Transcript Postnatal Depression - An-Najah National University

Postnatal Depression
Dr Barbara Bavdaž
International Conference on Women’s Health
October 8th/10th 2009
Nablus, Palestine
Childbearing
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One of the most complex events in
human experience
Physical changes of childbirth
Psychological changes of childbirth
Increased vulnerability to general
psychiatric disorders
Postnatal Depression
(PND) or PPD
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World-wide. Affects about 13% of women within
the first year of childbirth
Cultural changes (stigma !). Greater awareness
Information. Prevention. Can escape diagnosis
Antenatal and postnatal “screening”
Early intervention
Multidisciplinary approach
Mother-infant relationship and (can affect) child
growth and cognitive and emotional development
of the baby
Postnatal Depression in the
Developing World
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Attention tends to focus on seemingly more
pressing health problems
Recent studies show 25-30 % new mothers
(prevalence almost double)
Mental health pays a central role in
maintaining physical health and
development of the community
Lower status relative to men, lack of
autonomy, birth of a girl, poor housing,
isolation, poverty
Postnatal Depression in the
Developing World
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Environment more hostile
More infection, less sanitation
Lot of pressure, unable to do all those
things
Baby does not get all the nutrients;
diarrhoea, losing vital nutrients
Does not respond appropriately to child’s
illness, not taking the baby to be vaccinated
Postnatal Depression in the
Developing World
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In Ethiopia 10% die in their first year of life: 5060% because they are malnourished and don’t
have the strength to fight the illness
Projects asking local clinicians to use local and not
Western standards to define mental disorder
In Pakistan: ‘Lady Health Workers’ since 1994
About 96,000 LHW cover more than 80% of
Pakistan’s rural population
Support through empathic listening and positive
reinforcement
‘We are working for optimal health of the child’
‘A healthy mother leads to a healthy child’
Old Classification
Under Three Headings:
 Maternity blues (30-75% 3-4 days
after birth)
 Post-partum ( post-natal ) depression
 Post-partum ( puerperal ) psychosis
New classification *
Four-part classification:
 Psychosis
 Mother-infant relationship disorders
 Depression
 Anxiety and stress-related disorders
* I. Brockington
PND
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Depressed
Irritable
Tired
Sleepless
Lack of Appetite
Anhedonia
Sexuality
Unable to cope
Guilty
Anxious
Postnatal Depression *
Non-psychotic depression with an onset
within 1 year of childbirth,
But…
 A lay term ?
 Weak epidemiological association ( p/d )
 Common in adult women ( lower rates! )
 Heterogeneous group
 Causal associations same as for depression
generally
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* Ian Brokington, Univ. of Birmingham, UK
Detection, Prevention,
Treatment Interventions
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Reduce stigma, allow public recognition
E.I. / Prompt diagnosis and (prophylactic ?)
treatment
Antenatal clinics ( risk factors, history )
Midwifes, (community) nurses, general
practitioners, health visitors
Voluntary agencies, groups
Involvement of fathers, family members
Impact on infant well-being and
development !
Risk factors
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Unwanted pregnancy (single w.,
adolescents, over forty)
Young age (interruption of schooling and of
personal growth, future poverty)
Having three or more children
Single m. status or poor marital relationship
Lower socioeconomic status (maternal
education protective factor)
Low self esteem
Substance abuse
Risk factors continue…
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Ante-natal depression or anxiety
Previous episode of postnatal depression
History of depression or bipolar disorder
Family history of PPD
Gender of child (!)
Recent stressful life events
Inadequate social support (child care stress)
Obstetric and pregnancy complications
Prevention and detection
General screening:
-Use questionnaires e.g. EPDS ( “the whole gamut of
post-partum psychiatric disorders” ) !
-Explore wider context e.g. mother’s life history,
personality circumstances !
-Follow course of the pregnancy including parturition,
puerperium !
-Assess quality and strength of relationships !
-Identify vulnerability and availability of support !
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Prediction and Detection
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Healthcare professionals: midwives,
obstetricians, health visitors, GPs,
community nurses, voluntary agencies,
(peer) groups,
Pregnancy does not protect against
depression
High relapse rates in those who
discontinue medication
Treatment
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Should integrate both psychosocial and
biological modalities
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Psychological support: hospital and community
nurses, health visitors, counsellors ( groups and
individual sessions, anxiety management…)
Social support: social workers, motherhood classes,
o.t. (support workers), self help groups
Involvement of fathers
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Pharmacological treatment
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Risks of Not Treating PPD
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Harm to the mother through
Poor self-care
Lack of obstetric care
Self-harm
Harm to the foetus or neonate ranging
from
Neglect to
infanticide
Mild or Moderate Depression
During Pregnancy or During
Postnatal Period
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Self-help strategies
Non-directive counselling
Brief cognitive-behavioural therapy or
interpersonal psychotherapy
Treatment with Ad’s. The
Maudsley Recommendations
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Those who are already receiving AD
Those who develop a moderate or severe
depressive illness
Psychological management
Ad - tricyclics (amitript., imipr., nortript.)
- SSRIs (avoid paroxetine/first
trimester/linked to cardiac malformations!)
