Mental health issues frequently arise during the perinatal period, encompassing both pregnancy and the first year postpartum, including the puerperium. In the UK, approximately one in five women experience mental health challenges during this critical time. Alarmingly, suicide has become the leading cause of maternal mortality in this period. The societal cost of unmet mental health needs is staggering, estimated at £8.1 billion.
The burden of perinatal depression is not only profound in financial terms—averaging £74,000 per case—but it also disproportionately affects both mothers and their children, with costs of £23,000 impacting maternal health and £51,000 relating to the child’s well-being. Furthermore, research indicates that the prevalence of mental health disorders during this period is even higher in low- and middle-income countries (LMIC), where one in five women may experience conditions such as depression, anxiety, or somatic disorders, particularly among adolescents.
Barriers to Care in Low- and Middle-Income Countries
In LMIC, there is a critical shortage of resources, including trained professionals and psychoeducational programs to address these mental health challenges. Stigma surrounding mental health issues is a pervasive global concern, perpetuated by misconceptions regarding the treatability of mental disorders. This stigma can lead to social isolation, abuse, and rejection, exacerbating the suffering of those affected.
Integrated Mental Health Care
Effective mental health care during the puerperium must be comprehensive, integrating public health initiatives, primary care, and specialized services in physical, maternity, and mental health. This chapter aims to serve as a user-friendly guide to prevalent mental health disorders in the puerperium, offering guidance on screening, assessment, and treatment strategies that can be applied universally.
Conducting a Comprehensive Psychiatric Evaluation
When mental health concerns arise during the puerperium, it is essential to conduct a thorough psychiatric evaluation. This evaluation should include specific perinatal details:
Basic Information and Presenting Complaints
Gather fundamental data such as the individual’s name, age, marital status, and occupation. Understand the reason for referral through both the woman’s account and that of the referrer.
History of Presenting Complaints
A detailed account of current mental health symptoms should be documented. It is vital to include any past psychiatric history, including previous self-harm incidents, and a chronological record of any untreated medical conditions.
Family and Personal History
Attention should also be paid to family psychiatric history, emphasizing conditions such as psychosis and bipolar affective disorder (BPAD). Moreover, capturing the individual’s personal history, including birth experiences and early childhood, is crucial in understanding their current state.
Additional Considerations in the Puerperium
Delivery and Past Mental Health
Documenting delivery details—including the date, mode, and any complications—is essential. Clarifying any past postnatal mental health diagnoses, such as postpartum depression, can help identify potential risk factors.
Bonding and Attachment
Assessing bonding with the current baby and any previous children is important. Observing interactions can reveal the quality of attachment. Additionally, evaluating the level of social support and any recent changes can contribute to a comprehensive risk assessment.
Mental State Examination (MSE)
Conducting a Mental State Examination (MSE) is crucial for documenting the current mental status of the woman, aiding in the differential diagnosis and risk assessment.
Key Areas of Assessment
- Appearance and Behavior: Evaluate whether clothing is appropriate and observe the individual’s emotional state and demeanor.
- Speech: Assess coherence, volume, and the rate of speech.
- Thought Processes: Examine the content and form of thoughts, and look for any obsessive thinking.
- Mood and Affect: Determine subjective feelings of depression alongside objective observations of mood congruence.
- Cognitive Functioning: Assess orientation, attention, and memory.
- Insight: Gauge the individual’s understanding of their illness and their acceptance of treatment.
- Risk Assessment: Identify specific perinatal red flags, such as intense hopelessness or severe mood swings.
Identifying Suicide Risk Factors
Awareness of risk factors for suicide and mental health issues in the puerperium is critical. These may include:
- New violent thoughts of suicide.
- Persistent feelings of detachment from the baby.
- Rapid mood fluctuations.
- Thoughts of self-harm or harm to others.
It is crucial to engage in open discussions about suicide, as addressing these topics can help alleviate risk rather than exacerbate it.
Breastfeeding and Medication Considerations
The World Health Organization recommends exclusive breastfeeding for the first six months, followed by continued breastfeeding alongside complementary foods for up to two years or beyond. All psychotropic medications are transferred to breast milk, but typically in lower doses than during pregnancy. A relative infant dose of less than 10% of the mother’s dosage is deemed safe for breastfeeding.
General Treatment Recommendations for Breastfeeding Mothers
- Previous Treatment Response: Consider how the mother has responded to medications in the past.
- Access to Psychological Therapies: Ensure breastfeeding mothers have rapid access to psychological support.
- Low-Risk Treatments: Opt for treatments with minimal risk while breastfeeding.
Addressing Birth Trauma and PTSD
Birth trauma affects 33-45% of women, with approximately 4% developing post-traumatic stress disorder (PTSD). High-risk groups include those with traumatic birth experiences or a history of abuse. The global implications are significant; the WHO estimates that millions of women may experience birth trauma annually.
Symptoms of PTSD
Common symptoms include:
- Re-experiencing the trauma through flashbacks or nightmares.
- Avoidance of reminders associated with the trauma.
- Heightened vigilance or emotional dysregulation.
Effective Treatments for PTSD
Psychological therapies such as Trauma-focused Cognitive Behavioral Therapy (CBT) and Eye-Movement Desensitization and Reprocessing (EMDR) are recommended. In some cases, selective serotonin reuptake inhibitors (SSRIs) may be prescribed to address co-morbid symptoms.
Understanding Perinatal Obsessive-Compulsive Disorder (OCD)
Perinatal OCD affects a significant number of women during and after pregnancy. It is characterized by persistent obsessive thoughts and compulsive behaviors that disrupt daily life.
Management Strategies
Treatment may include cognitive behavioral therapy (CBT) as a first-line option for mild to moderate symptoms. SSRIs are also effective for managing OCD symptoms in the perinatal period.
Importance of Attachment and Bonding
Attachment between an infant and caregiver is crucial for emotional and cognitive development. Early attachment influences personality and emotional security.
Encouraging Bonding
To foster bonding, mothers should engage in activities such as skin-to-skin contact, vocalizing, and playing simple interactive games.
Conclusion
The importance of Mental Health in the Puerperium cannot be overstated. Identifying mental health issues early, offering appropriate treatment, and promoting healthy attachment can significantly improve outcomes for both mothers and their infants. Recognizing the complexities involved in mental health care during this critical time ensures that both mothers and their babies receive the support they need for a healthier future.
