Mothers - Prison Mental Health

Between 10 and 15% of women become depressed in the year following delivery of an infant. (ref 1) Women at higher risk include those with a previous history of depression (especially postnatal depression), who had psychological problems during pregnancy, lack social support or someone to confide in, have marital problems, have had a recent negative life event (eg bereavement), have lost their own mother when young or are ambivalent about the pregnancy. (ref 2)

References

1 O’Hara MW, Swain AM. Rates and risks of postpartum depression: a meta-analysis. International Review of Psychiatry 1996; 8: 37-54.

2 Kumar R. Postnatal mental illness: a transcultural perspective. Social Psychiatry and Psychiatric Epidemiology 1994; 29: 250-264.

Diagnostic features

There is usually a gradual onset, usually within 6 weeks of delivery, some within 6 months, and occasionally within 12 months.

Low mood and/or loss of interest and pleasure (including lack of pleasure in the baby) for most of the day for at least 2 weeks plus four of the following items.

Sleep disturbance.
Appetite disturbance.
Frequent tearfulness.
Tiredness and poor concentration.
Feelings of guilt or worthlessness.
Agitated behaviour (eg pacing).
Slowing of movement or speech.
Suicidal thoughts.
Increased irritability and aggression.

The following symptoms are also common.

Anxiety and/or panic, eg being afraid to be alone with the baby, having constant worries about the baby’s health, having fears about losing the baby.
Fear of having a heart attack or of going mad.

The more severe the depression, usually the greater number of symptoms and (most importantly) the greater the degree of interference with normal social or occupational functioning. Biological symptoms are more common in more severe depression.

The Edinburgh scale should be used in routine clinics, eg 6-week baby check, to screen for postnatal depression. However, this does not give an accurate assessment of severity. Women at a high risk of postnatal depression often score about 12, but clinical impression is more important and any positive score on the item relating to suicidal thoughts should be taken seriously.

Differential diagnosis

Maternity/baby blues: symptoms of weepiness, unusual emotional sensitivity, crying spells, mood swings, insomnia, a feeling of rejection by carers occur around days 3-5 and resolve within a few days. Maternity blues are common and 50-80% of women experience them. Treat the symptoms with reassurance, sleep and arranging short-term support in caring practically for her baby.
Panic disorder.
Alcohol misuse or Drug-use disorder. If heavy alcohol or drug use is present. Substance misuse may cause or increase depressive symptoms. It may also mask underlying depression (see Comorbidity).
Puerperal psychosis where delusions and, less commonly, hallucinations occur.
Chronic mixed anxiety and depression.
Delayed maternal response (see Problems of the mother-baby relationship).

Some medications may produce symptoms of depression. These include beta-blockers, other antihypertensives, H2-blockers, oral contraceptives and corticosteroids.

Comorbidity

Depression frequently coexists with anxiety and panic, unexplained physical complaints and problems in the mother-baby relationship (such as delayed maternal response). Specific treatments are indicated for each set of problems. See the relevant guidelines.

Essential information for the patient and the primary support group

Feelings of helplessness, hopelessness, anxiety and emotional swings are all symptoms of the illness. They do not mean that you are going mad. Postnatal depression is very common and anyone can get it.
Learning to care for a new baby is hard and tiring work. Mothering takes time to learn. Practical help is needed.
Not feeling the way you expected to towards the baby. This does not make you a bad mother, nor does it mean that you will harm your baby.
You will get better, but it may take time. Arrangements must be made for you to be supported until you have recovered. There are several different treatments that may speed your recovery.
The illness may recur in subsequent pregnancies.
Asking for and accepting help with the depression will increase the chances of the baby being allowed to stay in the MBU. Babies are only separated from their mothers if there is imminent risk to the baby or if, for health reasons, the mother can no longer look after the baby.

Advice and support for the patient

For advice on management, including suicide risk assessment, see the Depression guideline. In addition:

