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Mother’s Mental Health: Professional Perspectives and Childbirth Education Part I

December 6th, 2012 by avatar

By Walker Karraa

Regular contributor Walker Karraa has written an excellent three part series on Perinatal Mood and Anxiety Disorders (PMAD) and what the childbirth educator or birth professional can do to help women get the help they may need when dealing with mental illness during the prenatal and postpartum period.  Walker interviews experts in the field who all offer concrete steps, activities and resources so that educators and others can do to be more prepared to discuss this important subject with students and clients.  Recent press coverage of a British mother suffering from severe PMAD has made headlines and the topic is one that belongs in whatever childbirth class a woman chooses to take. – Sharon Muza, Community Manager.

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Safety regarding the use of a specific type of antidepressant medication, selective serotonin reuptake inhibitor (SSRI’s), is an important topic as maternal health care providers address the prevalence and negative effects of depression and other mood disorders in pregnancy and postpartum. Recently, the study The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond (Domar, Moragianni, Ryley & Urato, 2012) has garnered tremendous attention from media, researchers and childbirth professionals. I had the opportunity to ask the study’s authors and other experts about the dangers of discontinuation in a piece for Giving Birth With Confidence. From that article, we hear the overwhelming agreement; including two of the study’s authors, that sudden discontinuation of SSRI antidepressant medications in pregnancy is not advisable.

http://flic.kr/p/7oE1vk

A week later, I learned about the tragic case of Felicia Boots, a 35 year old woman in the United Kingdom who, fearing she was harming her baby by taking SSRI’s and breastfeeding, suddenly stopped. Shortly after, she took the lives of her 14-month old and 10 week old children. A special editorial published by The Lancet (November 10, 2012), noted: “She had stopped her prescribed antidepressants because she was convinced that the drugs would harm her baby through her breastmilk and feared that her children would be taken away from her”(p. 1621). The authors went on to state: “A society in which women know that they will receive empathy, understanding, and help might be one in which women seek advice more readily, and accept appropriate treatments” (Lancet, 2012, p. 1621).

This is a vision shared by the guiding principles of maternity care–as childbirth professionals have always worked for a society where women know they will be cared for, understood, and have access to appropriate interventions. Unfortunately, we have failed to include mental health. How might the childbirth education community better address these issues? Asking experts is a place to start. What is uniquely helpful here is that the same questions were given to all participants—shedding light on one commonality: education.

Today’s article features Julia Frank, MD. Dr. Frank is a Professor of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine and Health Sciences, where she has been the Director of Medical Student Education in Psychiatry since 2000. A graduate of the Yale University School of Medicine and of the residency program in psychiatry at Yale, Dr. Frank is also the founder of `Five Trimesters Clinic, a service for women with mental health needs relating to pregnancy and childbirth. In this installment, Dr. Frank addresses how childbirth educators might address these complex issues.

WK: How might childbirth professionals integrate an understanding of postpartum psychosis (PP) and other perinatal mood disorders in classes? 

Dr. Frank: It is important to stress that the condition is rare but serious and treatment is generally quickly successful. Women with a family history of bipolar disorder or of postpartum psychosis in relatives should be told that they are at somewhat increased risk. Giving information in writing to them and their partners about what to look out for (especially profound sleeplessness and confusion) in the first couple of weeks postpartum might also be helpful.

WK: The recent Lancet editorial regarding the Felicia Boots tragedy stated: “Postnatal depression and, more broadly, perinatal mental health disorders, are among the least discussed, and most stigmatizing, mental health illnesses today” (p. 1621).   

How would you describe the stigma of perinatal mental health disorders and its impact?

Dr. Frank: I think the widespread publicity given to the sensational cases with terrible outcomes makes it hard for women to admit to any difficulty postpartum. The general public tends to conflate postpartum depression with psychosis. I have had women say to me “I don’t think I’m depressed, because I don’t want to hurt my baby”. We also overemphasize depression and neglect anxiety. I am not sure that is a factor of stigma, but it certainly contributes to under diagnosis.

http://flic.kr/p/PYHj7

Obstetricians and pediatricians may not recognize or discuss a postpartum psychiatric disorder for fear of offending the affected mother. Other aspects of stigma that apply to professionals are the belief that psychiatric disorders are overwhelmingly time consuming to address, that women who have them lack insight, that treatment is generally no better than passage of time.

WK: What do you see as the most significant barriers to treatment for women with perinatal mood and anxiety disorders (PMAD)? 

Dr. Frank: In the US, the disconnection between mental health care and medical care, written into our insurance systems, is a major barrier. Also, the way pediatricians are trained to deal only with the child, and not to assume any responsibility for the health of the mother, keeps them from screening appropriately. Obstetricians also maintain an overly narrow focus on the woman’s organs, and they tend to have very little contact with mothers after delivery, nor do most of them see mental health as within their sphere of interest or expertise. Fears of liability from the effects on the fetus of treating the mother are another barrier, especially in the US, where medical injury to an infant can bring astronomically high damage awards. This is a particular barrier to some psychiatrists being willing to initiate or maintain treatment related to pregnancy.

