Mental Health Problems during Pregnancy - Essay Example

Mental Health Problems During Pregnancy "At the beginning of the twenty-first century, your chances of a healthy life still depended on what job you do, where you live, and how much your parents earn. That is unfair and unjust. That is why this Government is committed to narrowing the health inequalities that scar our nation and to improving health for all" (London HMSO) Yvette Cooper-Minister for Public Health and Professor Liam Donaldson-Chief Medical Officer stated this in a recent Department of Health publication ('From Vision to Reality', 2001). Her statement holds true to various groups of individuals in all kinds of society - even to the case of pregnancy. Pregnancy was once considered as a disease in ancient times because during the stage, a complete revolution happens in the woman's body. When a woman is pregnant, taking extra care has never been more important. Advices from everyone - doctor, family members, friends, co-workers, and even complete strangers - about what should and shouldn't be doing will be very imminent. But staying healthy during pregnancy depends on the women themselves, so it's crucial to arm themselves with information about the many ways to keep themselves and their baby as healthy as possible. However, there are cases when pregnant women become torn with issues concerning several areas of their lives. Sometimes some women are not equipped with the basic needs such as financial that would support basic nutrition, clothing, proper condition of environment; they also need support from their loved-ones, co-workers, especially the concern that there are some task no longer fit for pregnant women. Ideally, pregnant women should avail of prenatal care, proper nutrition, and right sleep. However, it is important to note as well that the health sector of a state provide the necessary programs that pregnant women needs during the course of their pregnancy. During pregnancy, from the first week to the fortieth, it's important to take care of themselves in order to take care of the baby as well. Even though they have to take some precautions and be ever-aware of how and what they do - and don't do - may affect the baby, many women say they've never felt healthier than when they carried their children. Problems may arise during pregnancy; one of the common problems faced by pregnant women is mental problems. Any mental problem may occur during pregnancy. These problems include depression, manic-depressive disorder, anxiety disorders, and schizophrenia. However, pregnancy does not seem to cause these disorders. The major mental problems usually start between the teenaged years and the 30s. This just happens to be the same time in which women often get pregnant. For six to eight weeks after a baby is born, mood disorders like major depression and manic-depressive disorder might start or get worse. Postpartum depression (also called "the baby blues") also occurs some time after delivery. But then some of these problems may be treated with proper advice from the health care provider because some medicines can be used in pregnant women the same way they are used in women who are not pregnant. Also some medicines should not be used at all during pregnancy. Some medicines can be used during pregnancy if the doctor keeps a careful watch on the mother. The use of these medicines depends on the situation and needs of the pregnant women. The health care provider and the pregnant women will have to balance the risks of these medicines with the severity of your mental problem. Some women have a severe mental problem that could be dangerous or even life-threatening if they stop taking their medicine. Other women have problems that could be managed with psychotherapy and close attention from the doctor, but without medicine. No decision is entirely free of risks. The health care provider (possibly with the help of a mental health professional) will help the pregnant woman make a treatment plan to manage their mental problem during pregnancy. This plan may include medicine and other forms of therapy. According to Randy Ward and Mark Zamorski, traditionally, psychiatric medications were withheld during pregnancy because of fear of teratogenic and other effects. Emergence of evidence of the safety of most commonly used psychiatric medications, the availability of this information in the form of online databases, and the documentation of the adverse effects of untreated maternal mental illness have all increased the comfort of physicians and patients with respect to the use of psychiatric medications during pregnancy. The tricyclic antidepressants and fluoxetine (Prozac) appear to be free of teratogenic effects, and emerging data support similar safety profiles for the other selective serotonin reuptake inhibitors. The mood stabilizers appear to be teratogenic. With the exception of the known risk for depression to worsen in the postpartum period, there is little consistent evidence of the effects of pregnancy on the natural history of mental illness. Decisions regarding the use of psychiatric medications should be individualized, and the most important factor is usually the patient's level of functioning in the past when she was not taking medications (Am Fam Physician 2002;66:629-36,639. Copyright 