Perinatal psychiatry
Case history 27
Bronwyn is 32 years old. She has two children and is in the tenth week of pregnancy. She has a history of recurrent depression, including an episode following the birth of her second child. She stopped sertraline four months ago, prior to conception. She now presents with low mood, tearfulness, poor sleep, fatigue and impaired concentration that has caused her to make uncharacteristic mistakes at work.
Perinatal psychiatry involves the recognition, assessment and management of mental disorders during pregnancy and the postnatal period. Traditionally, the focus has been on the period following delivery, during which there is a raised risk of depression and psychosis, and it is the postnatal conditions, outlined in Figure 1, that will be discussed in detail here. However, mental illness also occurs during pregnancy and, when present, will often persist postnatally.
Postnatal depression
There is a high rate of depression among women in the 12 months following childbirth. Community surveys have shown a prevalence of up to 20% and around 5% of women will consult their GP regarding depression during the postnatal period. These findings have given rise to the concept of postnatal depression as a discrete disorder, somehow different to other depressive illnesses, perhaps as a result of hormonal changes occurring after childbirth. This has been helpful in promoting the acceptance of depression in the postnatal period and reducing the feelings of shame felt by women who are not experiencing the happiness babies are expected to bring.
The epidemiology of depression in the postnatal period suggests the condition is not distinct from other depressive disorders. While the baby blues, consisting of a brief period of tearfulness, anxiety, irritability and fatigue, occurring in mothers typically around four days after delivery, may well be linked to hormonal changes, this does not seem to be the case with depression. There is no peak of new cases of depression in the first few weeks of the postnatal period, and the period of raised risk extends throughout the first year. Hormonal treatments, such as progesterone, do not appear to be effective. There is also no difference between the symptoms of depression in the postnatal period and those occurring at other times of life, and risk factors are also similar.
It seems more likely that raised rate of depression in the postnatal period is the result of psychological and social factors. Looking after a baby is challenging and the risk of depression is increased in cases of neonatal illness. The arrival of a new child has a great effect on relationships and family finances, and social isolation may occur. Notably, postnatal depression is more common following the birth of a first child and unwanted pregnancies, which suggests that adjustment to motherhood is an important factor.
Standard treatments for depression should be offered. Specific interventions, such as mother and baby groups, may be particularly helpful for women struggling to adjust to motherhood and those who have become socially isolated. Consideration of drug treatments should take into account the problems that may be encountered during breast-feeding, which are summarised below. Drugs with sedative effects should be prescribed with caution if there are not other people available to care for the baby.
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