tokophobiaDiane Shipley reports on the many challenges facing women with mental ilnesses when starting a family:

Pregnancy can be a challenging time for a woman’s mental health. During the perinatal period – loosely defined as the weeks before and after birth – at least 10% of women will experience mental illness. This may be an existing problem, recurrence of a previous illness, or a new diagnosis. Women with a past experience or family history of mental health problems, however mild, are most at risk.

Mild to moderate depression is the most common condition, affecting about 86,000 women a year. Severe depression and post-traumatic stress disorder both affect more than 20,000 women, and chronic mental health conditions and postnatal psychosis affect about 1,380 women each, or two in 1,000 maternities. While severe depression and psychosis are more likely to occur in the weeks after giving birth, the overall incidence of mental distress is highest in the third trimester.

This raises the issue of whether women who become pregnant or are planning a pregnancy should start, or continue, medication. In June, National Institute for Health and Care Excellence (NICE) adviser Professor Stephen Pilling recommended that all women of childbearing age with mild to moderate depression avoid selective serotonin re-uptake inhibitor (SSRI) antidepressants due to the potential risk of having a baby with a heart defect, a chance that doubles from two to four in 100.

Other psychiatric medications present pregnancy risks: lithium increases the chance of foetal heart defects from eight in 1,000 to about 60 in 1,000, benzodiazepines have been associated with cleft palate, and the antipsychotic olanzapine increases the mother’s likelihood of having gestational diabetes.

But coming off medication can also be a problem: pregnant women with bipolar disorder who stopped taking their medication were twice as likely to relapse, according to a study from Harvard Medical School. Research published in The Journal of the American Medical Association showed that 68% of pregnant women who discontinued antidepressants relapsed, compared to 26% who continued treatment.

Professor Ian Jones, a perinatal psychiatrist and deputy director of the National Centre for Mental Health, says that the link between antidepressants and birth defects shouldn’t be overstated, as we still don’t know how much is related to depressive illness or associated factors including poor diet, being overweight or drink and drug use. But he suggests that pregnancy might be a good time to consider any existing medication regime. “Having discussions with your medical team to weigh up the risks and benefits for you as an individual is the important thing.”

NICE guidelines state that all pregnant women with mental illness should be made aware of the risks and benefits of medication. They also say that each area should have a multidisciplinary perinatal service, mentally ill pregnant women should be offered appropriate psychological support within three months (preferably one) and that women who need inpatient care within 12 months of giving birth should be admitted to a mother and baby unit, where they can stay with their baby and receive specialist support, rather than a general psychiatric ward. Unfortunately, implementation of these recommendations varies widely.

Indeed, the NSPCC report, All Babies Count: Spotlight on perinatal mental health, found that 64% of primary care trusts have no perinatal mental health strategy, only 27% of maternal services have a mental health midwife and there is a shortage of 50 beds in mother and baby units.

But the government has started taking steps to redress these problems: in 2012, then health secretary Andrew Lansley announced that 5,000 more midwives would be trained and 4,200 extra health visitors would be recruited so that all women could have access to a named midwife and experience greater continuity of care.

Finding an accurate diagnosis
This is important because 31% of pregnant women are reluctant to talk about mental illness because they see a different professional at every appointment, according to Perinatal Mental Health: Experiences of women and health professionals, a report from Tommy’s, Netmums, the Royal College of Midwives and the Institute of Health Visiting.

Even if women are open about their symptoms, they may not be given an accurate diagnosis. When Hannah (not her real name) began experiencing severe anxiety in her third trimester, she didn’t realise that it was caused by her pregnancy – but nor did her GP, midwife, or obstetrician. She became increasingly anxious and depressed after giving birth and started having suicidal thoughts. “It was like a living hell,” she says.

Hannah saw the mental health crisis team and was briefly admitted to a psychiatric ward but her symptoms were still not acknowledged as perinatal illness. “Everyone did try within the remit of their expertise but I think they’d just never had any training in this,” she says. She heard about mother and baby units through a friend of a friend and asked her psychiatrist for a referral, but was told it was too expensive. Feeling out of options, she attempted to take her own life.

