History
A 28-year-old mother of a 2-month-old baby boy attends the GP surgery having been referred by her health visitor as she had become concerned about the safety of the baby following a routine postnatal check up. The mother says that she is finding it difficult to cope with the baby and sometimes has had thoughts that it would have been better if the baby was dead. She has feelings of guilt about having such thoughts and believes that she is not a good mother. The baby was born at full term via a normal vaginal delivery. The labour lasted 18 hours and there were no other complications. She reported feeling low and tearful during the first week post-partum but said that her mood improved within a few days. However, over the past 6 weeks, she describes feeling low and tired all the time. She complains of low energy levels, poor concentration and does not enjoy looking after her son as much as she did in the past. She feels overwhelmed with the responsibility of looking after the baby and has lost her self-confidence. Her sleep is poor.
She works as a nurse in a local hospital and went off work at 32 weeks of pregnancy. She was treated for a depressive episode by her GP 4 years ago. She had been prescribed fluoxetine 20 mg once a day. She took the medication for a year and then stopped the medication as she felt better. There is no other psychiatric or medical history. Her parents are retired and live in a different city. Her mother suffers from recurrent depressive disorder and has been treated with ECT in the past.
This is her first child and it was a planned pregnancy. She lives with her husband who is an engineer. She describes herself as a perfectionist who likes doing things in a particular way. She is a non-smoker and a social drinker.
Mental state examination
This woman is seen by her GP at home. She is dressed in her night clothes, has greasy hair and has not taken a shower. She is holding the baby appropriately but does not smile or make eye contact with the baby. During the interview she bottle feeds the baby. She has discontinued breast feeding due to mastitis. She feels that she has let her baby down by not being able to breast feed. She speaks in a monotonous voice and becomes tearful when asked how she is coping. She has feelings of guilt about not being a good mother. She says that she has had thoughts that it would be better if the baby was dead. On one occasion an image of her putting a pillow over the baby’s face flashed through her mind, although she says she would never do this. She finds these thoughts distressing. She has thoughts of wanting to be dead, but does not have any definite suicidal plans. Cognitive
• Post-partum blues are seen in up to 75% of women and are characterized by a
mild self-limiting episode of mood disturbance lasting a few days. It usually begins 3 to 10 days post-partum (peak onset day 5 to 7) and resolves spontaneously.
• Post-partum psychosis is seen in 1% of women and is characterized by rapid onset
of labile mood, thought disorder, confusion and disorientation. Previous history and family history of mental illness particularly of bipolar disorder are significant risk factors. This is a severe disorder and often requires in-patient treatment. Delirium (for example, infective) needs to be excluded with this presentation.
Differential diagnosis
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ANSWER 52
This woman is suffering from postnatal depression, which is defined as depression occurring after child birth. It is seen most often within 4 weeks of child birth but can occur up to 6 months post-partum. The symptoms of postnatal depression are similar to those seen in a depressive disorder. She has all the core symptoms of depression including low mood, low energy levels and anhedonia. These symptoms have been present for more than 2 weeks. She also has additional symptoms of depression such as feelings of guilt, loss of confidence, poor sleep and suicidal thoughts. She has had an episode of depression in the past and therefore fulfils the criteria for a recurrent depressive disorder, with the current episode being moderate to severe. The prevalence rate of postnatal depression is between 8% and 20%. Many women have had depression in the past. It is important to screen for depression in pregnancy and health visitors can use the Edinburgh Postnatal Depression Scale (EPDS) as a part of antenatal check up.
Management
This woman needs to be referred to a specialist Mother and Baby (Perinatal Psychiatric) team for urgent assessment of the risk of harm to the baby and risk of self-harm, which dictates the course of further management. One option, depending on risk and choice, is admission to the Mother and Baby Unit for further assessment and management. There are several benefits of admitting mother and baby together. It lets the mother continue to breast feed, allows for healthy development of attachment and maintains the confidence of the mother in her parenting ability. Parenting assessment allows early detection of problems with attachment and institution of remedial measures. Treatment for the depression includes cognitive behaviour therapy (CBT) and/or pharmacotherapy. Lofepramine, fluoxetine and sertraline, although expressed in breast milk, are considered relatively safe, unlike medications such as lithium and sodium valproate which should not be used in breast-feeding mothers. If the parenting assessment raises concerns about the safety of the child (risk of harm or neglect) then a referral to the child protection team should be made. Occasionally use of the Mental Health Act is necessary especially if there is high risk and little insight from the mother.
• Childbirth is a vulnerable period for women with risk of post-partum blues, post-partum depression and post-partum psychosis.
• Be aware of medications expressed in breast milk.
• Risk to the baby should dictate early involvement of specialist mother and baby team and child protection team.
• Health visitors and GPs need to have a high index of suspicion.
KEY POINTS