Perinatal Mental Health: A Clinical Guide

By Professor Colin Martin

The prospect of parenthood represents a milestone in anyone’s life course and is often a period of stress and challenge. There are a number of significant mental health problems that can occur during the perinatal period, the consequences of which can be both enduring and, occasionally, life threatening. However, irrespective of the specifics of the clinical manifestation of a disturbance, the distress and misery that accompanies it has significant ramifications for the mother or mother-to-be and her partner and family.

This book is arranged in themed parts that represent key aspects of facilitating access to effective clinical management during the antenatal and postnatal period. These are covered in the first two Parts One and Two of the book.

Part Three examines the pertinent areas of concern regarding partners, a critical but often neglected area of concern within the sphere of perinatal mental health. Part Four explores the social dimension of perinatal mental health, covering areas as diverse as the role of social workers to the psychological processes of obedience within the clinical setting.

Part Five focuses on key themes of assessment and psychological interventions, a complex and often misunderstood area.

Part Six highlights emerging issues of contemporary relevance, often challenging to the veracity and depth of the current evidence base but of increasing clinical and academic concern.

Finally, Part Seven considers the broad spectrum of child health, child care and child development, often significantly influenced by the themes established and explored in the preceding parts of the book.

It is hoped that this book will not only provide a handy and evidence-based book for the busy health professional, but will also promote interest and understanding of the complex area that represents perinatal mental health to a wider audience.

• Language: English
• Publisher: M&K Update Ltd
• Release date: Feb 28, 2012
• ISBN: 9781907830495

Book preview

audience.

Maternal mental health before and during pregnancy

Chapter 1Epidemiology of maternal mental health disorders

Jessica Gibson and Ron Gray

Chapter 2Major depressive disorder

Carol Henshaw

Chapter 3Anxiety

Amanda McGrandles and Tim Duffy

Chapter 4Personality disorders

Caroline J. Hollins Martin

Chapter 5Schizophrenia

Mick P. Fleming and Colin R. Martin

Chapter 6Bipolar affective disorder

Glenn R. Marland and Colin R. Martin

Chapter 7Eating disorders

Helen Fawkner

Chapter 8Sexual dysfunction

Olga B.A. van den Akker

Chapter 9Comorbid physical illnesses

Julie Jomeen and Colin R. Martin

Chapter 10Chronic fatigue syndrome

Yvonne Christley and Colin R. Martin

This chapter discusses the epidemiology of the antenatal period only (mental illness in the postnatal period is addressed later in this book). It considers the characteristics of the antenatal period to identify specific issues and risk factors associated with this stage. The discussion is confined to the pregnant woman, only referring to the fetus when it may be directly affected by maternal mental illness. Each diagnostic category is examined separately to consider whether pregnancy impinges on the course of mental illness in any way, but treatment in the antepartum period and the teratogenesis of psychotropic drugs are not discussed as they are beyond the scope of this chapter.

The perinatal period has been identified both as a risk factor for relapse of mental illness and a time of relative protection. It is timely, therefore, to investigate whether the antenatal period differs significantly from other times in a woman’s life in terms of developing a de novo mental illness or experiencing a relapse of a pre-existing disorder.

The peak age of onset for most severe mental illnesses occurs during the fertile years for women, that is between 15 and 45 years old. Up to 50 per cent of pregnancies in the UK are unplanned (Dex and Joshi, 2005) and this rate may be even higher among women with mental illness. Therefore, the possibility of pregnancy in all women with mental illness who are of reproductive age should be considered. Only by understanding how pregnancy affects mental illness and vice versa can we address how it might be detected and treated and what services need to be developed.

Review methodology

This literature review was informed by searching on Medline™, Embase™ and PsychInfo™ for the years 1998–2009. The terms ‘pregnancy’, ‘antenatal’, ‘prenatal’, ‘antepartum’, ‘obstetric’, ‘schizophrenia’, ‘psychosis’, ‘substance misuse’, ‘alcohol’, ‘bipolar’, ‘suicide’, ‘deliberate self-harm’, ‘obsessive–compulsive disorder’, ‘anxiety’, ‘post-traumatic stress disorder’, ‘tokophobia’, ‘depression’, ‘eating disorder’, ‘anorexia nervosa’ and ‘bulimia nervosa’ were used. Bibliographies were inspected and relevant citations examined.

What is special about the antenatal period with respect to mental health problems?

In the antenatal period there are two particular concerns: the mother and the developing child. The relationship between mother and the fetus is physiological, psychological and social. From a physiological perspective, virtually every substance that enters a woman’s body is transmitted to the fetus across the placenta. This is of particular relevance for medicinal or other drugs and alcohol, especially in the first trimester of pregnancy. At the same time, pregnancy has significant effects on the woman’s body. There are alterations in hormone levels, circulatory blood volume and blood pressure and on the immune system. Psychological changes during pregnancy are equally significant. Particularly in a first pregnancy, a woman needs to adapt to her changing role in society, her family structure and in her workplace. This may be a time when issues from childhood and the past may re-emerge. Difficulties in a relationship with parents are often re-awakened as a woman prepares for parenthood for the first time. Previous experiences of physical or sexual abuse may be recalled as she becomes increasingly aware of her evolving reproductive function (Austin, 2003). From a social perspective, pregnancy may entail additional financial costs and pressures about accommodation. Relationships between the woman and her partner, the father of the developing fetus, may be renegotiated in pregnancy, and this can change level of support and stability in her personal life.

The above demonstrates some of the ways in which pregnancy impacts on a mother. We also know that the woman’s mental state and behaviours can have a direct effect on the fetus. Maternal stress can cause changes in the fetus’s hypothalamic–pituitary–adrenal axis and predispose the infant to behavioural disorders and depression in later life (Hubel et al., 2008; O’Connor et al., 2002). The harmful effects of substance misuse during pregnancy are also well documented and include fetal malformations, stillbirth and premature delivery. Specific problems that arise in the antenatal period may be exacerbated in multiple pregnancies and may also arise following stillbirth, miscarriage and termination of pregnancy. What is more, any disorder arising in pregnancy may continue into the postnatal period, and beyond.

