Transcript Perinatal Mental Health 2005

Antenatal and Postnatal Mental
Health: improving outcomes for
mothers and children
Dr Alain Gregoire
Consultant/Hon. Senior Lecturer in Perinatal Psychiatry, Southampton
Member of APMH Guideline Group, NICE
FEELINGS/
MOOD
THOUGHTS/
BELIEFS
BEHAVIOUR
DEPRESSION
low
anxious
negative about
self, situation,
life, past, present
and future
slow, inactive,
withdrawn
ANXIETY
anxious,
fearful
negative
predictions
avoidant
BIPOLAR MANIA
OCD
elated
anxious
grandiose,
overambitious,
intrusive
(obsessional)
thoughts
overactive,
impulsive,
disinhibited
compulsions
Depressive illness: the most common
major complication of maternity
14%
12%
10%
8%
6%
4%
2%
te
s
pr
ec
la
m
ps
ia
di
ab
e
pr
et
er
m
PP
H
IU
nt
G
R
al
ab
ru
pt
io
n
pl
ac
e
m
aj
or
de
pr
es
si
on
hy
pe
rt
en
si
on
0%
Global Burden of Disease: DALYs (life years lost
through death or illness) for women aged 15–44
WHO, 2008
Perinatal period: the most efficient time
for detecting depression in women
pregnancy
34%
no exposure
34%
yrs 11-16
5%
yrs 4-11
1%
yrs 1-4
12%
yr 1 pp
14%
(Sharpe et al 2006)
Foetal programming
Environment in utero,
during different critical
periods for
specific outcomes,
can alter the
development
of the foetus,
with life long effects
Early growth of the human brain
Relative increase in brain size
20 week fetus
fold increase
birth
20
17
10
4
0
fetus
20-40
weeks
5 years
child
birth-5 years
The Fetal Brain “Under Construction”
• 3mm long neural tube: 100 billion
neurons and 100 trillion connections
• 250,000 neurons/minute formed
through gestation
• Proliferation, migration, differentiation,
synaptogenesis continue for 18+months
• Neural pruning til puberty…
The combined effects of raised anxiety (or
depression) both antenatally (32 weeks) and
postnatally (33months) on child outcome up to 13
years
O’Donnell et al 2014
Independent risk factors for adverse
emotional/behavioural child outcome
(SDQ) at 4 years (ORs)
Prenatal anxiety at 32 weeks
1.8
Maternal depression at 33 months
Life events in pregnancy
Maternal age
Maternal smoking in pregnancy
Maternal education
Housing problems
Social class
Financial difficulties
2.0
1.1
0.9
1.2
0.8
1.8
ns
ns
Depressed 16yr olds  100% of mothers depressed,
60% in pregnancy
70
% of adolescent offspring
60
50
40
30
Depressed
adolescents
20
Well
adolescents
10
Pawlby et al
2009
0
Never
In utero
1st year
Early
childhood
Middle Adolescence
childhood
When mother first depressed
Effects of maternal depression in year 1
postnatal on children at 11 years (Hay et al 2008)
z-scores
1
0.5
0
-0.5
al
Em
ot
io
n
n
tte
nt
io
A
ity
ct
iv
yp
er
a
H
at
hs
M
on
du
ct
C
R
ea
d
in
g
IQ
-1
Mother well
Mother ill
Childhood maltreatment: the most
important predictor of antenatal
depression (x10)
No antenatal depression
Antenatal depression
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Low childhood abuse
χ2(1) = 23.76, p < .001; OR = 10.00; CI: 3.57, 28.01
High childhood abuse
Plant et al, 2013
Mothers’ childhood maltreatment has
an impact on their children
Collishaw et al 2007- ALSPAC
eration 0
ood trauma
+
l antenatal
ression
Transgenerational trauma and
poor mental health
Generation 1
Childhood trauma
+
Maternal antenatal
depression
Generation 2
Childhood trauma
+
Maternal antenatal
depression
Generation 3
Childhood trauma
+
Maternal antenatal
depression
Generatio
Childhood t
+
Maternal an
depressi
Adult legacy:
what maltreated children learn
• Be wary
• Trust nobody
• Any little thing could mean big danger
• No control over what happens
• Self blame and self harm
• Self preservation through detachment from
reality: dissociation, non-psychotic voices
The adult effects of childhood trauma
• Borderline personality disorder
• Emotionally unstable personality
disorder
• Complex Post Traumatic Stress
Disorder
• Developmental Trauma Disorder
• Childhood Heroes
Trauma across the generations
•
•
•
80%+ of people with ‘Borderline PD’ were
abused as children (eg. Perry & Herman, 1993)
Earlier abuse  worse effects (van der Kolk et al, 1994)
Severity of both shows linear relationship
(Sansone et al 2005)
•
•
•
80% of infants of ‘BPD’ mothers are
disorganized in their attachment at 13
months (Hobson, Patrick, Crandell et al 2005)
Same percentage as found in maltreated
children (Carlson, Cicchetti, Barnett, & Braunwald, 1989)
30% of maltreated children develop ‘BPD’ (eg.
Bornovalova et al 2013)
Maternal mental health: impact on
ability to provide ‘good enough’ care
Physical needs (food, heat, health, motor)
Protection from harm (accidental & deliberate)
Emotional needs (comfort, control, stability)
Social needs (peer & other, experience &
modelling)
Cognitive and intellectual needs
Consistency
Adaptability, learning and generalising
Abuse and neglect
Over 50,000 children in England subject to
child protection (Department for Education,
2011)
Physical abuse; Sexual abuse
Emotional abuse: hostility, antipathy,
unpredictability, disparaging, degrading,
tormenting
Emotional neglect: indifference, lack of
support
Physical neglect: food, clothing, shelter
Domestic violence: witnessing parental
fighting
Other traumas..
School bullying
Parental death
Parental separations
Placement in institutional care
Parental incarceration
Developental PTSD
• How does this happen?
• http://developingchild.harvard.edu/res
ources/multimedia/videos/inbrief_seri
es/inbrief_neglect/
• http://developingchild.harvard.edu/ind
ex.php/resources/multimedia/videos/t
hree_core_concepts/toxic_stress/
Help for childhood heroes
• What can professionals and services
do:
• http://developingchild.harvard.edu/re
sources/multimedia/videos/theory_of
_change/
• Enhance knowledge, skills and
support
Effective Support: key issues
Effective support: key issues
Components: individuals and
networks
Products: emotional and practical
Network characteristics: size,
variety, interconnectedness
Individual characteristics:
responsivity, trust, closeness,
shared history
Treatment of depression: mild or
moderate or early signs of relapse
 Computerised CBT


livinglifetothefull.com
moodgym.anu.edu.au
 Exercise (pram pushing)
 Counselling (listening visits)
 Brief CBT from IAPT
Antidepressants
What do you know (think of some
obvious things)
Antidepressants
some obvious things:
 Treat depression…and anxiety but not ‘mild’
 Treat an illness which causes serious harm
 Don’t work instantly….2 weeks to start working
 don’t work if you don’t take them and everybody is
bad at taking medication regularly
 Do have side effects….but aren’t dangerous and
aren’t addictive
 Different ones suit different people… but give
yourself 2-3 weeks to adjust to them
 Different doses suit different people… “strong” dose
or “strong antidepressant” doesn’t mean anything
Specialist
Perinatal
Community
Care
NSPCC’s Prevention in Mind report