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Midwifery > Perinatal mental health > Flashcards

Perinatal mental health Flashcards

1
Q

What are the 5 main theories of psychology?

A
  • Behaviourist
  • Cognitive
  • Humanistic
  • Biopsychological
  • Psychodynamic
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2
Q

What is personality?

A
  • each persons unique, distinctive and consistent tendencies or enduring patterns of thinking and behaving, in different circumstances over time and across situations..
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3
Q

What are the key elements of the psychodynamic perspective?

A
  • freud
  • unconscious motivations
  • developmental conflicts
  • conflict between the ego (mediator, reality), id (devil, primitive + pleasure) and superego (angel, morality)
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4
Q

According to freuds theory and the psychodynamic perspective what are the most common defence mechanisms?

A
  • repression
  • regression
  • denial
  • displacement
  • rationalisation
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5
Q

What is the key belief of the behaviourist approach?

A
  • behaviour is influenced primarily by the environment, conditioning and reinforcement through consequences
  • concepts of behaviour should be observable and measurable
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6
Q

What is the key belief of the cognitive perspective?

A
  • that we cognitively appraise the world in terms of existing knowledge and learn through observation and vicarious reinforcement
  • influenced by attention, memory, perception, thinking, problem solving, reasoning, concept attainment and language
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7
Q

What is the key belief of the humanistic perspective?

A

that people are unique, free, rational, self-determining and have the potential for personal growth

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8
Q

From the humanistic perspective, what is Maslow’s hierarchy of needs?

A
  • physiological
  • safety
  • love + belonging
  • esteem
  • self-actualisation
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9
Q

What was Carl Rogers theory of personality from the humanistic perspective?

A
  • viewed personality in terms of self-concept, a persons thoughts and beliefs about themselves
  • self-image, self-esteem and ideal self
  • conflict arises when incongruence between experience and self-concept
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10
Q

What is the key belief of the biopsychological perspective?

A

that behaviour is largely shaped by physiological (structural, chemical, hormonal, pathological) and genetic factors

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11
Q

What is the definition of the perinatal period?

A
  • from conception to through to the end of the first year after birth.
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12
Q

What kinds of mental health problems may occur in the perinatal period?

A
  • baby blues
  • major depression
  • anxiety disorders
  • obsessive compulsive disorders
  • post traumatic stress disorder
  • eating disorders
  • bipolar
  • postpartum psychosis
  • schizophrenia
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13
Q

What factors may make women more vulnerable to developing mental health problems in the perinatal period?

A
  • family or personal history of mental illness
  • young age
  • poor support
  • history of prior miscarriage or stillbirth
  • unwanted pregnancy
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14
Q

What are some of the challenges of developing a mental illness in the perinatal period?

A
  • relationship with partner
  • mother-infant attachment
  • adaptation to being a parent
  • impact on the infant inutero
  • risk of adverse obstetric outcomes
  • impact on infant development
  • potential for mandatory reporting to child protection, court and custody considerations
  • risk of harm to mother or infant
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15
Q

What are the baby (or postpartum) blues?

A
  • commonly experienced with the onset of lactation around day 3-5 after birth
  • transient, can last for hours to days
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16
Q

What is the name of the australian and state government initiative to improve prevention, detection, and care for women experiencing perinatal depression?

A

the National Perinatal Depression Initiative (NPDI)

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17
Q

What are the key components of the National Perinatal Depression Initiative?

A
  • routine universal screening in antenatal and postnatal settings
  • follow up support for care of women
  • training of health professionals
  • research
  • clinical guidelines on perinatal mental health
  • community awareness
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18
Q

What is the main tool used to assess for signs of depression and anxiety in the perinatal period?

A

The Edinburgh Postnatal Depression Scale (EPDS)

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19
Q

What kind of questions may you ask a woman to assess her psychological wellbeing?

A
  • past and present mental health
  • family history
  • past/current physical, sexual or psychological abuse/violence
  • drug/alcohol abuse by self or partner
  • emotional/practical support
  • recent life stressors such as financial strain, relationship problems, illness, pregnancy complications or loss, loss of someone close or moving house
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20
Q

What kinds of questions might you ask to assess a woman’s past and present mental health?

