Depressive illness: the most common major complication of maternity 14% 12% 10% 8% 6% 4% 2% 0% PPH preterm preclampsia placental abruption IUGR major depression hypertension diabetes
Global Burden of Disease: DALYs (life years lost through death or illness) for women aged 15–44 WHO, 2008
Depressive illness: past history predicts high risk l Women with past history depression, on no an9depressants: up to 60% relapse postnatally (Wisner, 1994, 1998, 2004) l 3-5% on an9depressants at start of pregnancy l Stopping an9depressants: 70% relapse in pregnancy (Cohen et al, 1999)
Childhood maltreatment: the most important predictor of antenatal depression (x10) No$antenatal$depression$ Antenatal$depression$ 100%# 90%# 80%# 70%# 60%# 50%# 40%# 30%# 20%# 10%# 0%# Low$childhood$abuse$ High$childhood$abuse$ χ 2(1) = 23.76, p < .001; OR = 10.00; CI: 3.57, 28.01 Plant et al, 2013
Highest ever risk of psychosis 20 18 16 Admissions 14 12 10 8 6 4 2 36 34 32 30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 1 2 3 4 5 6 7 8 9 10 Weeks after Weeks before Kendell, 1987 Birth Puerperal psychosis: more rapid onset, more severe, and higher risk than at any other time (Oates, 1996; Appleby et al 1998)
Highest ever risk of bipolar relapse % Remaining well after stopping Lithium 100 Non pregnant 90 Pregnant 80 70 (n=42) 60 50 40 (n=59) 30 20 10 0 Pregnancy (Weeks 1–40) Postnatal (weeks 41–64) Viguera AC. Am J Psychiatry. 2000;157:179-184.
FEELINGS/ THOUGHTS/ BEHAVIOUR MOOD BELIEFS Negative about Low Slow, inactive, self, situation, DEPRESSION Anxious withdrawn, life, past, present suicidal numb and future Compulsions, Intrusive avoidance OCD Anxious (obsessional) thoughts Changeable, Confused, strange, agitated, bizarre, POSTPARTUM Muddled, withdrawn, suspicious, PSYCHOSIS high or low suicidal hopeless, ‘irrational’ Rapidly Rapidly Lack of trust, changeable, PTSD and changeable, suspicious, wary, extreme, extreme, self loathing, C-PTSD dismissive, mixed; numb detached self harm
• Acute psychosis (2/1000), Severe/complex (2/1000); Chronic SMI (2/1000) • Peer support • Services: Mother and Baby Units (2.5-3 beds/10,000 Severe, • Parent-infant births) high risk attachment • Commissioning: na9onal (England) services • Severe illness (30/1000) (‘Infant MH’) • Services: Specialist Perinatal Community Teams Admission (6-16,000 births) + effec9ve supported pathway vulnerable • Commissioning: CCGs: Mental Health; + maternity + LAs for health visitors • Mild/Moderate illnesses 10% • Services: Treatment Primary Care/IAPT; Mild/moderate Specialist MWs & HVs, specialist advice • Commissioning: CCGs and LAs • Mild illness and severe distress - 15% - 30% Mild illness and severe distress • Services : Time and skills in universal & Primary Care • Commissioning: CCGs and LAs • Good psychological care promo9ng good MH Maternal-child health and wellbeing • Services : Knowledge & compassion, understanding for all
What is ‘normal’? • Thoughts of accidentally harming baby = 100% 1 • Thoughts of deliberate harm = 50% 1 • Frequent and repeated thoughts: OCD = 2% 2 • As an indicator of risk of doing so = 0 1 Fairbrother & Woody, 2008; 2 Russell et al, 2013
Suffering so terrible that death seems the best option: suicide and maternity in the UK today If the women who died by 1 in 7 suicide became ill today: deaths of women • 40% would not were by be able to get suicide ANY specialist perinatal mental health care or 1 in 4 even advice deaths • Only 25% could between 6 access care that complies and 52 with NICE weeks after Guidelines birth were issued 9 years psychiatric ago
The Fetal Brain “Under Construc9on” • 3mm long neural tube: 100 billion neurons and 100 trillion connections • 250,000 neurons/minute formed through pregnancy • Proliferation, migration, differentiation, synaptogenesis continue for 18+months • Neural pruning til puberty …
Children depressed at 16 all had mothers who were depressed, mainly during pregnancy No maternal depression à No children depressed at 16 70 60 % of adolescent offspring 50 40 30 Depressed adolescents 20 Well adolescents 10 0 Never In utero 1st year Early Middle Adolescence childhood childhood When mother first depressed Pawlby et al 2009
Independent risk factors for adverse emo@onal/behavioural child outcome at 4 years: approximate risk Prenatal severe anxiety x2 Maternal depression at 33 months x2 Housing problems x2 But not: Smoking in pregnancy; Life events in pregnancy; Maternal age; Maternal educa9on; Social class; Financial difficul9es
