INTRODUCTION:

“You can’t pour from an empty cup, take care of yourself first”

The term peri meaning ‘around’ natal meaning ‘birth’. Perinatal’ means the period of time covering from pregnancy and up to roughly a year after giving birth. Pregnancy is bounded with emotional, physicaland social changes for the mother, partner and the family, butsome greatly enjoy thesechanges and adapt well to them, othersreact with severe distress^1.

Psychological morbidity is considerably high in women of reproductive age, particular mood and anxiety disorders are a common, often unrecognized and tabooed problem in pregnant women. The prevalence of mental disorders increases between the first and the third trimester of pregnancy. Maternal mental health difficulities whether mild, moderate or severe are known to impact critically on all aspects of a womans life.² According to science direct report 121 million womens are affected globally, WHO concur with these findings that 13% of women experience postnatal depression, higher in developing countries with 19.8%³.

Post partum period is usually characterized by range of emotions from transient mood liability, irritability and weepiness to marked agitation, delusions, confusion and delirium.⁴ Postpartum psychological distress leads to maternal disability and disturbed mother infant relationship, approximately 10-15% of all new mothers get postpartum depression, which most frequently occurs, in the first year after the birth of a child⁵, Shridevi D, S. Anuchithraetal (2014) study revealed thatchild birth preparation has an impact on reducing the depression level in antenatal period⁶. Naganandini. R etal (2012) conducted the study to assess the level of stress among primi mothers during pregnancy and early postnatal period found that 74% and 97% of mothers in control and experimental group had moderate stress.⁷Kavitha Rajagopal.V etal (2012) conducted study to identify the postnatal depression among postnatal mothers. The result shows that among 105 samples, 48 mothers were identified as to have a postnatal depression.⁸

Thus perinatal period is a time of tremendous flux in self-identity and a time of enormous physiological and psychological transition and change. These changes may include a dramatic drop in hormones, changes in metabolism, and sleep deprivation, among numerous other biological, psychological and sociological factors, these shifts in body chemistry and functioning contribute to the development of perinatal mood disorders.

Perinatal mood disorder:

Perinatal Mood Disorderis a set of disorders that can occur at any time during pregnancy as well as in the first year postpartum and can include depression (PPD), anxiety, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD) and postpartum psychosis.⁹

Causesof Perinatal Mood Disorders:

Exact causes are unknown. Certain factors that may contribute are

· Changes in hormone levels

· A difficult pregnancy

· A difficult birth

· Medical problems (mother or baby)

· Lack of sleep

· Feeling alone

· Perceived loss of freedom

· Sudden changes in routines

· Personal or family history of depression

· Prior experience with PPD or other perinatal mood disorders

· Life stressors such as illness or financial problems⁹

Risk Factor for PMD:

Can affect any woman of any age, race or economic background who:

· Is pregnant

· Has recently had a baby

· Has ended a pregnancy or miscarried

· Has stopped breastfeeding

Types of Perinatal Mood Disorders:

1 Baby Blues

2 Postpartum Anxiety and Depression (PPAD)

3 Postpartum Psychosis

1. Baby Blues:

Occurs during the first week post childbirth and can last for a few hours to a few days.

Symptoms include: crying, frustration, insomnia, confusion, mood lability (mood swings), anxiety and depressed Mood.

2. PostpartumAnxiety and Depression (PPAD):

Persist within the first month of post childbirth and can present upto 3 Years of post child birth, Occurs sudden or gradual.

Symptoms include:·profound sadness, overwhelming anxiety (including OCD symptoms), intrusive thoughts mood swings, irritability, isolation, crying a lot, sleep deprivation, appetite changes, a sense ofinadequacy, difficulty, Bonding with baby, feelings of guilt and shame, not feeling “like myself”, PTSDsymptoms, thoughts of harming the baby and suicidalthoughts.

3. Postpartum Psychosis:

Onset of symptoms is usually sudden, most often within the first 2 weeks post childbirth.

