This chapter covers psychiatric disorder in relation to

• pregnancy,
• childbirth and motherhood, and the
• menstrual cycle.

GENDER AND HEALTH It should be noted at some point that there are general effects of gender on health. Females consult more frequently for all health problems, including for neurotic conditions, throughout life. Prevalence of neurotic conditions is higher in females than males. Males have an excess of conduct disorder as children, and of criminality and substance misuse as adults. Males with psychotic disorders such as schizophrenia do worse than females. Females live longer.

PREGNANCY Pregnancy appears, broadly speaking, to protect against psychiatric disorder; an effect having probable survival value in evolutionary terms. First onset of psychiatric disorder during pregnancy is rare, existing disorders tend to become less severe, and suicide rates during pregnancy and the puerperium are low.

However, women with a history of chronic or recurrent psychiatric disorder require continuing assessment and care during pregnancy, and monitoring to detect and treat any worsening after childbirth, with the health and safety of both mother and baby in mind.

Psychotropic drug treatment during pregnancy, though best avoided for the babyís sake, is sometimes essential for the motherís mental health. There is no evidence that antipsychotics, tricyclic antidepressants or benzodiazepines cause serious harm to the foetus though, for example, a newborn whose mother had been taking a benzodiazepine might exhibit a transient withdrawal syndrome.

The key point is that organogenesis is largely complete by 3 months; hence it is most unlikely that medication taken from then on could cause malformation, the adverse effect most feared by parents and prescribers.

Lithium should however be avoided, because it may cause foetal thyroid enlargement and, if taken in the first trimester, foetal cardiac malformation. It is important that the mother receives full information about proposed drug therapy, and gives informed consent (see British National Formulary guidelines on prescribing in pregnancy).

ECT can safely be given in pregnancy.

Unplanned pregnancies sometimes occur in women whose judgement is affected by psychiatric illness or learning disability, and may remain undiagnosed until a late stage.

Hyperemesis gravidarum refers to unusually prolonged and severe forms of the normal experience of vomiting (ìmorning sicknessî) during the early stages of pregnancy. While there may be physical causes, for example multiple pregnancy, psycholosocial aspects- especially anxiety- are often prominent.

Pseudocyesis is ìphantom pregnancyî, that is, where the woman develops symptoms and evens signs of pregnancy, including abdominal distension, etc., in the absence of a pregnancy. It is however now rare in UK practice.

Couvade refers to an analagous syndrome in the man, who develops these features as it were in sympathy with the mother. Again, it is rare.

PUERPERAL PSYCHOSIS

Definition Psychosis beginning within 12 weeks of delivery.

Most cases are now ìfunctionalî, that is, a form of mental illness without organic factors. In previous generations, and possibly still in developing countries, the psychosis was frequently organic in origin (due to confusion consequent on infection or other medical causes).

Frequency About 1-2 per 1000 births.

Predisposing Factors

• Past history of psychosis.
• Past history of puerperal psychosis: 20% risk of recurrence in subsequent pregnancies
• Family history of psychosis.
• Primiparity.

Causes

• Medical disorders: pelvic infections, thromboembolism and other physical complications of childbirth, though not common nowadays, need to be excluded in every case. The clinical picture would in this case be one of delirium- in other words, it would be an organic psychosis. In early cases, the defining feature of confusion, reduced conscious level, may only be apparent on detailed cognitive testing.

• Hormone changes: the abrupt fall in oestrogen and progesterone concentrations, which occurs following delivery could precipitate psychosis in predisposed women.

• Psychosocial stress: childbirth as a major ìlife eventî could precipitate psychosis in predisposed women.
  

Clinical Features Premonitory symptoms may occur in late pregnancy, but onset of frank psychosis is usually sudden, 2ñ14 days after delivery. Even in the majority of cases, which do not have an identified physical cause, symptoms such as bewilderment, emotional lability and perplexity are often prominent.

Depressive and manic syndromes are commoner than schizophrenic ones, though mixed pictures often occur. The thought content, and any delusions or hallucinations present (for example ìI am too wicked to be a motherî; ìthis babyís body is rotting insideî) occasionally lead the patient to harm or even kill herself and/or her child.

