Depression during pregnancy
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39189.662581.55 (Published 10 May 2007) Cite this as: BMJ 2007;334:1003
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We thank Professor Brockington for his endorsement of our
recommendation in the recent NICE clinical guideline on antenatal and
postnatal mental health(1) for dedicated mother-and-baby units, and agree
that funding should be made available to undertake research into their
effectiveness. Professor Brockington then criticizes the guideline on a
number of points:
1) No recommendation about day hospitals – there was insufficient
evidence on which to base such a recommendation, other than a single non-
randomised study of their cost-effectiveness in women with depression in
the postnatal period (2) which was considered by the guideline development
group but did not constitute sufficient evidence.
2) No recommendation for community-based specialist teams - we could
find no evidence to support the widespread adoption of community-based
teams of the kind described by Professor Brockington. In view of this we
felt that the precise nature of community-based services should be for
local services to determine taking into account local factors such as
morbidity and current service arrangements.
3) Omission of mother-infant relationship disorders - we agree that
early mother-child interactions are important, and that dysfunctional or
otherwise unhealthy relationships are likely to have long-term sequelae.
However, such considerations were outside the scope of the guideline which
focused on maternal mental health, including the broad range of severe and
common mental disorders. We did consider the evidence for mother–infant
interventions where maternal mental health outcomes were available.
However, we have provided important and clear advice on the treatment of
women in the perinatal period which has been well received by perinatal
psychiatrists. The implementation of this advice remains the important
challenge that all those in the field of perinatal psychiatry should now
devote themselves to.
Dave Tomson (Chair1), Rachel Burbeck (Systematic Reviewer2), Stephen
Pilling (Director2), Liz McDonald (Consultant Perinatal Psychiatrist 1)
1 NICE antenatal and postnatal mental health guideline development
group
2 NCCMH
Reference List
1. National Institute for Clinical Excellence (NICE). Antenatal and
postnatal mental health: Clinical management and service guidance,
Clinical Guideline No. 47. 2007. London, National Institute for Clinical
Excellence.
2. Boath E, Major K, Cox J. When the cradle falls II: The cost-
effectiveness of treating postnatal depression in a psychiatric day
hospital compared with routine primary care. Journal of affective
disorders 2003;74:159-66.
Competing interests:
SP receives funding from NICE for the development of NICE clinical guidelines in mental health
Competing interests: No competing interests
Bravo, Professor Brockington!
The integration of 'mental illness' experience with experience of the
consequences for 'child abuse and neglect' is the key future challenge for
maternal and infant health services.[1]
Just before the National Institute for Social Work disappeared into
history, this was the problem they were beginning to address. [2] As well
as problems with the early 'mother-infant relationship' that may underpin
'rejection' and especially long-term emotional abuse of that child, the
same household may generate domestic violence or parental breakup, viewed
with terror by small, dependent children. The approximate successor to
NISW is the Social Care Institute for Excellence, whose 2003 'Report 2'
was also on working with families where parents had mental disorders. It
seems to be difficult for many generic professionals to accept that some
mothers do 'detest' their infants so specialist skills are essential for
the child's life chances, and perhaps even survival.[1] The UK's latest
Government strategy recognises that 'accountability for families can fall
between services'.[3] This urges us to Think Family in an 'integrated'
strategy. It remains to be seen whether this is compatible with the
Parenting Orders and other externally imposed measures proposed in the
same Review....
[1] Brockington IF. The NICE guidelines: a travesty of mother-infant
psychiatry. BMJ Rapid Response 21 June 2007.
[2] Kearney P, Levin E, Rosen G. Alcohol, Drug and Mental Health
Problems: Working with Families. London: NISW, 2000.
[3] Social Exclusion Task Force. Reaching Out: Think Family. Analysis
and themes from the Families At Risk Review. London: Cabinet Office, 2007.
Competing interests:
Unsuccessful attempts to give advice to NICE in the past.
Competing interests: No competing interests
Sir,
The NICE Guidelines on antenatal and postnatal mental health did well
to recommend a nationwide network of specialist teams, backed by dedicated
6-12 bed mother-and-baby units. But there are several omissions from
their service recommendations:
1. If NICE is sanctioning the deployment of mother & baby units, it
should prioritise research into their cost-effectiveness and safety.
Having worked on these units since 1975, I consider them much better than
conjoint admission to general psychiatric wards, or admission of the
mother alone. But this opinion is based on clinical experience, not
objective comparisons. Funding for such research has always been refused.
