Motivation and emotion/Book/2017/Perinatal depression

Overview
Pregnancy is often associated with being a joyful and happy time for the parents and families involved. As well as a woman's physical health, her mental health should be a pivotal aspect that is cared for during this maternal period. Research from around the world has identified that one in ten women experience symptoms of depression during pregnancy and one in seven women continue to experience depression one year after giving birth (post-partum). One in five women are also found to experience an anxiety disorder during this time with its comorbidity with depression being very high. These statistics are alarmingly high and often these mental health conditions go undetected during the perinatal period. This subsequently causes distress on the mother, her family and her baby.

The Perinatal Period & Depression
The perinatal period is the time between conception through to the end of the first postnatal year. This includes both the antenatal (Pre birth) and postnatal (Post birth) periods. This period is often stereotyped as being one of the happiest times for a woman and her family. However, this period is notorious for having an increased risk for onset and relapse of mental health conditions. The risk of this occuring is higher during this time than at any other time in a woman's life. Detection of depression and other mental health condition's is poor during this time due to an absence of a normal routine and no standardised screening. This has resulted in up to three quarters of women who meet the DSM 5 criteria go undetected (Spitzer et al 2000).

The DSM 5 includes 6 separate depressive disorders. These are known as disruptive mood dysregulation disorder (common in children), persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication induced depressive disorder, unspecified depressive disorder and major depressive disorder. Although these disorders have the potential to be diagnosed during the perinatal period, major depressive disorder is the most known diagnosis for this time. According to the DSM 5, Major depressive disorder is diagnosed when "five or more of the following symptoms have been present during the same 2-week period and represent a change from previous function; at least of one of the symptoms is either depressive mood or loss of interest or pleasure." (DSM V, pp. 160-161)
 * 1) Depressed mood
 * 2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day
 * 3) Significant weight loss when not dieting or weight gain
 * 4) Insomnia or hypersomnia nearly every day
 * 5) Psychomotor agitation or retardation nearly every day
 * 6) Fatigue or loss of energy nearly every day
 * 7) Feelings of worthlessness or excessive or inappropriate guilt
 * 8) Diminished ability to think or concentrate or indecisiveness, nearly everyday
 * 9) Recurrent thoughts of death, recurrent suicidal ideation without specific plan or a suicide attempt or a specific plan for committing suicide

It is important to note that along with one in 10 women experiencing depression during the perinatal period. Between 50% and 80% of new mothers will experience a mild form of depression which is not formally diagnosed, instead it is commonly referred to as "postpartum blues". This includes temporary mood swings and episodes of major depressive disorder. Symptoms for the post-partum blues can start to occur several weeks prior to delivery and usually diminish within four weeks of giving birth. These episodic cases are not as severe as ongoing depression during the perinatal period, although they are still are significant statistics to note during this time.

Who is at Risk?
Every woman in different in their own situation and considerations of their own emotional and social contributors are taken into account when determining the risk of depression during their maternal time. While many Australian women have the luxury of obtaining an education, have financial security and maintain reasonable health, many other women find themselves living under circumstances harder for one to be able to bring a baby into the world. Women are living in poverty, surviving on low-income pensions or low-income occupations, restricted by under-employment and experiencing poor health (Guidelines, 2017)

Some groups of women have significant stressors, trauma or lack of support in their lives, which put them at a higher risk of depression. These factors need to be considered when psychologically assessing a woman for a diagnosis of depression during this time. This will lead to an enhanced understanding the women’s situation.

Aboriginal & Torres Strait Islander
In 2013, Aboriginal and Torres Strait Islanders reported that they had experienced a death of a family member or close friend, serious illness, mental health conditions or alcohol related problems. A study conducted in South Australia found that one in four aboriginal and Torres Strait Islander women experience high to very high psychological distress during the first 12 months post partum (Weetra et al 2016).

Migrant Women
Refugees and asylum seekers experience higher rates of perinatal depression over their non migrant counter parts (Guidelines, 2017). The significance of social isolation and cultural barriers can pose hardship for new mothers (Guidelines, 2017).

Women Experiencing Intimate Partner Violence
Women in domestic violent households or relationships are deemed four times more likely to experience depressive symptoms during pregnancy. Two in five women are reported to experience depressive symptoms postpartum (Woolhouse et al 2012). Along with aboriginal and torres strait islander women, one in two women who report domestic violence with their intimate partner resulted in high to very high psychological distress throughout the perinatal period.

Lesbian, Gay, bisexual, Transexual & Intersexual Parents
Parents who belong to the LGBTI community experience discrimination and have their morals, methods and abilities to parent are questioned. Subsequently causing depressed emotions related to their perinatal period.