Classification of mental disorders in the antenatal period

The commonly used classification systems for mental illness have no specific category for antenatal occurrence of mental disorders. While there is a qualifier to denote if onset is in the puerperium, there is no equivalent for the antenatal period. This may impede the accurate recording of information concerning the onset of women’s mental illness and it poses limitations to research that may require such data. This approach also suggests that a relapse or new-onset illness in a woman in the antenatal period is widely considered to be no different from psychopathology that occurs at any other time (Henshaw et al., 2009).

How do we detect mental disorders in the antenatal period?

The National Institute for Health and Clinical Excellence (NICE) guidelines define ‘detection’ of antenatal mental illness as ‘the identification of a current disorder’, while ‘prediction’ refers to ‘the identification of risk factors, current or past, which increase the probability of onset of a mental disorder at some point in the future’.

Detection normally occurs through self-report by women with a degree of insight or with a known mental illness. The process of screening could, in theory, detect ‘hidden’ mental health problems. However, accurate detection of antenatal mental illness requires validated screening tools, but few instruments are validated for use in this population. Successful screening also depends on communication between the population of interest and the healthcare services. Unfortunately, women with existing mental illness are among those who are least likely to be in touch with medical services (McNeil et al., 1984).

The aim of screening would be to detect cases of illness that could be treated, thus reducing the overall morbidity associated with pregnancy. It would be unethical to screen anyone without the adequate provision of resources to treat those with detected disorders (National Screening Committee, 2001). Screening is not a diagnostic activity; it needs to be followed by formal assessment and diagnosis. A systematic review of antenatal assessments by Austin et al. (2008) found that screening for antenatal mental illness may increase clinicians’ awareness of psychosocial risk, but there was insufficient evidence that routine screening will lead to improved mental health outcomes.

Is the antenatal period associated with an increased risk of developing a psychiatric disorder or relapse or an unusual presentation?

To answer this question it is helpful to consider each broad diagnostic category of mental illness individually in order to investigate any patterns or trends that exist in the antenatal period, from bipolar disorder, anxiety and depression to eating disorders and substance misuse.

Bipolar disorder

It is well documented that the postpartum period is a time of significantly increased risk of relapse for women with bipolar disorder. However, there is varying evidence about the risk of women relapsing or developing bipolar disorder de novo in the antenatal period. There is some research to suggest that pregnancy exerts a protective effect (Grof et al., 2000) but other recent studies indicate that pregnancy is a time of substantial risk. Women who are prescribed with mood stabilising medication may abruptly cease taking medication, especially if the treatment is known to have potentially teratogenic effects. Sudden cessation of this medication is known to increase the risk of a depressive or manic relapse. A prospective study by Viguera et al. (2007) suggests that pregnancy carries a significant risk of relapse. In women with a known bipolar disorder, in whom mood-stabilising medication is stopped, the risk of relapse is twice as likely as in women who continued with their medication. The latent period to recurrence of the illness was also four times shorter in those who came off their medication, and the illness lasted longer. The risk of relapse was even higher if there was abrupt cessation of medication. A total of 86 per cent of these women experienced a relapse of a mood disorder meeting the diagnostic criteria for SCID (Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders)). The incidence of relapse in women who continued on their medication remained high, with 37 per cent of the cohort experiencing at least one episode of illness. Unplanned pregnancy was a predictor of antenatal relapse in this group. Most relapses (79 per cent) were depressive or mixed in type, with mania or hypomania accounting for the remaining 21 per cent of cases.

Schizophrenia

The peak age of onset of schizophrenia in women is in the mid- to late 20s, with a second smaller peak in women in their late 40s. This is later than in men and, as such, women are more likely to have completed their education, entered employment and started having children by the time of their diagnosis. While there is evidence of lower fertility rates in women with schizophrenia, the majority of women with psychotic disorders still have children (Howard et al., 2005). The impact of schizophrenia on the pregnancy is well documented; the mothers use more alcohol, tobacco and illicit drugs compared to women without schizophrenia and their nutritional status and attendance for antenatal care are poor. These factors may partly account for the increased rate of preterm delivery, intrauterine growth restriction, low birthweight, low Apgar scores and possibly stillbirth in their child (Altshuler et al., 1996; Howard, 2005).

However, it is not clear whether pregnancy has any effect on the course of pre-existing schizophrenia. One prospective study (McNeil et al., 1984) found higher rates of ‘active mental disturbance’ in pregnant women with a history of non-organic psychosis than in matched controls. Only one-third of these women were in contact with a psychiatrist during this time. The apparent avoidance of antenatal and mental health services by women with psychotic disorders means that it is difficult to gather accurate data in this area. There is no evidence that pregnancy increases the risk of developing schizophrenia de novo.

Depression

Antenatal depression has been relatively neglected, in terms of research, compared with postnatal depression. While diagnostic classification systems provide operational criteria by which to make a diagnosis, the ‘lay’ use of the term depression tends to be broader. Primary-care practitioners may also make less specific diagnoses, so data from primary care may relate to a greater range of psychological difficulties. Often a woman’s inability to cope or heightened anxiety and adjustment disorders find themselves included in the concept of ‘depression’. Therefore, data from research studies must be interpreted with caution paying close attention to the definition of ‘depression’ that is being used.

There is increasing evidence that rates of depression are at least as high, if not higher, during pregnancy than the postnatal period (Heron et al., 2004). The prevalence of antenatal depression is estimated at 10–20 per cent (Evans et al., 2001) which is similar to the prevalence of depression in the non-gravid population. Indeed, there is little evidence to suggest that there is a categorical difference between depression in the perinatal period and at other times.