2. Research on day hospitals is mentioned, but the Service Guidance fails
to recommend them. These units can provide, cheaply and with minimal
family disruption, a full range of therapies, plus interaction with other
mothers, appropriate for all but the most severely ill.
3. The guidelines recommend “integration with community-based mental
health services”, but do not recommend that the specialist teams should
themselves be community based, with domiciliary assessment and home
treatment involving community nurses, trained in mother-infant psychiatry.
Only a narrow range of disorders are reviewed, omitting more than half
those related to childbearing (Brockington, 1996). Chief among the
omissions are the mother-infant relationship disorders. Their
manifestations are not just ‘impaired mother-infant interaction’, but
rejection of the child and dangerous anger towards it. They are more
common, and more severe in their long term effects, than puerperal
psychosis. Their diagnosis, investigation and treatment are central to
the work of the specialist teams. Perhaps because paediatrics was not
represented on the Guideline Development Group, the most serious
consequences of maternal mental illness - child abuse and neglect – are
hardly mentioned, although severe abuse is more frequent than puerperal
psychosis (Baldwin & Oliver, 1975). Unless ‘perinatal psychiatrists’
learn that some mothers detest their infants, and can be helped by skilled
therapy to a normal loving relationship, many children will suffer
maternal hostility throughout their childhood, and ‘perinatal psychiatry’
will lose an opportunity to contribute to the prevention of child abuse
and neglect.
Ian Brockington
Competing interests:
No competing interests
Competing interests: No competing interests
June 18, 2007
Dear Editors:
I have several concerns regarding the recent “Pregnancy Plus” article
entitled “Depression during pregnancy” by Veronica O’Keane and Michael
Marsh.(1) I am concerned with the content of the piece as well as the
lack of transparency regarding the financial associations of Dr. O’Keane.
In the introduction to the piece, the authors comment: “The case
presented here highlights many of the key issues involved in the
management of pregnant woman with depression, particularly the importance
of active treatment.” Depression during pregnancy is a difficult issue
and one that I deal with on a regular basis as a practicing
perinatologist. Depression during pregnancy is very concerning, as is the
use of antidepressants during pregnancy. Active treatment is usually with
a selective serotonin reuptake inhibitor (SSRI) and there is much to be
worried about with maternal and fetal exposure to these drugs.
Antidepressants have not been shown to improve maternal or child health
outcomes during pregnancy. And in various studies antidepressant use in
pregnancy has been associated with increased rates of spontaneous
abortion,(2) congenital malformations,(3-6) preterm birth,(3,7) low
birthweight,(3,7,8) fetal death,(7) seizures,(7) neonatal withdrawal
syndrome,(3,9,10) persistent pulmonary hypertension of the newborn
(PPHN),(3,11) and a possible predisposition to psychopathology.(12)
The authors’ argument in the piece appears to be that while
antidepressant use is associated with risks, untreated depression is
worse. For example, in the summary, they write: “Untreated maternal
depression in pregnancy is associated with poorer maternal health
practices and less favorable obstetric outcomes.” This statement is
simply not accurate. It should have been written without the word
“untreated.” The use of antidepressants during pregnancy has not been
associated with more favorable obstetric outcomes in any study of which I
am aware.
It is not considered to be ethical to perform a randomized controlled
trial of antidepressants in pregnancy. So really the best trial (and, for
that matter, only trial) that we have so far that compares equally
depressed pregnant women on and off medication is the Oberlander study
from 2006.8 Dr. Oberlander expected that the patients who were being
treated with antidepressants would have better pregnancy outcomes, but
this was not the case. The women on antidepressants had more babies with
low birthweight and respiratory problems. The newborns exposed to SSRIs
also had longer hospital stays, feeding problems, and jaundice. So what
Dr. Oberlander showed is that if you take two women with equal levels of
depression, one of whom is on an SSRI antidepressant and the other who is
not, the patient on the SSRI antidepressant appears to be more likely to
have a child with low birthweight, respiratory distress, and other
complications.
So, yes, there are risks to untreated depression in pregnancy, but,
as far as we can tell, in the only study that has compared two groups with
similar levels of depression, treated maternal depression (when the
treatment is with an SSRI) is actually associated with less favorable
obstetric outcomes. BMJ should correct this error in the article as it is
misleading to readers.
So, in summary, the current statement in the article “Untreated
maternal depression in pregnancy is associated with poorer maternal health
practices and less favorable obstetric outcomes” suggests that the
obstetric outcomes are less favorable in untreated depressed gravidas than
in the treated depressed gravidas. However, the evidence does not support
this statement. In fact the available evidence (i.e. Oberlander, et al)
suggests the opposite.