WK: How would you respond to media-based concerns regarding the safety of SSRI medication in pregnancy? 

Dr. Frank: There is no pregnancy without risk, and the risks of not treating a serious psychiatric disorder are as important to consider as the risks associated with treatment.  When we bypass maternal suffering out of concern for the safety of a fetus, we are making a misguided moral judgment that privileges “innocent” life over life as lived. The risks of these drugs are important and should be weighed carefully, but it has taken literally decades and the review of the experience of tens of thousands of women to identify the risks. Absolute and percentage risks remain acceptable, when weighed against the known benefits of taking medication when necessary. Over fifty percent of pregnant women take something during pregnancy, and treating a mood disorder is as important as treating a UTI, or diabetes, or heartburn or any of the conditions that are typically addressed.

WK: What are your thoughts regarding discontinuation of medication in pregnancy? 

Dr. Frank: Depends on the medication, the woman’s history, and the illness being treated. Certainly, discontinuing a medication should not be an automatic response to a woman becoming pregnant.

WK: What suggestions do you have regarding how childbirth organizations can encompass perinatal mental health into training curriculum and practice? 

Dr. Frank: Widespread education in the use of efficient screening methods, particularly the PHQ 9 or the Edinburgh Postnatal Depression Scale would be a first step.  Educators  also need to develop routines for referring women to mental health services—the postpartum depression self-help  community , embodied in organizations like Postpartum Support International, is pretty well organized and can help bridge the gap between screening and referral . Ideally, these organizations could reach out to women postpartum, rather than waiting for them to come in. Routine phone calls two and four weeks after delivery, providing encouragement for everyone while also identifying and facilitating referrals for women in difficulty, might be quite effective in both preventing and intervening in postpartum mood problems. This is an area that merits systematic study. Finally, organizations that include mothers themselves might consider urging women who have been identified and treated to write thank you notes to the health care providers who contributed to them getting help. I think this would counter the fears that providers have about giving and offense and doing harm.

Conclusion

Dr. Frank contributes to the broadening conversation regarding how childbirth educators might better address perinatal mental health. How do her suggestions resonate with your practice? In what ways could you use her information?  Will you consider adding this information to your classes and new mother contact? And how could your certifying or professional organization become a source of support and education?

The second post in this series, scheduled for Thursday, features Nancy Byatt, D.O., MBA–Assistant Professor of Psychiatry and Obstetrics & Gynecology;  Psychiatrist, Psychosomatic Medicine and Women’s Mental Health UMass Medical School/UMass Memorial Medical Center.

References

Domar, A. D., Moragianni, V. A., Ryley, D.A., & Urato, A.C. (2012). The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond. Human Reproduction, Vol.0(0) pp. 1–12 doi:10.1093/humrep/des383

Bringing postnatal depression out of the shadows The Lancet – 10 November 2012 (Vol. 380, Issue 9854, Page 1621 ) doi: 10.1016/S0140-6736(12)61929-1

Other Resources: 

Department of Health and Human Services: Depression During and After Pregnancy: A Resource for Women, Their Families, & Friends

The Organization of Teratology Information Services (OTIS), (866) 626-6847

 

 

Babies, Breastfeeding, Childbirth Education, Depression, Giving Birth with Confidence, Guest Posts, Infant Attachment, Maternal Mental Health, Maternity Care, News about Pregnancy, Perinatal Mood Disorders, Postpartum Depression, Prenatal Illness, Research , , , , , , , , , , , , ,

Who is at Risk? A Call for Universal Antenatal Mood Disorder Screening

November 29th, 2010 by avatar

Pregnancy is a time when most women are eagerly anticipating and preparing for the birth of their child (or children), so it is surprising to note that approximately 10% of pregnant women may experience a depressive disorder during pregnancy. What is even more heartbreaking is the fact that as many as 2.6% of pregnant women may have thoughts of suicide. In pregnant women with major depression, the rates of suicidal ideation can reach nearly 30%. It is well known that major depression is associated with significant disease co-morbidity and mortality.  Clinicians must know which women are at highest risk for depressive disorders yet screen all their patients for depressive disorders at regular intervals during their prenatal care and provide treatments and/or resources when needed.

Jennifer Melville, MD, MPH, an associate professor in the Department of Obstetrics and Gynecology at the University of Washington School of Medicine, Seattle, WA sought to estimate the prevalence of depressive disorders during pregnancy in her 2004-’09 study, Depressive Disorders During Pregnancy:  Prevalence and Risk Factors in a Large Urban Sample . Melville and her colleagues also wanted to know if there are identifiable risk factors that make certain women more likely to develop depressive disorders than others. The results of this prospective study of 1,888 pregnant women over a five-year period have been published in the current issue of Obstetrics and Gynecology.

