Download Jagoda Banovic - Dr Andrew Mayers

FROM DAKSHA’S LAST NOTE
Finding it difficult to hand on to positive things anyone says, can’t hang on to it for long – hits
me in early hours of morning – thoughts churn round + round.
Starting to think that Dave hates me, wants me out the way, wants me to go crazy so he can get
another wife who’s better for him.
Finding it difficult to hang on to reality - am I bad + wicked?
I don’t deserve good things, who am I kidding?
Is this all a bad dream or really happening?
Is there really hope for the future?
I’ve tried to put a smile on, to hand on to positive but getting more + more difficult to know
what’s real.
Losing reason? Losing sanity?
Freya needs me, I can’t let her down. Need to get myself back to normal for her. She + Dave
mean world to me – I need to sort myself out for them. Fear I’m cracking up.
SAVING MOTHERS LIVES
Dr Daksha Emson, a psychiatrist, and
her daughter, aged three months,
died following an extended suicide
on 9th October 2000. A Panel of
Inquiry was set up to investigate
the causes of the deaths, and the
issues arising from the Part 8
Review under the Children Act
1989 commissioned by the London
Borough of Newham into the death
of Freya Emson. The Inquiry Panel
was asked to produce a report and
to make any relevant
recommendations.
PERINATAL MENTAL HEALTH
Definitions
The "emotional and psychological wellbeing
of women,
encompassing the influence on infant,
partner and family,
and commencing from preconception
through pregnancy
and up to 12 months postpartum."
FUNCTION OF A SPECIALIST PERINATAL MENTAL HEALTH SERVICE
1. It
will assess and manage those suffering
from puerperal psychosis and other
severe postnatal mental illnesses.
2. It will provide a range of facilities for their
management including an in-patient
mother and baby unit (or access to one),
out-patient clinics, alternatives to
admission (intensive home nursing
and/or day hospital)and community
treatment.
3. It will advise on and, if necessary, manage
patients with continuing psychiatric
disorder who become pregnant while
under the care of other adult
psychiatrists.
4. It will liaise with primary health care
professionals to assist in the
management of less serious psychiatric
conditions.
5.
It will provide an obstetric liaison service,
assessing mental health problems
associated with pregnancy and the postpartum period and dealing with
emergencies.
6. It will provide prenatal counselling and highrisk management for women at risk of
developing an illness post-partum owing
to previous major mental illness.
7. It may undertake the assessment of women
with severe chronic mental illness in
respect of their ability to parent their
child. A specialist perinatal mental health
service will also be in a position to play
lead role in the development of services
at all levels of health care provision, to
contribute to the education and training
of other health care professionals and to
engage in clinical research and
innovative clinical practice
COMMON PERINATAL MENTAL HEALTH ISSUES
A range of conditions that effect at least 10% of new mothers
Baby blues
Depression
Anxiety
Puerperal psychosis
Bi Polar Disorder
OCD
Pre existing Psychiatric conditions
BABY BLUES
The 'Baby Blues'
The 'baby blues' is the most common and least serious condition found in the postnatal
period, affecting up to 80% of new mothers. It usually lasts for one or two days and up
to a week at most.
Symptoms include: feeling tearful and sad
feeling anxious and irritable
having a 'low' mood
feeling unwell
having difficulty sleeping
More often than not, the condition does not require any specific treatment other than
reassurance, understanding and support from family, friends and health professionals.
It will usually pass as a new mother catches up on rest and things start to settle down.
However, if the symptoms continue longer than two weeks, it's a good idea to see what
else might be affecting the mother: for example, symptoms of anxiety and/or
depression.
DEPRESSION IN THE PERINATAL PERIOD
Effects 10-14% 0f mothers are affected either during pregnancy or after birth of baby.
Depression during the perinatal period is the same as clinical depression at other times.
Symptoms persist for at least 2 weeks and can include: Low mood
Lack of interest or pleasure in usual activities
Feelings of inadequacy, failure, hopelessness, guilt and shame
Sleeping a lot or having difficulty sleeping; nightmares
Significant changes in appetite or weight
Decreased energy and motivation
Decreased concentration
Persistent thoughts of death and/or suicide
Depression can occur during pregnancy ('antenatal depression') as well as after the birth of the baby ('postnatal
depression', or 'PND').