Assess the risk of harm to the baby: ask: How do you feel about the baby? Have you had any unusual thoughts? Have you been worried that harm might come to your baby, or even that you might harm him/her?:
– If there are signs of harmful intent towards the baby, involve the mental-health services and the liaison social worker, following the prison child-protection procedures. Consider transfer to an in-patient unit, preferably one with an MBU.
– Where there is no sign of harmful intent to the baby but the depression is chronic and the mother cannot meet the baby’s emotional needs (eg the baby appears flat and avoids eye contact with his/her mother), treat the depression and involve the social services. Involving the liaison social worker should be seen as a way of obtaining additional support for the mother and baby.
– Be aware that if the mother is admitted to the prison healthcare centre or an NHS hospital, arrangements will be made to hand her child to outside carers, except where the NHS hospital has an MBU.
Encourage steps to get more sleep, eg rest during the day as much as possible; learn the art of cat napping.
Encourage the woman to find some time for herself, eg 30 minutes for an uninterrupted bath.
Encourage the woman to eat regularly even if she does not feel like it and to aim for a balanced diet including plentiful fluids. (ref 1) This is not the time to try and lose weight. If appropriate, advise a reduction in caffeine intake. (ref 2)
Identify someone the patient can confide in. Encourage her to seek practical and emotional help from others. Inform her about the role and availability of the prison healthcare team, the health visitor and any other support available. Support her in obtaining additional telephone calls to family and friends outside. If appropriate, discuss support for a possible application for a temporary licence (see also Types of release on licence). Give her a copy of Coping with Depression.

After improvement, plan with the patient the action to be taken if signs of relapse occur. As psychiatric morbidity remains high during the second postpartum year, regular follow-up and monitoring should continue.

References

1 Wallin M, Rissanen A. Food and mood: relationship between food, serotonin and affective disorders. Acta Psychiatrica Scandinavica 1994; 377 (Suppl): 36-40. (CV)

2 Greden JF. Anxiety or caffeinism: a diagnosis dilemma. American Journal of Psychiatry 1974; 131: 1089-1092. (AV)

Liaison and advice for the health visitor, MBU staff and other carers

Ask the mother’s permission to discuss the following with the other staff caring for her. Inform her that you will only do this with her permission, except where there is a risk of harm to herself or others.

Inform them of the outcome of the assessment of risk to the mother herself or the baby and discuss risk management, including the level of monitoring required. Discuss the location, including a shared room, if possible.
The support of staff and family is an important element of treatment. Support to depressed women by caregivers may help the depression resolve more quickly. (ref 1) Discuss increasing the level of practical support to the mother, eg help with feeding and bathing the baby, institute a routine, arrange a break from the baby to allow sleep.
Discuss ways they can support the mother (eg helping her break routine tasks down into manageable bits, praising her when she completes even a small task, avoiding additional stresses). Give them a copy of Working with Mothers and Babies: The Psychological Aspects.
Inform staff of the likely impact of the illness on the mother’s functioning (eg irritability and aggression can cause an increase in arguments between the mother and carers, and between the mother and their partner and family during visits). If possible, explain this to the patient’s partner or family and encourage their additional patience and support for the mother.

References

1 Ray KL, Hodnett ED. Caregiver support for postpartum depression. Cochrane Library, Oxford 1998, issue 3. Update software.

Psychological treatments

Psychological treatments, where available, are often preferred to medication by women. Such therapy allows the woman to review her relationship with her baby, partner and family. The best evidence of effectiveness in the treatment of depression is available for cognitive-behavioural therapy and interpersonal therapy. (ref 1) Marital/couple and family therapy may have a particular role where there are problems in these relationships. (ref 2) Person-centred counselling by specially trained health visitors (ref 3) and psychodynamic psychotherapy (ref 4) may also be useful.

Professional and/or social support may also help postpartum depression. (ref 5) Parenting-training programmes may be helpful for mothers with mild depression or those recovering from more severe depression. (ref 6) Patients with chronic, relapsing depression may benefit more from cognitive-behavioural therapy (CBT) or a combination of CBT and antidepressants than from medication alone. (ref 7,8)

References

1 Department of Health. Treatment Choice in Psychological Therapies and Counselling. London: Department of Health, 2001.

2 Sandberg JG, Johnson LN, Dermer SB et al. Demonstrated efficacy of models of marriage and family therapy: an update of Gurman, Kniskern and Pinsof’s chart. American Journal of Family Therapy 1997; 25: 121-137.

3 Holden JM, Sagovsky R, Cox JL. Counselling in a general practice setting: controlled study of health visitors’ intervention in treatment of postnatal depression. British Medical Journal 1989; 298: 223-226.

4 Murray L, Cooper PJ (eds). Postpartum Depression and Child Development. London: Guildford, 1997.

5 Ray KL, Hodnett ED. Caregiver support for postpartum depression. Cochrane Library, Oxford 1998, issue 3. Update software.

6 Barlow J, Coren E. Parent-training programmes for improving maternal psychosocial health. Cochrane Library, Oxford 2001, issue 1. Update software. States that parenting programmes may make a substantial contribution to the improvement of maternal psychosocial health. However, further research is required to identify whether this is so, irrespective of the level of pathology present in the mother.