A similar error is made in the Summary Points section of the article.
In this section it states: “The treatment of depression during pregnancy
must be considered individually for each woman, with the possibility of
relapse and poorer obstetric outcomes balanced against the possible risks
associated with taking antidepressant medication.” This statement is also
misleading to the reader. It suggests that the risks of antidepressant
use in pregnancy must be balanced with the benefit of improved obstetric
outcomes. But, as I detailed above, in the only study I know of that has
controlled for degree of maternal depression, antidepressant use actually
led to poorer obstetric outcomes. Can the editors at BMJ or the authors
please provide the evidence showing that antidepressant treatment during
pregnancy is associated with improved obstetric outcomes? BMJ should
correct this error in the Summary Points section as it is also misleading
to readers.
Improving maternal mental health during pregnancy can stand on its
own as a legitimate goal. However, to suggest to pregnant women and the
providers who care for them that antidepressant use in pregnancy is
associated with better obstetric outcomes (as this piece does in the
Summary section and the Summary Points section) is not supported by the
available evidence and is misleading to readers.
Finally, I am concerned by the lack of transparency of the financial
disclosure in the “Competing Interests” section at the end of the piece.
Here it states: “VO’K has received fees for speaking at educational
meetings organized by pharmaceutical companies.” I don’t mean to seem
confrontational, but is this really considered an adequate level of
disclosure by the editors at the BMJ? It strikes me as inadequate.
Pardon my attempt at humor, but the current disclosure reads like:
“Someone at some point paid VO’K something.”
The question many readers might have after reading a piece that
emphasizes the importance of antidepressant medication use in pregnancy is
whether Dr. O’Keane is being paid by the antidepressant makers. The
current disclosure statement does not address this. Readers should be
made aware of her relationships with antidepressant manufacturers (if she
has any) to be able to make informed judgments regarding the article.
Thank you very much for your time, attention, and consideration of
these issues. I really do appreciate it.
Sincerely,
Adam C. Urato, MD
Assistant Professor
Maternal-Fetal Medicine,
Tufts University,
New England Medical Center,
Boston, MA
aurato@tufts-nemc.org
I have no competing financial interests.
References
1. O’Keane V, Marsh MS. Depression during pregnancy. BMJ
2007;334:1003-5.
2. Hemels ME, Einarson A, Koren G, et al. Antidepressant use during
pregnancy and the rates of spontaneous abortions: a meta-analysis. Ann
Pharmacother 2005;39:803-9.
3. Chambers CD, Johnson KA, Dick LN, et al. Birth outcomes in
pregnant women taking fluoxetine. N Engl J Med 1996;335:1010-15.
4. Kallen, B, Otterblad Olausson, P. Antidepressant drugs during
pregnancy and infant congenital heart defect. Reprod Toxicol 2006; 21:221.
5. Wogelius, P, Norgaard, M, Gislum, M, et al. Maternal use of
selective serotonin reuptake inhibitors and risk of congenital
malformations. Epidemiology 2006; 17:701.
6. Alwan, S, Reefhuis, J, Rasmussen, S, et al. Maternal use of
selective serotonin re-uptake inhibitors and risk for birth defects. Birth
Defects Research (Part A): Clinical and Molecular Teratology 2005;
731:291.
7. Wen SW, Yang Q, Garner P, et al. Selective serotonin reuptake
inhibitors and adverse pregnancy outcomes. Am J Obstet Gynecol
2006;194:961-6.
8. Oberlander TF, Warburton W, Misri S, et al. Neonatal outcomes
after prenatal exposure to selective serotonin reuptake inhibitor
antidepressants and maternal depression using population-based linked
health data. Arch Gen Psychiatry 2006;63:898-906.
9. Zeskind PS, Stephens LE. Maternal selective serotonin reuptake
inhibitor use during pregnancy and newborn neurobehavior. Pediatrics
2004;113:368-75.
10. Sanz EJ, De-las-Cuevas C, Kiuru A, et al. Selective serotonin
reuptake inhibitors in pregnant women and neonatal withdrawal syndrome: a
database analysis. Lancet 2005;365:451-53.
11. Chambers CD, Hernandez-Diaz S, Van Marter LJ, et al. Selective
serotonin-reuptake inhibitors and risk of persistent pulmonary
hypertension of the newborn. N Engl J Med 2006;354:579-87.
