Substance abuse and psychiatric disorders

Substance abuse in pregnancy 430

Morbidity and mortality in substance abusers 432 Substance misuse in pregnancy: management 434 Alcohol abuse 436

Drugs of abuse: opiates 438 Drugs of abuse: cocaine 440

Drugs of abuse: other stimulants 442 Drugs of abuse: sedatives and cannabis 444 Other drugs of abuse 445

Antenatal psychiatric disorders: overview 446 Antenatal psychiatric disorders: specific disorders 448 Psychiatric medications 450

Postnatal depression 454 Puerperal psychosis 456

430 CHAPTER 13 Substance abuse and psychiatric disorders

Substance abuse in pregnancy

•The huge increase in drug and alcohol abuse in the UK since the 1980s has been disproportionately large in women of childbearing age.

•The prevalence of substance abuse is:

•4.7% for alcohol

•2.2% for drug dependence.

•It has a serious effect on the mother’s health, as well as consequences for fetal well-being.

•There is under-identification because of:

•inadequate history taking

•reluctance to admit to substance abuse

•late booking

•poor antenatal attendance.

•Poor communication between GPs, social services, midwives, and obstetricians is a hindrance to adequate care.

•In the CEMACH report 2002–2005, there were 31 maternal deaths that were either directly or indirectly related to substance abuse:

•social deprivation was a common factor

•all but one pregnancy was unplanned.

Definitions relating to substance abuse

Problems associated with substance abuse are categorized in ICD-10 under the heading ‘Mental and behavioural disorders due to psychoactive substance abuse’.

•Harmful use: a pattern of psychoactive substance use that is causing damage to physical or mental health.

•Intoxication: transient syndrome due to recent substance ingestion that produces clinically significant psychological/physical impairment.

•Dependence syndrome: cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value.

•Tolerance: homeostatic adaptation to chronic administration of a drug; to ameliorate longer-term toxicity; and to allow the organism to continue functioning while chronically intoxicated.

•Withdrawal: characteristic pattern of signs and symptoms (psychological and physical) that occur when a drug is stopped after a period of chronic administration, or an antagonist to the drug is given.

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432 CHAPTER 13 Substance abuse and psychiatric disorders

Morbidity and mortality in substance abusers

Co-existing psychiatric disorders

There is a close association between substance misuse and other mental illnesses, such as personality disorder, depression, and anxiety.

Physical complications

•Substance misuse often accompanied by general neglect of health, with nutritional deficiency, poor hygiene, and generalized immunosuppression.

•As well as direct pharmacological consequences from the substance there are risks from route of administration.

•IV drug use may lead to:

•HIV infection

•hepatitis C (prevalence of between 50 and 80% in UK drug users) and hepatitis B (30–50%)

•venous thrombosis

•subcutaneous abscesses

•bacterial endocarditis

•septicaemia (may be fungal)

•poor venous access in an emergency situation.

Withdrawal effects

Withdrawal symptoms can be distressing, but rarely life-threatening.

Social damage

•May lead to problems with employer and work-related accidents.

•Leads to financial strain with damaging effects on the family.

•Antisocial and criminal activities may arise from behavioural changes and need for money.

•May be child protection issues as a result of neglect or abuse.

Death

•Significant mortality (10–15% in opioid misusers over 10yrs).

•Mostly accidental due to overdose.

•Suicide is also a frequent cause of death.

•Deaths from HIV and hepatitis infection are becoming more common.

•Approximately 60% of deaths in drug addicts are related to drug use itself.

MORBIDITY AND MORTALITY IN SUBSTANCE ABUSERS 433

Perinatal morbidity and mortality with substance abuse

Risks of the following are increased:

•Preterm birth and prematurity.

•IUGR.

•Low birth weight.

•Symptoms of withdrawal from drugs.

•Increased stillbirth and neonatal mortality.

•Sudden infant death syndrome.

