Women’s Health: Learn to manage maternal mental health
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Women’s Health: Learn to manage maternal mental health

Post by RK News on Sunday, January 22, 2023

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Dr. Abdul Majid & Dr. Farhana Rafiq
 
‘Pregnancy is often a very happy and exciting time. But not every woman feels this way. You may have mixed, or even negative, feelings about being pregnant. You may find it more difficult than others to cope with the changes and uncertainties which pregnancy brings’’
Perinatal period is demanding period characterized by overwhelming biological, physical, social, and emotional changes. It requires significant personal and interpersonal adaptation, especially in case of primigravida. Pregnant women and their families have lots of aspirations from the postpartum period, which is colored by the joyful arrival of a new-born baby. Unfortunately, women in the postpartum period can be vulnerable to a range of psychiatric disorders like postpartum blues, depression, and psychosis. Examples of common maternal mental health problems include depression in pregnancy and postnatally and anxiety disorders like phobias and obsessive compulsive disorder.
During pregnancy and postpartum period, psychiatric disorders are common and are very much treatable successfully. However if the symptoms are ignored, the severity of disease increases and can become potentially life threatening illnesses that becomes difficult for psychiatrists to treat. 
As we are aware that, most of these problems are often missed or undertreated, possibly because of its typical features such as fatigue and poor sleep which are also common in motherhood itself. 
The increasing severity of psychiatric illnesses results in increased maternal morbidity and mortality with increased risk of maternal suicide and impaired parenting capability which can badly affect the physical, emotional, social, and cognitive development of their children. Also, it can lead to marital problems and future mental health problems. They have an increased risk of obstetric complications and preterm labour. In India suicide is now a leading cause of death in young women in the childbearing age group . 
One in five pregnant women experience antenatal depression, and also, these antenatal depressed women have a sixfold increased risk of developing postpartum depression. 
Untreated maternal psychiatric disorders can have devastatingsequelae.Pregnancy-associatedself-harm kills more women than hemorrhage or pre-eclampsia, underscoring the importance of screening and treatment for perinatal mood disorders. 
Moreover, depressive symptoms are associated with adverse parenting practices, including reduced use of safety and child development practices and increased risk of harm including suicidal ideation and/or fears of hurting the new born. 
In addition, postpartum depression is associated with reduced maternal sensitivity, which may adversely affect development of infant emotional regulation and attachment. Insecure attachment, in turn, increases risk of psychiatric disease in the child. Untreated postpartum psychiatric disorders can have far-reaching ramifications for a family. 
At times, the postpartum psychiatric condition can become so severe that it warrants hospitalization. Postpartum psychiatric disorders can adversely affect mother-infant interaction and attachment. Hence, early diagnosis and management of the postpartum psychiatric disorder is extremely crucial.
It is vital for all healthcare providers involved in the care of pregnant women including medical practitioners, nurses, and midwives to be well aware of even subtle indicators of maternal mental illnesses and their management options. 
Early detection and effective interventions where necessary are important to prevent devastating consequences for women themselves, their children, and families. This also reduces the burden of maternal mental health problems for the individual, family, and the entire society. Mental illness related to pregnancy can have long-lasting consequences. Healthcare providers are often the most frequent medical contact with the potential for early detection of these mental disorders. 
With increased recognition of the consequences of perinatal psychiatric disorders, information about the efficacy and side effects of treatment is needed to inform clinical decision making. Treatment choices include pharmacotherapy, psychotherapy, and other approaches (e.g., Meditation, yoga, mindfulness, self-care, nutritional supplements). 
Pregnant and breast feeding women with mental health-related illnesses present a unique challenge to health professionals. During pregnancy, the decision to withhold, modify or continue psychotropic medication requires consideration of both maternal and infant outcomes. 
Health professionals must be aware of withdrawal of these medications during pregnancy can often lead to symptom relapse. It is essential that women do not receive conflicting information from health professionals because this can lead to confusion and both intentional and unintentional non-adherence.