12. Casper RC, Fleisher BE, Lee-Ancajas JC, et al. Follow-up of
children of depressed mothers exposed or not exposed to antidepressant
drugs during pregnancy. J Pediatr 2003;142:402-8.
Competing interests:
None declared
Competing interests: No competing interests
Similar to postpartum depression, antenatal depression or depression
during pregnancy is a term which includes a wide group of depressive
syndromes (from depressive bipolar episode to adaptative episode) with
different short and long-term prognosis. The therapeutical approach has to
take into account not only the severity of the depressive episode but also
the benefits and risks of treatment. For example, a significant compromise
of appetite and sleepiness should better be treated with antidepressants
although the severity of the episode was moderate.
Antidepressant treatment could be useful to improved mother’s mood and the
adverse foetal environment too. Biological correlated factors involved in
depression as hypercholesterolemia, protein restriction, tobacco/alcohol
consumption during intra-uterine development can result in increased
foetal exposure to biologically active glucocorticoids and promote foetal
growth restriction Also, some brain regions involved in cognitive and
emotions development can be affected resulting in vulnerability to
metabolic syndrome and cognitive and emotional disorders in later life(1).
This foetal adverse environmental could exert an apparently permanent
effect on gene expression related to stress response and form the basis
for vulnerability to illness in later life (2).
Competing interests: None declared
(1)Aquila JB, Autumn LH, Stowe Z. Maternal depression: an adverse
early environment
Perinatal Stress, mood and anxiety disorders. Ed. Riechler-Rössler, M
Steiner, 2005,pag 70-84
(2)Matthews,SG, Meaney MJ.Maternal adversity, vulnerability and disease.
Perinatal Stress, mood and anxiety disorders. Ed. Riechler-Rössler, M
Steiner ,2005,pag 28-49
Competing interests:
None declared
Competing interests: No competing interests
Pilling et al in their response to our article titled “Depression and
pregnancy” rightly say that the subject matter of the article was
depression. This was not intended to imply that anxiety disorders were not
important. Clearly both anxiety and depression are common mental disorders
both within and outside of pregnancy.
They also correctly point out that there were several inconsistencies
between our review of the literature in this area and the recent NICE
guidelines (“Antenatal and postnatal mental health”)(1). Along with many
of my colleagues in perinatal psychiatry, and as a registered stakeholder
with NICE, I submitted my objections to some of these guidelines prior to
their publication. In particular the recommendations for the treatment of
mild depression appear to be unrealistic and unsupported by the research
in this area. For example, is exercise therapy a realistic option for most
pregnant women? A small literature in the use of exercise therapy in
depression in general suggests that it may be more effective as an adjunct
to conventional treatments rather than as monotherapy (2). Another
recommendation is that computerised cognitive-behaviour therapy (C-CBT)
therapy should be used to treat mild depression. Among the conclusions
from a recent systematic review of C-CBT was that there were “concerns
with the quality of evidence on the response to therapy, longer term
outcomes and quality of life” (Health Technology Assessment, 2006)(3). It
would seem injudicious to roll out this therapy across primary care with
such limited evidence for efficacy. Is it helpful to primary care
colleagues to recommend treatments that have not been established as
effective or have no prospect of being availabe for most pregnant women
suffering from depression?
With regard to the point about referral to specialist psychiatric
services we stated that “Women with a history of recurring depression or
bipolar disorder should be referred to perinatal psychiatric services”
(“As pregnancy progresses”); and that “women with an established history
of mood disorder should be managed by specialist psychiatric services”
(“Conclusions”), and agree with Pilling et al “that referring women with
any affective disorder is impractical and unnecessary”.
The final point Pilling and colleagues make relates to the practice
of breastfeeding neonates exposed to antidepressants in utero. We would
like to clarify that, as stated in the article, this is our practice only
and do not make any recommendations as there is only anecdotal evidence to
guide practice in this area.
Lastly, it is regrettable that the members of this NICE panel think
it sufficiently convincing to quote mostly their own publications rather
than referring to the original research papers to support their arguments.
1. National Institute for Clinical excellence (NICE). Antenatal and
postnatal mental health: clinical management and service guidance. NICE
clinical guidelines 45. 2007. London, national Institute for Clinical
Excellence.
2. Manber r, Allen JJ, Morris MM. Alternative treatments for depression:
empirical support and relevance to women. J Clin Psychiatry 2002: 63: 628-
40.