•Physical and neurological damage from drugs or violence.

•Fetal alcohol syndrome.

434 CHAPTER 13 Substance abuse and psychiatric disorders

Substance misuse in pregnancy: management

Maternal issues

•To tailor proper anteand postnatal care, a detailed history including use of illicit drugs, tobacco, and alcohol should be taken.

•Women using opiates should be prescribed substitution therapy (methadone).

•Women should not undergo opiate detoxification during pregnancy.

•Women on illicit drugs may be at risk of violence and abuse, and have other complex social, psychiatric, and psychological problems.

•Thus, they should be handled very sensitively, with dignity, in full confidence, and encouraged to attend for antenatal care.

•All patients should have multidisciplinary care with involvement of:

•GP

•social services

•obstetric team (possibly including a specialist midwife)

•local addiction services (possibly including a psychiatrist).

•Contraceptive advice should be offered where indicated.

Fetal issues

Most abusers will use more than one substance so there may be multiple risks to fetus. By definition, this is a high-risk pregnancy. General considerations should include:

•Detailed anomaly USS: consider the need for a later cardiac anomaly USS.

•Serial USS for growth and well-being: irisk of IUGR.

•Increased awareness of the irisk of obstetric complications such as:

•preterm labour

•placental abruption.

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436 CHAPTER 13 Substance abuse and psychiatric disorders

Alcohol abuse

Alcohol abuse is defined as drinking that causes mental, physical, or social harm to an individual.

•Alcohol consumption by women has increased over the last 15yrs.

•Excessive consumption of alcohol can lead to alimentary disorders, such as liver damage, gastritis, peptic ulcer, oesophageal varices, and acute and chronic pancreatitis.

•Damage to liver, including fatty infiltration, hepatitis, cirrhosis, and hepatoma, is particularly important.

•Neurological damage, such as peripheral neuropathy, epilepsy, and cerebellar degeneration, and cardiovascular complications, such as hypertension and stroke, are common.

•There may be child protection issues arising from potential neglect, as well as direct harm.

Fetal alcohol syndrome

There is evidence that this occurs in some children born to mothers who drink excessively (0.5–5:1000 live births). The exact relationship between alcohol and birth defects is a complex one, but there is no known safe lower limit for alcohol consumption; current recommendations limit consumption to 1U/day. Women drinking 18U/day have a 1 in 3 chance of fetal alcohol syndrome, characterized by preand postnatal retardation, developmental delay, and characteristic craniofacial dysmorphism, correlating with low IQ.

Features of fetal alcohol syndrome

•IUGR.

•Short stature.

•Developmental delay.

•Micro-ophthalmia.

•Short palpebral fissure.

•Short nasal bridge.

•Microcephaly with prominent forehead.

•Thin upper lip and small philtrum.

•Cleft palate.

•Maxillary hypoplasia.

•Gait abnormalities.

•Cardiac abnormalities.

ALCOHOL ABUSE 437

Management of pregnancy in women abusing alcohol

•Attempt to reduce harm by:

•counselling about risks and encouraging dalcohol intake

•encouraging antenatal attendance (ensure supportive, non-judgemental environment)

•facilitating contact with support groups such as Alcoholics Anonymous (AA)

•facilitating contact with social services (for help with benefits and improving housing)

•screening for domestic abuse

•offering help with smoking cessation if required.

•Detailed anomaly USS.

•Serial USS to assess growth and fetal well-being.

•Multidisciplinary team management with involvement of:

•paediatric team

•anaesthetic team

•social services

•local specialist alcohol support workers.

•May need child protection case conference.

438 CHAPTER 13 Substance abuse and psychiatric disorders

Drugs of abuse: opiates

Routes of administration

Opiates (including morphine, heroin, methadone, buprenorphine) may be taken by snorting (intranasally), smoking, SC (‘skin popping’), orally, or IV.

Maternal effects of opiates

•Act on the opioid receptors distributed throughout the CNS.