Pregnancy may affect the course of a depressive disorder in several ways. Firstly, the pregnancy itself may act as a trigger because it is a major life event and all major life events are associated with an increased risk of relapse in affective disorders (Paykel, 2003). There are also significant biological changes in pregnancy that affect mood state. These include raised levels of female sex steroids that act at the mood regulation area of the brain (O’Keane, 2006). Discontinuation of antidepressant medication is another contributing factor (Cohen et al., 2006). In terms of relapse of pre-existing depression during pregnancy, Cohen et al. (2006) report that 43 per cent of women with a history of depression undergo a relapse during pregnancy. If their medications were decreased or stopped, the rate of relapse was 68 per cent. In those who continued antidepressant treatment throughout their pregnancy, 26 per cent experienced a relapse. Those who stopped or decreased their medication were found to have a five-fold greater risk of relapse than those who continued it. Of these occurrences, over half were within the first trimester, with the risk decreasing throughout the pregnancy. Other risk factors for antenatal depression include a history of depression of over five years, the occurrence of more than four previous episodes, low self-esteem and poor social support (Leigh and Milgrom, 2008).

Antenatal depression has important effects on the pregnancy and postpartum period, including poor attendance at antenatal clinics, substance misuse, preterm delivery and low birthweight (Pagel et al., 2001).

There is some evidence that antenatal depression may exert a harmful effect on the developing fetal nervous system (Hansen et al., 2000). Furthermore, antenatal depression is the single most significant risk factor for postnatal depression (Milgrom et al., 2008) with its associated risks for both mother and infant.

Anxiety

Much of the literature on anxiety in pregnancy uses the broader term ‘stress’. This may be objectively defined as exposure to a catastrophe or major life event or subjectively defined as the mother’s experience (Hobel et al., 2008). We focus on anxiety as defined in DSM-IV and ICD (International Classification of Diseases)-10, that is the subjective experience of a range of psychological and physical symptoms. These include autonomic arousal, feelings of apprehension, fear and irritability.

There is evidence that pregnancy may give rise to ‘pregnancy-specific anxiety’, a distinct disorder that is unique to the antenatal period. Three factors are included: ‘fear of giving birth’, ‘fear of bearing a handicapped child’ and ‘concern about one’s appearance’ (Huizink et al., 2004). Pregnancy-specific anxiety is more closely related to adverse obstetric outcomes such as preterm birth, than generalised anxiety disorder occurring in pregnancy (Roesch et al., 2004). Another anxiety disorder specifically associated with the perinatal period is tokophobia, which is an intense dread of childbirth. This may be primary, occurring before the experience of a delivery or it may be secondary to a traumatic delivery (Hofberg and Brockington, 2000). The prevalence has been reported to be 5.5 per cent and it is often associated with avoidance of pregnancy and elective caesarean delivery (Heimstad et al., 2006).

In a study of mothers admitted to specialist psychiatric services, it was found that antenatal anxiety was more frequent than antenatal depression, and that the most common theme was fear of fetal death (Brockington et al., 2006). In terms of panic disorder, there is conflicting evidence regarding the impact of pregnancy on the course and severity of illness. One review found that 41 per cent of women with pre-existing panic disorder experienced an improvement in their symptoms during pregnancy, but postpartum relapse was not uncommon (Hertzberg and Wahlbeck, 1999). Other studies found that panic symptoms were unchanged in pregnancy (Cohen et al., 1996).

Post-traumatic stress disorder has been found to occur in around 7 per cent of pregnancies and to have high comorbidity with depression, generalised anxiety disorder and substance misuse (Loveland Cook et al., 2004). Obsessive–compulsive disorder may occur de novo in pregnancy. One retrospective study reported that over a third of parous women identified that their first episode occurred during pregnancy (Neziroglu et al., 1992). Pre-existing obsessive–compulsive disorder has been shown to worsen in pregnancy in several studies (Williams and Koran, 1997; Uguz et al., 2007), and to improve in other smaller samples (Geller et al., 2001).

However, all types of anxiety and stress pose a potential risk to the pregnancy (in terms of preterm birth and low birthweight) and subsequent neurodevelopment of the infant. O’Donnell et al. (2009) showed that a variety of prenatal stressors increase the risk of adverse neurodevelopmental outcomes in children including impaired cognitive development and behavioural problems (O’Donnell et al., 2009.).

Eating disorders

Pregnancy can complicate eating disorders because changes in maternal body shape can cause anxiety about weight gain. Both anorexia nervosa and bulimia nervosa affect women at their peak age of reproductive functioning. Women who experience anorexia have a disturbed menstrual cycle and are less likely to conceive in the active stage of their illness and a return to normal fertility rates may be delayed even after adequate weight gain (ESHRE Capri Workshop Group, 2006). As a result, anorexia is less common in pregnancy than in the general population. There is some evidence to suggest that the prevalence of eating disorders increases in the postpartum period (Larrson and Andersson-Ellstron, 2003), but evidence concerning the course of eating disorders in the antenatal period is conflicting. While the weight gain associated with pregnancy may cause a worsening of the symptoms in anorexia and bulimia, one prospective study has shown that the illness symptoms may improve if the mother is concerned about adverse affects on the developing fetus (Rocco et al., 2005). Two prospective studies have shown that the symptom burden during pregnancy may improve for women with bulimia (Rocco et al., 2005; Blais et al., 2000) but that both women with anorexia and bulimia may suffer a postpartum relapse, most likely within the first six months of delivery.

Eating disorders are likely to be under-detected in pregnancy. Women may feel shame and may fear being forced to gain weight if they reveal their eating patterns (Lemberg and Phillips, 1989).

Substance misuse

It is difficult to accurately determine the prevalence of alcohol, nicotine and other illicit drugs during pregnancy. The rate of substance misuse is likely to be significantly under-reported due to the stigma and shame attached to such behaviours, especially during pregnancy.

