Health care providers - What you can do

Introduction

Incidence and symptoms of PPMD
Postpartum psychosis
Recognizing mothers with PPMD
Top 5 risk factors for PPMD
Screening and diagnosis

What you can do

Talk to your patient and validate her feelings
Be aware of barriers mothers face recognizing and/or disclosing PPMD
Help overcome barriers
Treatment should include
Treatment options

Resources

What you can do?

Talk to your patient and validate her feelings

Ask open-ended questions and maintain a non-judgemental position. Even if the patient looks perfectly put together, do not assume anything - ask questions to encourage new mothers to talk. The questions can very easily become part of the well-baby check-up & will provide a great deal of insight into the emotional & physical well-being of a new mom.

Women presenting to an emergency room/family doctor/clinic, & have a child under the age of 1, should be asked the following four questions (PASS-CAN questions with rationale):

1) Are you able to sleep when the baby sleeps?
This question will help identify mothers who sleep too much & those who cannot sleep at all due to constant worrying and racing thoughts. Drastic changes in sleep pattern can be an indicator of possible PPMD. Don't assume that sleeping is a problem because of a crying baby. Find out what the mother does when her baby is sleeping.

2) Are you getting out?
This question will pick up anxiety, depression, agoraphobia, exhaustion & the inability to cope. Women are not always going to look depressed & are experts at disguising their symptoms. Women experiencing PPMD will often isolate themselves to keep their symptoms secret. Find out if they are socializing.

3) Are you eating & if so, what are you eating?
This question will pick up severe anxiety, i.e. a mother feels like she has a rock in her stomach or something constricting her throat, no appetite (& in some cases diarrhoea & vomiting), over-eating, especially eating too many carbohydrates. Find out if this began before or after the baby's birth.

4) Are you having scary &/or repetitive thoughts?
Mothers sometimes have intrusive thoughts about their baby &/or themselves. Asking this question may open lines of communication, but do not expect that a woman will confide in you at this point. She may be afraid that her baby will be taken from her by a child welfare agency. Reassurance that other new mothers also have had scary & repetitive thoughts can be helpful. Providing a mother with a safe environment to express her feelings and fears is of utmost importance.

[Also see, PPMD Desk Reference]

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Be aware of barriers mothers face recognizing and/or disclosing PPMD

Believing the myth society holds that equate motherhood with happiness.
Fearing a mental illness stigma.
Fear of what the treatment may involve, i.e. taking medication while breastfeeding, lack of confidentiality in a support group, lack of transportation and child care to get to counselling sessions, lack of motivation and energy to attend sessions.
Not knowing where or how to access help.
Family members telling them not to discuss their feelings with others.
Cultural or religious reasons why these feelings should not be disclosed.

Barriers must be explored and addressed. Involvement of family members or friends and community resources is paramount in overcoming these barriers.

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Help overcome barriers

You can help overcome these barriers by doing the following:

Make sure you are sensitive when asking questions: your patient is likely intimidated, embarrassed, and afraid of what you may think of her.
Listen to your patient's answers: some women will not disclose their feelings but they will talk about physical symptoms instead (e.g., headache, backache, stomach ache).
Do not minimize symptoms of depression or anxiety.
Do not be afraid to raise issues even if unsure how to help: there are many resources and treatment options you can refer your patient to for help.

The immigrant and refugee population is especially vulnerable as they are unfamiliar with our health care system and may not be aware that it is acceptable and necessary to discuss their feelings with their health care providers. The rates of PPMD are consistent throughout most ethno-cultural groups but may be higher in newcomers to Canada possibly due to the increased stress of relocation and the lack of social support.

There are other vulnerable and at risk populations or those that require a non-traditional approach. Additional and specific strategies may be needed when working with these women.

Women from rural or remote communities
Women who use substances
Women with current and/or past experience of abuse and violence
Aboriginal women
Adolescent women
Single women
Lesbian and bisexual women
Women with chronic mental illness
Women with disabilities
Women after infertility treatments and/or adoption

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Treatment should include

Validation of experience
Reiterate that PPMD is a real disorder and she cannot 'will' it away.
Patient education
Recruitment of family and partners for assistance
Education of partners and family
Ensuring the mother has adequate sleep is an important preventive and treatment measure.

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Treatment options

More emotional, practical, and social support from the mother's partner or spouse, friends and relatives.

Self-care. Strategies such as getting as much rest as possible, asking support people for help, eating well, getting moderate exercise and building a strong support network are of utmost importance to a new mom. However, these are not a substitute for appropriate medical or psychological treatment and should be encouraged and considered as part of the comprehensive treatment plan.

Peer or professionally led support groups. Lack of support is a strong risk factor for the development of PPMD. Support groups allow new moms to identify with other women in similar situations, normalize their experiences and demonstrate that others share their feelings.

Non directive counseling promotes a safe, non-judgemental, confidential space for women to explore their feelings.

Psychotherapy, such as Interpersonal (IPT) or Cognitive Behavioural Therapy (CBT); has good evidence for effectiveness in depression in general; recommended for mild to moderate PPMD

Interpersonal Psychotherapy (IPT): focuses on the changing roles of parenthood and improving relationship dynamics; can help resolve the marital or relationship conflicts that are common among new parents.

Cognitive Behavioural Therapy (CBT): aims to replace negative thought patterns with a more reality-based and positive cognitive style that improves coping skills.

Antidepressants have good evidence for effectiveness in depression in general Selective Serotonin Reuptake Inhibitors (SSRIs) like Paxil, Zoloft and Prozac are the most frequently prescribed antidepressants in the postpartum period.

The decision whether or not to use antidepressant mediation while breastfeeding, as well as which medication to use, should be made by each individual woman, her family and her physician based on the risks and benefits to her and her baby.

For information about safety or risk of drugs during pregnancy and lactation please contact Motherisk at http://www.motherisk.org or call 416 813 6780

· Refer to psychiatric consultation or consider hospitalization when patients:

Have moderate to severe symptoms and do not respond to psychotherapy alone
Endorse suicidal or homicidal ideation
Have a history of severe depression in the past
Need more support and monitoring than you can provide
Have psychotic or manic symptoms

Many mothers use a combination of treatments to overcome PPMD. Health care providers should follow up once treatment has begun to assess the effectiveness of the treatment. Adapt or change the treatment plan together with the mother. Research has shown that most mothers respond better to treatment if they have been able to discuss the options and participate in the formulation of their treatment plan.

Breastfeeding is not contra-indicated with most treatment options. Many mothers feel better if they are able to breastfeed successfully, but will need support and resources to assist with the establishment of lactation. Every mother should be assessed on an individual basis.

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