Screening
Attendance at antenatal clinics is a first-class opportunity for finding pregnant women at high risk, such as those with a history of depression or psychosis, drug or alcohol abuse, major social problems or unwanted pregnancy. After the birth, maternity staff can make close observations of the initial responses of vulnerable mothers, and in many countries, staff from various disciplines visit the mother at home. Those involved in screening should know how and to whom they can refer if difficulties are identified, as no screening is effective without a supportive network for intervention.
A range of screening questions or questionnaires may be used to determine which mothers may need referral for further diagnosis and treatment. It is best to begin with general, open questions rather than specific enquiries about depression or anxieties. For example, one could ask,
“How do you feel about this pregnancy?”
“What are your main worries at the present time?”
“How are things going with (name of baby)?”
Each professional will have his or her favourite questions. Observations of the mother’s appearance or handling of the baby are equally important. The Edinburgh Postnatal Depression Scale (Cox et al.
1987) has been widely evaluated and used and translated into many languages. If there are difficulties in a mother’s emotional response to pregnancy or the baby, there are several useful scales: during pregnancy, there is the Prenatal Attachment Inventory (Müller
1993). After the birth, there is the Postpartum Bonding Questionnaire (Brockington et al.
2006), which has been validated and widely translated.
Planning during pregnancy
If a mother with a severe mental disorder becomes pregnant, a multi-disciplinary planning meeting should be convened as soon as possible, to share information and coordinate management. The reason for urgency is that the interval between diagnosis of pregnancy (which may be delayed) and birth (with may be premature) can be short. The meeting should include all those involved in treatment, which will vary from country to country: the full list includes the general practitioner, a representative of the obstetric and mental health teams, (if appropriate) a social worker and (if possible) the expectant mother and family members. There are many issues to be addressed—pharmaceutical treatment, antenatal care, early signs of a recurrence, the management of the puerperium, the care of the infant and sometimes action to protect the child. It is important that the mental health team be alerted as soon as the mother goes into labour.
Interviewing
Once a mother has been referred to the service, in addition to the standard psychiatric history, it is essential to explore thoroughly the current pregnancy and birth.
During pregnancy, the interview should cover:
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The pregnancy’s social, cultural, psychological, psychiatric and obstetric background
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The circumstances under which conception occurred
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The expectant mother’s reaction and adjustment to the pregnancy, and her expectations of maternity
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The reaction of others, especially the baby’s father
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Changes in life-style including the mother’s sacrifices to complete this pregnancy
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Her burgeoning relationship with the unborn child
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Her health (mental and physical) during pregnancy
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Her worries and preoccupations
Next comes parturition and its effect on mother and neonate.
After the birth, the interview should cover:
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The mother’s reaction to the new-born and to infant feeding and care
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The father’s reaction and participation in infant care
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The effect of the birth on the family circle
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The support available to the young family
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Sleep deprivation and medical complications
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Psychiatric disorders including anxiety, morbid preoccupations, irritability, depression and psychotic symptoms
Finally, there is the mother-infant relationship:
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As background, the baby’s health, temperament, development and any specific difficulties
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The timing and quality of the mother’s emotional response
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Evidence of pathological anger and rejection
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The safety of the infant with these parents
There may be other interviews, but all these areas are covered in the Stafford Interview (the sixth edition of the Birmingham Interview), developed over the course of 22 years and translated into several languages (Brockington et al.
2016). It is useful in training, clinical practice and research.
Therapy
A great deal can be done, using the full range of psychiatric and psychological treatments, to improve the mental health of pregnant and newly delivered mothers, their partners and infants. The costs and benefits of treatment options for parents and child should be discussed with all the participants—the mother and her wider family, the mental health team and the obstetric service. This requires a compassionate approach and a strong therapeutic alliance. The history of treatment compliance will also influence the balance of the cost-benefit analysis.
Therapy in pregnancy and the postpartum period is a rapidly developing field in terms of both pharmaceutical and psychotherapeutic interventions. We, therefore, hesitate to make any dogmatic statements and instead recommend that all clinicians maintain an up-to-date knowledge of the emerging evidence-base and local recommendations. The following sections outline some of the more solid conclusions from the available evidence.
Mood stabilisers, such as lithium and carbamazepine, given during pregnancy, reduce the recurrence rate in bipolar disorder. Parturition alters lithium clearance, and there have been a number of reports of dangerous levels of lithium in mothers taking their normal dose.
ECT can be given during pregnancy, but there are complications including preterm labour, which can be suppressed by tocolytic drugs such as terbutaline.
In the postpartum period, lithium, given immediately after the birth, can reduce bipolar episodes. Mothers with bipolar/cycloid disorders are highly susceptible to side effects from neuroleptics, and there have been several cases of neuroleptic malignant syndrome. The effects on breast-fed infants are minor, and even lithium has only occasionally led to adverse effects; but fever, gastro-intestinal illness and electrolyte loss could result in toxicity and this is a concern in nations where dysentery rates are high.
Crisis intervention may be required, for example, in obstetric and paediatric consultations.
Specific psychological treatments are available for prepartum and postpartum anxiety, obsessional disorders, post-traumatic stress disorder and complaining disorders.
Interpersonal psychotherapy focuses on the resolution of emotional conflicts. Cognitive therapy is directed at the correction of maladaptive thoughts and beliefs. Group therapy, psychoanalysis, mindfulness and yoga are available in some services.
In major disorders of the mother-infant relationship, depression or other disorders should be identified and thoroughly treated as a first step. In addition, a wide variety of interactive therapies have been developed, such as baby massage, parent-infant psychotherapy (including play therapy and Wait, Watch & Wonder) and video interaction techniques. Occasionally, the parents may decide to relinquish the baby, and this decision must be respected and supported throughout.
Working with fathers (if possible) and involving them in the therapeutic process is important in the development of this specialty. They may need personal support. In some cases, couple therapy or family therapy is indicated.