Alcohol

The negative effects of alcohol on the developing fetus are well-established. These range from fetal alcohol syndrome (a pattern of facial anomalies, growth retardation and nervous system abnormalities associated with maternal alcohol dependency) to congenital anomalies (Baumann et al., 2006) and stillbirth (Kesmodel et al., 2002). It is estimated that up to 50 per cent of all pregnant women will drink some alcohol (Goransson et al., 2003). In a large American study, 2.3 per cent of pregnant women were found to be alcohol dependent and 16.7 per cent were binge-drinkers (Caetano et al., 2006).

Women who continue to drink in pregnancy tend to be younger, single, unemployed and have a history of sexual or physical abuse (Leonardson and Loudenberg, 2003). The use of alcohol in pregnancy is also associated with higher rates of smoking and other substance misuse (Burns et al., 2006). There is no evidence to suggest that alcohol misuse increases in pregnancy and specific psychosocial interventions have been developed for use in pregnancy. These include motivational interviewing (Handmaker and Wilbourne, 2001) and cognitive–behavioural therapy (Peterson and Lowe, 1992). There is evidence that these interventions have resulted in decreased use of alcohol during pregnancy and reduction in adverse perinatal outcomes.

Nicotine

The prevalence of smoking in young women has declined in the USA and western Europe, but may be on the increase in some Eastern European countries (Cnattingius, 2004). However, women with comorbid psychiatric illness are more likely to smoke during pregnancy. Rates of smoking in women with schizophrenia have been found to be 31 per cent and those with affective psychosis are 24 per cent, compared to 12 per cent of controls (Henriksson and McNeil, 2006). Smoking is known to be associated with a range of adverse outcomes for the mother and infant, including stillbirth (Gold et al., 2007), preterm delivery (Malik et al., 2008), low birthweight (Steyn et al., 2006) and intrauterine growth restriction (Hammoud et al., 2005).

Pregnancy provides a powerful incentive to stop smoking and comprehensive information about the negative impact of nicotine on outcomes for the mother and infant is made available by obstetric services. Around 20–40 per cent of women are able to abstain from smoking during pregnancy but many start again after delivery (Colman and Joyce, 2003).

Drug misuse

Women account for around one quarter of drug users undergoing treatment in the UK. Over 90 per cent of these are of child-bearing age (15–44 years) and therefore may become pregnant (Department of Health, 1999). Self-reports of drug use are unreliable and underestimate the problem. This is driven, in part, by a fear that the mother’s baby or older children might be taken into care (Confidential Enquiries into Maternal and Child Health, 2007). Biological markers provide more reliable results than self-report; meconium testing is the most reliable.

In UK studies of anonymous testing in inner-city obstetric populations, between 6.5 per cent and 8.5 per cent of urine samples were found to be positive for cannabis and two per cent were positive for opioids (London et al., 1990). In Spain, a study using meconium testing, showed that 7.9 per cent of samples were positive for illicit substances, mainly opiates and cocaine (Pichini et al., 2005). Other substances that are used in pregnancy include methamphetamines, solvents and volatile agents.

There are substantial risks to the fetus and mother when substances are used in pregnancy, especially if they are injected. These arise both from the direct effect of the substance on the pregnancy and from associated social and environmental risk factors. Direct effects on the pregnancy include placental abruption, preterm birth, stillbirth and neonatal death (Kennare et al., 2005). Lifestyle risk factors such as sex-working and living rough can increase the pregnant woman’s vulnerability. Physical complications such as blood-borne viruses, bacterial endocarditis and sexually transmitted diseases can have an additional negative impact on the pregnancy.

Treatment of substance misuse in pregnancy remains a high priority. It is postulated that pregnancy may offer a period of enhanced motivation for the pregnant woman to address issues of addiction; specialist treatment units provide unique services in this area. However, there is little evidence that more women are able to change behaviours during this time or that the changes are sustained beyond delivery.

Suicide

The finding that pregnancy confers a protective effect against suicide has been replicated extensively. One meta-analysis (Harris and Barraclough, 1997) showed that suicide rates are three to eight times lower in pregnancy than among the general population, even in people with a history of mental illness. In an American study (Marzuk et al., 1997), the standardised mortality ratio (SMR) for suicide in pregnancy was 0.33, a third of that expected in non-pregnant women. Appleby (1991) made even more striking findings using suicide data from the UK in the 1970s. He found the SMR during pregnancy to be 0.17 (one-sixth of that expected in non-pregnant women). Within this low-risk population, teenagers represented a high-risk group with an SMR of 0.28. This higher rate was thought to be due to a higher incidence of unwanted pregnancies among teenagers.

However, suicide is still a leading cause of maternal death in pregnancy. In England and Wales, maternal suicide rates are presented in the Confidential Enquiries into Maternal and Child Health (Confidential Enquiries into Maternal and Child Health, 2007) triennial reports. The most recent of these focused on the period 2003 to 2005. In this, eight pregnancies out of over two million ended in maternal suicide. This made suicide the third most common cause of pregnancy-related death after cardiovascular disease and thromboembolism.

The rate of suicide in pregnancy is likely to be under-detected as death certificates and coroner’s reports may not specify whether a woman was pregnant at the point of her death. In some cases, it is not possible to ascertain if a death is suicide or accidental, especially in women with active substance misuse problems. For those women who do commit suicide in pregnancy, the majority suffer from a diagnosable mental illness and use more violent methods than those used by the non-pregnant female population (for example, hanging, jumping from a height or self-immolation) (Confidential Enquiries into Maternal and Child Health, 2007).