2002 American Academy of Family Physicians). Psychiatric disorders are common in women of reproductive age (Frank JB, Weihs K, Minerva E, Lieberman DZ. Women's mental health in primary care; 1998;82:359-89.) Despite the morbidity associated with these disorders, there has been a tendency to avoid prescribing psychiatric medications during pregnancy. An expanding body of knowledge about the risks and benefits of these medications has made it possible to make more rational decisions about their use.2,3 Growing evidence suggests that many of these agents are safe; however, there are some that clearly should be avoided. Psychiatric symptoms can affect pregnancy because of their effect on the mother's emotional state, functional status, ability to obtain proper prenatal care, and potential to engage in dangerous behavior.2 After the birth of a child, untreated maternal mental illness may have an effect on the infant's development and well-being.2,3,5 All currently available psychopharmacologic agents and their metabolites cross the placenta, principally by simple diffusion.6 The specific fetal serum levels are unknown, but they may be higher than maternal levels.6 Individualizing Treatment Decisions In individualizing treatment decisions, several general considerations must be addressed. The most important consideration is the patient's past level of function when not taking medication. An assessment of the level of function should include a history of previous psychiatric hospitalization (generally considered evidence of significant dysfunction); suicidality or similar self-destructive thoughts or behaviors; and an assessment of the patient's ability to meet home, educational, and occupational responsibilities. The natural history of symptoms and dysfunction during previous pregnancies and deliveries, if known, is also important, especially in patients with depressive and bipolar disorders. If the patient has a psychotherapy-responsive condition, the possibility of substituting this form of therapy for medication should be considered within the context of patient preference, availability of quality psychotherapy and the patient's previous response to such therapy. Although patient preferences and values should be considered, mental illness can cause cognitive distortions that interfere with good decision-making. Ideally, preferences should be elicited when the patient is well. DEPRESSIVE DISORDERS In women, it is clear that the onset of major depression tends to occur in the child-bearing ages.1 Studies have shown a similar incidence of major depressive episodes in matched gravid and nongravid women, so pregnancy appears to have neither a protective nor a detrimental effect.24 In contrast, the postpartum period is one of high risk for the development of a depressive episode, particularly in women with a history of major depression (especially if it had a postpartum component), depressive symptoms during pregnancy, or bipolar disorder.24,25 The management of women with depression during pregnancy is based on balancing the potential risk of the symptoms against the potential risks of pharmacotherapy.3 Antidepressant medications are among the best-studied medications in pregnancy, and the evidence of their safety is substantial.2,8 BIPOLAR DISORDER Little is known about the course of bipolar disorder during pregnancy, but the postpartum period is clearly one of high risk.24,27 Postpartum relapse rates in women not treated with prophylactic mood stabilizers are 30 to 50 percent.25 Initiation of treatment with a mood stabilizer before delivery or immediately postpartum markedly reduces this risk.25 In addition, many patients who present with postpartum psychosis may be having an initial episode of bipolar disorder.27 Again, treatment should be guided by the patient's history of previous and current mood symptoms balanced against the risks of pharmacotherapy, as detailed in Table 3.25,26 Involvement of a psychiatrist will be helpful in characterizing the risk and predicted severity of relapse. Women taking mood stabilizing agents should be offered folate supplementation and prenatal screening for cardiac and neural tube defects, as indicated.2,9,23 PSYCHOTIC DISORDERS There are few data on the impact of pregnancy on the course of schizophrenia.2,3 The delusions, hallucinations, and disorganized thinking and behavior present in persons with untreated schizophrenia can have a particularly devastating effect on the person's overall function and ability to comply with prenatal care.28 Chronic schizophrenia has an extremely high rate of relapse when medications are withdrawn.2 Pharmacologic treatment is guided by the woman's psychiatric history, with continued maintenance treatment usually being the safest overall strategy.2 New-onset psychosis during pregnancy is a psychiatric and obstetric emergency. Careful diagnostic assessment to evaluate for psychiatric and organic disorders is necessary. Decisions regarding regular dosing or as-needed use of antipsychotics are guided by the patient's symptoms and the likely primary diagnosis. Ordinarily, these decisions are made in consultation with the patient's psychiatrist.2 ANXIETY DISORDERS Pregnancy does not have a clear impact on the natural history of anxiety disorders, although there is an apparent risk