•They have many physical effects, including drowsiness, respiratory depression, nausea, hypotension, and papillary constriction.

•They act on pain receptors and may have significant mood-altering effects, producing a sensation of euphoria or intense pleasure.

•They are both physically and psychologically addictive.

•Withdrawal syndrome occurs within 4–12h after the last opiate dose, peaking at 48–72h, and subsiding by the end of 7–10 days.

•Characteristic symptoms of withdrawal include myalgia, arthralgia, dysphoria, insomnia, agitation, diarrhoea, and shivering.

•Withdrawal is not life-threatening.

•Annual mortality rate is about 1–2%, mostly due to overdose.

Effects of opiates on pregnancy

•Opiates not known to cause any specific congenital abnormalities.

•Babies of mothers abusing opiates are at irisk of:

•IUGR

•stillbirth

•sudden infant death syndrome.

•Withdrawal usually occurs within 24h of birth; symptoms include:

•irritability and exaggerated startle response

•jitteriness and tremors

•poor feeding

•hypotonicity.

DRUGS OF ABUSE: OPIATES 439

Methadone maintenance treatment

•Methadone has a longer half-life than heroin, resulting in a more stable plasma concentration and allowing once-daily administration.

•Women already on replacement may need their methadone dose i due to the physiological plasma dilution effect of pregnancy.

•Starting methadone may help with risk reduction by:

•dthe physical risks of injecting

•stabilizing lifestyle

•dthe financial burden of purchasing street drugs

•improving contact with healthcare professionals.

•Compliance with the treatment may:

•dneonatal mortality

•ibirth weight.

Benefits can be lost if the mother also uses street drugs.

Withdrawal in pregnancy has a high risk to the fetus and should only be considered in highly motivated women with good social support.

Management of pregnancy in women abusing opiates

•Attempt to reduce harm by:

•starting methadone

•encouraging antenatal attendance (ensure supportive, non-judgemental environment)

•facilitating contact with social services (for help with benefits and improve housing)

•screening for domestic abuse

•offering help with smoking cessation if required.

•Screening for STIs including HIV and hepatitis.

•Monitor injection sites for infection.

•Low threshold for antibiotics with symptoms of sepsis (may be atypical pathogens).

•High index of suspicion with any symptoms of VTE (may be unusual sites).

•Detailed anomaly USS.

•Serial USS to assess growth and fetal well-being.

•Multidisciplinary team management with involvement of:

•paediatric team (baby will need admission to SCBU)

•anaesthetic team (IV access may be difficult)

•social services

•local specialist drug support workers.

•Child protection case conference.

440 CHAPTER 13 Substance abuse and psychiatric disorders

Drugs of abuse: cocaine

Routes of administration

•Intranasal is the major route.

•IV use either alone or with heroin has a high mortality rate.

•Smoking the freed alkaloid base as ‘crack’ is increasingly common in the UK.

Maternal effects of cocaine

•Inhibits the reuptake of neurotransmitters including dopamine.

•May result in euphoria, anorexia, verbosity, and sense of well-being.

•Also has stimulant effects from sympathetic overdrive.

•Deaths are mostly from accidents, cerebrovascular complications (intracranial bleed and emboli), and cardiac arrhythmias.

Effects of cocaine on pregnancy

•Teratogenicity

•microcephaly

•cardiac defects

•possible genitourinary, limb, and gut defects.

•Vasoconstriction may cause abnormal placentation, resulting in:

•irisk of pre-eclampsia

•irisk of abruption

•IUGR.

•Down-regulation of myometrial β-adrenoreceptors may cause:

•miscarriage

•uterine irritability

•preterm labour.

•Neonates:

•a limited withdrawal syndrome may occur

•occasionally show hypotension and cardiac arrhythmias

•are at irisk of sudden infant death.

X Cocaine may have a detrimental effect on neurodevelopment, leading to developmental delay.