There are several potential explanations about pregnancy protecting a woman from suicide, despite increased rates of depression and anxiety in the antenatal period. The fertility rate is lower in women with schizophrenia, substance misuse and severe personality disorder (Kendell et al., 1987), although this is unlikely to fully account for the significantly lower suicide rate. Studies have shown that serotonin levels rise throughout pregnancy (Gujrati et al., 1985) and that low serotonin levels are associated with an increased risk of suicide. In addition, pregnancy is likely to inhibit women from certain impulsive and reckless behaviours in order to protect their unborn child.

Deliberate self-harm

Deliberate self-harm has been described as ‘an expression of personal distress, usually made in private, by an individual who hurts her or himself’ (National Institute for Health and Clinical Excellence, 2004). As such, self-harm is a secretive act and may only come to the attention of medical services at its most extreme. This makes it difficult to accurately assess its prevalence in the community. The majority of people who self-harm are women of child-bearing age. Peak incidence is in women between the ages of 16 and 25 years. The estimated prevalence of self-harm in the UK ranges between 400 and 1000 per 100,000 of the population per year (Department of Health, 2003). We might expect rates of self-harm to be affected by pregnancy. Self-harm may serve as a way of regulating powerful feelings and pregnancy is a time when these feelings may re-emerge. However, pregnancy may also be a period when women are motivated to protect themselves and their unborn child. There has been little research into the prevalence and incidence of self-harm in pregnancy, but two American studies report data on hospital admissions as a result of self-harm in pregnancy. Both found that the incidence of self-harm requiring hospitalisation was significantly lower in pregnant women compared to age-matched, non-pregnant controls (Greenblatt et al., 1997; Weiss, 1999).

What are the risk factors for antenatal mental health disorders?

Pregnancy may provide a period of improved mental health and function for women with certain disorders, for example, bulimia nervosa or suicidality associated with depression. However, it is associated with an increased risk of onset or relapse for others, notably bipolar disorder as mentioned above. While the risk factors for individual illnesses vary, there are common themes. For women with pre-existing mental illness the abrupt cessation or decrease in dose of medication may trigger a relapse. Pregnancy is associated with higher rates of domestic violence (Confidential Enquiries into Maternal and Child Health, 2007) which predisposes women to depression, anxiety, substance misuse and poor service uptake with its associated risks.

Predisposing factors for antenatal mental illness include a personal history of any mental illness, family history of mental illness, social vulnerability (such as social isolation), an abusive relationship or experience of racism, psychological vulnerability (e.g. low self-esteem) and teenage pregnancy. The same factors also serve as maintaining factors for mental illness in the antenatal period, as does lack of access to services or poor treatment response.

Availability of specialist mental health services in the antenatal period

Maternal mental health is a neglected area, although its importance is increasingly recognised in the developed world. For the most part in the UK, maternal mental healthcare is provided by the same agencies that care for non-gravid women. These include primary care services such as general practitioners or secondary services such as community mental health teams. Inpatient care is generally provided by general adult mental health services. Obstetric services provide regular important points of contact for women who have engaged in antenatal care. It is therefore crucial that midwives and obstetricians are able to recognise possible mental illness in their antenatal population.

Concerns about including pregnant women in mainstream adult mental health services focus on several key areas: difficulties in delivering care in the restricted time frame of a pregnancy; the need for improved access to psychological services due to concerns about drug therapies in pregnancy; expertise in prescribing during pregnancy; and safety issues arising because pregnant women are being seen in an environment where severely ill patients may pose a risk (National Institute for Health and Clinical Excellence, 2007).

For these and other reasons, specialist services are being developed in an increasing number of areas in the UK where none already exist. Perinatal mental health services should provide multidisciplinary input from specialised psychiatrists, psychologists, nurses, social workers and occupational therapists. There may be access to beds on a mother-and-baby unit, where women may be admitted before or after delivery, with the infant.

Nevertheless, even where specialist services are provided, pregnant women with mental illness experience barriers to care. Women who are homeless have difficulties accessing all antenatal services. Women with comorbid substance misuse may refrain from accessing services due to the stigma of drug and alcohol use and because fear of social-service involvement or criminal proceedings. Teenage mothers may have less stable lifestyles and poor uptake of services, and for some ethnic groups psychological distress may present differently or it may be hidden and therefore not come to the attention of the services. Further financial and logistic barriers exist include lack of money, transportation or child care for women with existing children (Kopelman et al., 2008).

Conclusions

The antenatal period is a unique time; important biological changes take place in the woman’s body, strong emotions about the pregnancy and past relationship experiences may emerge and the woman’s social role and function are in flux. While research has focused on the risks of the postnatal period, the relationship between pregnancy and maternal mental health is less well established. It is important to establish whether the incidence and prevalence of mental illness in pregnancy, either de novo or occurring as a relapse, is any different from mental illness occurring at other times in a woman’s life. We need to move forward from the traditional notion that pregnancy is a time of ‘quiescence’ in mental illness. It is not. Pregnancy appears to offer protection against maternal suicide alone. The antenatal period is a time of significantly elevated risk of relapse of bipolar disorder, even when treatment is maintained. For all other mental illnesses, relapse or a new presentation is as common in pregnancy as at other times in a woman’s life.

References and further reading

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Appleby, L. (1991). Suicide during pregnancy and the first postnatal year. British Medical Journal, 302(6769), 137–40.

Austin, M. (2003). Psychosocial assessment and management of depression and anxiety in pregnancy. Australian Family Physician, 32(3), 119–26.

Austin, M.P., Priest, S.R. and Sullivan, E.A. (2008). Antenatal psychosocial assessment for reducing perinatal mental health morbidity (Cochrane Review). The Cochrane Library, 4.

Baumann, P., Schild, C., Hume, R.F., et al. (2006). Alcohol abuse: A persistent and preventable risk for congenital anomalies. International Journal of Gynaecology and Obstetrics, 95, 66–72.