A Look at the Research

The methodology used  in this study to determine major and minor depression was based on patient responses to the Patient Health Questionnaire and  in accordance with criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), as follows:

“In our study, women meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major or minor depression on the Patient Health Questionnaire were classified as experiencing current depression.  The DSM-IV criteria for major depression on the Patient Health Questionnaire require the participant to have, for at least 2 weeks, five or more depressive symptoms present for more than half the days, with at least one of these symptoms being depressed mood or anhedonia.  The criteria for minor depression (or depression not otherwise specified) require the participant to have, for at least 2 weeks, two to four depressive symptoms present for more than half the days, with at least one of these symptoms being depressed mood or anhedonia.  The criteria for panic disorder require affirmative answers to all five panic symptoms and follow the DSM-IV.”

A summary of the Melville et. al study findings includes:

  • Antenatal depressive disorders were present in 9.9% of study participants and 5.1% of those identified also met the criteria for probable major depression; 4.8% met the criteria for probable minor depression.
  • 3.2% of women had probable panic disorder and of those, 52.5% had co-morbid depression (31% major and 21% minor).  47.5% had isolated panic disorder. 19.6% of women with probable major depression had panic disorder while 14.4% of women with probable minor depression had panic disorder.
  • Suicidal ideation was present in 2.6% of the women studied, but of those with major depression, 29.5% reported suicidal ideation.

Melville and her colleagues found that antenatal depressive disorders are more prevalent in younger, less educated, single women. Other aggravating factors that heightened a woman’s risk of antenatal depression included:

  • women with two or more co-morbidities
  • prior pregnancy complications (including medically required bed rest)
  • psychosocial stressors (lower socioeconomic status and limited resources)
  • domestic violence
  • Asian, African American and Hispanic ethnicity

Discussion

First and foremost, we have to recognize that pregnancy is not a welcomed event for all women.  And, even in women for whom pregnancy is a welcomed event, antenatal mood disorders can still develop.   In fact, many people remain unaware of the prevalence of antenatal depressive disorders—including some clinicians. The first step to combating this problem is through creating heightened awareness.  With evidence-based training (utilizing studies like Melville’s) and implementation of universal screening and intervention protocols during prenatal visits, diagnosing and treating these pregnancy-related mood disorders can become a widespread reality.

If a clinician suspects a prenatal depressive disorder in one of their patients, she must be ready to provide not only prescriptions for medical therapy (if indicated) but also address other medical and social issues contributing to the condition. For women with underlying co-morbidities, clinicians must identify and treat these conditions accordingly.  Challenges to this might include maintaining frequency and consistency in prenatal care: socioeconomic, geographic, and patient age issues can sometimes prompt less-than-optimal attendance of regular prenatal office visits.   Also, for women whom English is not their first language or for whom American culture and medical care are unfamiliar, a similar deleterious effect on prenatal care consistency might be observed. In these cases, clinicians may need to invite the assistance of social workers, other support services, family members and/or friends of the patient to both educate her as well as increase her access to appropriate care.

Melville’s study confirms what other research had already identified:  domestic violence bears a hefty association with antenatal depressive disorders (odds ratio = 3:45).  While some clinicians may experience discomfort in questioning their patients about the possibility of domestic violence, the data suggests this line of questioning should be imperative.   If  a clinician suspects or confirms a case of abuse he must be prepared to immediately provide appropriate resources to his patient in the form of patient education pamphlets, hotline phone numbers, shelter information and counseling resources.  Alternatively, a trained individual within the practice can also act as a liaison between the patient and appropriate resources, along with maintaining follow- up with the patient at each subsequent prenatal visit.   Because domestic violence happens to women of all ages, races and ethnicities and in all socioeconomic brackets, clinicians must screen all their prenatal patients for this antenatal mood disorder risk factor.

Antenatal depressive disorders are more common than most people realize and they are a real challenge for clinicians to manage.  Melville and her colleagues have provided a useful set of identifiable risk factors that can alert clinicians to patients with potential problems. My greatest concern is that this data may lead some clinicians to screen only those women who have one of the herein analyzed risk factors or who appear to fit the criteria and ignore the potential for antenatal depressive disorders in other women.  The researchers acknowledge that this study has limitations despite being carried out on a large sample and producing data very similar to previous studies. Therefore, they recommend that further studies be conducted to determine if the risk factors identified for antenatal depressive disorders are applicable to a wider subset of patients.  I commend Melville, et. al for their work and for acknowledging the study’s limitations. All pregnant women are at risk for antenatal depressive disorders, with some possessing a greater risk than others. As such, it behooves clinicians to make the extra effort to screen all antenatal women at regular intervals during pregnancy for depressive disorders.

Posted by:  Darline Turner-Lee, BS, MHS, PA-C,

Patient Advocacy, Practice Guidelines, Prenatal Illness, Research , , , , , , , , , , , , , , , , ,