Episode 30 Maternal Mental Health: Recognizing and Managing Depression & Anxiety

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Hello, I'm Professor Anne Buist, Professor of Women's Mental Health and I've worked for the last 35 years in perinatal psychiatry. I'm based at the Austin where we also have an inpatient mother-baby unit or in fact parent-infant unit. I'm going to talk primarily about anxiety and depression.

This is really common in the perinatal population and part of working with this group in the obstetric field is making sense of whether this anxiety and depression is within normal limits or it's clinical and needs further assessment and treatment.

Anxiety in pregnancy and in the postnatal period can have a significant effect on the child. In pregnancy, high levels of cortisol in anxious women have shown to increase the risk factors for the baby being born with altered stress responses, which are probably a flag for later increased risk of the child developing anxiety and depression.

We also know from research that someone with anxiety and depression in those early postnatal months can significantly affect attachment, which also can have an ongoing effect for the child in their later risk for anxiety and depression, as well as difficulties in relationships. So this is an important area and important to assess early, to reassess when necessary and to treat assertively.

As I have said, anxiety is common. Most women are anxious at some level in pregnancy because there's a deluge of information. Most mums want to be the best parent they can be. And it's very hard to make sense of the information they're provided and just the anxiety of avoiding foods, certain foods. And then if they've suddenly realised they've had something that was not on the list, the anxiety that causes, often way out of proportion, for instance, for the risk of actually getting listeria and having negative outcomes from it.

So the factors in there for anxiety are in there early and tend to increase with the amount of information that people are provided and indeed go home with when they're discharged from hospital after usually a very brief time in hospital. It's the first time for many women to be actually admitted to hospital have very little idea of what the risk factors are, of the potential problems. And there's a balance of this, of giving them that information and preparing without increasing their risk of anxiety unnecessarily.

First thing to do is try and make sense of, are they particularly at risk? What risk factors do they have for anxiety and depression? The women you're going to particularly want to watch are those who have previous history or are currently being treated for either anxiety and depression.

Next are the group who have a family history of anxiety, depression or other mental health problems, particularly bipolar and suicide. For those who have a family history of bipolar or suicide, these are the group you're going to want to watch particularly closely in that first postnatal month or particularly the first postnatal day, week and then month for risk of postpartum psychosis, which occurs in one in 600 births.

They're far less common, of course, than anxiety and depression, but you don't want to miss them because they are the ones that are at potential risk of suicide and their babies may also be at risk more acutely.

But much more commonly are those with anxiety and depression. And the risk factors, the next risk factors for them is what levels of support do they have? Is there a partner? Was this baby wanted?

Is there any physical complications with the pregnancy that are going to add to that anxiety? And are there other people that can support them postnatally, such as parents or parents-in-law? What sort of childhood did this mum have?

Childhood abuse and neglect increase the risk for difficulties in the perinatal period. There's going to be a lack of role model for what good parenting is, but also there may be less likelihood to have a parent that's there supportive, but also it can have had an effect on the women themselves with an increased risk through that abuse of them having difficulties in relationships and with increased risk of anxiety and depression. The biggest risk is going to be in the third trimester and that first postnatal months when sleep deprivation is going to be another trigger.

Reassess, re-ask questions, make sense of how they're managing each phase of the pregnancy and the early phase of breastfeeding. Lactation is often a source of great anxiety. How are they managing that? Are they getting reassured by the lactation consultant? Are they able to then put it in perspective or is their anxiety escalating? Are they able to get back to sleep after their baby has woken them?

Obviously, sleep disturbance is really common postnatally. It's normal, but women without significant depression and anxiety can generally get back to sleep. So you're going to be particularly interested in those who are not able to get back to sleep. What is their mood like? Did they have the baby blues and then recover from that or has it continued? Have they continued to feel a bit low, worry that they're not a good mother, worry about the health of the baby?

These worries are really excessive and very much preoccupying them. I would suggest a psychiatric assessment in case it's a presentation of postpartum psychosis that looks more like severe anxiety but is in fact psychosis. But the normal anxiety can be reassured, but there's this low grade, ongoing, just not feeling back to normal, constant worry, not sleeping well. They may have some obsessions and worrying about health, worrying about cleanliness. They may have some panic attacks. Ask about all of those and make a sense of if there's something that is really disabling them every day. And if so, probably need to see a general practitioner, maybe a referral to a psychologist.

I've put in the references three online organizations, and this can include online groups. Maternal child health nurses are a great source of support. The enhanced service can do home visits, but they also provide mothers groups for peer support.

But in many cases, there are also options for support groups that are more orientated towards depression and anxiety, and groups like Panda can do one-to-one counselling over the phone. If this is ongoing, there's also, of course, inpatient options.

In Victoria, we are particularly well off for mother-baby units. There are three mother-baby or parent-infant units that cover the metropolitan area, one at Werribee for the West, the Northeast covered by the Austin, and Monash for the South and Southeast. But then we also have some in regional areas, in Traralgon, in Bendigo, and these are also able, oh, and Ballarat, are able to look at the regional women and have inpatient care for them.

So whilst most people don't need inpatient care, most people, reassurance, groups, support for their sleep deprivation, whether that's a mother-in-law or mother caring for baby during the day so they can catch up and sleep, or a husband at nighttime doing some feeds, maybe with some sleeping tablets involved for a night or two, most are going to be able to be managed with that. Next step would be seeing a psychologist, and the mother-infant unit or parent-infant unit would be the final sort of suggestion for management.

Sometimes these women don't present till three to six months postnatally. They've kind of managed, they've got through it, they've felt that they were doing okay, they understood that they were going to have some problems for a while, but that the ongoing issues have finally caught up with them and they've realized their peer group are getting on with things and they are not.

So re-ask, reassess, and make sense of where they are. For a small number of women, and particularly that group who have had childhood abuse or neglect issues, that there may need some extra help with attachment, and there are particularly groups for attachment once the depression and anxiety has been treated. The most common of these is Circle of Security, and a number of maternal child health nurses run these, and a number of individual psychologists and mother-infant therapists also work in this sphere.

So my final message to you is don't forget to ask about risk factors in pregnancy. Don't forget to re-ask about anxiety and depression and how people are managing, and treat assertively, whether that's with a general practitioner, psychology, or psychiatry, and with a possible inpatient.

One more final thing is a number of women, of course, will be concerned about taking medication if they're lactating or pregnant, and I would suggest getting up-to-date online information about this.

But as a general rule, most of medication will go through the placenta and also through breast milk. But in general, at low to average doses, antidepressants and anxiety medication appear to be safe. And certainly, when weighing up the risk factors of untreated depression and anxiety versus medication in breast milk or across the placenta, then general practice is the treatment is the most important thing.

So don't forget anxiety and depression, and help your women to have the best pregnancy and the best experience they possibly can.