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Major depressive disorder is defined as one or more episodes of depression with no mixed, manic or hypomanic episodes. It may occur as a single episode or be part of a recurrent depressive disorder. Although pregnancy has traditionally been thought to be a time of mental well-being, the risk of depression is two times higher in women compared with men, and it is maximal in the child-bearing years (Merikingas, 2000). Hence it is no surprise that major depression during pregnancy is as common as it is postpartum and in non-child-bearing populations (Cooper et al., 1988; O’Hara, 1986; O’Hara et al., 1990). The prevalence range has been reported at 6.5–12.9 per cent (Gavin et al., 2005) and at 7.4 per cent, 12.8 per cent and 12.0 per cent for the first, second and third trimesters respectively (Bennett et al., 2004). One study reported higher rates, of at least 19.4 per cent, in women who are hospitalised for high obstetric risk (Brandon et al., 2008). Between a third and a half of all depressions occurring after birth will be continuations of episodes that onset during or before pregnancy (Gotlib et al., 1989; Watson et al., 1984).

Presentation

Symptoms of depression during pregnancy are similar to those at other times of life. However, they may be more difficult to distinguish from physical symptoms related to pregnancy, such as poor sleep, fatigue, low energy and weight gain. Hence, careful assessment is required. Depressive cognitions often focus on pregnancy concerns regarding the health of the fetus and labour. As in depression at any other time of life, anxiety or obsessive–compulsive symptoms may be present.

Risk factors

Depressive symptoms in pregnancy are associated with factors such as substance misuse, smoking, psychosocial difficulties, stressful life events, unemployment and lower educational attainment (Marcus et al., 2003; Pajulo et al., 2001; Pritchard et al., 1994; Rubertsson et al., 2005) indicating that the prevalence may be higher among disadvantaged populations both in high-income and low-income countries (Husain et al., 2009). There are also associations with a history of physical or sexual abuse (Horrigan et al., 2000; Leigh and Milgrom, 2007) as well as low self-esteem, antenatal anxiety, low social support networks, a negative cognitive style and low income (Leigh and Milgrom, 2007).

In Asian women living in the UK, family male-gender preference, unplanned pregnancy, a history of depression and feeling anxious in pregnancy were found to be independently associated with an increased likelihood of depressive symptoms (Dhillon and MacArthur, 2008); in Sweden symptoms were more likely to occur in women whose native language was other than that of their host country (Rubertsson et al., 2005).

Recurrence

Major depressive disorder is a highly recurrent disorder (Solomon et al., 2000) with most sufferers experiencing at least one recurrence and the risk of occurrence increasing by 16 per cent with each successive recurrence. Therefore a pregnant woman with a history of the disorder may be likely to experience a recurrence during pregnancy, especially if she discontinued her medication. More than two-thirds of euthymic women taking antidepressants who discontinued them in early pregnancy experienced a relapse, compared with less than half of women who remained on medication (Cohen et al., 2006). Stopping medication conferred a five-fold risk of recurrence, half of which occurred during the first trimester and 90 per cent by the end of the second. Recurrences in women who stop medication have a faster onset than those who continued to take antidepressants.

Consequences

Depressed or anxious mood during pregnancy (particularly in the last trimester) predicts postpartum depression and is associated with increased nausea and vomiting, prolonged sick leave during pregnancy, and an increase in the number of antenatal visits to the obstetrician (Andersson et al., 2004). Depressed women also find it harder to stop smoking when they become pregnant (Ludman et al., 2000).

Pregnancy complications include higher rates of placental abnormalities (Jablensky et al., 2005), pre-eclampsia (Kurki et al., 2000) and miscarriage (Nakano et al., 2004; Sugiura-Ogasawara et al., 2002). Planned caesarean delivery and epidural analgesia are also significantly more common in women with antenatal depression (Andersson et al., 2004). Several studies have demonstrated that depressed women are more likely to deliver prematurely (Jesse et al., 2003; Li et al., 2009; Moncuso et al., 2004; Orr et al., 2002; Wisner et al., 2009) and neonates of depressed mothers are at a greater risk of having a low birthweight and being small for their gestational age (Field et al., 2004; Hoffman and Hatch, 2000).

Field and colleagues (Field et al., 2006) reviewed the literature relating to the impact of depression during pregnancy on the fetus and neonate. They concluded that fetal activity was increased, growth was delayed and preterm delivery and low birthweight occurred more frequently. Neonates exhibit elevated levels of cortisol, lower levels of the neurotransmitters dopamine and serotonin, greater relative right frontal EEG (electroencephalogram) activation and lower vagal tone. Alder et al. (2007) reported similar findings but noted that formal diagnosis of a mood disorder was rarely made and the conclusions therefore are limited to subclinical symptoms.

Depression in the year before delivery is an independent risk factor for sudden infant death syndrome (SIDS), along with smoking and having a male infant (Howard et al., 2007) and it is associated with developmental delay in the child at 18 months of age (Deave et al., 2008). Depressive symptoms predict sleep problems in infants and toddlers (O’Connor et al., 2007) and maternal reports of ‘difficult’ infant temperaments (Austin et al., 2005). Long-term effects include an increased risk of adolescent depression (Pawlby et al., 2009) and a small, but significant, increase in criminality in the adult children of mothers who were depressed during pregnancy (Mäki et al., 2003).

Identification and screening

Despite the fact that pregnant women are in regular contact with health professionals with ample opportunities for detection, many of those suffering from depression are not identified (Andersson et al., 2003; Smith et al., 2004). Recent evidence suggests that psychosocial assessments and screening for depression are acceptable to women (Leigh and Milgrom, 2007; Matthey et al., 2005). The NICE guidelines recommend screening for depression at the booking interview, which usually takes place at 4–6 weeks’ gestation (National Institute for Health and Clinical Excellence, 2007). The guideline advocates asking two questions, as shown in Box 2.1.

Box 2.1 Recommended screening questions for depression (NICE, 2007)

Question 1: During the past month, have you often been bothered by feeling down, depressed or hopeless?