Psychotropic medications in pregnancy are indicated for women who develop a significant psychiatric illness during the pregnancy, women who experience an exacerbation of a pre-existing illness during pregnancy, and women who have experienced a rapid deterioration of their condition after discontinuing medication. When a medication of any kind is prescribed in pregnancy, the lowest possible dose that will provide complete symptom control should be used. 
The decision to use a psychotropic medication of any kind during pregnancy or in the postpartum period always requires a careful weighing of the risks and benefits to both the mother and her fetus or new born. There are several factors that must be considered, including the possible teratogenic effects of the medication, the safety of the medication during labor and delivery, the possible long-term neurobehavioral effects on childhood development, and the effects of ongoing exposure during breastfeeding. 
Total avoidance of pharmacological treatment in pregnancy is not possible and may be dangerous because some women getting pregnant with psychiatric conditions that require ongoing and episodic treatment (e.g. panic symptoms,depression,psychosis). 
Also during perinatal period new psychiatric problems can develop and old ones can be exacerbated (e.g. mania, migraine,psychosis) requiring pharmacological therapy. The fact that certain drugs given during pregnancy may prove harmful to the unborn child is one of the classical problems in treatment. 
It is important to get specialist advice even if you are well during this pregnancy. Women who have had these illnesses have a high risk of becoming unwell after birth. Your midwife or treating doctor (GP) can refer you to mental health service if there is one in your area, or otherwise tospecialist psychiatrist. Mental health professionals can discuss modalities of treatment with you as well as your treating doctor. They will help you make a plan for your care, with your midwife, obstetrician, health visitor etc. Your GP or psychiatrist can help you decide what is best for you and your baby.
Because mental illness in the mother is not a benign event, and may itself pose significant risks to both mother and child, simply discontinuing or avoiding medication use during pregnancy may not be possible. Decisions regarding drug choice, dose, and duration should be made carefully, by balancing severity, chronicity, and co-morbidity of the mental illness, disorder, or condition against the potential risk for adverse outcomes due to drug exposure. 
Commencing treatment of pregnant women with psychiatric disorders:
•Discuss the treatment options with the patient and her carers.
•Discuss the risks of remaining untreated and the risks and benefits of treatment to the child and the mother.
•Start from the lowest possible dose and monitor frequently.
•Assess the possibility of delaying the prescription until the second or even third trimester.
•Look into alternative treatment possibilities.
•General approach to treatment in pregnancy.
•Once the decision has been made that the woman will need medication, try to avoid combination therapies in view of their greater potential for teratogenicity.
•In the majority of cases, women who become pregnant while on medication need to be maintained on medication.
•Maintenance strategies should involve dosage reduction and regular review of side-effects.
•Discontinuation of mood stabilisers in pregnancy should take place only when absolutely necessary and be followed by frequent monitoring.
•Midwives, obstetricians and health visitors should be involved in the discussion and should be informed of the risks and benefits.
 
Role of family
1. Families can learn about the mental disorder their loved one has. 
2. They can find out what symptoms are associated with the illness during perinatal period. 
3. They can prepare plans to deal with any problems that may arise. 
4. Families can find out what mental services are available in the area, and they can ensure their loved one can get access to these services.
5. One of the most important roles families can play is monitoring the patient’s progress, and watching out for signs of relapse. 
6. They also play a vital role in monitoring the use of medication. 
7. Family can help the patient by learning about side effects and how to deal with them.
8. Families can also play a role in increasing treatment adherence in the patient. 
9. This is done by providing medication to the patient, supervising and monitoring the drug intake, taking the patient to doctor’s chamber at regular intervals.
Last but not the least, we need to understand, the moment female conceives or gives birth to a child, the mother is also born because she was never a mother before this (for first pregnancy). These mothers in particular have special needs and we all need to acknowledge them and respond well in time to prevent early symptoms of stress turning into a full blown psychiatric illness.  
 

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