A
  • feeling down, depressed or hopeless
  • feeling little interest or pleasure
  • worrying so much it affects day-to-day life
  • currently/previously receiving treatment for a mental health condition such as depression or anxiety disorders, bipolar disorder or psychosis
  • immediate family experiencing or receiving treatment for a mental health problem particularly significant depression, bipolar, psychoses, self-harm and/or suicide attempts, significant drug and alcohol use
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21
Q

What are the diagnostic signs and symptoms of perinatal depression?

A 
occurring on most days in the last 2 weeks:
- low mood
- irritability
- tearfulness
- feelings of hopelessness
- lack of interest
- weight or appetite changes
- sleeping problems
- fatigue
- feelings of worthlessness/guilt
- difficulties concentrating
- thoughts of death or suicide
- agitation
some symptoms may overlap with normal changes associated with motherhood
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22
Q

What are some examples of anxiety disorders in the perinatal period?

A
  • generalised anxiety disorder
  • phobias
  • obsessive compulsive disorder
  • panic disorders
  • agoraphobia
  • post traumatic stress disorder
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23
Q

What are the diagnostic signs and symptoms of perinatal anxiety?

A
  • anxiety and worry
  • restlessness
  • easily fatigued
  • difficulty concentrating
  • irritability
  • muscle tension
  • sleep disturbance
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24
Q

What are the diagnostic signs and symptoms of panic disorder?

A

panic attacks:

  • pounding heart
  • trembling or numbness
  • shortness of breath
  • chills or hot flushes
  • dizziness, lightheadedness or faintness
  • fear of losing control
  • fear of dying
  • agoraphobia
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25
Q

What are the signs and symptoms of post traumatic stress disorder?

A
  • persistent repetitive thoughts, dreams or flashbacks associated with intense distress
  • avoidance of thoughts, feelings and situations associated with the traumatic even
  • feelings of detachment
  • restricted range of affect
  • hyper vigilance
  • sleeping difficulties
  • irritability
  • anger
  • difficulty concentrating
  • easily triggered
    for at least a month
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26
Q

What are the major risk factors for developing depression and anxiety in the perinatal period?

A
  • past history of depression/anxiety
  • antenatal depression/anxiety
  • lack of support from partner or relationship problems
  • family history of depression or other mental health problems
  • lack of practical, financial, social, emotional support
  • major life stressors (death, relationship breakdown, unemployment, moving house, miscarriage, illness)
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27
Q

What is puerperal psychosis?

A
  • a psychotic episode that arises following childbirth
  • a psychiatric emergency
  • risk of harming themselves or their baby
  • requires hospitalisation for treatment
  • may be associated with underlying bipolar disorder, schizophrenia or may occur only in the context of childbirth
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28
Q

When does puerperal psychosis usually manifest?

A
  • within the first month after birth
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29
Q

What are the diagnostic signs and symptoms of puerperal psychosis?

A
  • delusional beliefs
  • disorganised thinking/confusion
  • mood lability or elevated/depressed mood
  • irritability
  • hallucinations (false sensory perceptions)
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30
Q

What is Bipolar disorder?

A

a set of conditions characterised by extreme mood swings that can include mania, hypomania, depression and psychotic experiences that interfere with day-to-day life

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31
Q

What are the characteristics of mania and hypomania?

A
  • high energy levels
  • positive mood
  • rapid speech
  • irritability
  • impaired judgement and impulsive behaviour
  • increased libido
  • creativity
  • mystical experiences
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32
Q

In the context of bipolar disorder, how is hypomania different from mania?

A

generally less severe, shorter (less than four days duration), not severe enough to impair social or occupational functioning or necessitate hospitalisation and no psychotic features

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33
Q

When does bipolar disorder usually manifest?

A
  • typically in late adolescence and early adulthood

- often in the perinatal period

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34
Q

What diagnostic signs and symptoms of schizophrenia?