Following this she was taken to hospital, and then admitted to a mother and baby unit with her son, near her family but 300 miles from home and her husband, who commuted every weekend. “It was still incredibly tough but I was speaking to people who could explain to me what was happening as opposed to just looking blank,” she says.

After five months in the unit, Hannah recovered, but her stay could possibly have been shorter had her illness been identified sooner – the average length of stay is six weeks. She says it’s unlikely she will have another child.

“If there were services in place and I could have faith in those services then I would have taken longer to make that decision.”

Specialist care
For those with existing conditions, there are worries about relapse. For instance, Jenni Regan was worried about hormones triggering a relapse when she started IVF six months after being diagnosed with bipolar disorder. But she remained stable on medication and is now pregnant and feeling well. She is under the care of the perinatal mental health team at Whipps Cross Hospital in London, seeing a specialist midwife, psychiatrist and social worker regularly. The effects of her medication – an antidepressant and an antipsychotic – are being monitored because she might need to increase the dosage as her bump gets bigger, and she is also at risk of gestational diabetes.

But the possible effect of medication on the baby does worry her: “Every time I go for a scan I think, ‘Oh God, have I harmed my baby in some way?’ But in my opinion the risks were lower than the risks of me relapsing.” One reason she didn’t want to stop her medication is her increased risk of postnatal psychosis.

Although it only affects 1–2 in 1,000 women, more than 72% of those have bipolar or schizoaffective disorder. While Regan is happy with the care she’s received, she wonders if she would have got such good treatment had she not already been in contact with the crisis team.

Professor Jones adds that one problem in identifying women at risk of perinatal mental illness is that service users no longer accessing secondary care may not appear to need specialist help during pregnancy. “Those women are still at really high risk and we must get better at giving them the support and monitoring they need.”

Integrated approach
But some areas do give a greater priority to mental health. For example in Nottingham, questions about mental health are a routine part of a woman’s first appointment with a midwife. “I tell women it’s as important for us to know and understand about your emotional wellbeing as it is for us to know and understand about your physical wellbeing,” says Gillian Barker, a midwife with a special interest role in maternal mental health.

Also, midwives in the trust are given extra training and materials to facilitate this conversation. “We have an algorithm within our maternity notes which helps us to ask a woman specifically about her mental health. That stays in the women’s notes so that when they come into contact with a hospital midwife or obstetrician, they understand what level of care or treatment she’s experienced in the past.”

While this type of integrated approach is still in the minority, there are hopes it will become standard practice. The Maternal Mental Health Alliance, a coalition of 40 organisations invested in women’s maternal health, recently launched ‘Maternal Mental Health – Everyone’s business’, a three-year campaign aimed at ensuring every woman who needs it has access to perinatal mental health care at the right level for her needs.

In addition, The Royal College of GPs has chosen perinatal mental health as one of its clinical priorities for 2014–17 and updated NICE guidelines will be published in 2014, which could bring renewed focus to their implementation.

Hannah says that her recovery illustrates what’s possible. “This is a good news story. From what I understand, the UK is pioneering the way in how to treat these mental illnesses. The best practice is out there and people get better. So why aren’t we doing this and celebrating what we know we can do?”

This article first appeared in the November/December 2013 issue of Mental Health Today. For more information on the magazine, as well as details of how to subscribe, visit www.pavpub.com/mental-health-today/ 

References
Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC, Suri R, Burt VK, Hendrick V, Reminick AM, Loughead A, Vitonis AF & Stowe ZN (2006) Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. The Journal of the American Medical Association 295 (5).
Hogg S (2013) All Babies Count: Spotlight on perinatal mental health. London: NSPCC.
NICE (2007) Antenatal and Postnatal Mental Health. London: NICE.
Sit D, Rothschild AJ & Wisner KL (2006) A review of postpartum psychosis. Journal of Women’s Health 15 (4) 352–368.
Tommy’s et al (2013) Perinatal Mental Health: Experiences of women and health professionals. London: Tommy’s. Available at: https://www.tommys.org/perinatal-mental-health-report
Viguera AC, Whitfield T, Baldessarini RJ, Newport DJ, Stowe Z, Reminick A, Zurick A & Cohen LS (2007) Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. American Journal of Psychiatry 164 1817–1824 doi:10.1176.