7 Thase M, Greenhouse J, Frank E et al. Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapy combinations. Archives of General Psychiatry 1997; 54: 1009-1015.

8 Evans M, Hollins S, De Rubeis R et al. Differential relapse following cognitive therapy and pharmacotherapy of depression. Archives of General Psychiatry 1992; 49: 802-808.

Medication

For advice about prescribing for depression, see the Depression guideline. In addition, check thyroid function and treat it if found to be abnormal. (ref 1)

Choice of medication

In general, non-sedating antidepressants (a tricyclic such as lofepramine or a selective serotonin re-uptake inhibitor [SSRI]) are preferred, especially if the mother is breast-feeding. If the woman cannot sleep, a sedative tricyclic (eg trazodone) may be used. If this is not sufficient, consider the use of hypnotics in the short-term, except where breast-feeding. If either type of sedating drug is used, provision must be made for adequate supervision of the baby.

References

1 Harris B, Othman S, Davis JA et al. Association between postpartum thyroid dysfunction and thyroid antibodies and depression. British Medical Journal 1992; 305: 152-156.

If the patient is breast-feeding

Decisions about safety are difficult: all psychotropic drugs pass into breast milk, and while concentrations are normally much lower than those that pass through the placenta during pregnancy, infants are poor metabolisers of drugs.
All drugs should be avoided if the infant is premature or has renal, hepatic, cardiac or neurological impairment. The infant’s renal and hepatic function should be checked before it is breast-fed by a mother who has been prescribed psychotropic medication.
In general, older drugs are preferred, as more is known about their effects on the baby. (ref 1) Prefer tricyclic antidepressants (TCAs) (except doxepin). If SSRIs used, prefer those with short half-lives. Avoid monoamine oxidase inhibitors (MAOIs) and lithium.
It is best to avoid sedating drugs and those with long half-lives.
Avoid polypharmacy.
If possible, give the drug as a single daily dose before the infant’s longest sleep period. Breast-feeding should occur immediately before the dose is due. If possible, avoid breast-feeding when drug concentrations peak in milk where this is known (eg amitriptyline 1.5 hours, imipramine 1 hour).
Monitor the infant for adverse effects, eg sedation, irritability. If these occur, take appropriate action (eg dose reduction, drug change, referral for advice).
Treat the mother with the lowest effective dose as adverse effects in the infant are often dose-related.

References

1 Yoshida K, Kumar R. Breastfeeding and psychotropic drugs. International Review of Psychiatry 1996; 8: 117-124, as quoted in World Psychiatric Association. Depressive Disorders in Physical Illness. New York: NCM Publications, 1998.

Referral

Refer for weekly listening visits by a specially trained health visitor if the depression is mild and there is no significant suicide risk. (ref 1) Referral to the secondary mental-health services is advised:

as an emergency if there is a significant risk of suicide or danger to the baby, or if there are psychotic symptoms, severe agitation or retardation with impaired food/fluid intake or
as a non-emergency if:
– significant depression persists despite treatment in primary care. Antidepressant therapy has failed if the patient remains symptomatic after a full course of treatment at an adequate dosage. If there is no clear improvement with the first drug, it should be changed to another class of drug
– there is a history of severe depression, especially of bipolar disorder.

If drug or alcohol misuse is also a problem, see the guidelines for these disorders. If the mother has used alcohol or drugs during pregnancy, the baby will require close monitoring physically. There is increased risk of foetal alcohol syndrome, neonatal withdrawal syndrome and low birth weight. Problematic alcohol or drug use after pregnancy may reduce the parent’s ability to provide adequate care for the infant due to unpredictable, inconsistent and ineffective patterns of behaviour.

Involve non-healthcare support (eg chaplain, counsellor, voluntary support group) in all other cases where symptoms persist, where the patient has a poor or non-existent support network, or where social or relationship problems are contributing to the depression. (ref 2)

Severely depressed adolescents are difficult to assess and manage, and referral is recommended.

Throughcare and prerelease planning should include advice on services available to support mothers who have psychological problems and their babies (such as Homestart and Newpin, see below), as well as close liaison with medical and socialcare staff in the community (for more details, see Managing the interface with the NHS and other agencies).

References

1 Holden JM, Sagovsky R, Cox JL. Counselling in a general practice setting: controlled study of health visitors’ intervention in treatment of postnatal depression. British Medical Journal 1989; 298: 223-226.

2 Ostler KJ, Thompson C, Kinmonth ALK et al. Influence of socio-economic deprivation on the prevalence and outcome of depression in primary care: the Hampshire Depression Project. British Journal of Psychiatry 2001; 178:12-17.