Fundamentals of Midwifery: A Textbook for Students (121 page)

Activity 13.1 Antenatal or postnatal?

Reflect on how many of Beck’s predictors of PND could equally apply to the antenatal period.

Box 13.4 Common false beliefs related to PND

Its symptoms and effects are less severe.

It goes away by itself.

It is somehow associated with whether or not the woman is breastfeeding.

It is all due to hormones.

It has no risk of non-puerperal recurrence.

It carries an inevitable risk of future postnatal recurrence.

Depression is less common antenatally.

Depression which is already present before birth is not the same thing.

There has been concern that misuse of the term (PND) is widespread with potentially serious negative consequences. These include its use in clinical situations as a label for any mental illness occurring postnatally (NICE 2007) and a traditional tendency to have a preoccupation with PND to the exclusion of other aspects of mental health. This reinforces a view that PND is somehow different from depression at other times. (Box 13.4 summarises some of the false beliefs relating to PND.)

Individual women will demonstrate wide variation in their emotional status, from a minor transient experience such as baby blues to severe mental illness (SMI), such as puerperal psy- chosis (PP). Whilst the range and type of PMI might vary, they form part of a continuum. All PMI can present across the perinatal period. Practitioners will see both women with existing mental health disorder who become pregnant, as well as women who develop PMHP when they have previously been well.

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Activity 13.2

Consider some of the potential stressors that might be associated with pregnancy that might

affect a woman’s emotional state during:

antenatal period

intrapartum period

postnatal period
Prevalence and incidence
Psychiatric conditions are prevalent in the general population, with over 20% of individualsaffected (ONS 2002). A large proportion of those will be mild to moderate anxiety and depres- sion and often those conditions can be co-morbid (Teixeira et al. 2009), a profile which is reflected in the pregnant population (Oates 2006). The incidence of mild–moderate affective288
states such as depression and anxiety in the perinatal period are approximately 10–15%, with higher figures quoted in some studies (Jomeen and Martin 2008). The prevalence of AND is at least as high of that of PND and rates have been demonstrated to be higher in late pregnancy than postnatal (Evans et al. 2001; Jomeen and Martin 2008), with a similar profile identified for anxiety (Jomeen and Martin 2008). Approximately 3% of women will suffer from a more severe depression (Joint Commissioning Panel for Mental Health 2012); one to two of every 1000 women with a live birth will develop puerperal psychosis (PP) (Brockington 1996; Munk- Olsen et al. 2006). PTSD occurs in 3% of all maternities and in 6% of women following an emergency caesarean section (Joint Commissioning Panel for Mental Health 2012). Clearly pregnancy is a more vulnerable time for the inception of PMI than at other times in a woman’s life even though the level of risk is broadly similar to the general population. The risk of being admitted to hospital with an SMI following childbirth is significantly increased compared to the general population (Oates 1996). New cases of SMI are more likely to occur in the postnatal rather than antenatal periods. However, for certain SMIs such as severe depressive illnesses, schizophrenia and bipolar disorder, the risk of reoccurrence of relapse can be increased in pregnancy, particularly if medication is stopped (Joint Commissioning Panel for Mental Health 2012).
Categories of PMI
Oates and Raynor (2009) suggest six categories of PMI (see Table 13.2).
Further categories within which women might present

Organic disorders
which would include infections, anaemia, nutritional deficiencies (forexample, Vitamin D), stroke, endocrine problems (hypo/hyperthyroidism).

Medically unexplained symptoms
which might include unexplained chest pain, abdominal

pain, gynaecological problems, pseudo-pregnancy, hypochondriasis, Munchausen syndrome or Munchausen by proxy.

Categories of PMI

(psychotic disorders)

Schizophrenia, bipolar disorder, severe depression and other psychotic conditions.

(neurotic disorders)

Mild–moderate depression (non-psychotic), mixed anxiety and depression, panic disorder, anxiety disorders such as OCD, PTSD and panic disorder.

Distressing reactions to life events such as bereavement or social adversity.

Those who misuse or are dependent on substances such as alcohol and legal or illegal drugs.

Individuals who have persistent and severe problems throughout their adult life in dealing with the stresses of normal life. As a consequence they demonstrate difficulty in areas such as controlling their behaviour, maintaining satisfactory relationships, causing distress to others and acting irresponsibly with no insight into the consequences of their actions.

Individuals with intellectual or cognitive impairment.

As already stated, depression is one of the most prevalent conditions across the perinatal period. A number of studies have identified that women with PND also had AND and could have been identified antenatally (NSPCC 2013). Approximately 10% of women will, however, develop a new episode of depressive illness (Raynor and England 2010), which may vary in level of severity. Whilst risk factors have been identified, as outlined earlier, their predictive value is unclear. One of the challenges of identifying depression can be the overlap with symptoms of pregnancy and the effects of early motherhood, fatigue and sleeplessness being good examples, which also highlights the importance of not over-pathologising women’s emotional status. The weeks and months after giving birth have been identified as time of considerable stress (Glazener 2005a; Glazener 2005b), which has led to a focus in the international literature (Yelland et al. 2009) and policy on postpartum psychological morbidity (CMACE 2011). Yet, some emotional lability and even some depressive type symptoms may just be part of the adaptation to preg- nancy and the mothering role (Raynor and England 2010). It is therefore crucial that practition- ers are familiar with the signs and symptoms of depression, levels of severity and can recognise how women might present (see Figure 13.1). This is important, firstly to avoid the dangers of over-diagnosing PMI, but also to be able to create a context from which women feel able to disclose; women are unlikely to do so if they feel stigmatized and judged by revealing a SMI in either in pregnancy or postnatally.

Cognitive symptoms might be reflected in the kind of things that women say.

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‘I’m a useless mother.’

‘I’m good for nothing and burden on the family.’

‘Nothing is going to get better, no light at the end of tunnel.’

‘I feel miserable for neglecting my baby’s and family’s need.’

‘People look at me and think that I’m failing.’

‘There is no point in carrying on . . . I wish I don’t wake-up the next day.’

I feel like ending it all’, ‘the children will be better off without me.’