Management

1
Management

• After Screening comes assessment, before
  management!

2
Mental State Examination

• ABC, APC-MOAT, IJIR
• Appearance
• Behaviour
• Conversation
• Affect
• Perceptions
• Cognition- memory, orientation time, place
  person
• attention, thoughts
• Insight
• Judgement
• Intelligence
• Rapport

3
MSE- Quick Version

• Looks like/Acts like
• Sounds like
• Feels like
• Perceives like
• Thinks like
• And makes ME feelworried, concerned, OK,
• helpful, helpless, confused, angry
• NB some women go to great lengths to present well
  despite terrible feelings of depression and
  despair

4
Risk Assessment-Suicide

• Questions
• Do you ever feel so bad that you feel life is not
  worth living? Plans? Recently? When? In what
  context, how often? What would influence you to
  do it? What would stop you?
• History of impulsiveness - ever tried to harm
  yourself on the spur of the moment or in reaction
  to an event? Ask for details.

5
Risk Assessment- Suicide

• Questions
• Substance use what, how often, how does it
  effect your mood, thinking, behaviour, impulse
  control?
• Ever tried to harm self whilst under the
  influence of a substance? Details.

6
Risk Assessment- Infanticide

• Ever had negative thoughts about harming your
  baby?
• Plans? Actions? Details (antenatal and postnatal)
• Ever felt like losing control with your
  baby-when, how often, stressors, what did you do,
  strategies to manage the situation
• How disturbed are you by these thoughts? (no
  guilt or disturbance probablypsychosis)
• sense of guilt risk of suicidal thoughts

7
General principles

• BIO-PSYCHO-SOCIAL
• Varies depending on diagnosis, severity
• Support systems crucial
• Education
• Involve others
• Beware Dual diagnosis (Substances)

8
Management- Biological

• Ensure appropriate physical examination
• Investigations- TFTs, Hb
• Medications

9
Medications

• ALWAYS RISK- BENEFIT ANALYSIS
• No drugs can be said to be completely safe.
  However the effects of illness on mother and
  infant must be considered when thinking of the
  problems of medications in either pregnancy
  and/or breastfeeding

10
Medications

• Views change over time as to what is safe and
  what medications are available
• Important therefore to keep in touch frequently
  either through relevant hospital pharmacy or
  literature or a website eg motherisk.com
  (Canadian site very good)

11
Medications Mood Stabilizers

• Sodium valproate never use in first trimester,
  neural tube defects 5-9, breastfeeding OK. More
  info now re ongoing problems in later pregnancy.
• Lithium Ebsteins anomaly 1/1000, care in
  labour, ??use in breastfeeding
• Carbamazepine rarely use in first trimester
• Lamotrigine currently considered less
  teratogenic but beware Stevens-Johnson

12
Medications antidepressants

• SSRIs variable press and new problems emerging
  eg. pulmonary hypertension in infants whose
  mothers used in later pregnancy, neonatal
  behavioural syndrome.
• Mirtazapine less info possibly OK
• Venlafaxine possibly problems. Unclear
• Reboxetine little information
• TCAs probably OK for foetus and infant but
  beware risks of fatal o/d in mother

13
Neonatal Behavioural Syndrome

• Most reports fluoxetine, paroxetine.
• Poor neonatal adaptation
• CNS, Gastrointestinal, motor, respiratory signs
• Self-limiting, usually up to 2 weeks
• Supportive care
• Special care nursery
• No neonatal deaths reported

14
Neonatal Behavioural Syndrome

• Irritability
• Hypertonia
• Jitteriness
• Trouble feeding
• Tremor
• Agitation
• Seizures
• Tachypnoea

15
Antipsychotics

• SGAs Quetiapine, risperidone (NB Consta),
  olanzapine relatively little published
  possibly acceptable but minimize doses by
  alternating with benzos
• Older antipsychotics chlorpromazine,
  pericyazine, trifluperazine, haloperidol etc
  used over many years and still have a significant
  place

16
Antipsychotics

• No teratogenic effects found
• Reports of increased birth defects in untreated
  psychosis
• Atypicals should be safer
• Risk to mother and infant of untreated disease is
  major consideration

17
Sedatives

• Benzodiazepines Said to have some problems so
  use sparingly but certainly have a place in
  severe illness
• for anxiety eg lorazepam
• for nocturnal sedation eg. temazepam ?zolpidem
• use near term can affect infant
• withdrawal syndromes with chronic use

18
ECT (electroconvulsive therapy

• Very good results in puerperal psychosis
• Can be used antenatally provided obstetric
  monitoring and facilities close by appropriate
  anaesthetic
• Same problems as in use elsewhere eg. memory
  loss, headaches, confusion, stigma

19
Psychological

• CBT
• ITP
• PTSD counselling
• Eclectic
• psychodynamic

20
BATHE Technique

• BATHE simple straightforward support
• Can you tell me the Background
• How does this Affect you?
• What Troubles you the most?
• How are you Handling this?
• Empathy

21
Social - 1. Therapies

• Systems eg. couples, mother-infant, triadic,
  family with family of origin
• Group eg. PND groups, others
• Women and families very open to change at the
  time they have an infant for the sake of the
  baby

22
Social - 2. Community supports

• Multiple agency support maternal-child health
  nurses, GP, psychologists and psychiatrists,
  NGOs, CAMHS, child protection services
  (frequently involved in severe mental illness),
  Drug and Alcohol services, etc

23
Social - 3. Community normalisation

• First time mothers groups (not a good idea for
  some as they compare themselves unfavourably)
• Appropriate community groups eg. crafts, sports,
  physical fitness generally, study, etc.
• Involving family of origin where possible in both
  emotional and practical support, and friends

24
Cultural

• Cultural awareness
• Appropriate interpreters
• Many cultural groups eg. Vietnamese womens group
  etc.

25
5 Key Messages from women

• 1. Give Hope
• 2. Validate
• 3. Education
• 4. Be Available
• 5. Positive parenting

26
Give Hope

• Hang in there, things will get better
• This will pass and you will recover
• One day at a time
• Be kind to yourself and look for the positives

27
Validate

• Its not your fault
• You are good enough
• You are not alone
• Its no wonder you are going through this
  when..Blah, Blah
• Time out - childcare etc.
• Get out of the house

28
Education

• Destigmatise the role of medication
• Information and statistics about PND
• Normalise the experience
• Direct to further help
• Groups, websites

29
Be Available

• If you need to talk come and see me
• You are not wasting the GPs time
• I am here for you
• Who (if not you) will be available if I need
  support?

30
Positive parenting

• Fake it until you make it
• Persevere with bonding with your child- eye
  contact
• Get more help with your baby - time out - put
  baby in childcare etc.