of susceptibility in the postpartum period.24 Patients on maintenance pharmacotherapy for these disorders show high rates of relapse with medication discontinuation. Cognitive behavior therapy has been shown to be an effective treatment modality in many of these disorders, and it may be a reasonable option for patients who wish to discontinue medications during pregnancy.22 If benzodiazepines are used during pregnancy, they should be avoided in the first trimester because of possible teratogenicity and before delivery because of an apparent perinatal syndrome.2,19 In women receiving chronic daily benzodiazepine therapy who wish to conceive, medication should be weaned gradually (approximately 10 percent per week) and consideration given to cognitive behavior therapy or antidepressant therapy.22 The best-studied agents for use during pregnancy are alprazolam (Xanax), clonazepam (Klonopin), and diazepam (Valium).2 Despite the many uncertainties about the effects of psychiatric disorders and various medications on the mother, fetus, and infant, there are guidelines for making decisions about using pharmacologic agents during pregnancy. The patient's psychiatric history is the best predictor of future functioning. The patient's diagnosis, severity of previous episodes, necessity for medication, and responsiveness to medication are strong predictors of the need for medication to maintain remission. Patients with schizophrenia, bipolar disorder, severe chronic depression, and panic disorder with agoraphobia are generally at risk for a high degree of dysfunction and morbidity with relapse. Patients with disorders such as dysthymia, generalized anxiety disorder, or panic disorder without agoraphobia may experience less of an impact on their functional status. Nonpharmacologic therapies may eliminate or reduce the need for medications in some disorders. Cognitive behavior therapy for anxiety disorders and interpersonal psychotherapy and cognitive behavior therapy for depressive disorders have proved efficacious. When medications are used, those that are most appropriate for the patient's condition should be chosen. The SSRIs are usually the agents of choice in the treatment of depressive and anxiety disorders. When there is a choice, medications should be selected on the basis of existing data. Collaboration and consultation with mental health professionals is an important aspect of treatment planning. Diagnosis, risk assessment, symptom monitoring, and optimal medication management can require special expertise and can be time intensive. Patients with chronic severe depressive and anxiety disorders, psychotic disorders, and bipolar disorders are particularly in need of specialty consultation and management. Psychotherapy, in addition to being an appropriate primary symptomatic treatment for some depressive and anxiety disorders, should be considered as a means of helping patients deal with issues related to their psychiatric disorder, pregnancy, and other life stresses. Mental health Mental health services in England are experiencing a period of unprecedented change. In the last five years, a wealth of evidence has emerged about which practices are effective and which are not. But the country has come up with several programs to answered to the needs concerning mental health. There are many different types of mental health services to offer support and treat a range of mental illnesses. Mental health services are provided by; * the NHS and social services, * charities and other not-for-profit organisations, and * privately run services. Mental health care may be primary or secondary. Primary mental health care services include treatment at your GP surgery, local hospital, or walk-in centre. Drug treatment, counselling services, and advice and information may be provided from a primary service. People with more severe mental health problems may be referred to specialist mental health services. This is called secondary care, and involves community-based treatment, usually provided by mental health trusts. Depending on the type of service, treatment can be accessed through a day hospital, inpatient clinic, home visits, 24-hour help lines, crisis centres, voluntary drop-in centres, and day-care centres. National Health Service The aim of the National Health Service (NHS) is to improve the health and wellbeing of the population in general by promoting better health, helping to prevent illness, and providing the best treatment and continuing care when needed. Improving the health of all children and young people is just one, a vital part the Every Child Matters: Change for Children programme, contributing directly to the "Be healthy" and "Stay safe" outcomes, and indirectly to others. Children and young people who are suffering from ill health or malnutrition will be less likely to "enjoy and achieve", and may have difficulty in "making a positive contribution" to their schools, local communities and wider society. But one of the major target even before these children should be the mothers who bear them during the pregnancy stages because it is there where children accumulate the basic health indicators when they are finally come face to face with the reality. But normally, programs for pregnant women are always come by with programs for the young and