DRUGS OF ABUSE: COCAINE 441

Management of pregnancy in women abusing cocaine

•Attempt to reduce harm by:

•counselling about the risks and encouraging dcocaine use

•encouraging antenatal attendance (ensure supportive, non-judgemental environment)

•facilitating contact with social services if needed

•screening for domestic abuse

•offering help with smoking cessation if required.

•Detailed anomaly USS.

•Fetal cardiac USS at 23–24wks.

•Serial USS to assess growth and fetal well-being.

•Multidisciplinary team management with involvement of:

•paediatric team

•anaesthetic team

•social services

•local specialist drug support workers.

•Child protection case conference.

442 CHAPTER 13 Substance abuse and psychiatric disorders

Drugs of abuse: other stimulants

Amphetamine sulphate

Routes of administration

Illicit amphetamine can be taken orally, intranasally, or IV.

Maternal effects of amphetamine

•Enhances the dopaminergic neurotransmitter system.

•The stimulant properties are dose related and characterized by sympathetic overdrive (tachycardia, sweating, dry mouth, tremor).

•Effects on pregnancy.

•No proven syndrome of congenital abnormalities.

•Neonates occasionally show hyperactivity and poor feeding.

X May have similar risk of miscarriage, preterm labour, and IUGR as cocaine.

Ecstasy (MDMA)

Mode of action

•Like amphetamines, it increases the release of dopamine and also releases 5-hydroxytryptamine (5-HT), which may account for its hallucinogenic properties.

•It is selectively neurotoxic to fine serotonergic neurons.

Routes of administration

•Most commonly taken as a capsule in a dose of about 50–150mg.

•May also be injected or snorted.

Maternal effects

•Feelings of positive mood state, euphoria, sociability, and intimacy.

•Panic, paranoia, psychosis, and neuroses are also common and may

extend to visual hallucinations, delusions, and suicidal feelings.

Effects on pregnancy

•Appears to have similar teratogenicity to cocaine, with reported iin:

•cardiac defects

•limb and gut abnormalities.

•Neonates occasionally show hyperactivity and poor feeding.

X May have similar risk of miscarriage, preterm labour, and IUGR as cocaine.

DRUGS OF ABUSE: OTHER STIMULANTS 443

Management of pregnancy in women abusing stimulants

•Attempt to reduce harm by;

•counselling about the risks and encouraging ddrug use

•encouraging antenatal attendance (ensure supportive, non-judgemental environment)

•facilitating contact with social services if needed

•screening for domestic abuse

•offering help with smoking cessation if required.

•Detailed anomaly USS.

•If using ecstasy, consider fetal cardiac USS at 23–24wks.

•Serial USS to assess growth and fetal well-being.

•Multidisciplinary team management with involvement of:

•paediatric team

•anaesthetic team

•social services

•local specialist drug support workers.

•May need child protection case conference.

OTHER DRUGS OF ABUSE 445

Other drugs of abuse

Hallucinogens, lysergic acid diethylamide, and mescaline

•Usually consumed orally as small squares of blotting paper soaked in lysergic acid diethylamide (LSD), the drug causes hallucinations and visual illusions without lowering consciousness.

•Its action is mediated through the activation of the 5-HT2 receptors.

•The physical actions of LSD are variable:

•initially there is an increase in the heart rate and BP with adverse myocardial and cerebrovascular effects

•however, overdosage does not have a significant physiological reaction.

XThere may be a risk of miscarriage and congenital abnormalities among regular users.

Volatile substances (‘glue sniffing’)

•Volatile substance misuse is a widespread problem, mainly in the younger population.

•Substances used are generally solvents and adhesives (hence the term ‘glue sniffing’).

•Toluene, acetone, petrol, cleaning fluids, and aerosols are usually inhaled.

•Most often this is associated with other addictions, such as tobacco and alcohol.

