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Beyond the blues ... perinatal mental health disorders

Jane Hanley
PhD RGN RMN Dip HV Dip Counselling
Lecturer in Primary Care and Mental Health
School of Health Science
Swansea University

Postnatal depression is the well-known term for mothers who suffer from mental health problems during the postnatal period. However, evidence is emerging about the incidence of women experiencing depression during pregnancy. Jane Hanley looks at why such episodes occur and how they can be managed effectively

It is believed that women have more symptoms of depression and anxiety during pregnancy than in the postnatal period. To recognise the importance of this phenomenon the term "perinatal mental health" is more descriptive than "postnatal depression" and denotes any period of time from conception to one year after the birth of the child. If a mother suffers from stress, anxiety or depression during pregnancy there is the possibility of a broad spectrum of adverse effects on the developing foetus.

There is undisputed evidence that stress, particularly chronic stress, causes an alteration in the environment in utero, and that during critical periods, this may influence the developmental outcomes of the foetus.1 An excess of the stress hormone cortisol will cause the foetus to grow more slowly.

It has been recorded in some studies that the high levels of stress some mothers experience have resulted in infants being born prematurely and/or with smaller heads and limbs. An infant's low birth weight is associated with a predicted event of future cardiovascular disease, hypertension, type 2 diabetes and/or depression. In one study it was found that when mothers were asked to do a mental arithmetic test, the foetal heart rate increased in those women who displayed more anxiety while performing the task.

It has been postulated that an attributable amount of behavioural and emotional problems within
the whole population are caused as a result of
antenatal stress.2

Other conditions that have been linked to maternal stress include attention deficit hyperactive disorder (ADHD) and impaired cognitive and language development.3 What is significant about this emerging research is the suggestion that diseases which were once attributed to lifestyle choice in child and adulthood may have their beginnings during the ante- and postnatal period.

Postnatal depression
The postnatal "blues"
The "blues" are regarded as a fleeting phenomenon and have little clinical significance. Most mothers experience feelings of weepiness and weariness within the first few days of the birth and this alteration in mood is attributed to hormonal changes. However, some studies have indicated a link between the blues and postnatal depression, and mothers who experience severe mood changes in the early days postpartum are more likely to become depressed. Therefore, the severity of the blues should be an indicator of a risk factor.4 It is possible that the symptoms may be a continuum of depression during the antenatal period.

Severe postnatal depression
Less than half of women who have previously suffered from postnatal depression may have a repeated episode following the birth of their next infant. Prevention is possible and some studies have demonstrated this when the same antidepressants that were used during the previous depression are prescribed immediately after the birth.5

During the first postnatal year the incidence of severe depression is approximately one in 10; but it is thought that one in four mothers suffers from a more minor form of depression. These rates reflect those found in the general population; however, what is important is that the majority of cases of postnatal depression occur within the first six weeks, the crucial time for the infant who requires a sensitive and responsive primary caregiver who can respond to his or her needs.

The depression is usually characterised by persistent and pervasive symptoms over a two-week period and prevents the mother from managing her life as she used to. Low mood and loss of pleasure or interest are the minimum requirements for a clinical diagnosis. Many mothers will describe their symptoms as physical; for example, changes in appetite, either over-eating or anorexia; disturbance in sleep patterns, not solely precipitated by their infant; loss of, or wavering, interest in sex; and changes in bowel or urinary habits. They can develop negative ideas about their skills and abilities, and concentration levels may be poor. There may also be an overwhelming sense of hopelessness. Motivation may be compromised and everyday tasks more difficult to complete as they feel apathetic and helpless. Emotionally, this may translate into feelings of resentment which, in turn, can lead to feelings of anger and guilt. Several causes are postulated, including biological, which questions the importance of chemical and hormonal imbalances. Research in the human genome is examining genetic components entailing depression and psychosis, but currently the debate remains a part of the nature/nurture continuum. If there is a direct genetic link this reinforces the importance of awareness and early intervention.

