

across the UK = £67/woman

• Total NHS maternity budget £2.6bn
• Maternity negligence costs £482m
• Whole APMH pathway £337m
• ♯hiddenhalf £20m

Costs if we stay as we are = £8.1bn

The future: all UK

• Clear pathway across all services
• Specialist community perinatal mental

health teams

• Access to therapy
• Parent-infant therapy
• Mental health in maternity and health

visiting

• Specialist Mental Health Midwives and

Health Visitors

Inpatient Mother and Baby Units

4 new MBUs in 2018

Specialist Perinatal Community Services: 2015