Question 2: During the past month, have you often been bothered by having little interest or pleasure in doing things?

If there is a positive answer to both questions, this third question should follow:

Question 3: Is this something you feel you need or want help with?

However, these questions have not been validated for use in women who are pregnant. A variety of instruments, both existing and new, have been employed to screen pregnant women and some have been validated for use in this population.

The Edinburgh Postnatal Depression Scale (EPDS) has been validated for use during pregnancy (Adouard et al., 2005; Felice et al., 2006; Murray and Cox, 1990). A higher cut-off (a score of 14 or 15) is advised than that in the postnatal period (a score of 12 or 13). The EPDS and other scales should only be used in the context of a clinical assessment and are not diagnostic tools. The Beck Depression Inventory (BDI) also requires the use of a higher cut-off score than in the non-pregnant women (Holcomb et al., 1996). However, another commonly used scale, the Hospital Anxiety and Depression (HAD) scale does not reliably assess distinct domains of anxiety and depression in early pregnancy (Jomeen and Martin, 2004) or at 12 and 34 weeks’ gestation (Karimova and Martin, 2003), therefore it is not a suitable screening tool for use in pregnant women. Others have devised screening tools or adapted existing instruments. There is a two-item depression screening measure comprising the questions ‘Are you often sad and depressed?’ and ‘Have you had a loss of pleasurable activities?’. This has been found to have a sensitivity of 91 per cent and a specificity of 52 per cent, whereas the Brief Depression Scale (BDS) had a sensitivity of 53 per cent and a specificity of 80 per cent (Jesse and Graham, 2005). Altshuler et al. (2008) devised the Pregnancy Depression Scale (PDS) using seven items from the Hamilton Depression Rating Scale (HDRS) which were highly predictive of a major depressive disorder in pregnancy.

Bennett et al. (2008) assessed the diagnostic accuracy of the modified two-item Patient Health Questionnaire (PHQ-2) in assessing depression in pregnant women. A positive two-item screen had a sensitivity of 93 per cent, 82 per cent and 80 per cent and a specificity of 75 per cent compared to 80 per cent and 86 per cent, respectively, for the EPDS. The predictive values for the PHQ-2 were 44 and 98 (positive) and 24 and 91 (negative) at 15 and 30 weeks’ gestation, respectively.

Management

Studies suggest that less than 15 per cent of depressed pregnant women receive any formal treatment (Andersson et al., 2003; Marcus et al., 2003). This may be due to a lack of professional action or it may relate to concerns of the women. One study exploring the attitudes of pregnant women to various treatments for depression found that although 92 per cent would participate in individual therapy, only 14 per cent would consider group therapy, and only a third would take antidepressants. The women expressed a clear preference for accessing their mental healthcare through the maternity care setting and cited barriers to care as lacking time, stigma and childcare issues (Goodman, 2009). NICE (2007) recommends a lower threshold for access to psychological therapies during pregnancy, advising that women should be seen for treatment within a month of assessment. Those with mild to moderate depression are recommended to use self-help strategies such as guided self-help, computerised cognitive–behavioural therapy (CBT) or exercise.

Psychological therapies

Not all the psychological interventions used to treat major depressive disorder have been studied in pregnant women. For example, there are no trials of CBT or non-directive counselling in pregnant women. NICE recommends non-directive counselling that is delivered at home (listening visits), and brief cognitive–behavioural therapy or interpersonal psychotherapy (IPT). IPT has been adapted for use in pregnant women and in one small trial was found to be superior to an educational programme (Spinelli and Endicott, 2003). However, a recent Cochrane review concluded that this trial was too small to be conclusive (Dennis et al., 2007).

Antidepressants

Two studies in the USA have observed an increase in the prescribing of antidepressants to pregnant women since the late 1990s, from 2.0 per cent in 1996 to 7.6 per cent in 2004–2005 (Andrade et al., 2008) and from 1.5 per cent in 1999 to 13.4 per cent in 2003 (Cooper et al., 2007). The increase was largely accounted for by selective serotonin-reuptake inhibitors (SSRIs). Any decision regarding the use of antidepressants must involve a risk–benefit analysis, taking into account the benefits of treatment and the impact of withholding treatment on the mother, versus any potential adverse effects on the fetus and the potential impact of untreated depression on the fetus. General guidelines involve avoiding the first trimester whenever possible, using the lowest effective dose (bearing in mind that as pregnancy progresses, hepatic metabolism increases and the dose might need to be increased), and avoiding combinations of drugs (given concomitantly or sequentially).

Details of specific antidepressants and their impact on the fetus are provided in Henshaw et al. (2009) and the NICE (2007) recommendations. Many studies are unable to determine whether any adverse outcomes identified are due to a drug or some other factor or the depressive illness itself. One study demonstrated an increased rate of preterm delivery in both depressed women who were treated with SSRIs and in those who were not (Wisner et al., 2009).

Readers are reminded that the evidence base is rapidly changing, so specialist drug information services should be consulted in addition to any texts.

St John’s wort (Hypericum)

There are as yet insufficient human data regarding the safety of St John’s wort during pregnancy so it is best avoided at present.

Electroconvulsive therapy (ECT)

Electroconvulsive therapy may be the treatment of choice for a severely depressed or psychotic patient as it minimises exposure to medication and avoids the use of polypharmaceuticals for which there are few or no safety data. There are reports of successful treatments during pregnancy, but most successful treatments are not published; others report complications including fetal ascites at 34 weeks followed by death after surgery, fetal heart decelerations, a miscarriage, uterine contractions, reduced fetal heart variability and contraction-related late cardiac decelerations (indicating a compromised fetus), uterine contractions and bleeding (suggesting placental abruption), premature labour and status epilepticus (Henshaw et al., 2009). There is also the risk of hypoxia with any general anaesthetic. Anderson and Reti (2009) reviewed 339 cases in the English-language literature between 1942 and 1991 and found only 25 that reported fetal or neonatal complications. Only 11 of these were thought to have a causal relationship with ECT. They concluded that ECT is an effective treatment for severe illness during pregnancy and that the risks are low. However, certain precautions are advisable and full informed consent is essential.