The psychosocial model may view poor maternal mental health as a social construct as society changes and the previous revered status of mothers is ignored. Support networks of family - in particular female relatives - and friends are fragmented as most are working or do not have the time to engage with the mother and her needs, and there is no longer the greater emphasis on motherhood being a rite of passage. Whether the cause is biological or emotional, the symptoms are debilitating both for the mother and her infant. If the symptoms are not detected and left untreated it is possible for over a quarter of mothers to be poorly six months later, with some mothers reporting having never been "well" since the first episode.

Psychosis
Psychosis is a relatively rare condition, and more serious occurrence affects one in 1,000 mothers. Nevertheless, there is evidence to suggest that the figure may be higher as some mothers manage to conceal their symptoms, which may be transient in nature.

Psychotic episodes are currently linked with bipolar disorder and research has shown that childbirth is one potent trigger for severe mood changes.6 Other causes suggested are hormonal, stressful life events and/or psychosocial.

Some symptoms of psychosis may include acute irrational beliefs, where the mother may think an external force is controlling her actions that she is unable to resist, in the form of "the devil" or "aliens" who tell her to do strange things to herself or her infant, and may account for the way in which she moves or speaks.

She may experience auditory hallucinations with voices she does not recognise. These are sometimes coherent, with clear commands, and at other times they are distorted. Although she might be aware of the voices in her head, she may not be able to interpret them. The voices can be loud and offensive, and often screaming or shouting, causing the mother to cover her ears inappropriately to obscure the full impact of the noise. Sometimes it is possible she may not be able to distinguish between what is being said by other people and what is an hallucination. Delusions can be equally bizarre. Some are nihilistic and the mother may have a fixed belief that the end of the world is imminent. Some women take the decision to end their lives and that of their child, to prevent them suffering this fate.

A more common type of delusion is where the mother feels she is being persecuted and believes that the care of her child is being scrutinised by the authorities. She may construct a complex scenario that will inevitably alienate her from the social services and this will justify her refusal to allow any statutory interventions. This makes it difficult to decide whether her actions are voluntary or whether she is suffering from paranoid delusions. Other negative thoughts centre on irrational guilt and shame, where the mother feels responsible for a natural or accidental disaster because she chastised her infant or was unable to master the television remote control.
These feelings can be difficult to dispel as other similar occurrences may be invented to maintain her guilt.
Some women experience delusions of grandeur, where they firmly believe they are a royal mother or a "super mother". These eccentric beliefs are likely to be executed and may have serious implications for both the mother and infant.

Bipolar disorder
This was previously known as manic depression. It involves severe shifts in mood function and, at its most severe, can cause episodes of extreme mania, predisposing the mother to high energy levels. The mother's mood may be excessively euphoric. Her thoughts are rapid and the ideas expressed are disjointed and superficial. Her speech may be verbose and sometimes incoherent. She is unable to concentrate for long and is easily distracted. The moods swing dramatically and it is equally possible for the mother to suffer from a debilitating depression, with intense feelings of sadness and despair.

Diagnosis is only completely reliable following a clear-cut episode of mania. However, other causes of mania should not be discounted. Illicit stimulant drugs induce manic symptoms but they usually diminish once the drug is withdrawn. There is also the possibility an organic condition may be associated with secondary mania. Once mania is noted a hospital admission should be considered, although in some areas it is possible to offer intensive and specialist management within
the community.

There is compelling evidence to suggest that mothers with bipolar disorder are at high risk of developing puerperal psychosis and episodes occur following 25-50% of deliveries.6 A mother who has suffered from a previous incident of puerperal psychosis has an increased chance of a repeat of the condition.

Anxiety disorders
There are several forms of anxiety disorder, all with varying symptoms. The main feature of anxiety is the tendency to worry excessively, which is difficult to control. This results in physical complaints, including sleep and eating disturbances, musculoskeletal disorders, abdominal pain and headaches. The emotional consequences include a lack of concentration, irritability and agitation.

