GG JIWA PRE DAN PASCA NATAL

DEPT .OF PSYCHIATRY MED FAC UII 2014

PROF.DR. Dr. H. SOEWADI MPH , SpKJ (K)
Mental Disorder and New Mothers
 Having a baby can be both an exciting and
thrilling time for any mother.

 However, it can also be a time when many new

mothers feel overwhelmed.

 Nearly 10 percent of new mothers experience a

distress known as postpartum depression.
BEHAVIOR OF PREGNANT WOMEN
 PREGNANT WOMEN ARE EXTRAORDINARILY
SENSITIVE TO PRENATAL MOVEMENTS.

 THEY DESCRIBE THEIR UNBORN BABIES AS ACTIVE

OR PASSIVE, AS KICKING VIGOROUSLY OR ROLLING
AROUND,

 AS QUIET WHEN THE MOTHERS ARE ACTIVE BUT

AS KICKING AS SOON AS THE MOTHERS TRY TO
REST
Biology of pregnancy
 The first presumptive sign in pregnancy is the
absence of menses for one cycle
 other presumptive signs are breast engorgement
and tenderness, changes in breast size and shape,
nausea with or without vomiting (morning
sickness), frequent urination, and fatigue.
Mental Disorder
pre and postnatal
PMD includes other Mental Health diagnoses:

Depression / Anxiety / OCD

Panic Disorders,Agoraphobia
Bi- Polar Disorder / Psychosis / PTSD

PMD occurs before, during & up to 12 months

postpartum.
 Spectrum of Postpartum
Mood Changes
Transient, Serious, Medical
nonpathologic disabling emergency

100% Postpartum Blues

90% risk for Postpartum
80%  Depression

70%
Postpartum Depression
Incidence

50% to 70%
60% 2/3 have onset by
50% 6 wks postpartum

40% Postpartum Psychosis

30% 70% are affective
(Bipolar, Major
20% 10% Depression)
10% 0.01%
0%

Cohen LS. Depress Anxiety. 1998:1:18-26.

 Prevalence maternal depression
and related symptoms

Type Onset Prevalence Symptoms

Prenatal During 10 to 20 percent of • Crying, weepiness
depression pregnancy pregnant mothers • Sleep problems
• Fatigue
• Appetite disturbance
• Anhedonia
• Anxiety
• Poor fetal attachment
• Irritability
 Prevalence maternal depression
and related symptoms

Type Onset Prevalence Symptoms

Baby Blues Begins during As high as 80 • Crying, weepiness
the first few percent of new • Sadness
weeks after mothers • Irritability
• Exaggerated sense of
delivery (usually
empathy
in first week, • Anxiety
peaking at 3-5 • Mood lability (“ups” and
days). Symptoms “downs”)
usually resolve by • Feeling overwhelmed
two weeks after • Insomnia, trouble falling
pregnancy. or staying asleep;
fatigue/exhaustion
• Frustration
 Prevalence maternal depression
and related symptoms
Type Onset Prevalenc Symptoms
e

Postpartum Usually within 10 to 20 • Persistent sadness

depression the first two to percent of • Frequent crying, even about little things
three months new mothers • Poor concentration
post-partum, • Difficulty remembering things
though onset • Feelings of worthlessness, inadequacy or guilt
can be • Irritability, crankiness
immediate • Loss of interest in caring for oneself
after delivery • Not feeling up to doing everyday tasks
(distinguishab • Psychomotor agitation or retardation
le from “baby • Fatigue, loss of energy
blues” as it • Insomnia or hyperinsomnia
lasts beyond • Significant decrease or increase in appetite
two weeks • Anxiety manifested as bizarre thoughts and fears,
post-partum) such as obsessive thoughts of harm to the baby
• Feeling overwhelmed
• Somatic symptoms (headaches, chest pains, heart
palpitations, numbness and hyperventilation)
• Poor bonding with the baby (no attachments),
lack of interest in the baby, family or activities
Postpartum Depression: Symptom
Onset

• 40%: After first postnatal visit

– At 6 weeks
• 20%: Coincided with weaning
• 16%: At return of menstruation
– At 2 to 3 months if not breast feeding
• 14%: Initiation of oral contraceptives
 Admissions to a Psychiatric Hospital:
2 Years Pre and Post Delivery
70

60

50
Admissions/Month

40

30

20
Pregnancy

10

0
–2 Years – 1 Year Childbirth +1 Year +2 Years

Kendell RE et al. Br J Psychiatry. 1987;150:662; presented at WMH, Berlin 2001.