Symptoms include:· strange beliefs (delusions), seeing or hearing things that aren’t there (hallucinations), hyperactivity, decreased need for sleep, extreme irritability, rapid mood swings, paranoia and suspiciousness, difficulty communicating, family history of bipolar disorder or a previous psychotic episode.¹⁰

Common scales to assess PMD:

· Edinburgh Postnatal Depression Scale (EPDS)

· Post partum distress measures

· Perinatal anxiety screening scale

· PHQ or GAD

· Verbally asking if either parent has a previous mental health history.

· Whooley questions in combination with EPDS - a valid strategy to screen for perinatal depression.¹⁰

Diagnostics: DSM-V Criteria:

DSM-V has a postpartum onset specifier within 4 weeks of delivery. Five (or more) symptoms present in the same 2 week period:

1 Depressed mood most of the day

2 Diminished interest or pleasure in activities

3 Significant weight loss or weight gain

4 Insomnia or hypersomnia

5 Psychomotor agitation or retardation

6 Fatigue or loss of energy

7 Feelings of worthlessness or excessive guilt

8 Diminished ability to think or concentrate

9. Recurrent thoughts of death or suicidal ideation¹⁰

Barriers to Accessing Care:

· Stigma of mental health and psychiatric illness in general

· Lack of timely intervention

· Aversion to take medications

· Lack of knowledge

· Negative feedback from support system on symptoms or use of medications

● Providers are quick to offer a prescription without listening which disrupts the therapeutic alliance

Treatment and selfcare management:

Severity of symptoms common treatment:

1. Mild to moderate

A Psycho education.

B Self-care: the NEST-S program

C Psychotherapies

1 Cognitive behavioral therapy

2 Interpersonal therapy

3 Psychodynamic therapy

4 Group therapy

5 Parent-infant psychotherapy

6 Couples and family therapy

2. Moderate to severe or

At high risk of relapse.Treatments listed above plus:

E. pharmacotherapy

F. Electroconvulsive therapy

Psychoeducation:

Goal is to help women and their families to understand the symptoms and the underlying disorder, so to learn about available treatment and reinforce effective coping strategies.

Self–care :the NEST-S program:

NEST-S stands for one area of self-care;

Nutrition:

Eating nutritional foods throughout the day.

Exercise:

Getting regular exercise has possible benefits for improving depression

Sleep and rest:

Getting enough sleep and rest in the prenatal period is very important.

Time for self:

Taking self-time.This is a particular concern in women experiencing depression

Support:

Social support helps new mother to adjust to the life changing factors against depression.

Mind-body modalities:

Mind –body interventions helps to reduce stress and improve overall mood in prenatal women. Mind techniques include* Meditation* Mindfulness* Tai chi* Yoga* Biofeedback* Guided imagery*Creative therapy *Relaxation *Hypnosis*Prayer.

Psychotherapies:

CBT, IPT and PDT are effective treatments.

1. Cognitive behavioural therapy:

CBT focuses on how thoughts can affect emotions which, in turn, can affect behavior responses.

· Identify the upset, negative, distorted thoughts.

· Understand how their negative, distorted thoughts influence their mood and behavior.

· Challenge and replace their negative, distorted thoughts and assumptions with more realistic and accurate

· Reduce behaviors that contribute to depression.

· Increase behaviors that contribute to great physical and mental well-being.

· Prevent relapse of symptoms

2. Interpersonal Psychotherapy:

It focuses on role transitions, including chancing role and relationships with other people.It teaches the skill that is needed to adjust to changing roles and improve the interaction.

3. Psychodynamic Therapy:

Goal is to increase awareness and understanding the influence of the past on present behavior. It focuses on unconscious processes as they manifest in present behavior.

4. Group Therapy:

Group therapy provides a safe accepting place to vent frustration and fears, so asto receive comfort and encouragement from other.

5. Parent-infant Psychotherapy:

Aim is to improve the qualityrelationship of the parent and infant and socio emotional functioning of the baby.