A
  • hallucinations
  • delusions
  • lack of motivation
  • lacks expression of feelings
  • limited speech
  • inability to enjoy activity
  • reduced self-care
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35
Q

What signs are you looking for when you consider mother-infant interaction?

A
  • physical attentiveness
  • eye contact
  • empathy
  • response to infant
  • identification of infant cues
  • enjoyment and emotional engagement
  • infant that responds to stimuli (cries when distressed and settles when comforted)
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36
Q

What kind of questions might you ask to assess the mental health of a woman’s partner?

A
  • how has your partner been coping since the birth of your baby?
  • how is your partner adjusting to parenthood?
  • how is your relationship with your partner?
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37
Q

What are some common reasons why women may not seek help when they experience symptoms of perinatal mental health disorders?

A
  • cultural differences
  • language barriers
  • lack of familiarity with the Victorian health system
  • belief that a ‘good’ mother should be able to cope on her own or that this is a normal part of motherhood
  • reluctance to ask for help or disclose information to a health professional
  • stigma/shame
  • guilt
  • denial
  • not wanting to waste peoples time
  • fear of having feelings dismissed, trivialised or normalised
  • prior negative experience with a health professional
  • concerns about privacy/confidentiality
  • lack of awareness of available resources
  • unwillingness to undertake treatment
  • logistical barriers (lack of time, childcare, transport, money)
  • family disapproval
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38
Q

What are the limitations of the EPDS?

A
  • not diagnostic
  • rapid screening tool
  • should not replace clinical judgement
  • not predictive of future depression
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39
Q

When should the EPDS be used by health professionals in the perinatal period?

A
  • to screen all women for symptoms of depression or depression and anxiety
  • at least once, preferably twice in both the antenatal and postnatal periods (ideally 6-12 weeks after birth)
40
Q

What treatments are recommended for women with mild to moderate depression in the postnatal period?

A
  • non-directive counselling in the context of home visits
  • cognitive behavioural therapy
  • interpersonal therapy
  • psychodynamic therapy
41
Q

What are some considerations that are important to ensure that screening with the EPDS is effective?

A
  • trained health professional
  • time to discuss process and results
  • privacy
  • support to manage baby during screening
  • literacy/language/cultural issues
  • therapeutic communication
  • explore symptoms and contributing factors
  • woman-centred care
42
Q

What are some important steps in gaining informed consent for screening with the EPDS?

A
  • screening tool recommended to every woman
  • importance of emotional health
  • confidentiality
  • rationale for assessment: to identify women who would benifit from follow up care
  • procedure: talk about past/present issues, ask questions about how she is feeling, fill out form and discuss it
  • relates just to the previous 7 days
  • documentation of consenting or declining consent
43
Q

What is the highest possible score on the EPDS?

A
  • 30

- each of the 10 questions is scored with 0, 1, 2 or 3

44
Q

What score on the Edinburgh Postnatal Depression Scale indicates a need for follow-up assessment?

A
  • a score greater than or equal to 13 indicates that diagnostic follow up assessment should be offered
  • however if a woman scores below this a health professional should use their judgement
  • any score greater than 1 on item 10 requires exploration as it reflects thoughts of self-harm
  • scores of 10, 11 or 13 require re-administration in 2-4 weeks
45
Q

What are some ways of explaining a positive (i.e.>13) result on screening with the EPDS?

A
  • over half the women who answer like you have, find after further assessment that they need professional help with depression
  • this screening isn’t perfect and is sometimes wrong, you might just be having a bad day but from your answers I would suggest a further assessment
  • further assessment would explore how you are feeling, to see if you have symptoms of depression and whether additional support might be helpful
46
Q

What kind of follow up questions might you ask if a woman scored greater than zero on the self harm question (no 10)?

A
  • i notice you have marked that you have sometimes thought about harming yourself. Can you tell me a bit more about these feelings?
  • have you had thoughts that life isn’t worth living?
  • have you thought about suicide?
  • how often have you had these thoughts?
  • what have you been thinking you might do?
  • do you think that you would follow through on these thoughts? - what factors stop you from acting on these thoughts?
    Also consider safety of the baby
47
Q

What further responsibilities does the midwife have where a woman requires follow up care?