- fluoxetine has the lowest known risk
Continue breast-feeding and switch to mixed
(breast/bottle) feeding
All AD carry the risk of withdrawal or toxicity
Resources and Services
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Aims= prevention, early diagnosis, versatile
intervention with minimal family disruption
(community based…)
The multidisciplinary specialist team:
psychiatrists, psychologists, nurses and
nursery nurses, social workers (Ts)
Voluntary agencies, self-help groups,
leaflets and booklets (RCPsych, MIND in
U.K.)
State of Art in the World
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Domiciliary assessment and home treatment
Day hospital ( putting women with similar
problems in touch with each other )
Mother and baby units, linked to obstetric
units and paediatric units in UK, Australia,
New Zealand, France, Germany, Belgium,
The Netherlands
Italy: Trieste
Service evaluation/research need to be
implemented
Psychological Intervention
in High Risk Pregnancy
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IRCCS Burlo Garofolo- Department of Obstetrics and Gynaecology
Dr Viviana Ive, psychologist, psychotherapist
Centre for High Risk Pregnancy: pre-eclampsia, multiple pregnancy,
previous pregnancy with intrauterine death or previous interruption
caused by severe delay in foetal growth, elective medical abortion
Multidisciplinary integrated team to support women before
pregnancy and monitor during pregnancy, in order to reduce at most
the risks (for health) of mother and baby. Centred on physical
health, emotional and psychological health
Coordinated by one Psychologist/Psychotherapist
Psychological Intervention
in High Risk Pregnancy 2
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Referrals: from medical staff or midwife, who offer the possibility of
psych. intervention), sometimes requested directly by the women.
Assessments: on ward if urgent, alternatively opa’s
Crisis intervention (on ward): intra-uterine death or peri-natal
death
communication of dubious or poor
prognosis (after echography)
emotional distress during
pregnancy (panic attacks, phobias, mood disorders)
traumatised by parturition
post-natal emotional distress
(difficulties in relating with newborn baby)
Intensive psychological intervention during hospital admission. Some
women need further care and follow up in OPC.
Network intervention: the hospital social service and the
community based services
Psychological Intervention
in High Risk Pregnancy 3
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OPA Counselling and psychotherapy, focussed on
bereavement (with disfunctional features),
emotional disturbance in pregnancy (anxiety, mood
disorders) or post- natal depression, difficulties
in relationship with baby or marital problems, PTSD
Network intervention: hospital social service,
community based services (CMHTs, PCTs, Social
Services, GPs, Alcohol and Substance Misuse
Services)
Aims of intervention: to provide care, support,
containment and elaboration of pain caused by any
pathological condition, foetal death, emotional
distress; to allow sufficient or good care to new
born baby in any circumstances
‘Synergic Effects of Oxytocin and
Psychotherapy in Postpartum
Depression’ 1
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A 3 year randomized controlled trial
on 150 women; area of intervention is the province of Trieste
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Financed by the Department of Reproductional and
Developmental Science
-Dr. Andrea Clarici - MD - Senior Lecturer at the University of
Trieste Faculty of Medicine
(IRCCS Paediatric Hospital Burlo Garofolo, Trieste).
-Dr. Sandra Pellizzoni - Psychologist - Postgraduate student at
the
IRCCS Paediatric Hospital Burlo Garofolo Trieste
‘Synergic Effects of Oxytocin and
Psychotherapy in Postpartum Depression’ 2
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Hypothalamic neuropeptide implicated in regulation
of social, reproductive and stress-related functions
A key role in intimate attachment such as marital
relationship and early interaction with offspring
Twofold effect: to strengthen attachment and
reduce stress
Referrals from paediatricians, obstetricians and
midwifes
Two random groups: psychotherapy and Oxytocin
vs. psychotherapy and placebo
Depression, post-partum,
violence 1
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Trieste, IRCCS-Burlo G. – Psychology Dept.
University of Trieste and University of California in
San Francisco
Study on 352 women, mean age 32, September
2004 to March 2005
Part 1: two questionnaires
(Common) violence acted by partner or family
member
Leads to depression, anxiety, low self esteem, has
negative impact on physical and mental health (well
being) of both, mother and child
Depression, post-partum,
violence 2
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8 months after giving birth 10% of
women experience domestic violence
(psychological, sexual, physical)
5% high levels of psychophysical
distress with depression
Incidence of depression x13 higher in
those who experience intrafamilial
violence (27,6% vs. 2,7%)
PPD and employment
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3
8 months later 32% not satisfied with
current occupational situation GHQ-12*
No difference between those at home and
those at work
Significant the congruence between reality
and desired situation
Employment dissatisfaction negatively
associated with woman’s health after
childbirth
*General Health
Questionnaire (GHQ-12)
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General Health Questionnaire (GHQ-12)
We would like to know how your health has been in general,
over the past few weeks.
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Please answer the following questions by circling the
number that best applies to you.
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Have you recently….
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…much less than usual-same as usual-more than usualmuch more than usual…
Been able to concentrate on whatever you are doing? Lost much
sleep over worry? Felt that you were playing a useful part in things?
