The Business of Practice

Maternal Mental Illness

Structural changes occur as mothers undergo the childbearing process, impacting their physical, mental, and behavioral health. Individuals who are pregnant or recently have had a child are likely to develop depression or anxiety, which are among the most prevalent illnesses in maternal populations.

Maternal Mental Illness

When treating maternal mental illness in pregnancy or childrearing, there is an acknowledgment that the patient experiences neuroendocrine alterations and psychosocial adjustments. Of the most impactful, estrogen plays a key role. 

Researchers Dr. Grigoriadis and Dr. Kennedy from the Center for Addiction and Mental Health at the University of Toronto emphasize postpuberty and premenopausal women are more likely to experience depression than their male and postmenopausal counterparts, which leads to speculation on the role of estrogen in the treatment of depression 

Foundational in sexual and reproductive health, estrogen further affects the following physiological regulations: 

  • Increases sensory perception
  • Decreases seizure threshold
  • Increase cerebral blood flow
  • Reduces acute-phase inflammatory response
  • Blunts HPA-axis reactivity
  • Effects Pain
  • Enhances Mood

What is Maternal Depression?

Maternal depression is a term that encompasses one of the most prevalent maternal mental illnesses, regardless of the stage of the maternal development process. The several stages of maternal development include the following:

  1. Prenatal Stage or Pregnancy: The foundational period before childbirth consists of the child’s growth and development in the womb.
  2. Childbirth: Childbirth marks the act that transitions an individual from the prenatal to the postnatal stage.
  3. Peripartum: This terminology refers to the stage around labor and delivery.
  4. Postnatal Stage: This is the period that follows childbirth and includes post-partum recovery, where the body attempts to heal to its pre-pregnancy stage.

Not only does maternal depression affect the mother, but the consequences of untreated maternal mental illness adversely impact child development. Long-term problems that arise in maternal depression, such as anxiety, rumination, irritability, high negative affect, and low positive affect influence how a mother is able to be present and assist in the child’s emotional regulation process. Difficulties that onset closely after childbirth consist of suicide risk and isolated incidents, particularly maternal infanticide or filicide.

For healthcare providers whose work or interest overlaps with forensic evaluations and expert testimonies, Dr. Gina Wong and Dr. Diana Lynn Barnes offer the following courses in partnership with CONCEPT’s first program on Maternal Mental Health and its Application to Forensics:

  1. Basic Diagnosis and Assessment of Maternal Mental Illness in the Forensic Area
  2. Role of the Expert Witness in Establishing the Relationship Between Maternal Mental Illness & Criminally Charged Behaviour
  3. Advanced Issues in Maternal Mental Health Forensics
  4. Advanced Training in Maternal Mental Health Forensics and Courtroom Testimony

Dr. Wong and Dr. Lynn Barnes reveal that more psychiatric admissions transpire around a female’s childbearing years than at any other time in the female cycle.

Types of Maternal Depression

Healthcare providers categorize the various maternal depressions through time-specific developmental stages. According to the Centers for Disease Control and Prevention, common symptoms of maternal depression, which 1 out of 8 women will experience, include:

  • A lasting sad, anxious, or empty mood
  • Feelings of hopelessness or pessimism
  • Feelings of guilt, worthlessness, or helplessness
  • Feelings of irritability or restlessness
  • Problems concentrating, recalling details, and making decisions 
  • Loss of energy
  • Difficulty falling asleep or sleeping too much
  • Overeating or loss of appetite
  • Suicidal thoughts or suicide attempts
  • Thinking about hurting your baby
  • Doubting your ability to care for your baby
  • Aches or pains that do not get better with treatment

There are four types of maternal depression:

  1. Prenatal Depression
    • Emergence: Pregnancy
    • Rate: 10-20%
  2. Baby Blues
    • Emergence: Post-childbirth, peaking at 3-5 days and typically resolved after two weeks
    • Rate: As high as 80%
  3. Postpartum Depression
    • Emergence: 2-3 months post-childbirth
    • Rate: 10-20%
  4. Postpartum Psychosis
    • Emergence: Postpartum, typically 2-3 weeks after childbirth, following up to 1 year
    • Rate: 0.10-0.20%

Mood episodes can drastically impact maternal mental illness, depending on the presentation of psychosis. Psychosis is not a necessary condition to qualify for a depressive episode. Common hallucinations or delusions revolve around the potential of an infant to be possessed, particularly in religious individuals. Postpartum mood disorders with psychotic features are higher in those with a history of depressive or bipolar disorder and primiparous women, those who have given birth once before. If a psychotic episode occurs postpartum, there is a 30%-50% chance of recurrence with each successive delivery.