•It can lead to sudden death from acute intoxication due to respiratory depression and cardiac arrhythmias.

XLittle is known about the effects in pregnancy.

Tobacco

This is the most common substance of abuse and leads to complications including:

•iRisk of miscarriage.

•iRisk of placental abruption.

•Low birth weight.

•iRisk of neonatal death and sudden infant death syndrome.

2 Women should be advised to stop smoking, or at least cut down, in pregnancy.

•Help from specialist smoking cessation advisers should be available.

•Nicotine replacement therapy (patches or gum) may be used in pregnancy.

446 CHAPTER 13 Substance abuse and psychiatric disorders

Antenatal psychiatric disorders: overview

Women of childbearing age carry a high burden of psychiatric disorders, particularly depression and anxiety. Although rates of psychiatric disorder during pregnancy appear similar to rates at other times in the life cycle (5–10%) the consequences are complicated by the additional risks to mother and fetus. Women with existing mental disorder require particularly careful management during pregnancy.

The importance of screening

Mental illness is one of the leading causes of maternal death in the UK.

•The majority of these deaths are the result of suicide, which is itself most strongly associated with perinatal depression.

•Over half of suicides occur between 6wks prenatally and 12wks postnatally, emphasizing the importance of early detection of antenatal psychiatric disorder and suicidal ideation.

•Most psychiatric disorders in pregnancy go unrecognized and unrecorded in the absence of systematic screening.

•Past history of mental illness is the best predictor of psychiatric disorder in pregnancy.

•Routine screening should include:

•personal mental health history

•other vulnerability factors, including substance misuse

•family history of bipolar affective disorder (confers genetic vulnerability and a first episode is 7 times more likely to present in the immediate postnatal period).

Planning pregnancy with psychiatric disorders

Women suffering with recurrent and severe mental disorders who want to have children may benefit from pregnancy planning, as:

•Relapses are predicted by major life events.

•A medication holiday can be tried before conception, avoiding complications of relapse on pregnancy.

•Reproductive toxicology of essential medication can be minimized.

•Closer antenatal monitoring can be planned in advance.

•Contingency plans, including those for child protection, can be made with, and shared by, all the relevant agencies and caregivers.

Further reading

NICE. (2007). Antenatal and postnatal mental health. Clinical management and service guidance, NICE Clinical Guideline 45. London: National Institute for Health and Clinical Excellence. Mhttp://www.nice.org.uk/CG45

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448 CHAPTER 13 Substance abuse and psychiatric disorders

Antenatal psychiatric disorders: specific disorders

The classification and symptoms of psychiatric disorders appear in the ICD-10.

Anxiety disorders

•Panic disorder, generalized anxiety disorder, and obsessive–compulsive disorder are all relatively common in pregnancy.

•Symptoms include pervasive or episodic fearfulness, avoidance, and autonomic arousal.

•Excessive reassurance-seeking may be a presenting feature.

•Must identify any concurrent depression requiring treatment.

•Can be highly distressing and merit clinical attention, although evidence for an adverse effect on fetal outcome remains conflicting.

•High antenatal anxiety is a predictor for postnatal depression.

•Psychological management (including cognitive-behavioural therapy (CBT)) is preferable to anxiolytics, but access within the timescale of pregnancy may be limited.

Benzodiazepine use should be avoided.

Bipolar affective disorder

•Affects 71% of women of childbearing age.

•Characterized by severe episodes of depression or mania (elevated mood, excitability, irritability, overactivity) often associated with psychotic symptoms. Can pose significant risk to mother and fetus.

•Associated with a 2-fold higher risk of admission postnatally than at other times.

•Decision to stop medication in existing patients when pregnancy is

discovered should be made only after a careful risk/benefit review.

Associated with a high suicide rate.

Schizophrenia

•Affects 71% of women of childbearing age.

•Clinical features vary, but include delusions, hallucinations, and abnormalities of affect, speech, and volition.

