Managing Postnatal Depression (PND)

PND: MANAGEMENT
Dr Umi Adzlin Silim
Consultation-Liaison Psychiatrist
Hospital Kuala Lumpur
KAJIAN POSTNATAL DEPRESSION
MALAYSIA ASPIRE 2016
KEMENTERIAN KESIHATAN MALAYSIA

NICE Guidelines on Perinatal Mental Health
Perinatal Women
Anxiety/Depression Drug Addiction
Severe Mental
Illness
(New/Known)
KAJIAN POSTNATAL DEPRESSION: MALAYSIA ASPIRE 2016 ©umiadzlin@gmail.com

PND: CASE VIGNETTE
Zarina, 28, a professional who had just been a mother, described how
isolated she felt fom family support due to her mother’s expectation that
she must be as independent as she used to be. Her childbirth was traumatic,
due to unexpected LSCS after a prolonged labour far from the natural
birth she had always imagined, and she had difficulty coping since giving
birth. Her baby developed jaundice, and she was heart-broken that her
baby has to be given formula milk, thus it was no more exclusive breastmilk
as she always dreamed of. She believed everyone expected her to be
happy, and that she had not really told everyone how bad she felt.

PND: Typical Risk Factors 2/2
She had difficulties managing her baby routine and felt severe sense of
failure as a mother. Her personality with a strong need to be organized,
predictability and perfectionism had been disrupted by her newborn & she
struggled to cope with many aspects of her life. She experienced her
husband as unsupportive and their relationship deteriorating. She felt a
sense of loss of her previous lifestyle & with the tremendous demands of
early parenting, she felt she was alone and helpless.

Source Beyond Blue National PND Initiative, National Action Plan Full Report 2008-2010

TREATMENT OF PERINATAL DEPRESSION
• Psychological interventions, counselling,
CBTMild depression
• Risk benefit analysis, Antidepressant
therapy, CBT
Moderate
depression
• Antidepressant therapy, CBT, CMHTSevere depression
• Address Mother-Baby InteractionAll Levels

Consideration for Antidepressant
• Balancing risk and benefitKAJIAN POSTNATAL DEPRESSION: MALAYSIA ASPIRE 2016 ©umiadzlin@gmail.com

RISK OF SSRI IN PREGNANCY
A. Relatively no risk of teratogenicity
B. Uncertain risk of low birth weight and prematurity
C. Risk of neonatal adaptation syndrome
D. Small risk of persistent pulmonary hypertension neonatarum (PPHN)

RISKS OF UNTREATED DEPRESSION
A. Seriously interfere with the adjustment to motherhood, care of the
newborn baby as well as older children.
B. Lasting effects on maternal self-esteem
C. Lasting effects partner relationship & family relationships
D. Mental health and social adjustment of the child.

RISKS OF UNTREATED DEPRESSION
E. Risks of I.U.G.R., prematurity, lower birth weight, smaller head
circumference, lower APGAR scores, and HPA dysfunction possibly
leading to an increased risk of psychopathology later in life,
developmental delay, or later disturbance in the areas of cognitive,
emotional and social functioning
F. Women with major depression who cease their antidepressants in
pregnancy have a 50-75% risk of relapse, and even higher for those
with bipolar disorder who cease their medication.
Psychotropic Medication in Pregnancy/Lactation. 2nd Edition. Mercy Hospital For Women. 2008

Balancing Benefits & Risks
in Pregnant Mothers
(a) To the mother:
• By taking medication
• Side effects of the medication
• By not taking medication:
• Risk of deterioration and relapse
without the medication
(b) To the fetus and infant:
• By taking medication
• (i) teratogenicity,
• (ii) pregnancy complications (e.g.
miscarriage, prematurity, low birth
weight)
• (iii) neonatal complications (withdrawal
syndromes, sedation, persistent
newborn pulmonary hypertension)
• (iv)longer term complications (e.g.
neurobehavioural disturbance,
neurodevelopmental outcomes)
• By not taking medication
• From having an unwell / untreated
mother.
Psychotropic Medication in Pregnanc/Lactation. 2nd Edition. Mercy Hospital For Women. 2008

SSRI IN LACTATION
A. Most SSRIs is safe in lactation
B. Sertraline has lowest placental passage and lower excretion to
breastmilk
C. Discarding of breast milk or timing feeding around medication will
not make a big difference to the dose received by the infant.
D. All breastfeeding infants to mothers taking SSRI must be monitored
for sedation, manifested with poor feeding.

SSRI and Placental Passage
• Lowest in Sertraline and Paroxetine
• Highest in Citalopram and Fluoxetine.
Hendrick V et. Al. 2003. Placental passage of antidepressant medications. Am J Psychiatry. 2003 May;160(5):993-6. .