Felt capable of making decisions about things? Felt constantly under
strain? Felt that you couldn't overcome your difficulties? Been able to
enjoy your normal day-to-day activities? Been able to face up to your
problems? Been feeling unhappy and depressed? Been losing selfconfidence in yourself? Been thinking of yourself as a worthless
person? Been feeling reasonably happy, all things considered?
NHS- Mother & Baby Unit
(Thumbswood) 1
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Hertfordshire, Welwyn G.C., QE II
Hospital
Purpose-built, self-contained unit
Provide specialist assessmnet, care
and treatment for mothers suffering
from mental illnesses associated with
childbirth (as early as possible)
Support to families and carers
NHS- Mother & Baby Unit
(Thumbswood) 2
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Provide a joint service between health and
social care professionals
Ensure comprehensive follow-up care
Sensitive to cultural differences in parenting
practices
Sustain and facilitate the developing
relationship between mother and baby and
other family members
MDT, liaison with Health Visitors, GPs, and
Community Services
NHS- Mother & Baby Unit
(Thumbswood) 3
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Referrals from any area but exclusively from
GP, consultant psychiatrist, maternity within
QE II Hospital
Treatment: education, O.T., psychotherapy,
postnatal groups, baby massage sessions,
cooking, practical guidance, empowerment
and ventilation of feelings, fathers’ group,
weekly review; on-site support from
midwives, obstetricians, gynaecologists,
paediatricians
NHS- Mother & Baby Units
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November 27th 2008 1st annual forum for
the Quality Network for Perinatal Mental
Health Services
13 mother and baby units from across the
country
Emergency admissions, admissions in late
pregnancy, involvement of specialised
community teams, safety and formal
physical assessment of infants
Mind.org.uk; Perinatal.nhs.uk;
Cemach.org.uk
Community Based Service
ASS1 Trieste and ‘Percorso
Nascita’ since 1997-2002
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Based in Consultorio Familiare (Family Planning
Clinics) in each Health District
Support in non problematic (physiologic) pregnancy
Antenatal classes, postnatal classes, advice through
breastfeeding; vaccinations
Cervical screening; menopause clinics; breast
cancer prevention-self examination
Direct access; privacy and confidentiality for under
18; teen pregnancy
(Illegal) immigrant women and the most vulnerable
situations
Percorso Nascita
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Midwife has a central and independent role (max. autonomy!),
collaborating (when necessary) with gynaecologist
3 groups monthly, each with 20 participants. Increasing
number.
Assessments, referrals, home visits when needed, visits to
mother and baby after discharge from hospital
Network with other community based services
High users’ satisfaction : continuity, accessibility;
multidisciplinary, positive, constructive, optimistic approach,
users’ centred, shaped on needs
Connected with other health and social services (e.g.DSM)
Baby blues, no PND recalled by the staff; is that prevention?
Services network? Accessibility?
Primary Health Care - Now
More than Ever (WHO)
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44 year discrepancy between
industrialized and developing countries
58 million on 136 mothers of new
born babies without sanitary
assistance
Public health costs p.p./ per year vary
between 20 and more than 6 thousand
U.S.dollars
Primary Health Care - Now
More than Ever (WHO)
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Infant mortality rate (IMR) under 5y.
varies even within same city (Nairobi)
from 1,5 to 25,4 per cent
Lack of drinkable water, vaccination,
nutrition
Primary health care
Integrated community services
Holistic approach
Primary Health Care - Now
More than Ever (WHO)
Prevention as important as cure
 GPs at the core
 Equity, accessibility, efficiency
 Guidelines to develop health systems:
-available to everyone
-person centred
-integrated approach
-political leadership
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Immigrants and PND
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In Italy, 50% are women
Isolation, lack of social support, poor
knowledge of language and culture, stress,
housing problems, young age, victims of
genital mutilation
Specific approach and service provision
‘Dakar-Fann School’ meet under the village
tree (patient, carers, friends,
professionals...)
Illegal Immigrant
Pregnant Women
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The most vulnerable group of
immigrants
Often mother of other children (one or
more)
In Italy has the right to health care in
pregnancy
STP (foreigner, temporarily in Italy)
Interpreter for small groups
Traditional Communities
in Africa
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During pregnancy and after birth care
and support to mother
Whole village involved
Minimum rates of PPD
Urbanization brings consequences as
reduced solidarity and isolation
Increased rates of PPD
‘A Very Positive Impact’
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Successful athletes, politicians, writers,
intellectuals after giving birth or
breastfeeding
Cultural and social circumstances
Postpartum wellness, joy, positive
feelings, physical energies
When pregnancy is a planned choice
and based on a strong relationship
‘A world that is unequal as regards health
provisions, is unstable and unsafe.’
BAN KI-MOON
WHO Secretary General
Thank you
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Thanks to dr Daniela Gerin, gynaecologist and
coordinator of the project Salute Donna ASS1
Trieste
Claudia Massopust, senior midwife, District 4, ASS1
Trieste and her very kind colleague Chiara
Menegolli
Special thanks to Ms Martina Kalc mother of Filip
born on September 4th 2009 and who lost her first
baby during pregnancy in 2007