Presented by : SITI NUR SYAKINAH BINTI MD SABUDIN

Postpartum psychiatric disorder

a.Postpartum blue
b.Postpartum depression c.Postpartum psychosis

 Childbirth contributes a substantial risk to mental health of women. Antenatal period is not a particularly high risk time for the onset of new psychiatric diseases. Postpartum is more significant in which the risk to develop psychiatric disease is higher. Affects 17 out of every 1000 women 50% have mild depressive mood disturbance in first week of delivery 10-15 % develop postnatal depression 2% develop postpartum psychosis

 Also known as baby blues Occurs in 75% to 80% in women Duration: Occur within 2-3 days of delivery Symptoms peak on 4th or 5th postpartum day Symptoms resolve within 2 weeks (self-limiting) Risk Factors History of depression or premenstrual mood changes Depressive symptoms during pregnancy Concern about child care leads to stress Psychosocial impairment & lack of sleep

 Symptoms :
Fatigue, short temperedness, difficulty sleeping, depressed mood & tearfullness

Treatment :

INTRODUCTION DSM-IV - the onset of depressive symptoms within 4 weeks of childbirth. 10-15% women suffer with some form of depression in the first year after delivery of their baby insidious - first 3 postpartum months, although may have a more acute onset. more persistent and debilitating than postpartum blues. 50% higher risk of recurrent history of depression prior to pregnancy : risk 25 30% Without treatment, most women recover spontaneously within 3-6months 1/10 will remain depressed @ 1 year

RISK FACTORS :

Past history of psychiatric illness

Depression during pregnancy Obstetric factors (Caesarean, fetal/neonatal loss) Social isolation and deprivation Poor relationship

Recent adverse life events

Severe postnatal blues

SIGNS & SYMPTOMS Signs and symptoms are clinically indistinguishable from major depression that occurs in women at other times. Symptoms may include : depressed mood Tearfulness inability to enjoy pleasurable activities Insomnia Fatigue appetite disturbance suicidal thought recurrent thoughts of death.

WHAT HAPPEN?

No clear etiology Might probably due to combination of :

Genetic susceptibility
Hormonal changes Stressful life events

Screening
Edinburgh Postnatal Depression Scale 10 item questionnaire Each response scored 0 3, with total score of 30 possible Scores > 12 identify most women with postpartum depression

Diagnosis Exclude other causes.

DSM IV diagnosis criteria.

DIAGNOSIS : DSM IV-TR Criteria for major depression includes at least a two-week period of depressed mood or loss of interest in almost all normal activities and at least four other symptoms from the following:
changes in weight, insomnia feelings of guilt or worthlessness, difficulty in thinking, difficulty in concentrating or making decisions, decreased energy /psychomotor activity, recurrent thoughts of death , suicidal thoughts, ideation or attempts

occurring within 4 weeks of delivery.

MANAGEMENT Aim: complete normalization of mood and physiologic and social functioning Include :
Pharmacological rx- antidepressants SSRI- first line drug because it has low risk of toxic effects in patients who take an overdose, are easy to administer, and have been used relatively frequently in breast-feeding women Initiated at half dose, administered at least six months after full remission to prevent relapse. Non-pharmacological rx- social support, self help groups, psychotherapy

Referral to psychiatric care if there is intention to harm self or child

PREVENTION : Monitor for signs in high risk women Educate women and family members Counseling and increase social support prior to delivery

INTRODUCTION Very severe disorder - Affect between 1 in 500 and 1 in 1000 women after delivery. Most commonly present on the fifth post delivery, before 4 weeks (rarely before 3rd postpartum day) Onset abrupt The condition resembles a rapidly evolving manic episode with symptoms such as restlessness and insomnia, irritability, rapidly shifting depressed or elated mood, and disorganized behavior. The mother may have delusional beliefs that relate to the infant (eg, baby is defective or dying, infant is Satan or God), or she may have auditory hallucinations that instruct her to harm herself or her infant. Risks for infanticide and suicide are high among women with this disorder 4 %

RISK FACTORS : Previous history of postpartum psychosis History of mood disorders, particularly major depression

and bipolar disorder

Family history (1st and 2nd degree relative) of bipolar disorder/affective psychosis.

SYMPTOMS :
Restless agitation Insomnia Perplexity Confusion Fear and suspicion Delusion Hallucination Failure to eat and drinks Thought of self-harm Depressive symptoms Loss of insight

MANAGEMENT :

Patient should be referred urgently to a psychiatrist.

Suicidal precautions if presence of suicidal ideation. Do not leave the infant alone with the mother if she has delusions or ruminates about infants health. With any psychotic disorder, must ruled out first general medication and substance abuse that cause psychotic symptoms. Admission to psychiatric unit - mother and baby unit with 24 hour under supervision

 Pharmacological treatment Affective disorder: mood stabilizer/ antidepressents Schizophrenia: antipsychotics

Role of ECT: best treatment for depressive disorder of moderate severity

Rapid effects- enable mom to resume care of baby

Treatment within 1 month delivery- more favourable outcome

Less likely to suffer long-term disability(13%) Treatment after one month- long-term disability(33%)

 A good majority of Muslims tend to believe that the Islamic perspective on mental illness is due to a lack of faith, punishment, or my all-time favorite, demon possession! A lot of Muslim women dont want to admit to any of the symptoms of a perinatal mood or anxiety disorder, thinking it means they are not committed enough to God, etc. Its important to understand how Islam views mental illness in general. Many of Islams greatest scholars and physicians were among the first to view mental illness as actual medical conditions. And this was at a time when most of the world opted to view mental illness as evidence of demonic possession. In fact, two Muslim giants made some of the greatest contributions to the field of psychiatry at the time: with Avicenna/Ibn Sina (considered the father of modern medicine) including mental illnesses in his Canon of Medicine and Rhazes/al Razi being the first to open a psychiatric ward.

 Based on the view that mental disorders were medical conditions, patients were treated not only humanely and compassionately but also using psychotherapy and drug treatments. All this should be ample proof that in Islam, mental disorders are considered as illnesses that warrant medical attention and treatment, including medication, if prescribed. In fact, taking medication and treating ourselves via experts is an important Islamic teaching. The Prophet Muhammad (peace be upon him), is reported to have said, Treat yourself through medications, for God has sent down a cure even as He has sent down the disease. All this being said, one should supplement treatment for

 Obstetrics By Ten Teachers, 18th Edition DSM IV-TR Williams Obstetric, 22nd edition, Cunningham F G Psychiatry Oxford Core Text, 3rd edition, Gelder M Wisner et al, Postpartum depression, NEMJ 2002 vol. 347, no. 2 pg. 194-199