•Maintenance medication is usually required throughout pregnancy.

•Significant proportion of patients are unable to care for the child.

•The lifetime risk of schizophrenia for a child with one affected parent is in the order of 10%.

ANTENATAL PSYCHIATRIC DISORDERS: SPECIFIC DISORDERS 449

Eating disorders

•Bulimia nervosa affects 1% of women of childbearing age and anorexia nervosa 0.2%.

•Characterized by disturbances in eating behaviour and abnormalities in body image.

•Although anorexia nervosa is associated with reduced fertility and fecundity, patients with sub-threshold symptoms can become pregnant and require careful monitoring and management.

•Possible effects on fetal outcome include IUGR, low birth weight, prematurity, and a possible increase in congenital anomalies.

Depression

As common antenatally as it is postnatally.

•Characterized by:

•low mood

•lack of energy or increased fatigability

•loss of enjoyment or interest in usual activities

•low self-esteem

•feelings of guilt, worthlessness, or hopelessness

•poor concentration

•change in appetite (leading to weight loss or gain)

•suicidal ideation.

•Associated with an increased risk of suicide.

•Can be effectively treated with pharmacological and psychological therapy.

Further reading

WHO. (1992). ICD-10 Classification of mental and behavioural disorders. WHO, Geneva.

450 CHAPTER 13 Substance abuse and psychiatric disorders

Psychiatric medications

Anticonvulsant mood stabilizers

Carbamazepine

Major malformation rate 2.2%:

•High rate of neural tube defects.

•Others include craniofacial abnormalities and distal digit hypoplasia.

2Breast-feeding is not recommended.

Lamotrigine

Major malformation rate 2.1%: high rate of cleft palate.

2Caution with breast-feeding (dermatological problems in infants).

Sodium valproate

Major malformation rate 6%:

•Very high rate of neural tube defects.

•Others include craniofacial abnormalities and distal digit hypoplasia.

•Significant neurobehavioural toxicity (22% of exposed infants develop low verbal IQ).

Should not be routinely prescribed to women with childbearing potential.

Should not be prescribed to women under 18 due to i risk of developing polycystic ovary syndrome (PCOS) and i risk of unplanned pregnancy.

Benzodiazepines

See bDrugs of abuse: sedatives and cannabis, p. 444.

Lithium

•50% of women with bipolar affective disorder stabilized on lithium relapse within 40wks of stopping it.

•Early pregnancy: risk of Ebstein’s anomaly lower than previously estimated at 0.05–0.1% against a background risk of 0.0005%.

•Late pregnancy: levels need to be measured more frequently as plasma volume and GFR increase.

•Labour: reduced vascular volume and potential dehydration necessitates careful fluid balance and monitoring of serum lithium levels.

•Neonate: reported association with floppy baby syndrome, neonatal thyroid abnormalities, and nephrogenic diabetes insipidus.

Breast-feeding is not recommended.

2 If women continue to take lithium, serum levels should be checked every 4wks until 36wks, then weekly.

2Women taking lithium should deliver in a consultant-led obstetric unit.

PSYCHIATRIC MEDICATIONS 451

Antipsychotics

•Older antipsychotics (such as haloperidol) are preferred because more data are available with no strong evidence of imalformations.

•May be an effective alternative to mood stabilizers in women with bipolar affective disorder.

•Clozapine is not routinely used in pregnancy and breast-feeding due to the theoretical risk of agranulocytosis in the fetus/neonate.

Antidepressants in pregnancy and lactation

When choosing an antidepressant, prescribers should bear in mind that the safety is not well understood, but take into account:

•Tricyclic antidepressants (amitriptyline, imipramine, and nortriptyline) have lower known risks than other newer antidepressants.

•Most tricyclics have a higher fat toxicity index than SSRIs.

•Fluoxetine is the SSRI with lowest known risk in pregnancy.

•No strong evidence of imalformations with tricyclic drugs.