SSRI in Breastfeeding
• Low levels excreted for most SSRIs.
• Relative infant doses: a relative infant dose of lower than 10% of the
weight adjusted maternal dose is considered to be safe for breastfeeding.
• Relative Infant Doses:
• Sertraline 2.2%,
• Escitalopram 3.6%,
• Paroxetine 2.1%,
• Fluvoxamine 1.3%,
• Fluoxetine 6.8%.
• Some concern with Fluoxetine given its long half life and the risk of accumulation in the infant
Psychotropic Medication in Pregnancy/Lactation. 2nd Edition. Mercy Hospital For Women. 2008

Psychological & Psychosocial Interventions
• Psychoeducation
• Counselling
• Cognitive Behaviour Therapy
• Mobilizing Psychosocial Support
• Interventions for Mother-Baby Interactions

Components of CBT for PND

‘Getting Ahead of PND’ CBT
 Techniques derived from depression literature, in context for
considering the special case of PND.
 Adaptation from ‘Coping with Depression’ course developed by
Lewinshon et al (1984)
 Evidenced-based psychological treatment for PND (Milgrom et al
2005)
 May be delivered as a group therapy or individual therapy

‘Getting Ahead of PND’ CBT
 Treatment model that combines cognitive & behavioural strategies to
address:
 Introducing behavioural activation (increasing pleasant activities) before
cognitive strategies
 Recommending relaxation ‘on the run’
 Reducing ‘homework’
 Building support network
 Incorporating partner session (up to 3 sessions)
 Incorporating mother-baby interaction (3 sessions)

Phase 1: Behavioural Interventions
 Session 1: Understanding PND
 Discussion about pregnancy, birth & now
 What is PND & approach to treatment
 Monitoring of daily activities & daily mood
 Session 2: Pleasant activites – How can I find time
 Pleasant activities & mood to prevent depressive spiral
 Increasing pleasant activities
 Session 3: Relaxation on the Run
 Relaxation on the run
 Identifying high stress time
 Session 4: Assertiveness & Self Esteem
 Assertiveness Skill & Self esteem: Telling others what I think & feel
 Love letter

SOME ACTIVITIES & STRATEGIES IN CBT

Behaviour Chart

Awful & Beautiful Behaviour
A A
A AA A
A A
B B
B B
B B
B B B B
B B

Depressive Spiral

BREATHING 4… 2… 6… 2….

Phase 2: Cognitive Interventions
 Session 5: Unrealistic Expectations of parenting
 Family of Origin
 Challenging unhelpful thoughts
 Session 6: My Internal Dialogue
 Session 7: Developing a more helpful thinking style
 Session 8: Challenging my Internal Critique

Discuss on Family of Origin From Grandparents, Parents, Patient
Discuss about parenting style
Beliefs about self as a mother
Beliefs about how infant should behave
The link with these parenting models

Thinking style

Phase 3: Relapse Prevention
 Session 9: Putting it All Together
 Session 10: Consolidating what I have learned

Partner Sessions
 Session 1: Partners & PND
 How life has changed after the baby
 Psychoeducation on PND
 Session 2: The Couple Relationship
 How relationship has changed after the baby
 Session 3: Doing it Ourselves
 Reviewed previous session & where to from now

Including Infants
 Session 1: Let’s Play & Physical Contact
 Session 2: Let’s Learn about baby-observing and understanding your
baby signals
 Session 3: Let’s examine our feelings-parental response to infant cues

Addressing Mother Baby Interaction
 Treating maternal depression alone, will not improve mother-baby
engagement and infant outcome (Murray & Copper 1997)
 Interventions that may be offered:
 Basic Parenting
 Attachment based parenting intervention – Circle of Security Parenting
 Therapeutic Playgroup
Murray, L., & Cooper, P. (1997) Postpartum depression and child development. New York: Guilford Press

A Framework for Mother-Baby Interventions based on the
Attachment Theory
Circle of Security

It’s all about secure attachment
 We’re all hardwired to feel
secure
 Children naturally seek security
& caregivers want to provide
security
 COS is based on researches on
how security is supported

Circle of Security Parenting

Having a framework in mind
 Caregivers often feel lost and
without a clue about what a
child needs.
 Knowing the circle is a great
way to make sense of what
they are really asking for. And
if we know, our lives and their
lives go so much smoother.

Key process of attachment
 Key process: going out and
coming back
 Having ease with the process of
going out and coming back is
the foundation of secure
attachment

‘Skills’ for attachment
 COS increase caregivers observational skills & inferential skills (seeing
& guessing) on child’s needs.
 Identify whether the child is at the top or bottom of circle & which
need is being exhibited
 COS increase caregivers understanding about being “Hands” and the
challenge

Reflective Functioning
 COS : parental reflection program
 Reflective Functioning: the psychological capacity for understanding
one’s own thoughts, feelings, behavior and intentions as well as those
of the other.
 Mother’s reflective functioning during pregnancy predicts their
children’s secure/insecure attachment at age 1 (Fonagi et al, 1991)

CONCLUSION
 PND is a high prevalent illness in perinatal period
 Effective evidenced-based interventions for depressed mothers are
available
 Addressing mother-baby interactions is crucial in managing PND

umiadzlin@gmail.com
Thank you

Managing Postnatal Depression (PND)

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