South African Psychiatry - November 2018

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FEATURE CLINICAL AND SOCIAL ASPECTS OF PERINATAL DEPRESSION IN SOUTH AFRICA Carina Marsay The term perinatal depression is used to refer to both major and minor depression occurring at any time between conception and the baby’s first birthday. Much of the focus until recently has been on postnatal depression, but the prevalence and the importance of antenatal depression, as the greatest predictor of postnatal depression, is being increasingly recognized. IN ADDITION TO THIS MANY CASES OF POSTPARTUM DEPRESSION BEGIN ANTENATALLY WITH FEATURES OF ANXIETY. RECENT LITERATURE SUGGESTS THAT POSTNATAL ANXIETY IS AS COMMON AS POSTNATAL DEPRESSION, AND THAT ANTENATAL DEPRESSION IS AS COMMON AS POSTNATAL DEPRESSION. THIS HAS LED TO THE EMERGENCE OF A DEFINITION OF PERINATAL DEPRESSION THAT INCLUDES BOTH DEPRESSION AND ANXIETY SYMPTOMS IN THE PERINATAL PERIOD. Postpartum psychosis is relatively rare, with an incidence of 1.1 – 4 per 1000 deliveries, and usually occurs in women with a personal or family history of bipolar or schizoaffective disorder. CLINICAL PRESENTATION Perinatal depression and anxiety occur on a continuum and therefore, there are a wide range of clinical presentations. Core symptoms of depression include: • A depressed mood most of the day and nearly every day • Loss of interest in pleasurable activities • Feeling down and hopeless or worthless • Trouble sleeping, especially early morning awakening or hypersomnia • Decreased appetite or weight loss, or increased appetite and weight gain • Inability to concentrate and impaired thinking and decision making • Psychomotor agitation or retardation • Fatigue and decreased energy • Feelings of guilt • Suicidal and recurrent morbid thoughts Carina Marsay These symptoms need to be present for two or more weeks and cause impairment in functioning. Anxiety can be part of and separate to perinatal depression, and there is a very high comorbidity. Not all women meet the diagnostic criteria for a mood or anxiety disorder, but their levels of distress are significant and clinically relevant. Other commonly reported symptoms include: • Sadness, weepiness, low mood, irritability, impaired concentration and feeling overwhelmed • Anxiety and agitation, ruminating or obsessional thoughts about the pregnancy or baby • Severe hypervigilance of the baby, including inability to sleep at night when the baby is sleeping 18 * SOUTH AFRICAN PSYCHIATRY ISSUE 17 2018
FEATURE • Feeling detached from the infant • Lack of interest in holding or caring for the baby • Guilt that they are not able to enjoy the baby. PREVALENCE AND RISK FACTORS Rates of depression in women during the perinatal period are reported to be around 10-15% in highincome countries. In other low and middle-income countries rates are 16-20%. In South Africa however, the rates of perinatal depression are significantly higher, ranging from 22-47%. The high rates of perinatal depression in South Africa may be related to the compounding nature of multiple economic, social and psychosocial stressors. THESE INCLUDING POVERTY AND UNEMPLOYMENT, INTIMATE PARTNER VIOLENCE, LACK OF PARTNER SUPPORT, UNPLANNED PREGNANCY, AND THE HIGH PREVALENCE OF HIV IN PREGNANT WOMEN (39-45%), INCLUDING DIAGNOSIS OF HIV INFECTION IN THE COURSE OF ANTENATAL CARE. SIMILAR ASSOCIATIONS HAVE BEEN FOUND IN OTHER LOW AND MIDDLE-INCOME COUNTRIES, WHERE SOCIO-ECONOMIC DISADVANTAGES COMPRISING OF FOOD INSECURITY, FINANCIAL DIFFICULTIES, UNEMPLOYED PARTNERS AND LOW INCOME WERE ASSOCIATED WITH PERINATAL DEPRESSION. In addition, social disadvantage comprising of poor emotional support and lack of empathy from partners, having hostile in-laws and having insufficient practical and emotional support, contributed to the risk of perinatal depression. From this, it is clear that maternal depression has multiple etiologies, and cannot be solely explained by women’s biological and psychological vulnerability. Rather, social and environmental factors are important contributing factors and determinants of risk and socio-cultural context impacts both prevalence and presentation of perinatal depression. Protective factors include; having more education, permanent job, a kind and trustworthy intimate partner, as well as support from friends and family. CONSEQUENCES Infants and children of depressed mothers have poorer physical, cognitive and emotional outcomes. Among women living in relative poverty, poor maternal mental health during the antenatal period is a risk factor for low birth weight and preterm delivery. Postnatally, malnutrition, poor infant growth, and increased frequency of infant diarrheal illness are prevalent, which may be related to the early cessation of breastfeeding in depressed mothers living in poverty. This can lead to an increase in child mortality. The emotional development of infants is compromised because of a disturbed mother-infant relationship, where mothers are less sensitive towards their infants and infants are less responsive towards mothers. This in turn leads to poorer quality attachment, resulting in behavioural and psychological difficulties that can last into adolescence and adulthood. Compromised cognitive functioning and delayed development also affect infants and children of depressed mothers, impacting on their scholastic achievement. In the context of chronic social and economic adversity, poor quality parenting as a result of maternal depression is especially harmful. THESE ADVERSE OUTCOMES FURTHER PERPETUATE SOCIAL AND ECONOMIC INEQUALITY IN THE NEXT GENERATION. DEPRESSED MOTHERS ARE ALSO AT RISK OF LOSING THEIR INCOME AND ECONOMIC POTENTIAL AS A RESULT OF THEIR IMPAIRED MENTAL STATE. THESE WOMEN ALSO HAVE HIGHER RISKS OF INTIMATE PARTNER VIOLENCE, SUBSTANCE ABUSE AND SUICIDE. Possible mechanisms for the above mentioned consequences may include; poor uptake of health and social services by depressed mothers; increased stress hormones in utero impacting on the developing fetus as well as a co-occurrence with worse physical health, poor nutrition and substance abuse. Luckily, some of the factors contributing to these adverse consequences are modifiable and we can prevent some of these devastating effects. SCREENING FOR PERINATAL MENTAL DISORDERS Given the high rates and compounding associated risk factors for maternal depression, its early identification and management is vital. Screening with referral is a valuable, strategy for mitigating the devastating consequences of the illness on mothers and their families. Secondary prevention consists of early identification and treatment of a disease to prevent potential future complications and disabilities from the disease. TRADITIONALLY, SCREENING PROGRAMMES ARE A GOOD EXAMPLE OF SECONDARY PREVENTION IN MEDICINE. THE PERINATAL PERIOD IS AN IDEAL TIME AS PREGNANT WOMEN ARE LIKELY TO HAVE ACCESS TO HEALTH CARE AND THE PERINATAL PERIOD PROVIDES MULTIPLE OPPORTUNITIES FOR EDUCATION, PREVENTION, DETECTION AND TREATMENT OF COMMON PERINATAL MENTAL DISORDERS. SOUTH AFRICAN PSYCHIATRY ISSUE 17 2018 * 19
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South African Psychiatry - November 2018

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