Prevalence rates for antenatal depression range from 8% to 15%, and for PND, from 10% to 15%. Mild to
moderate cases of depression are sometimes unrecognised. If left untreated, depression in the perinatal
period it can develop into a long-lasting depression, or return with subsequent pregnancies.
ANXIETY IN THE PERINATAL PERIOD
Anxiety in the perinatal period has the same symptoms as anxiety at other times. The prevalence
is not clear, however some studies have shown that anxiety is more common postnatally than
depression.
Anxiety is a core protective emotion which is helpful in situations of realistic danger. For some
people anxiety can reach clinical levels and interfere with daily life. People may fear that they
are going crazy or losing control. It may seem like the anxiety occurs for no particular reason,
and the anxious reactions may be very difficult to contain.
Symptoms can include: feeling restless, nervous or nauseous
finding it hard to relax
having a 'racing' mind
having a churning stomach
feeling a sense of dread
If the anxiety is particularly debilitating it may meet the criteria for an anxiety disorder. These
include Generalised Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, Obsessive
Compulsive Disorder, Post-Traumatic Stress Disorder and the numerous Phobias. The anxiety
disorders can be present in the perinatal period.
PUERPERAL (POSTNATAL) PSYCHOSIS
Puerperal psychosis is the most serious and least common mental health issue found
in the postnatal period. Only one or two mothers out of a thousand are affected
by this condition. It is most likely to present in mothers who have a personal or
family history of mental illnesses such as schizophrenia or bipolar disorder.
Symptoms usually begin abruptly in the month following childbirth, and can include:
confused or erratic behaviour
hallucinations and delusions
severe mood swings
significantly reduced need for sleep
There is a potential for women with puerperal psychosis to harm themselves or their
babies, so immediate psychiatric intervention is necessary. Recurrences are
common in subsequent pregnancies (25% to 75% of cases). It is important to
note that puerperal psychosis is treatable, especially with early intervention.
BI POLAR DISORDER
Bipolar Disorder is classified into at least two subtypes:
Bipolar I type presents as mania† with psychotic features that is often followed by major depression.
Bipolar II type presents as depressive episodes or dysthymia (chronic low mood) and brief episodes of hypomania
Rates of substance abuse and suicide are high in both subtypes 76 making diagnosis and treatment complex.
In patients with a history of bipolar disorder the risk for relapse during and after pregnancy is high, especially if medications
are ceased and after birth when some might develop psychotic symptoms 71. They must be monitored very closely in
the first two weeks after delivery, with specialist psychiatric involvement if indicated. Risk remains high during the first
four months after delivery 58.
To date, psychosocial factors have not been demonstrated to affect the risk of developing a perinatal bipolar episode whilst
biological factors have; these include early age of onset of bipolar disorder, experiencing an episode of mood disorder
during the first pregnancy, and experiencing medical problems during the index pregnancy 77. Women who experience
episodes around childbearing are less likely to have more children compared to women whose episodes are not
related to childbearing 77. In the past, women with a known diagnosis of bipolar disorder were advised to avoid
pregnancy. A recommended approach is to offer relevant information about treatment risks and benefits during a
specialized preconception consultation so that women and their partners can make an informed decision 78.
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ROLE OF A PERINATAL SERVICE
Severe Mental Illness
Bonding attachment
Prevent separation
Treat mothers mental illness
EIS
WHAT IS A PERINATAL MENTAL HEALTH TEAM ?
In Patient Care
Community Team
ROYAL COLLEGE OF PSYCHIATRISTS
In Patient
Standards
Community
Standards
Peer review then
Accreditation
Peer review then
Accreditation
IN PATIENT CARE
Coming into hospital
Recovery
Focus on mother infant relationship
Bonding attachment
Safety/ safeguarding
Therapeutic interventions incl
medication
Education/training
Function
Strengths / weakness
Set up on the ward
Routine,
nursery nurse
Psychology
Link with community
AREAS FOR DEVELOPMENT
Parental mental health service
Research/ education --stigma