Obsessive compulsive disorder is a common occurrence for some mothers and becomes noticeable when it interferes with family relationships and restricts everyday life events. There is evidence to show that the perinatal period is a precipitating factor in this disorder.7

Eating disorders
The body image and appearance of a woman during and after pregnancy is often as important as the pregnancy itself. The effort of a mother to control her shape and body weight should be taken seriously, particularly if she chooses an eating disorder to achieve this. The purging type of eating disorder is more of a concern than a restricted intake. However, it is not as easy to detect and relies on the skills of the health professional.

Once the mother has agreed to some form of management, recovery is relatively straightforward and the result can help the woman to be less vulnerable to a depressive disorder during the postnatal period.

Effect on children and fathers
Bowlby (1980) described "attachment" as the strong emotional link between two people.8 When infants become attached to their mother they use her as a safe base to provide the comfort and encouragement that allows them to explore their environment. Newborn babies are able to cry, make eye contact, cling, cuddle and respond to efforts at being soothed and it is this highly effective behaviour that ensures people are always on hand to care for them.

An event of major depression during the early part of pregnancy can have a subtle effect on the female infant's motor functioning, whereas the male's mental and motor development both appear to be more severely affected. There is overwhelming evidence that if a mother has impaired mental health, this has adverse effects on the infant's, social, emotional, behavioural and cognitive development.9 Wan et al (2007) found that when mothers suffered from a psychotic episode they tended to have poorer interaction with their infant, particularly for the duration of their illness because they were often preoccupied with their own thoughts and feelings.10 When they have recovered, they often remain vulnerable and require specific interventions.

The unrealistic expectations of society on fathers, particularly those who are young or inexperienced in understanding or coping with the emotional demands made upon them, not only by their partner but also their new infant, is understandable and many fathers feel ill equipped to deal with this.11 Nevertheless, in these cases the role of the father cannot be underestimated and where parent-infant bonding is an issue the interaction of the father is crucial.

Studies have found that fathers can protect infants from the deleterious effects of their mother's condition and infants will respond favourably to their fathers when social communication and responses has been denied by their mothers.12 However, having both parents depressed brings about further detrimental consequences for the family, as studies have shown that the emotional and behavioural problems in children were associated with an earlier depression in their fathers.13

Management
Monitoring the mother's mental health should be as important as monitoring her physical health in both the ante- and postnatal period. In some instances where there is a history of previous mental disorder a full risk assessment should be considered, and in these cases there should be full consultation and liaison with members of a multidisciplinary team. If a mother expresses or even intimates she has feelings of anxiety or depression it is important to ascertain if she has any suicidal intentions or ideas, and if she does what she intends to do about it and what plans has she made to carry it out.

Sensitivity and compassion are the main components of care but vigilance is also important in prevention. The use of questionnaires, interventions, clinical interviews and mood assessments all serve to screen the mother for depressive illness or anxiety and although some authorities debate the wisdom of investment in them, the merit in doing so is insurmountable. Listening to mothers and allowing an
expression of their innermost feelings can have a cathartic effect.14,15

Several studies have demonstrated the benefits of cognitive behavioural therapy to explore her feelings of sadness and despair and examine how they might be dealt with in a constructive way to prevent them from reoccurring.
Legitimising and normalising the condition often makes a significant difference. Practical solutions to childcare issues might be offered by statutory agencies and non-governmental organisations, while alternative therapies and exercise regimens can also provide therapeutic effects.

When pharmaceutical interventions are necessary they often include the use of antidepressants. The most common are the selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac) and paroxetine. These effectively block the reuptake of serotonin at presynaptic neurons in the brain. This blockade enhances the activity of serotonin, which modulates mood, emotion, sleep and appetite.16

The drugs may take from two to six weeks or longer before they become fully effective and are prescribed when the risk from postnatal depression is greater than the risk of taking the medication. Some GPs prefer tricyclic antidepressants (TCAs), such as lofeprimine, or the older versions, such as amitriptyline
and imipramine.17 The SSRIs are claimed to be safer medication, particularly in mothers who are likely to attempt suicide, as they do not cause cardiotoxic effects and, unlike TCAs, are not generally fatal. However, the most effective treatment involves the use of antidepressants, complemented by "listening visits" initiated by the nurse.18

Conclusion
Research continues to highlight the impact of perinatal mental health disorders on the mother, infant, family and society, but an element of stigma remains. Interestingly, postnatal depression was uncommon in the past, and has only come to the fore during the last 30 years. This period has seen significant, and in some cases detrimental, changes to family structure and values. It is suggested that women of a previous era would have felt the same pressures and stresses had they shared the lifestyles of today's women.19

Despite this, women have redefined their role in society in past years and as a result there may be gains and losses which may inevitably affect childcare responsibilities and partnerships between mothers and fathers. It is important that an awareness of these societal changes is reflected in nursing practice.