Postpartum Psychosis
 Is relatively rare, occurring one to three cases per
1000 births
 Is a severe and life threatening condition for both
mother and infant
 Develops soon after birth, often within two weeks,
usually within a month
 Requires intense treatment and hospitalization: A
medical emergency
 Is usually followed by Postpartum Depression
Symptoms of Postpartum
Psychosis
 Delusions: False beliefs, often of a religious nature and
very frequently involving the infant
 Perceptual distortions: Seeing or hearing things which
are not present
 Often, feelings of excessive well being or importance
What are obsessions and
compulsions?
 An obsession is a repetitive, intrusive and
disturbing thought that enters the mind and is out
of the individual's control.
 A compulsion is a repetitive act that is done in an
attempt to be rid of the obsessional thought.
 Both cause great anxiety and discomfort in the
individual.
Postpartum obsessions
 Commonly focused on infant
 Thoughts(obsessions) of hurting the infant
 Dropping infant
 Drowning infant
 Stabbing infant
 Putting infant in oven or microwave
 Sexually abusing infant
 Thoughts that someone will steal or harm the infant
Postpartum compulsions
 Commonly follow the obsessions as an attempt to
alleviate the thought
 Avoid holding baby by staircases, etc
 Avoid bathing infant
 Hide knives
 Avoid kitchen area
 Avoid changing diapers or bathing infant
 Avoid leaving the house
Although the presence of obsessions and
compulsions indicates need for treatment,
these mothers are rarely dangerous to the
infants.
They are actually at higher risk to hurt
themselves as a result of their fear of possibly
hurting the infant.
There are risk factors that
predispose women to
postpartum disorders.
Risk Factors
 First pregnancy
 Young age
 Psychiatric illness during pregnancy
 Prior history of postpartum illness
 Prior history of mental illness
 Family history of mental illness
 Recent stressful life events
 Problems in the marriage
In addition, there are many
societal and cultural factors that
may predispose women to
postpartum problems including...
 Isolation…

…Diminished
extended family
Involvement.
Distorted and glamorized perceptions
of pregnancy…
 …and of
recovery
in the
postpartum...
…frequently
promoted
in the
media.
As well as unrealistic
expectations of the postpartum mother
 In summary, postpartum psychiatric
illness exists.
 It can be debilitating and dangerous to
both mother and child.
 Effective treatments are available.
 Support groups of mothers in recovery
are also available in many areas of the
country.
How is Postpartum Depression
treated?
 Psychiatric medication
 Antidepressants:
 In particular, those that increase release of serotonin in the
brain
 Medicines for anxiety and to help with sleep
 Individual, couples and family psychotherapy
The incidence of breast feeding in birthing
mothers is increasing as the next slide
shows.
80%

67%
61%
49% 52%

37%
28%
20%

1926- 1951- 1966- 1972 1975 1998 2000 2001

1930 1955 1970

Briggs, Freeman, Yafee, Drugs in Pregnancy and Lactation, 1998

Maternity Survey, Parents Express, Phil.,PA., 4/01, 4/02
Breast feeding…

…a reasonable option
in Postpartum
Depression ?
Although all medications cross
into breast milk, there are a few
antidepressants that appear to
cross less than others and may
be safer in breast feeding.
Terapi Kejang Listrik
 TKL untuk yang mengalami kehamilan, diketahui aman
dan efektif bagi ibu maupun janinnya.
 Terapi ini berpotensi baik pada ibu hamil yang juga
mengalami gangguan bipolar pada:
 Episode Depresi
 Episode campuran
 Episode manik
 Untuk ibu hamil, ECT mempunyai risiko lebih rendah
dibandingkan dengan ibu hamil yang tidak diberi terapi
atau yang mendapat obat yang berbahaya bagi janin.
Terapi Kejang Listrik
 Komplikasi pemberian ECT pada masa
kehamilan bagi ibu dengan gangguan bipolar:
sangat jarang dijumpai.

 Pemantauan denyut jantung dan kadar oksigen

janin selama proses pemberian ECT dapat
mendeteksi problem-problem yang mungkin
terjadi, dan bila pun terjadi  dapat dikoreksi
dengan pemberian obat
Terapi Kejang Listrik
 Untuk mengurangi risiko regurgitasi gastrik atau
peradangan paru selama proses anestesi
 intubasi atau diberikan antasida .

 ECT juga dapat diberikan pada ibu yang

menyusui.