Prevalence
Symptoms of depression during the perinatal period are no different to depression at any other times, which range from mild to severe. In Australia, reports of a 4-year period prevalence of depression during the antenatal period are one in ten women. Twelve-month postnatal prevalence of depression is one in six women (Woolhouse et al 2012).

Screening & Psychosocial Assessment
Key factors are taken into consideration before a screening and psychosocial assessments are undertaken. First of all, systems for follow up and support are taken into account to ensure that the appropriate health professions are available to provide the necessary follow up care if required (Guidelines, 2017). Follow up procedure are usually in place when the health professionals believes that there are safety concerns for the woman, foetus, infant or other children in the woman's care.

When the assessment is taking place, who is there, is a very important component that needs a lot of consideration. Women need to feel safe and at ease during an assessment which can be a daunting process. While the attendance of significant family and friends is often helpful, usually it is not appropriate for some to be in the room due to its sensitivity. It is important for the mother to have the support she wishes in the room with her.

Informed consent is needed for the assessment to take place. A full explanation of the process of the assessment as well as results remaining confidential is to be provided.

Follow up screenings are to take place and ongoing care and support

Care Plan
When professionals are setting out a care plan for a woman with depression in the perinatal period, it is important that the treatments are established. Along with a monitoring schedule for the treatments and regular therapy the health professional will need to provide interventions when needed (NICE, 2015).

Treatment
Pharmalogical treatments are usually the first to be tried for treatment of depression. Once the medication has been perceived to take a positive effect, psychological therapies begin to take. This has been known to be an effective style of treatment for many women (Guidelines, 2017). However, before this can happen, many options need to be considered for what is going to be the best fit for the individual mother.
 * Treatment benefits for individual cases especially taking into account the more severe cases
 * A woman's response to any previous treatment she may have received
 * The potential for risk of relapse (for drug abusing mothers) caused by pregnancy and child birth
 * How treatment may affect parenting
 * The risk of harming the fetus, baby or mother with treatment
 * The risk of sudden onset or relapse of mental health conditions.

Antidepressants
During pregnancy the effects of antidepressants are not seen to have a different effect on a woman if she weren't pregnant. Antidepressants have high quality RCT evidence on the efficacy of them (Guidelines, 2017). The evidence to suggest that there is a risk to the fetus by using medications is very poor (Guidelines, 2017). Research conducted in the first trimester of pregnancy found the use of selective serotonin reuptake inhibitors (SSRIs) or Tricyclic antidepressants are not linked with any risk to:
 * neonatal mortality (Ban et al 2012),
 * major or cardiac malformations (Margulis et al 2013)
 * too small for gestational age (Oberlander et al 2006)
 * miscarriage (Ban et al, 2012)

Other effective forms of treatment

 * Integrating physical activity into their daily lives such as yoga, walking and light jogs  (Guideline, 2017)
 * Structured Psychoeducation will help to improve symptoms  (NICE, 2015)
 * MindfuInl based cognitive therapy for women with a high risk and history of depression, but who aren’t currently depressed is an effective form of prevention (Dimidjian et al, 2016)
 * Involvement in social groups
 * Individual structured psychological interventions such at CBT or IPT
 * Directive counseling
 * On call telephone support

What about Dad?
A lot of the time when referring to perinatal depression, people often forget to think about how dad is going during this time of change. One in twenty dads experience depression during theirs partners pregnancy and one in ten dads struggle with depression following birth (PANDA, 2017). Dads feel the constant pressure of being the "man of the house" and holding it together for their family, when most of the time they are struggling with the new changes.

Symptoms in Men
The following list has been extracted from the PANDA website:
 * Constant tiredness or exhaustion
 * Ongoing headache. High physical stress levels e.g. muscle tension
 * Loss of interest in things that were once enjoyed
 * Changes in appetite
 * Sleep problems (unrelated to baby’s sleep)
 * Ongoing irritability, anger or moodiness
 * Emotional withdrawal from your partner, baby, family, friends
 * Fear of looking after your baby
 * Not wanting to communicate with your partner, family and friends
 * Feeling isolated
 * Using alcohol or drugs to ‘escape’ or cope
 * Suicide thoughts.

As well as the contributing factors for depression that are considered for women, the following is a list of contributing factors of depression for men.

This list has ben extracted from PANDA 2017
 * Family or personal history of anxiety or depression
 * Partner is struggling with perinatal depression
 * Stressful life events
 * A troubled pregnancy
 * Infertility or previous pregnancy loss
 * Lack of social support
 * Financial difficulties