A
  • documentation
  • appropriate referral
  • follow up to ensure referral is acted on
  • review progress
48
Q

What contacts might be useful for women at risk of depression, self harm or suicide?

A 
PANDA
Maternal child health line
Parentline
Lifeline
Lifeline Suicide helpline
Suicide call back
Mental health advice line
beyondblue 24 hour support line
pregnancy, birth & baby helpline
Mensline
49
Q

Depending on the nature of thoughts of self harm or suicide what might be some appropriate actions?

A
  • depends on clinical situation and local protocol
  • develop a safety and management plan with a GP and partner
  • consult a senior colleague
  • call crisis assessment and treatment team (CATT)
  • arrange for support person/partner to pick up
  • take woman to emergency department (if in community)
  • request permission to inform GP, psychiatrist and other HCPs involved
  • risk assessment
50
Q

Has the EPDS been formally validated for screening of anxiety?

A

No

51
Q

What should be included when documenting screening with the EPDS?

A
  • consent for screening
  • EPDS score
  • score to question 10
  • any psychosocial issues
  • information about what was discussed with woman
  • information about care recommended to woman
  • any further management, follow up or referral made
52
Q

What are some challenges for women from culturally and linguistically diverse backgrounds to accessing quality perinatal care?

A
  • langage and cultural barriers
  • literacy
  • inaccesibility of services
  • issues regarding male health professionals
  • cultural stigma
  • absence of family and peer support
  • traditional expectations around birth and motherhood
  • history of grief or trauma
  • migration
  • lack of interpreter services
  • health care professional’s own prejudices, preconceptions and attitudes
53
Q

What are some strategies for adapting screening for indigenous women?

A
  • involve ATSI health worker, liason officer or interpreter
  • culturally appropriate education materials
  • specific programs
  • comfortable setting
  • acknowledging importance of kin and traditional healers
54
Q

What do questions 3, 4 & 5 of the EPDS particularly deal with?

A

indicators of anxiety

55
Q

What is the aim of routine psychosocial assessment as part of the EPDS?

A
  • to gain a more holistic understanding of the woman in the context of her family and life circumstances including her past and current social, emoitonal and psychological status
56
Q

In providing feedback on screening for women what factors might be useful to discuss to put the result in context?

A
  • predisposing factors
  • recent stressors or triggers
  • maintaining factors (lack of support, reluctance to ask for help, social isolation, strategies for coping)
  • woman’s strengths (family support, coping strategies, financial resources, baby, motivation, past success in treatment)
57
Q

Depending the individual woman, what kinds of follow up care may be helpful?

A
  • ensure that the woman knows she should feel free to discuss how she is going at appointments and that there is a lot of information and support available
  • ask the woman what support she would find helpful
  • assess partner’s ability to support
  • referral for further assessment
  • referral to GP for mental health care plan (10 sessions under medicare)
  • MCHN, counsellor, psychologist, psychiatrist
  • community or peer support groups
  • psychosocial support
  • psychological therapies
  • referral to GP, psychiatrist, hospital or mother-baby unit for
    pharmacological treatment or admission
  • natural and complementary therapies
  • couples counselling
  • referral to specialist agency for specific issue (e.g. substance abuse, domestic violence)
  • parenting support (practical help, respite, parenting/settling classes or programs)
  • notification to family & children’s services if “at-risk”
58
Q

what are some pathways for psychosocial support that may be suggested?

A
  • lifestyle advice
  • increased care/home visits
  • mobilise practical/emotional support structures especially partner
  • non-directive counselling (listening, debriefing, discussing problems, developing goals)
59
Q

what are some psychological therapies that may be suggested?

A
  • cognitive behavioural therapy
  • interpersonal psychotherapy
  • psychodynamic therapy
  • possibly mother-infant therapy
60
Q

What is the main focus of cognitive behavioural therapy (CBT)?

A

focuses the influences of peoples thinking patterns and coping skills on their behaviour and mood

61
Q

What is the main focus of interpersonal therapy (IPT)?

A

focuses on improving interpersonal relationships

62
Q

What is the main focus of psychodynamic therapy?

