“Postnatal Depression? That’s the Health Visitor’s job, isn’t it?”

This piece was published in October 2016 on the NB Medical Education website which can be found here:

http://www.nbmedical.com/the-hot-topics-blog/postnatal-depression-that-s-the-health-visitor-s-job-isn-t-it

Having a baby is supposed to be an overwhelmingly positive experience but for up to 1 in 5 women this precious time is clouded by symptoms significant enough to warrant a mental health diagnosis. You may be surprised to learn that fathers can also experience postnatal anxiety and depression with some estimates suggesting 1:10 men may be affected. Mental health problems during the perinatal time (pregnancy and the first year postnatal) have no prejudice – people from every socioeconomic, cultural or educational background can be affected – including GPs.

Up to 50% of cases of PMH cases are thought to be missed. Stigma is a barrier to the disclosure and detection of all mental health problems, but the perinatal time brings a particular challenge.

A severely depressed pregnant woman is such a cultural contradiction that many of us find it hard to accept, whether consciously or subconsciously. There are also time constraints, competing priorities in the GP consultation such as a woman’s physical health, or postnatally, the infant’s. As well, there are often assumptions that someone else has asked, and so GPs may not ask themselves.

Have you heard of Perinatal Post Traumatic Stress Disorder? It affects 3% women who have children with a traumatic birth being a significant risk factor.

How about Postpartum psychosis? A rare but critically important condition we all need to know about including the 4 hour target set by NICE for psychiatry review when a woman presents with active symptoms.

Perinatal OCD is also an important condition affecting 2% of pregnant women and 2.5% of those postnatal – more common than in the general population. The presentation can be similar to OCD in general but often excessive cleaning, concern about health of infant and intrusive thoughts are part of the picture. I would encourage GPs to ask if women have had any “unwelcome dark thoughts” or “unusual repetitive behaviours”– you’ll be surprised how many cases you’ll find.

When considering medication for mental health issues in women who are pregnant and breastfeeding, there is a lot of misinformation. Many women are told to stop their antidepressants in pregnancy, or that they can’t take them whilst breastfeeding. This is a tricky area, and many GPs don’t feel particularly confident in these discussions. As presented in this seasons Hot Topics Course, there is a lack of robust evidence to suggest one SSRI over another, with the exception of paroxetine NOT being recommended in pregnancy. Further information can be found in the Toolkit listed below.

Although not inevitable, there is a growing evidence base that links PMH illness to a wide range of negative consequences for that child. Infants exposed to higher levels of stress hormones antenatally, for example, show neurodevelopmental differences and higher levels of infant mental health problems. Children of mothers with PMH illness have a higher chance of mental health problems themselves, as a young adult and beyond.

What is really needed is all of us to ask every woman at every contact how they are doing and specifically in relation to their mental health. This is not rocket science – perhaps consider a gentle prompt on your computer system to ask the relevant questions during pregnancy and postnatal contacts?

I highly recommend the RCGP PMH Toolkit – over 400 resources, free to access even if you are not a member. It contains many useful links, and lots of Top Tip documents including a piece on medication use in the perinatal time, which is always an area GPs look for guidance:

http://www.rcgp.org.uk/clinical-and-research/toolkits/perinatal-mental-health-toolkit.aspx

Dr Carrie Ladd is a GP; she has spent the last 18 months as a Clinical Fellow supporting the Perinatal Mental Health RCGP Clinical Priority Programme.  @LaddCar