•Paroxetine may have association with cardiac malformations.

•SSRIs in late pregnancy have been associated with iincidence of persistent pulmonary hypertension in infants.

•Venlafaxine may be associated with irisk of high BP, itoxicity in overdose, and idifficulty in withdrawal.

•Serotonin and norepinephrine reuptake inhibitors (SNRIs) are relatively untested and so are not recommended as first-line drugs in pregnancy.

2Citalopram and fluoxetine are present in breastmilk at relatively high concentrations.

2Imipramine, nortriptyline, sertraline, and paroxetine have particularly low concentrations in breastmilk and are therefore recommended for breast-feeding mothers.

452 CHAPTER 13 Substance abuse and psychiatric disorders

Considerations for managing psychiatric medications in pregnancy

•Any decision to stop psychiatric medication for women with serious mental health problems should be made in consultation with a specialist, bearing in mind that the period of maximum vulnerability has often passed by the time pregnancy is identified. For example, an estimated 50% of women with bipolar affective disorder maintained on lithium will relapse during a 40wk pregnancy if it is stopped.

•Most psychiatric drugs are not associated with a significant increase in fetal anomalies.

•The risks of a relapse of psychiatric disorder during pregnancy tend to be underestimated.

•The risks of continuing medication need to be considered in terms of:

•early fetal exposure

•late fetal expose

•delivery and neonatal withdrawal

•breast-feeding

•longer-term neurobehavioural toxicity.

Further reading

NICE. (2007). Antenatal and postnatal mental health. Clinical management and service guidance, NICE Clinical Guideline 45. National Institute for Health and Clinical Excellence, London. Mhttp://www.nice.org.uk/CG45

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454 CHAPTER 13 Substance abuse and psychiatric disorders

Postnatal depression

Over 10% of women are depressed in the postnatal period. Although the term ‘postnatal depression’ is both clinically useful and acceptable to women, there is no evidence that it is any different from depression at any other time in a woman’s life. It should accordingly be taken seriously and not dismissed as a mild, self-resolving condition that does not require treatment. Emphasized by recent evidence of a link between postnatal depression and infant developmental problems when there are associated difficulties in the mother–infant relationship.

Diagnosis

Key features of depression are (see b Antenatal psychiatric disorders: specific disorders p. 448):

•Tearfulness.

•Irritability.

•Anxiety.

•Poor sleep.

It can easily be missed if specific enquiries are not made, especially with milder cases. New mothers with depression are often embarrassed by their feelings and reluctant to admit to sadness at a time when they feel they are expected to be happy.

Screening for depression

NICE suggests the following questions are used to screen for depression both antenatally and at 4–6wks and 3–4mths postnatally:

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

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

If the woman answers ‘yes’ to both of these:

• Is this something you feel you need or want help with?

Other screening questionnaires like the Edinburgh Postnatal Depression Scale (EPDS) are also helpful in identifying postnatal depression, and are routinely used by health visitors in many services.

Treatment and recovery

Mild to moderate depression may respond to self-help strategies and non-directive counselling (‘listening visits’ by a health visitor). Moderate to severe depression usually requires treatment with antidepressant medication and/or psychotherapy (CBT). Breast-feeding is not a contraindication for antidepressant treatment, but drugs with low excretion in breastmilk, such as sertraline, are preferred.

Women who have experienced postnatal depression have a high (>70%) lifetime risk of further depression and a 25% risk of depression following subsequent deliveries. For this reason, women who present in pregnancy with a history of postnatal depression are likely to benefit from closer postnatal follow-up.

POSTNATAL DEPRESSION 455

Post-partum ‘baby blues’

Over 50% of women experience a brief period of emotional instability starting around 3 days after delivery and resolving spontaneously within 10 days, characterized by:

•Tearfulness.

•Irritability.

•Anxiety.

•Poor sleep.

This usually responds to support and reassurance.