Chapter 5 Carol Henshaw1 and James Patterson2 1 Liverpool Women’s NHS Foundation Trust, Crown Street, Liverpool, UK 2 Greenmoss Medical Centre, Scholar Green, Stoke on Trent, UK This chapter considers what is known about anxiety and depression during pregnancy and in the postpartum period and the effective treatments. We will discuss this in relation to the two cases in Box 5.1. Postnatal depression is the most common medical complication of childbirth and follows around 13% of deliveries. Higher rates are reported in areas with social adversity and deprivation. There are a number of factors that increase the risk of postnatal depression (see Box 5.2). This leaves women like Hannah – in the second case study in Box 5.1 – vulnerable to depression following delivery as her partner has left, she is feeling isolated from her friends, and her parents are disapproving of her situation. Shabila, in the first case study, feels unsupported by her children and already has some symptoms suggestive of depression, which increase her risk after delivery. Untreated depression can last for a few weeks to a few months but around 10% of cases will last into the second year after childbirth. Pregnancy has often been thought to be a time of emotional wellbeing but depression is as common during pregnancy as it is after delivery. Up to one-third of postnatal depressive episodes have onset during pregnancy. Three to five percent of women will experience a depression severe enough to require referral to secondary mental health care, and 1 in 500 will suffer a puerperal psychosis. Two-thirds of puerperal psychoses are psychotic depressions and one-third are manic episodes. Manic episodes tend to onset more rapidly than depression but more severe depressive episodes can also develop quickly. Less attention has been paid to anxiety disorders in the perinatal period, but they are as common as depression and comorbidity with depression is not unusual. Generalised anxiety disorder, panic disorder and phobic disorders occur during pregnancy and postpartum, and some women suffering from depression will experience anxiety symptoms such as panic attacks, intrusive obsessional thoughts or compulsions during a depressive episode. Severe anxiety during pregnancy often focuses on fear of miscarriage or stillbirth (particularly if there is a history of reproductive loss) and fetal abnormality. After delivery, fears of a cot death or of being criticised as a mother are common. Obsessional symptoms often focus on cleaning or hand washing and fears that the baby might become infected with something. Sometimes compulsive checking of the baby to make sure he or she is still breathing can occur. Some women experience distressing intrusive obsessional thoughts that some harm might come to their baby. This can be misinterpreted as intention to harm, and careful clinical assessment is essential to distinguish between obsessional thoughts that a mother is not going to carry out and a woman with thoughts of harming her child that she is at risk of acting on. Post-traumatic stress symptoms and post-traumatic stress disorder (PTSD) can occur after traumatic deliveries. Women with a history of sexual trauma and/or mental health problems are at increased risk, but perceived poor support in labour from a partner or professionals, being in pain, perceived loss of control, feeling powerless and medical interventions are also important. It can lead to fear of future childbirth (tokophobia), and some women will avoid or terminate a pregnancy of a much-wanted baby, or may demand a Caesarean section as a result. Phobic anxiety can also require assessment and intervention if it might have an impact on care during pregnancy and labour. Needle and blood phobias can be treated effectively with systematic desensitation, and if they are identified at booking for antenatal care prompt referral is essential so that treatment can start as soon as possible. Anxiety and depression during pregnancy are associated with a number of adverse obstetric outcomes (see Box 5.3).
Antenatal and Postnatal Mental Health
Background
Depression
Anxiety
Impact of depression and anxiety during pregnancy
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