women. Within the NHS, the mechanism for improving the health of children and young people is the National Service Framework (NSF) for Children, Young People and Maternity Services. This was launched by the Department of Health in September 2004. The NSF is a ten-year programme designed to bring about sustained improvement in children's health and wellbeing. Because full implementation is expected to take up to ten years, the NSF forms part of the NHS 'developmental standards' that NHS organisations must work towards ('core standards' are those which NHS bodies are expected to meet) and which will be taken into account by the Healthcare Commission. (The Healthcare Commission inspects health care provision in accordance with national standards and other service priorities, and reports directly to Parliament on the state of healthcare in England and Wales.) The NSF is an integral part of the Every Child Matters: Change for Children programme. Just as the Change for Children programme can only be delivered by a number of organisations working in close partnership, so the NSF cannot be delivered by the NHS alone. Like Change for Children, the NSF is intended to lead a cultural shift that will result in services that are designed and delivered around the needs of children and their families, rather than around the needs of organisations. How is the NHS structured The Department of Health, led by the Secretary of State, is the government department responsible for setting the overall direction of the NHS. It sets national standards designed to improve service quality; secures resources and makes investment decisions to ensure that the NHS is able to deliver services. The Department of Health works with key partners (such as the NHS Modernisation Agency and Strategic Health Authorities) to ensure the quality of services. Authorities and trusts are the different types of organisation that run the NHS at a local level. Strategic health authorities There are 28 strategic health authorities (SHAs), created by the Government (in 2002) to manage the local NHS. They are the key link between the Department of Health and local NHS trusts. SHAs are responsible for developing plans for * Improving health services in their area * Making sure that services are of a high quality and performing well * Increasing the capacity of local services so that they can provide more services * Making sure that national priorities are integrated into local health service plans Within each SHA, the NHS is split into various types of trusts that take responsibility for running the NHS at a more local level. Primary care trusts Primary care trusts (PCTs) are the cornerstone of the NHS. Not only do they manage all primary care services (GPs, pharmacists, dentists, and so on), they are also responsible for buying almost all of the healthcare, both primary and secondary, for the local population. PCTs receive 75% of the NHS budget. As local organisations, they are thought to be in the best position to understand the needs of the local community and make sure that organisations providing health and social care are working effectively. PCTs work with local authorities and other agencies that provide health and social care locally to make sure that the local community's needs are being met; they are responsible for getting health and social care systems working together to the benefit of patients. Care trusts Care trusts work in both health and social care. They are set up when the NHS and local authorities agree to work closely together because it is felt this is the best way to improve local care services. Care trusts may provide a range of services, including social care, mental health services, or primary care. At present, there are only a small number of care trusts in England. Acute trusts Hospitals are managed by acute trusts, which make sure that hospitals provide high-quality healthcare and spend their money efficiently. They also decide on strategy for how the hospital will develop, so that services improve. Some acute trusts are regional or national centres for more specialised care; others are attached to universities and help to train health professionals. Acute trusts may sometimes provide services in the community (eg through clinics or health centres). Foundation trusts These are a new type of NHS hospital run by local managers, staff and lay members, that have been given more financial and operational freedom than other NHS trusts and have come to represent the government's commitment to de-centralising control of public services. Foundation trusts remain within the NHS and its performance inspection system. Special health authorities These are health authorities that provide a national (rather than local) service, either to the public or to the NHS - for example NHS Direct, the National Blood Authority, and the Heath Development Agency. They are independent, but can be subject to ministerial direction like other NHS bodies. What do they do The Children Act 2004 requires all partners in a local area to cooperate with the local authority in making arrangements to deliver improved outcomes for children and young people; this includes SHAs and PCTs. A key element of these arrangements is joint planning and commissioning by the partners involved; in particular, working together on