References
1. Talge NM, Neal C, Glover V; Early Stress, Translational Research and Prevention Science Network: Fetal and Neonatal Experience on Child and Adolescent Mental Health. Antenatal maternal stress and long-term effects on child neurological development: how and why? J Child Psychol Psychiatry 2007;48(3/4):245-61.
2. O'Connor TG, Heron J, Golding J, Beveridge M, Glover V. Maternal antenatal anxiety and children's behavioural/emotional problems at 4 years. Report from the Avon Longitudinal Study of Parents and Children. Br J Psychiatry 2002;180:502-8.
3. Bergman K, Sarkar P, O'Connor TG, Modi N, Glover V. Maternal stress during pregnancy predicts cognitive ability and fearfulness in infancy. J Am Acad Child Adolesc Psychiatry 2007;46(11):1454-63.
4. Henshaw C, Foreman D, Cox J. Postnatal blues: A risk factor for postnatal depression. J Psychosom Obstet Gyneacol 2004;25(3-4):267-72.
5. Wisner KL, Wheeler SB. Prevention of recurrent postpartum major depression. Hosp Community Psychiatry 1994;45:1191-6.
6. Jones I, Craddock N. Bipolar disorder and childbirth: the importance of recognising risk. Br J Psychiatry 2005;186:453-4.
7. Abramowitz JS, Schwartz SA, Moore KM, Luenzmann KR. Obsessive-compulsive symptoms in pregnancy and the puerperium: a review of the literature. J Anxiety Disord 2003;17:461-78.
8. Bowlby J. Attachment and loss vol 3. Loss Sadness and Depression. Basic Books: New York; 1980.
9. Kurstjens S, Wolke D. Effects of maternal depression on cognitive development of children over the first 7 years of life. J Child Psychol Psychiatry 2001;42(5):623-36.
10. Wan MW, Salmon MP, Riordan DM, Appleby L, Webb R, Abel KM. What predicts poor mother-infant interaction in schizophrenia? Psychol Med 2007;37(4):537-46.
11. Huang YC, Mathers NJ. A comparison of sexual satisfaction and post-natal depression in the UK and Taiwan. Int Nurs Rev 2006;53(3):197-204.
12. Kaplan PS, Dungan JK, Zinser MC. Infants of chronically depressed mothers learn in response to male, but not female, infant-directed speech. Dev Psychol 2004;(40):140-8.
13. Ramchandani P, Stein A, Evans J, O'Connor T, ALSPAC study team. Paternal depression in the postnatal period and child development: a prospective population study. Lancet 2005;365(9478):2201-5.
14. Holden J, Sagovsky R, Cox JL. Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression. BMJ 1989;298:223-6.
15. Seeley S, Murray L, Cooper PJ. Postnatal depression: the outcome for mothers and babies of health visitor intervention. Health Visitor 1996;69(4):135-8.
16. Schloss P, Williams DC. The serotonin transporter:
a primary target for antidepressant drugs.
J Psychopharmacol 1998;12(2):115-21.
17. Hoffbrand S, Howard L, Crawley H. Antidepressant drug treatment for postnatal depression. Nurs Times 2001;97(45):35.
18. Misri S, Reebye P, Corral M, Milis L. The use of paroxetine and cognitive-behavioral therapy in postpartum depression and anxiety: a randomized controlled trial. J Clin Psychiatry 2004;65(9):1236-41.
19. Hanley J. Perinatal Mental Health. Wiley Blackwell. Oxford; 2009.