Depression Symptoms

Major depressive disorder is the official diagnosis for mothers who experience mental illness, and the classifier “with peripartum onset” defines the development of illness within that specific timeframe. The DSM-5 outlines the symptoms of major depressive disorder as:

  1. Five or more of the following symptoms present in a two-week period where at least one of the symptoms is 1) depressed mood or 2) loss of interest or pleasure. Exclude symptoms clearly attributed to other medical conditions.
    1. Depressed mood, most or nearly every day
    2. Diminished interest or pleasure in daily activities
    3. Significant weight loss & decreases in appetite
    4. Insomnia or hypersomnia nearly daily
    5. Psychomotor agitation nearly daily
    6. Fatigue or loss of energy nearly daily
    7. Feelings of worthlessness and guilt nearly daily
    8. Diminished ability to think or concentrate nearly daily
    9. Recurrent thoughts of death & suicidal ideations or attempts
  2. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  3. The episode is not attributable to the physiological effects of a substance or another medical condition.
  4. Another mental disorder does not better explain the occurrence of the episode.
  5. There has never been a manic or hypomanic episode.

Peripartum onset is a specifier for depressive disorders if the mood disorder onset occurs during pregnancy or in the four weeks following delivery. Unique symptoms of maternal depression, apart from major depressive symptoms, include feeling inadequately prepared to care for the child or thoughts of harming the child.

Between 3%-6% of women experience an onset of a major depressive episode in the peripartum period, while the start of 50% of postpartum major depressive episodes, in fact, begin prior to delivery. Mood and anxiety symptoms during pregnancy increase the risk for postpartum depressive episodes. 

Treatments for Maternal Depression

Treatments for maternal depression are precise to the individual who seeks treatment. To facilitate treatment in maternal populations, explore the possible options for childcare with your patient or provide alternative methods, such as virtual therapy.

Regular screenings at medical care check-ups are the first checkpoints in educating mothers about depressive symptoms. Discuss with the appropriate medical providers whether medication is an option and the guidelines around taking medication while breastfeeding.

According to the American Psychological Association, the clinical practice guidelines corroborate the effectiveness of the subsequent treatments for depression:

  • Behavioral Therapy
  • Cognitive Therapy
  • Cognitive-Behavioral Therapy
  • Interpersonal Psychotherapy (IPT)
  • Mindfulness-Based Cognitive Therapy (MBCT)
  • Psychodynamic Therapy
  • Supportive Therapy
  • Medication

In addition, the Substance Abuse and Mental Health Services Administration reveals barriers to accessing care are:

  • Cost and affordability of treatment
  • Lack of health insurance or adequate coverage of mental health services
  • Availability of transportation
  • Availability of childcare
  • Availability of appropriate treatment, including culturally and linguistically competent treatment for diverse families
  • Availability of quality treatment

According to the American Hospital Association, 75% of maternal mental health conditions remain untreated. To highlight the large gap in mental health infrastructure for mothers, the United States only contains three perinatal inpatient psychiatry units.

The National Institute of Mental Health (NIMH) Treatment of Depression investigated the effectiveness of interpersonal therapy, cognitive behavioral therapy, medication (imipramine) with clinical management, and a placebo treatment with clinical management. All treatments effectively reduced depressive symptoms and are still classified as evidence-based treatments recognizable by the American Psychology Association. This research suggests depending on the severity of the depression, specific treatments may prove more effective, such as medication with clinical management, in more severely depressed populations.

Maternal mental illness is a prevalent event for women who experience childbirth. The peripartum onset of major depressive disorder affects roughly one in five women in their prepartum and postpartum stages. A much higher percentage, nearly four out of five women, experience an unofficial diagnosis of baby blues near their child’s birth. Major depressive disorder with peripartum onset consists of specific symptoms regarding the mother’s feelings of inadequate ability to care for the child and a fear of harming the child. Effective treatments for maternal mental illness include medication, talk, and behavioral therapies.

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