Download Case studies: depression

Case studies: peri-natal
depression
Dr. Matthew Miller
Consultant psychiatrist
Contents
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Screening
Case study
History taking
Risk assessment
Treatment
Services available
Depression in pregnancy: case
• 35 year old woman, 8 weeks pregnant
• History of depression, anxiety, OCD, eating
disorder
• Had been on Fluoxetine until a year before
which she thinks helped her
• Now on direct questioning presents with
sudden onset depression and severe anxiety
about the foetus
Questions
1. What do you want to know from your
patient?
2. What treatment can we give to the patient?
3. Should we refer? Who to?
Information required
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Current symptoms
Psychiatric History
Obstetric history
Medical history
Social situation
Preferences
Risk
Current presentation
• Symptoms
• Severity
• Consequences; social effects
• Risk
Psychiatric history
• Presence of severe and enduring Mental
illness
• Details of anxiety, depression, ED, OCD
• ?psychosis
• ?PND
Obstetric history
• Course of previous pregnancies
• PND
Past medical history
• Access to dangerous medications
Social
• What support does she have
– Do they have needs?
• Is she functioning?
Risk
• Static risks:
– Patients history (esp PND, self harm)
– Family history
• Dynamic risks
– Mental state
– Social situation
• Ask about ideas of harm to the baby
Treatment: Pregnancy
What do we know
• TCAs better understood in pregnancy
• SSRIs taken after 20 weeks' gestation may be
associated with an increased risk of persistent
pulmonary hypertension in the neonate
• Paroxetine may be associated with increased
rate of cardiac defects
• All antidepressants thought to increase risk of
spontaneous abortion
Post natally
• Most antidepressants associated with withdrawal
syndrome
• imipramine, nortriptyline and sertraline are in
breast milk at low levels
• Citalopram and Fluoxetine are found in high
levels in breast milk
• Effects on children unclear
Other psychotropics
• Benzodiazepines associated with birth defects
• Antipsychotics may be safe except
– Depot
– Clozapine
• Valproate and CBZ associated with neural tube
defects
• Lithium increases cardiac malformation
• Lamotrigine can cause Stephens Johnson
syndrome in neonates
Guidelines for treatment of depression
in pregnancy
• No antidepressant in mild depression
• Consider CBT earlier in moderate depression
• Use low risk antidepressant in moderatesevere depression
• Consider ECT in severe treatment resistant
depression
Non pharmacological strategies
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Self help
CBT
IPT
Support groups
etc
Services
Mild depression/ low risk:
Think positive, primary care, NCT
Moderate depression:
SPOA
Obstetrics may consider specialist midwives
Severe depression:
CMHT (via SPOA) , tertiary services, A&E?
Depression in pregnancy: case
• 35 year old woman, 8 weeks pregnant
• History of depression, anxiety, OCD, eating
disorder
• Had been on Fluoxetine until a year before
which she thinks helped her
• Now on direct questioning presents with
sudden onset depression and severe anxiety
about the foetus
Advice in pregnancy
• Eat a healthy, balanced diet
• Reduce your alcohol intake. You should stop drinking if possible.
Otherwise you should not drink more than 1-2 units, once or twice
a week
• Stop smoking
• Find some time each week to do something which you enjoy,
improves your mood or helps you to relax.
• Let family and friends help you with housework, shopping etc.
• Exercise (ask your midwife about exercise in pregnancy and local
exercise classes).
• Discuss any worries you may have with your family, your midwife or
GP.
• Get regular sleep
Who else can help
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NCT
Meet a mum
Net-mums
The Association for Postnatal Illness (APNI)
Family action
Samaritans
Thanks
• Any questions