A

focuses on unconscious processes as relevant to a woman’s present behaviour

63
Q

What kind of skills might be built through follow up care?

A
  • relaxation
  • problem solving
  • anger management
  • social skills
  • communication
  • stress management
  • parenting skills and strategies
64
Q

What is mother-infant psychotherapy?

A

a specialised treatment approach where the mother and baby are seen together and treatment focuses on the mother-infant relationship

65
Q

What options for referral exist in the victorian public health care system?

A
  • GP can refer to psychiatrist, psychologist with mental health care plan
  • free services through area mental health services (AMHS) including crisis assessment and treatment teams (CATT)
  • community mental health services
  • public hospital emergency department
  • mother baby inpatient psychiatric units at monash, austin, werribee mercy
  • psychiatric inpatient units
  • Austin health women’s perinatal depression clinic
  • victorian parenting centres - Tweddle, o’connell family centre, queen elizabeth center (particularly with sleeping/settling concerns)
  • PANDA
66
Q

What private hospital programs are there?

A
  • north park private
  • mitcham private
  • Masada
  • Albert road clinic
  • melbourne clinic
  • st john of god raphael center
67
Q

What might be the next step if there are concerns about the safety and wellbeing of an infant?

A
  • report to child first or child protection
68
Q

What are key recommendations for effective therapeutic communication?

A
  • attention
  • appropriate eye contact
  • open relaxed posture
  • friendly interested facial expression
  • private comfortable environment with few distractions
  • active listening (affirmation, repitition, paraphrasing, reflecting, summarising)
  • empathy
  • open ended questions
  • clarification
69
Q

What documents outline requirements for midwives in terms of confidentiality?

A
  • NMBA code of conduct and code of ethics for Midwives in Australia
  • common-law
70
Q

When may a midwife share infomation about a woman or disclosed by the woman with another person?

A
  • with the woman’s specific consent
  • where it is mandated by a court order
  • where there is mandatory reporting (of notifiable diseases or suspected child abuse)
  • where it is “in the public interest” (i.e. criminal)
71
Q

What are some websites that might be useful for women and their families living with a mental health disorder?

A

beyondblue. org.au
blackdoginstitute. org.au
motherisk. org
panda. org.au
gigetfoundation. com.au
pregnancybirthbay. org.au
moodgym. anu.org.au

72
Q

What are the 3 main types of antidepressants?

A
  • selective serotonin reuptake inhibitors (SSRIs)
  • tricyclics (TCAs)
  • monoamine oxidase inhibitors (MAOIs)
73
Q

What are the risks of taking Lithium in pregnancy?

A
  • lack of evidence
  • decisions require multidisciplinary consultation including psychiatric and obstetric involvement
  • must balance risk of relapse with impact of treatment on developing baby
  • first trimester lithium use associated with increased cardiac defects particularly Ebstein’s anomaly
74
Q

What can be done to reduce the risks of taking Lithium in pregnancy?

A
  • ECG with 20 week scan
  • monitor lithium levels, renal and thyroid function in order to adjust dose if needed
  • decrease dose 24-48 hours before planned birth or cease at onset of spont labour
  • return to prepregnancy levels after birth
  • long term impacts on baby generally reassuring
75
Q

What considerations are important for women with bipolar taking lithium and breastfeeding

A
  • consider implications of sleep deprivation and loss of circadian rhythms
  • variable concentration of lithium in breast milk
  • consultation with neonatologist to monitor infants hydration, renal and thyroid function
76
Q

What other treatments for bipolar are usually not recommended as they may have higher risks in pregnancy?

A
  • sodium valproate
  • lamotrigine
  • carbamazepine
  • clozapine
77
Q

What elements does a mental state examination consider?

A
  • appearance
  • behaviour (non-verbal)
  • mood and affect (emotion, range, appropriateness, stability)
  • speech
  • cognition (conciousness, memory, processing, attention)
  • thoughts (delusions, self-harm, suicidal, obsessive)
  • perception (dissociation, illusions, hallucinations)
  • Insight and judgment
78
Q

At the commencement of care, what is the responsibility of the midwife in terms of consultation and referral if a woman has problems with dependence or misuse of alcohol or drugs?