The suggested precautions are assessment of uterine contractions or vaginal bleeding after treatment, fetal heart monitoring during treatment, and placing the patient in a slightly left lateral position to minimise aortocaval compression. As patients beyond the first trimester are at increased risk of regurgitation of their gastric contents, anaesthetic advice is required regarding the use of anticholinergics and intubation. Pregnancy is accompanied by mild hyperventilation, and the respiratory alkalosis caused by excessive hyperventilation sometimes used to reduce the seizure threshold should be avoided because it can reduce oxygen transfer from maternal to fetal haemoglobin (Henshaw et al., 2009).

Omega-3 fatty acids

Trials of omega-3 fatty acids in pregnant women have yielded conflicting results. There is one open trial (Freeman et al., 2006) that reports positive findings and a small randomised controlled trial (randomised, clinical trial) in which the treatment group had a greater reduction in symptoms, a higher response rate, and a non-significantly higher rate of remission (Su et al., 2008). There did not appear to be any adverse effects. However, two randomised, clinical trials that included both pregnant and postpartum women found no significant differences between responses obtained with omega-3 fatty acids and placebo (Freeman et al., 2008; Rees et al., 2008).

Bright-light therapy

In an open study, morning bright-light therapy for two weeks improved depressive symptoms in pregnant women with major depressive disorder. Withdrawal resulted in a relapse of symptoms (Oren et al., 2002). A small randomised, clinical trial involving 10 patients observed improvement in depressive symptoms after 10 weeks of treatment, with an effect size of 0.43, which is similar to that seen in trials of antidepressant drugs. Successful treatment with bright light was associated with phase advances of the melatonin rhythm (Epperson et al., 2004). One patient experienced hypomania. Clearly further evidence is required before bright-light therapy can be recommended.

Acupuncture

One randomised, clinical trial involving 61 pregnant women with major depressive disorder reported that the greatest reduction in depressive symptom scores were responders to active acupuncture treatment compared with a control treatment and massage therapy (Manber et al., 2004). However, a recent Cochrane review concluded that the evidence for massage therapy and acupuncture was, at present, inconclusive (Dennis and Allen, 2008).

Transcranial magnetic stimulation (TMS)

To date, there are only case reports of pregnant women who were treated successfully with TMS, and reported no adverse events (Klirova et al., 2008; Nahas et al., 1999). There are no data from controlled trials.

Vagus nerve stimulation (VNS)

There is one case report of a depressed patient who became pregnant while being treated with VNS. Her depression remitted and her pregnancy and delivery were uneventful, with the delivery of a healthy term baby (Husain et al., 2005).

Conclusions

Major depressive disorder is common during pregnancy and as is associated with a number of factors predicting poor maternal, fetal and neonatal outcomes. Identification should happen more frequently than at present, considering the frequency with which most pregnant women are seen by health professionals, and a range of appropriate interventions are available for mild, moderate and severe depression.

References and further reading

Adouard, F., Glangeaud-Freudenthal, N.M. and Golse, B. (2005). Validation of the Edinburgh postnatal depression Scale (EPDS) in a sample of women with high-risk pregnancies in France. Archives of Women’s Mental Health, 8, 89–95.

Alder, J., Fink, N., Bitzer, J., et al. (2007). Depression and anxiety during pregnancy: A risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. The Journal of Maternal–Fetal and Neonatal Medicine, 20, 189–209.

Altshuler, L.L., Cohen, L.S., Vitonis, A.F., et al. (2008). The Pregnancy Depression Scale (PDS). A screening tool for depression in pregnancy. Archives of Women’s Mental Health, 11, 277–85.

Anderson, E.L. and Reti, I.M. (2009). ECT in pregnancy: A review of the literature from 1941 to 2007. Psychosomatic Medicine, 71, 235–42.

Andersson, L., Sundstrom-Poromaa, I., Bixo, M., et al. (2003). Point prevalence of psychiatric disorders during the second trimester of pregnancy: A population-based study. American Journal of Obstetrics and Gynecology, 189, 148–54.

Andersson, L., Sundstrom-Poromaa, I., Wulff, M., et al. (2004). Implications of antenatal depression and anxiety for obstetric outcome. Obstetrics and Gynecology, 104, 467–76.

Andrade, S.E., Raebel, M.A., Brown, J., et al. (2008). Use of antidepressant medications during pregnancy: A multisite study. American Journal of Obstetrics and Gynecology, 198, E1-E5.

Austin, M.-P., Hadzi-Pavlovic, D., Leader, L., et al. (2005). Maternal trait anxiety, depression and life event stress in pregnancy: Relationships with infant temperament. Early Human Development, 81, 183–90.

Bennett, H.A., Einarson, A., Taddio, A., Koren, G. and Einarson, T.E. (2004). Prevalence of depression during pregnancy: A systematic review. Obstetrics and Gynecology, 103, 698–709.

Bennett, I.M., Coco, A., Coyne, J., et al. (2008). United States obstetrician–gynaecologists’ accuracy in the simulation of diagnosing anxiety disorders and depression during pregnancy. Efficiency of a two-item pre-screen to reduce the burden of depression screening in pregnancy and postpartum: An IMPLICIT network study. Journal of the American Board of Family Medicine, 21, 317–25.

Brandon, A.R., Madhukar, H., Trivedi, M.D., et al. (2008). Prenatal depression in women hospitalized for obstetric risk. Journal of Clinical Psychiatry, 69, 635–43.

Cohen, L.S., Altshuler, L.L., Harlow, B.L., et al. (2006). Relapse of major