Treatment These illnesses can be severe and unpredictable. The safety of the mother and particularly of the baby must always be paramount. Hospital admission is usually necessary, preferably to a specialized mother and baby unit.

Treatment is in principle the same as would be used for the equivalent psychosis occurring apart from the puerperium. However, ECT should more readily be considered, for manic and schizophrenic syndromes as well as depressive ones.

ECT often relieves symptoms more quickly than drugs, and most psychotropic drugs enter breast milk, which is a potential (though sometimes overemphasized) concern if the mother is breast-feeding. High-dose progesterone is reported to be helpful but has not been tested in a clinical trial. The issue of contraception may need addressing if the illness is at all prolonged.

Prognosis Short-term prognosis is good, but there is a 20% chance of recurrence after any subsequent pregnancy, and a 50% chance of later recurrence not related to pregnancy.

POSTNATAL DEPRESSION AND OTHER NEUROTIC SYNDROMES

Any neurotic disorder can occur in the postnatal period. In addition to postnatal depression and ìmaternity bluesî, the two syndromes (see below) most frequently described, anxiety disorders and obsessive-compulsive disorders sometimes occur.

Symptomatology usually centres on the baby. Affected mothers often try to hide their symptoms because they know they are expected to be happy at this time, feel ashamed of their negative attitudes towards their baby, or are afraid the baby will be taken into care.

Maternity Blues About 50% of mothers experience irritability, lability of mood and tearfulness following delivery, maximal at about four days, tending gradually to resolve by about day 10.

Such symptoms may be considered normal in the sense of being extremely common; however they can cause considerable distress to the patient and family, and there is evidence of a weak linkage with psychiatric disorder. This is an appropriate subject for prenatal education, and supportive care from family, midwife and GP. If the syndrome fails to resolve, further care may be required.

Postnatal Depression Depression which is more persistent than ìmaternity bluesî occurs after 10ñ20% of births, and is termed postnatal depression.

The term can be used to cover depression within the first year after birth.

However, it is not separately coded in either DSM or ICD.

It tends to present later than puerperal psychosis. Many cases represent the continuation, exacerbation or recurrence of depression, which was present before the birth or even before the pregnancy: psychosocial factors are of particular importance.

A subgroup of women suffers depressive illness specifically related to childbirth, and their rates of depression at other times are not raised. Psychological difficulties in adjusting to motherhood, coping with the added responsibilities and changed social role, especially when there are social problems such as lack of support from the childís father or poor housing, may contribute to these depressive states. Minor hormone imbalance might also be involved.

Clinical features are not intrinsically distinct from other depressive illnesses, and may include depression of mood, anxiety, panic attacks, fatigue, loss of libido, anorexia and insomnia.

However, some of the symptoms are focussed on the baby, such as worries about being a good enough mother or about whether her feelings for the baby are warm and normal.

Some of these symptoms are difficult to distinguish from the inevitable changes in sleep, eating pattern and sexual function brought about by giving birth and caring for a child.

Thoughts of hating or wishing to harm the baby are common, and should always sensitively be asked about; the mother will feel very guilty about any thoughts of this kind, and may be much helped by talking about them, and understanding that she is not alone in experiencing them. Actual harming of the baby is rare unless the mother is psychotic.

The illness may last for months or years especially if, as is often the case, it goes undetected and untreated. This chronic ill-health in the mother is believed to hinder cognitive and emotional development in the child.

Treatment includes a combination of the following:

• Social support: training in child care, ongoing contact with named midwives and health visitors, introduction to other mothers of young children. Such measures in pregnancy have been shown to have preventive value, and health visitors given special training can provide valuable supportive counselling after the birth.

• Antidepressant drugs: there are few trials in postnatal women, who probably usually would not wish to partake in trials- and there could be ethical concerns about offering them placebo treatments when an effective treatment for (non-postnatal) depression is available. Use of the medications depends therefore on extrapolation from non-postnatal subjects. In practice, the drugs seem as effective as they usually would, and becuase of ready availability they are the mainstay of treatment of established cases..
  