3. Kaltenthaler E, Brazier J, De Nigris E, et al. Computerised cognitive
behaviour therapy for depression and anxiety update: a systematic review
and economic evaluation. Health Technol Assess 2006; 10: 1-168.
Competing interests:
None declared
Competing interests: No competing interests
Bright light treatment is an obvious potential alternative to
pharmacological treatments for pregnant or lactating women.
Here is a positive cochrane metastudy on bright light treatment for
non-seasonal depression: Tuunainen A, Kripke DF, Endo T.. Light therapy
for non-seasonal depression. Art. No.: CD004050. DOI:
10.1002/14651858.CD004050.pub2.
http://www.cochrane.org/reviews/en/ab004050.html
Here is a positive study of bright light treatment for Post Natal
Depression: Am J Psychiatry 159:666-669, April 2002 An Open Trial of
Morning Light Therapy for Treatment of Antepartum Depression Oren et al
Study partners are hereby invited. Commercial interest clearly
declared.
Competing interests:
Shareholder in and consultant to Outside In (Cambridge) Ltd who make light therapy devices
Competing interests: No competing interests
Depression during pregnancy is not just common [1], it is also
associated with a high rate of both mortality and morbidity for infants as
well as mothers [2]. Although the causes described are many, the most
common are the overwhelming of coping mechanisms due to this major life
event and discontinuation of anti-depressant medications. Rebound
depression that occurs due to relapse, is often more severe [3] and
associated with psychosis than depression occurring at any other time. It
therefore becomes imperative that antidepressant medications be continued,
under guidance by a psychiatrist. Although none of the antidepressants are
safe, fluoxetine, an SSRI, has been generally advocated to be safer [4].
In the end, one ultimately has to balance the risk-benefit ratio when
deciding whether or not to treat depression during pregnancy.
1.O’Keane V, Marsh MS. Depression during pregnancy. BMJ 2007:334:1003
-5
2.Rondo PH, Ferreira RF, Nogueira F, Ribeiro MC, Lobert H, Artes R.
Maternal psychological stress and distress as predictors of low
birthweight, prematurity and intrauterine growth retardation. Eur J Clin
Nutr 2003;57:266–272.
3.Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera
AC, et al. Relapse of major depression during pregnancy in women who
maintain or discontinue antidepressant medication. JAMA 2006;295:499-507.
4.Nonacs R, Cohen LS. Depression during pregnancy: diagnosis and
treatment options. J Clin Psychiatry 2002; 63 (S7):24-30.
Competing interests:
None declared
Competing interests: No competing interests
As the developers of the recent NICE guideline on antenatal and
postnatal mental health (1) we found aspects of O’Keane and Marsh’s
article on depression during pregnancy helpful, but have a number of
concerns. First, by focusing only on depression it perpetuates the myth
that depression is the only significant mental disorder of pregnancy and
the postpartum period, when other disorders are also important, notably
anxiety disorders. Secondly, it is written from a secondary care
perspective when the burden of care for women with common mental disorders
during the antenatal and postnatal periods falls on primary care. Thirdly,
there are several inconsistencies between the article and the recent NICE
guideline which we highlight below.
For example, in discussing treatment for depression during pregnancy,
the authors focus almost exclusively on antidepressant treatment. They
fail to mention that for mild to moderate depression and anxiety a range
of interventions such as various forms of guided self-help, and brief
psychological treatments (including listening visits) are effective. (1-3)
Indeed, the risk/benefit ratio antidepressants does not normally support
their use in mild depression. (3)
We agree with the authors that treatment needs to be individually
tailored (including some patients continuing medication throughout
pregnancy) and on the importance of a balanced risk and benefit discussion
with patients. However, pregnant women are often reluctant to take drugs
so are unlikely to complete a course of antidepressants but this is not
acknowledged by the authors who recommend antidepressants for women with
moderate depression. In contrast the guideline recommends that equally
effective psychological therapies, are to be preferred.1 Mindful of the
potentially negative consequences of untreated depression and anxiety in
pregnancy the guideline also sets out recommendations for prompt access
for pregnant women to psychological therapies.
O’Keane and Marsh suggest that women with an affective disorder who
are planning a pregnancy should be referred to specialist psychiatric
services, and that those with a history of recurrent depression or bipolar
disorder should be referred to perinatal psychiatric services where these
exist. Whilst we agree that this should be carefully considered for women
with bipolar disorder or recurrent depression, we consider that referring
women with any affective disorder is impractical and unnecessary, and may
lead to an inappropriate use of specialist services.