Mothers’ childhood maltreatment has an impact on their children SDQ: childhood emo9onal and behavioural problems Collishaw et al 2007
Transgenerational emotional adversity and poor mental health eneration 0 dhood trauma + rnal antenatal depression Generation 1 Childhood trauma + Maternal antenatal depression Generation 2 Childhood trauma + Maternal antenatal Generation 3 depression Generation Childhood trauma + Childhood tra Maternal antenatal + depression Maternal ante depression
The adult effects of childhood emotional adversity • Lack of trust, suspiciousness (from tendency- pervasive); reject help • Hypervigilance, fear; beliefs that negative events could occur unpredictably at any time • Minor events precipitate rapid and extreme changes in mood, thinking and behaviour • Self preservation through detachment from current anguish: dissociation, non-psychotic voices, somatisation • Self blame and self harm
The adult effects of childhood emotional adversity • A lijle bit in most of us • Complex Post Trauma9c Stress Disorder • Developmental Trauma Disorder • Childhood Heroes • Borderline personality disorder • Emo9onally unstable personality disorder
The path to complex PTSD • What is neglect and what does it do to us (6mins. Harvard clip): hjp://developingchild.harvard.edu/resources/ mul9media/videos/inbrief_series/inbrief_neglect/ • Impact of stress in pregnancy on foetus (2mins.Harvard clip): hjp://developingchild.harvard.edu/index.php/resources/ mul9media/videos/three_core_concepts/toxic_stress/ • More detail on what childhood maltreatment does to brains of adults (15 mins Harvard lecture) : hjps:// www.youtube.com/watch?v=dxv3hareoQ8 • Drama@c impact of childhood maltreatment on life@me physical health (TED 15 mins.): hjps://www.youtube.com/ watch?v=95ovIJ3dsNk
Enhancing perinatal mental health • Society: value parents and children; understand the critical importance of attachment and the 1 st 1000 days; positive attitudes to mental health and constructive attitudes to mental illness; paternity and maternity leave; massive shift in engagement of fathers/partners • Individuals: above + actively provide support
What makes ‘support’ effec9ve? • Products: emo9onal AND prac9cal • Components: individuals and networks • Individuals: responsivity, trust, closeness, shared history • Networks: size, variety, interconnectedness
Professional help • All of the above • Identify women at high risk for extra support/prevention (past mental illness; childhood adversity) • Information, advice and support • Don’t stop antidepressants without careful consideration • Psychological therapies and medications
Perinatal period: the most efficient time for detection of depression in women pregnancy no exposure 34% 34% yrs 11-16 5% yrs 4-11 yr 1 pp 1% yrs 1-4 14% 12% (Sharpe et al 2006)
Routine detection: primary care and maternity services (NICE) • At first pregnancy contact • At 4-6 weeks PN ( ♯ hiddenhalf) • At 3-4 months PN
Treatment • Exercise (pram pushing): occupy mind and body and increase social contact • Computerised CBT – livinglifetothefull.com – moodgym.anu.edu.au • Mindfulness apps: eg Headspace • Cognitive Behaviour Therapy (CBT) - ‘IAPT’ in England • Antidepressants and antipsychotics • Specialist perinatal MH care for severe illness
Unacceptable postnatal depression care (Gavin, Meltzer-Brody, Glover, and Gaynes 2014) 100% 90% 80% 70% 60% 50% 40% 40% 30% 24% 20% 10% 10% 0% Prevalent PND Recognized Any Treatment Adequate Cases Clinically Treatment
Economic costs (LSE, 2014) Cost if we don’t act £8.1bn £337m Cost of taking action
Can we afford it? • UK maternity care = £2800/woman • Specialist perinatal mental health care across the UK = £67/woman • Total NHS maternity budget £2.6bn • Maternity negligence costs £482m • Whole APMH pathway £337m • ♯ hiddenhalf £20m Costs if we stay as we are = £8.1bn
The future: all UK • Clear pathway across all services • Specialist community perinatal mental health teams • Access to therapy • Parent-infant therapy • Mental health in maternity and health visiting • Specialist Mental Health Midwives and Health Visitors
Inpatient Mother and Baby Units 4 new MBUs in 2018
Specialist Perinatal Community Services: 2015
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