REVIEW OF RESEARCH ON EPIDEMIOLOGY, CAUSES AND CONSEQUENCES OF POSTPARTUM DEPRESSION

Professor Michael O'Hara, Dept of Psychology, University of Iowa, USA

Postpartum depression is a serious mental health problem affecting women and their children and families. The prevalence of depression after childbirth is in the range of 12% to 14%, with the rate of incident cases being somewhat lower. These depressions do not appear to be culturally bound and are found in all societies where systematic research has been undertaken. The sociodemographic variables most strongly associated with postpartum depression relate to lower social class, other variables such as age and parity are not associated with risk for postpartum depression. The most significant risk factor is past history of depression. Other risk factors consistently found in the literature include stressful life events, including obstetrical stressors, marital distress, poor social support, and dysfunctional ways of thinking. Hormones such as the estrogens and thyroid may also play a role in the development of postpartum depression. Episodes of postpartum depression range in severity from mild to severe and in duration from relatively brief to many months. Postpartum depression impairs the functioning of afflicted women in all of their social roles, including the mothering role. The woman who has recovered from postpartum depression continues to be at increased risk for depression recurrences for many years. Children exposed to maternal depression are themselves at increased risk for problems in their social-emotional development. These consequences point to the importance of the development of effective programs to treat and precent postpartum depression.

WOMEN & DEPRESSION: HORMONAL BASIS OF MOOD DISORDERS IN WOMEN

Assoc Prof Barbara Parry, Dept of Psychiatry, University of California, USA

Women are more prone to episodes of major depression compared with men. They are also prone to develop depression at times of reproductive hormonal change at puberty, with use of oral contraceptives, during the premenstrual phase of the menstrual cycle, during the postpartum period and at menopause. The endocrine, including thyroid, changes that occur during those vulnerable time periods will be examined to determine if they can shed light on the contributing or exacerbating factors to these sometimes disabling disorders. Treatment implications will be discussed.

"MY BELOVED CHLOROFORM": THE MEDICALISATION OF MIDWIFERY IN QUEENSLAND IN THE LATE NINETEENTH CENTURY

Professor Kay Saunders, Dept of History, University of Queensland, Brisbane

The discovery of chloroform in 1847 heralded a new era in pain management during childbirth. There was moreover an increase in the medical dominance of obstetrics, traditionally in the hands of women midwives. These new practices were controversial: theologians challenged any notion that childbirth should escape the "curse of Eve" and women practitioners resented the new male dominance. Medical historians have largely ignored how the patient viewed the advent of this new drug. This paper concentrates on how educated settler women in Colonial Queensland viewed both childbirth and the use of chloroform.

PSYCHIATRY AND INFERTILITY

Clin Assoc Prof Tom George, Winston Noble Unit, The Prince Charles Hospital, Brisbane

Infertility is a very prevalent condition which presents many issues for both the individual and/or couple affected and for health professionals who may be involved. This paper will describe the challenges and issues that health professionals need to be aware of when couples present for reasons of infertility. Such issues include the role of stress in infertility, psychological reactions to infertility, the intrapsychic and interpersonal consequences (from diagnosis through to investigation, treatment and thereafter), the effects of treatment success and failure, and the impact on the child. The role of health professionals, with particular reference to mental health professionals, in meeting these challenges and issues will be discussed.

PSYCHOTROPIC MEDICATIONS DURING PREGNANCY & LACTATION

Assoc Prof Barbara Parry, Dept of Psychiatry, University of California, USA

Women may develop psychiatric illness requiring pharmacologic intervention during pregnancy or lactation. In this lecture, which pharmacologic agents are relatively safe during pregnancy and lactation and which agents are contraindicated or should be avoided will be discussed. Often, sufficient information is not available in the literature, and the clinician, with participation from the patient and her family, must make a reasonable cost vs benefit decision. What is often not appreciated is the increased risk of negative sequelae from psychiatric illness compared with the relatively minor risk, in some instances, of adverse consequences from psychotropic medication.

CHRONIC MENTAL ILLNESS & CHILDBIRTH

Dr Margaret Oates, Hon Consultant Perinatal Psychiatrist, University Hospital, Nottingham, UK

In marked contrast to the widespread recognition of PND there is a relative neglect of the problem of women with serious mental illness who become pregnant. This paper discusses the needs of those suffering from chronic psychotic illness. The severely mentally ill population ranges from women who are stable but at risk of relapse to those who are chronically disabled and symptomatic .... Psychiatrist need to be aware of their patients as parents. Mental health workers should be prepared to discuss contraception and the impact of parenthood and childbirth on their patients' health .... Unless the needs of mothers suffering from chronic psychosis are met the wholesale removal of their children into care will continue with adverse and often tragic consequences to both mother and child.