• Psychotherapy: individual, marital, family or group.

MEDICATION AND BREASTFEEDING This is a convenient point to discuss the question of psychotropic medication and breast-feeding, as it is antidepressants which are the most common drugs to be considered at this time.

Almost all psychiatric drugs enter breast milk, though the concentrations are very low. Adverse effect on the baby are therefore very rare, though, of course, parents naturally worry about these very much.

Any theoretical risk to the baby from exposure to medication, has to be balanced against the likely adverse effects of untreated illness in the mother. If there is significant illness in the mother, then usually the risk/benefit analysis would come down in favour of prescription of medication.

Tricyclic drugs have been around a lot longer than the SSRIs, and are regarded as having a more established safety record in this situation.

Mothers often accept this provided that there are arrangements for the health visitor, for example, to monitor the infant for side-effects.

The key point is that the baby needs the mother to be healthy, in order to thrive.


ABORTION The Abortion Act 1967, with its subsequent amendments, permits abortion before 24 weeksí gestation in the case of risk to the motherís life, the motherís physical health or mental health, or the health of her existing children; later abortion is permitted in the case of foetal abnormality. Most abortions are carried out on the grounds of risk to the motherís mental health, but usually without a psychiatric opinion.

Postpartum psychosis after a previous delivery is usually regarded as a justification for abortion if the woman wants one, but since the risk of recurrence of postpartum psychosis after a single previous episode is only 20%, abortion should not necessarily be advised in such cases.

Abortion seldom has serious psychiatric sequelae, but about 25% of women experience significant guilt or depression afterwards, especially if they were ambivalent about the abortion or pressurized to accept it.

STILLBIRTH AND PERINATAL DEATH Mothers of babies who were stillborn, or died soon after birth, almost always develop grief reactions as found after other forms of bereavement. They are at high risk of prolonged depression and have an increased suicide rate.

Fathers are also affected but have not been so thoroughly studied. Management after neonatal bereavement should include opportunities for the parents to see and touch the dead child, encouragement to give the baby a name, take a photograph, hold a funeral, receive an explanation for the death and obstetric/genetic advice about future pregnancies, and bereavement counselling from an experienced professional. Such measures have been shown to reduce the duration of psychiatric morbidity.

PREMENSTRUAL SYNDROME Many women report depressed mood, irritability or anxiety, often combined with physical symptoms such as breast tenderness, headaches, bloated feelings and weight gain, for up to two weeks before the onset of menstruation.

Premenstrual tension has been used successfully as a defence in criminal trials, though this would be exceptional.

Regarding treatment, a wide variety of interventions has been systematically reviewed: diuretics, non-steroidal anti-inflammatory drugs, and SSRIs are considered to have evidence of effectiveness. ìLikely to be beneficialî treatments include CBT, exercise, low dose oestrogens and oral contraceptives. Popular treatments including vitamins and evening primrose are of ìunknown effectivenessî, and progesterone is ìlikely to be ineffective or harmfulî.

THE MENOPAUSE Epidemiological studies do not demonstrate any increase in major psychiatric morbidity in women of menopausal age. However, mild to moderate depression or anxiety may develop at this time of life; perhaps secondary to hormone changes, perhaps reactive to physical symptoms, or perhaps reflecting life changes such as children leaving home, death of parents and awareness of ageing.

Again, a variety of treatments has been used (ref. 2), especially hormone replacement therapy, HRT: progesterone alone is ìbeneficialî, but oestrogen alone or in combination with progesterone causes ìimproved menopausal symptoms but increased risk of breast cancer, endometrial cancer, stroke, and venous thromboembolism after long term useî, and there is a ìTrade off between benefits and harmsî.

HYSTERECTOMY Depressive reactions may occur following hysterectomy; some women having this operation are distressed by the loss of their childbearing capacity and/or their sense of femininity. However, follow-up of women having hysterectomies for menorrhagia of benign origin shows the majority to be pleased with the results, and overall psychiatric morbidity significantly lower after the operation than before, though still higher than in the general population.