6. Couples and family therapy:

It ismore effectivein reducing relationship distress during perinatal period.

7. Bright Light Therapy:

BLT can be an effective treatment for depression in the perinatal period.

8. Electroconvulsive Therapy:

Electroconvulsive therapy is reported in the literature to be safe and effective in the treatment of severe mental illness during pregnancy and in the postpartum period .it is generally used for women experiencing severe depression who have not responded to medication.

Pharmacotherapy:

· Antidepressants.

· Benzodiazepines

· Selective Serotonin Reuptake Inhibitors(SSRI)

· Serotonin Nor Epinephrine Reuptake Inhibitors¹⁰

RECOMMENDATIONS:

· Health policy makers should makespecialist services accessibleto pregnant women with mental health disorders.

· Training and education onpreventing, identifying and managingperinatal mental health disorders

· Multidisciplinarycare must be coordinatedand clear referral pathways should be inplace.

· Women with mental health disordersshould be treated sensitively and with respect.

· Educate and raisethe awareness of society aboutperinatal mental illness so to reduce the stigma.

· Proper utilization of perinatal mental health care services.

· There is a need for health professionals to be adequately trained in the recognition and management of mental health disorders in pregnancy.

· This need is largely unmet, and many doctors, midwives and allied professionals lack the confidence and knowledge required for effective, woman-centred care.

· Comprehensive training programme in the prevention, identification and management of perinatal mental health disorders needed.

· It is an exemplar template that can be adapted to suit local training needs at various levels.¹¹

CONCLUSION:

Perinatal mental health is rapidly expanding field which emphasizes the need for health and emotional well being of all members of family, infants. An evidencebase for best practice is slowly emerging but considerable work is still needed to identify the women at risk of perinatal mood disorder. Maternal health policies, should be a priority in developing countries, must integrate maternal mood disorder as a disorder of public health importance. Intervention should target women in the early antenatal period.

REFERENCES:

1. Burt VK, Quezada V. Mood disorder in women: Focus on reproductive psychiatry in the 21st century. Can J Clin Pharmacol. 2009; 16(1):e6-14.

2. Perinatal mental health consortium, beyond blue national action plan for perinatal mental health 2008-2010- full report https://www.beyoundblue.org.au/ perinatal.

3. HomeWomen's Health Postpartum Health2018 Latest Statistics of Postpartum Depression Occurrence rate;https://www.checkpregnancy.com/2018-statistics-postpartum-depression-occurrence-rate/

4. Shashi rai, Abhishek pathak etal;Postpartum psychiatric disorder; Early diagnosis and management; Indian journal of psychiatry;vol57(6); 216-221

5. Irfan Naveen and Badar Ahmed, Determinants and pattern of postpartum Psychological disorders in Hazata decision of Pakistan; 2002; 6(7); 7.

6. Shridevi D., S. Anuchithra etal; Impact of Child Birth Preparation on AntenatalDepression; Asian.J.Nur.Edu and Research 4(4):oct-Dec.; 2014; 436-442.

7. R. Naganandini; Effectiveness of Structured Stress Management, Module on Stress of Primi Mothers EarlyPostnatal period in a selected Private Hospital,Salem, Tamil Nadu; Asian.J.Nur.Edu and Research; 2(4); oct-Dec ; 2012 :220-221.

8. Kavitha Rajagopal. V, Leethyal; Prevalence of postnatal depression among postnatal mothers;Asian.J.Nur.Edu and Research:2(1):Jan –march;2012;-33

9. https//www.med.unc.edu>psych>wmd

10. Best practice guidelines for mental health disorder in perinatal period; 2014; BC Reproductive mental health programme;

11. WHO; Improving mental heath, Millennium development goal, http;//www. Who.int/mentai health /prevention/suicide/perinatal_ depression_ mmh_final pdf

Received on 12.05.2018 Modified on 16.06.2018

Int. J. of Advances in Nur. Management. 2018; 6(3): 249-252.

DOI: 10.5958/2454-2652.2018.00055.0