A

B - consult

79
Q

At the commencement of care, what is the responsibility of the midwife in terms of consultation and referral if a woman is dependent on medicines?

A

B - consult

80
Q

At the commencement of care, what is the responsibility of the midwife in terms of consultation and referral if a woman has a history of puerperal psychosis?

A

C- refer

81
Q

At the commencement of care, what is the responsibility of the midwife in terms of consultation and referral if a woman has previously scored >12 on the EPDS?

A

B - consult

82
Q

At the commencement of care, what is the responsibility of the midwife in terms of consultation and referral if a woman has previously given a positive response to Q10 on self harm on the EPDS?

A

B - consult

83
Q

At the commencement of care, what is the responsibility of the midwife in terms of consultation and referral if a woman has a history of a psychiatric illness requiring medication?

A

B - consult

84
Q

At the commencement of care, what is the responsibility of the midwife in terms of consultation and referral if a woman has current or previous child protection concerns?

A

B - consult

85
Q

During pregnancy, what is the responsibility of the midwife in terms of consultation and referral if a woman scores >12 or gives a positive response on Q10 on the EPDS?

A

B/C - consult or refer

86
Q

During pregnancy, what is the responsibility of the midwife in terms of consultation and referral if a woman develops a mental health issue requiring medication?

A

B/C - consult or refer

87
Q

During pregnancy, what is the responsibility of the midwife in terms of consultation and referral if a woman is discovered to have current or previous child protection concerns?

A

B - consult

88
Q

In the postnatal period, what is the responsibility of the midwife in terms of consultation and referral if a woman develps a serious psychological disturbance, has significant social isolation or lack of social suppot?

A

B - consult

89
Q

What is borderline personality disorder?

A

a mental illness that can make people feel unsafe in their relationships and difficult to control their emotions and impulses. may lead to distress in work, family and social life and self-harm

90
Q

What are some signs and symptoms of borderline personality disorder?

A
  • fear of abandonment
  • intense and unstable relationships
  • unsure who they are and what they think about themselves
  • impulsiveness
  • self harm or risk of suicide
  • low mood
  • irritability
  • anxiety
  • feeling empty
  • inability to control anger
  • paranoia
  • detatchment
  • may coexist with substance misuse, eating disorders
  • very difficult to diagnose
91
Q

Apart from the EPDS what other assessments may be required in the perinatal period?

A
  • assessment of mother-infant interaction
  • referral for comprehensive mental health assessment
  • assessment of risk of harm to the infant or self
  • assessment of risk of suicide
  • assessment for puerperal psychosis
92
Q

What care may be effective in promoting emotional health and well-being in the perinatal period?

A
  • lifestyle advice (physical activity, relaxation and healthy sleep patterns)
  • nutrition
  • support
  • debriefing
  • psychoeducation
  • telephone-based peer support
  • non-directive counselling (active listening, empathy)
  • involve the woman’s partner and family as appropriate
93
Q

What are the risks and benefits of SSRIs in pregnancy

A
  • reduces risk of relapse
  • 1st trimester miscarriage
  • preterm birth
  • low birth weight
  • admission to SCN
  • poor neonatal adaption
  • possible neonatal persistant pulmonary hypertension or delayed motor development
94
Q

What are the risks and benefits of benzodiazepines in pregnancy?

A
  • often recommended as short term therapy while awaiting SSRIs to take effect
  • recent studies show now increase in orofacial cleft defects
  • sedation
  • preterm birth
  • low birth weight
  • low apgar scores
95
Q

Are SSRIs ok to take while breastfeeding?

A
  • there are no contraindications to SSRIs in breastfeeding

- fluozetine can accumulate in the infant and cause jitteriness

96
Q

Are Benzodiazepines ok to take while breastfeeding?

A
  • short acting benzos may be used for a limited period

- long acting benzos are not recommended

97
Q

What antipsychotics are contraindicated in breastfeeding?

A
  • clozapine

Midwifery (27 decks)

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