THE ROLE & NEEDS OF POSTNATAL DISORDERS SUPPORT GROUPS

Sharon Cook, President, Postnatal Disorders Support Group Assoc Inc, QLD

The aim of this paper will be to highlight how these groups help and support women with postnatal disorders and their families, sometimes in isolation from health professionals and at other times, in conjunction with professional support. The Groups will also recommend how the community - government and non-government agencies, health and non-health professionals - can assist these groups in delivering their service to an optimal level. It is hoped that this discussion will generate a lively and practical dialogue between the speakers and audience as to how services can work together more effectively to meet the needs of support groups and, ultimately, the needs of those experiencing perinatal distress and depression.

"TWO STEPS FORWARD, ONE STEP BACK" - A SELF HELP GROUP'S PERSPECTIVE

Lisa Fettling, President, PaNDa, VIC

This paper will describe the aims and activities of PaNDa, the Post and Antenatal Depression Association. It will address ways of improving both the detection rate of women with postnatal illness and their management. The importance of including women's partners in the management of PND will be emphasised. In addition, the paper will highlight the difficulties that Mother/Baby Units face. In conclusion, a plea will be made to researchers on behalf of women with PND to think carefully about what is asked of those participating in studies.

ANTENATAL INTERVENTION TO REDUCE THE RISK OF POSTNATAL DEPRESSION: A REVIEW

Bryanne Barnett, Paediatric Mental Health Services, South West Sydney Area Health Service, NSW

Despite the number of people who seem to be working in the perinatal psychiatry field these days, there is surprisingly little published material on this topic. The situation is apparently similar in the area of postnatal intervention (Boyce, 1997). The available antenatal material will be reviewed and the possible reasons for the paucity of published work in both areas will be discussed. Relevant work in progress in South Western Sydney will be reported.

CHILDHOOD SEXUAL ABUSE, POSTPARTUM DEPRESSION & PARENTING

Anne Buist, University of Melbourne, Dept of Psychiatry, Austin-Repatriation Medical Centre, Heidleberg, Melbourne, VIC

Whilst research has suggested a strong link between maternal depression and later cognitive and behavioural difficulties in children, whether this is a risk for all children of all depressed mothers, or who is most at risk, remains clear.

The first part of a study is presented, where it is hypothesised women with a history of childhood abuse, who then develop postpartum depression will be at a higher risk of having an impaired negative mother-infant relationship and a child with later developmental difficulties.

Fifty-six women who were admitted to the Mercy Mother Baby Unit with a depressive illness within 12 months postpartum participated in a follow up study looking at the effect of a history of sexual abuse on the severity of the depression and intimate relationships. The 28 women in the study group had a history of childhood sexual abuse; of the 28 women in the control group 9 had a history of physical abuse. The principle difference over a number of scales was a less positive mother-infant interaction in the study group, on the Monash scale (p<.007). However, when those women with a history of childhood physical abuse were removed from the control group, they appeared statistically very similar to the study group, and both this subgroup and the sexually abused group differed from the control (with no abuse): they shared higher levels of depression on the BDI (p<.03), less positive mother-infant interaction (p<.0001) and a negative score on the neonatal perception inventory. A number of other trends are also noted.

"I DON'T KNOW HOW TO DO THIS!"

Marian Sullivan, Child & Adolescent Psychiatrist in Private Practice, Brisbane, QLD

This presentation will look at the contribution that Child Psychiatry can make to the understanding of parenting problems and its effect on parental mood. Issues relating to the changes of parenting skills in a highly urbanised society will be discussed and therapeutic responses will be illustrated

A BROAD REVIEW OF MANAGEMENT ISSUES AND INTERVENTIONS IN POSTPARTUM DEPRESSION

Professor Michael O'Hara, Dept of Psychology, University of Iowa, USA

Because postpartum depression is rarely treated, women and their families often suffer needlessly. Comprehensive clinical services and coordination among health care providers are necessary to identify and treat postpartum depressed women. Proper management of postpartum depression requires early identification of at-risk women during pregnancy. Major risk factors identifiable during pregnancy include current or past depression (particularly, a past postpartum depression), marital discord, and severe life stressors. These risk factors can be determined in the course of routine prenatal care and a determination of level of risk for each woman can easily be made. Three categories of risk will emerge, very high, high, low risk. These risk levels are particularly associated with past history and current presence of major psychopathology as well as the presence of significant psychosocial stressors. Very high risk and high risk women should be followed closely through pregnancy and the first several months postpartum. Brief clinical assessments conducted in person or over the telephone may be used as well as self-report measures like the Edinburgh Postnatal Depression Scale. Women who are determined to be depressed may be offered a range of interventions including psychotherapy, pharmacotherapy, and in very severe cases, hospitalisation. Several psychological treatments may be useful with postpartum depressed women. The Iowa group (michael O'Hara and Scott Stuart) are currently evaluating Interpersonal Psychotherapy as a specific treatment for postpartum depression. Importantly, this intervention focuses on the important role transitions that women make after childbirth and on interpersonal difficulties in a woman's important interpersonal relationships, particularly with the woman's partner, parents and child. Early intervention and appropriate follow-up with postpartum depressed women will reduce suffering in these women and assure the best possible parenting environment for their children.