Finally, O’Keane and Marsh suggest that women taking antidepressants
should gradually stop breast feeding to reduce withdrawal phenomena in the
neonate. This is not recommended as routine practice in the guideline.
Difficulties for the infant may arise not just from withdrawal symptoms
but also from serotonin toxicity (the symptoms are similar,(4)in which
case the strategy they advise is not appropriate.
Dave Tomson (Chair 1), Rachel Burbeck (Systematic Reviewer 2),
Stephen Pilling (Director 2), Liz McDonald (Consultant Perinatal
Psychiatrist 1)
1 NICE antenatal and postnatal mental health guideline development
group
2 National Collaborating Centre for Mental Health
Reference List
1. National Institute for Clinical Excellence (NICE). Antenatal and
postnatal mental health: Clinical management and service guidance,
Clinical Guideline No. 47. 2007. London, National Institute for Clinical
Excellence.
2. National Institute for Clinical Excellence (NICE). Depression:
Management of depression in primary and secondary care, Clinical Guideline
No. 23. 2004. London, National Institute for Clinical Excellence.
3. National Collaborating Centre for Mental Health. Depression:
Management of depression in primary and secondary care. London: The Royal
College of Psychiatrists and The British Psychological Society, 2005.
4. Haddad P, Pal BR, Clarke P, Wieck A, Sridhiran S. Neonatal
symptoms following maternal paroxetine treatment: Serotonin toxicity or
paroxetine discontinuation syndrome? Journal of Psychopharmacology 2005;19
(5): 554-557.
Competing interests:
SP receives funding from NICE for the development of NICE clinical guidelines in mental health
Competing interests: No competing interests
The NICE Guidelines on Antenatal and Postnatal Mental Health
Mr Pilling and his colleagues invoke the concept ‘evidence-based’ to
defend their failure to recommend day hospitals and home treatment
programmes for mentally ill mothers. But they have applied this concept
selectively. They recommended the general deployment of in-patient mother
and baby units, for which there is no ‘evidence-base’ [1]. Thus the
shibboleth ‘evidence-based’ is used to suppress some proposals, and is
waived for others. In the absence of good evidence, the Guideline
Development Group (GDG) was instructed to develop recommendations by
informal consensus [2]: this (not ‘evidence-base’) was the reason for
these service recommendations. Perhaps those reaching the consensus did
not have the experience to know that day hospitals can provide a full
range of therapies, appropriate for all but the most severely ill, at less
cost, risk and disruption than in-patient units.
If they “agree that funding should be made available” to study the
cost-effectiveness of conjoint admission, why did they not say so in the
Guidelines? That would have had an influence which half a sentence in a
letter to the British Medical Journal will not have. Such research should
include the safety of babies on these units, which has never been properly
assessed [3].
Mother-infant relationship disorders are much more than
‘dysfunctional mother child interactions’, and are present in about 25% of
referrals to these specialist services [4]. Mr Pilling and his colleagues
justify their omission on the grounds that they are not within the compass
of ‘maternal mental health’. But they omitted all the specific disorders
related to childbearing. For example, they failed to mention obsessions
of infanticide: this is a manifestation of obsessive compulsive disorder
specific to the puerperium; it was described over 200 years ago and has an
extensive literature. Apart from the suffering it causes, its crucial
importance is the differential diagnosis of impulses to harm the child.
Was this disorder excluded because it is not relevant to ‘maternal mental
health’? The same question can be asked of denial of pregnancy, absence
of prepartum affiliation, foetal abuse (all complications of unwanted
pregnancy which, with child abuse and neglect, is hardly mentioned in
these Guidelines), and the specific anxiety disorders, such as tocophobia,
pathological fear of cot death and phobia for the infant. Whatever the
GDG’s definition of ‘maternal mental health’, the specialist teams they
are promoting will have to deal with these disorders, and must become
expert in their diagnosis and treatment. To this objective, these
Guidelines make no contribution.
References:
[1] Joy C B, Saylan M (2007). Mother and baby units for schizophrenia.
Cochrane Database Systematic Review January 24th, (1) CD006333.
[2] Antenatal and Postnatal Mental Health: Clinical Management and Service
Guidance, page 49.
[3] Brockington I F. Motherhood and Mental Health, Oxford, Oxford
University Press, pages 566-568.
[4] Brockington I F, Aucamp H M, Fraser C (2006). Severe disorders of the
mother-infant relationship: definitions and frequency. Archives of
Women’s Mental Health 9: 243-252.
Competing interests:
None declared
Competing interests: No competing interests