the new children and young people's plan, which every local authority has to have in place by April 2006. Within the NHS, there is a basic five-stage delivery cycle to the provision of local services for children and young people. These stages can be seen as a continuous cycle of improvement which mirror those that children's trusts will follow in planning and commissioning services. The five stages are: * Assessing the needs of children, young people and pregnant women (gathering, analysing and interpreting information to plan and improve services systematically) * Identifying priorities: setting targets and standards (this will include national targets, as well as local targets) * Planning services (working with local partners including local authorities PCTs set three-year local delivery plans (LDPs)) * Commissioning services to meet those needs (based on the LDP and children and young people's plan) * Managing performance, assessing and inspecting outcomes (this includes internal evaluation, performance management by SHAs, and inspection by the Healthcare Commission, other inspectorates and joint area reviews) All PCTs are required to set LDPs in Spring 2005 for the three financial years 2005/06-2007/08. (The levels of performance in LDPs will be agreed and signed off by SHAs; the Department of Health will, in turn, sign off SHA-level plans, ensuring that national performance expectations are fully agreed.) Local partners will need to ensure that the LDP and the children and young people's plan are consistent. Together, the two plans will form the basis for effective local commissioning. Key to the success of the NSF is how effectively local partners work together on commissioning services for children and young people, including the use of joint commissioning. The NSF for Children, Young People and Maternity Services was published in September 2004. It sets out a ten-year programme for sustained improvement in children's health and wellbeing by setting national standards for children's health and social services (and the interface with education), from before birth through to adulthood. The first five core standards of the framework apply to universal services for all children; standards 6 to 10 apply to particular groups of children and young people (children who are ill, children in hospital, disabled children and children with complex needs, children who have mental health problems, and medicines for children); standard 11 covers maternity services. The Children's NSF is directed at everyone involved in the delivery of services to children, young people or pregnant women. Different mental health services provide different treatments, including drug treatment, talking therapies, psychotherapy and art therapy. Medication can relieve symptoms in the short term, and is often used alongside other techniques such as counselling. Some people are prescribed drugs to help them deal with an immediate crisis, and others rely on medication to help them live with long-term, severe mental health problems. Talking treatments include counselling, behavioural therapy, cognitive therapy, group therapy and psychoanalysis. The therapies all work in different ways, but aim to help people understand the problem, look at possible causes, or find ways of coping with their illness. Psychotherapy is generally used to treat more complex psychological problems that have built up over many years. It's a way of helping people understand their difficulties, weaknesses and anxieties in order to manage them. Other therapies include art and music therapy, hypnotherapy and acupuncture. Some of these are available on the NHS and may be used alongside conventional drug treatments. REFERENCES 1. Frank JB, Weihs K, Minerva E, Lieberman DZ. Women's mental health in primary care. Depression, anxiety, somatization, eating disorders, and substance abuse. Med Clin North Am 1998;82:359-89. 2. Altshuler LL, Cohen L, Szuba MP, Burt VK, Gitlin M, Mintz J. Pharmacologic management of psychiatric illness during pregnancy: dilemmas and guidelines. Am J Psychiatry 1996;153:592-606. 3. Cohen LS, Rosenbaum JF. Psychotropic drug use during pregnancy: weighing the risks. J Clin Psychiatry 1998;59(suppl 2):18-28. 4. Spencer JP, Gonzales LS 3d, Barnhardt DJ. Medications in the breast-feeding mother. Am Fam Physician 2001;64:119-26. 5. Weinberg MK, Tronick EZ. The impact of maternal psychiatric illness on infant development. J Clin Psychiatry 1998;59(suppl 2):53-61. 6. Stowe ZN, Strader JR, Nemeroff CB. Psychopharmacology during pregnancy and lactation. In: Schatzberg AF, Nemeroff CB, eds. The American Psychiatric Press Textbook of psychopharmacology. 2d ed. Washington, D.C.: American Psychiatric Press, 1998:979-96. 7. Little BB, Gilstrap LC. Introduction to drugs in pregnancy. In: Gilstrap LC, Little BB, eds. Drugs and pregnancy. 2d ed. New York: Chapman & Hall, 1998:523. 8. Wisner KL, Gelenberg AJ, Leonard H, Zarin D, Frank E. 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Bull Menninger Clin 2000;64:5-17. 28. Bennedsen BE. Adverse pregnancy outcome in schizophrenic women: occurrence and risk factors. Schizophr Res 1998;33:1-26. 29. RANDY K. WARD, M.D., MARK A. ZAMORSKI, M.D., Benefits and Risks of Psychiatric Medications During Pregnancy 30. NHS Direct Online Health Encyclopaedia Read More