Perinatal Mental Health

A Guide for Health Professionals and Users

Jane Hanley

• Publisher: Wiley
• Year: 2013
• ISBN:
  9781118707975
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Perinatal Mental Health is an invaluable reference for nurses, midwives and other health professionals working with this client group, covering current thinking on the causes of mothers' mood disorders and the consequences for her infant, the family, society and most importantly the mother herself.

This book covers the recognition, treatment, care and management of perinatal mental health disorders with chapters on the antenatal period; postnatal depression and bipolar disorder; psychosis, personality disorders, eating disorders, sexual issues, self harm and suicide; possible causes of postnatal depression; the multidisciplinary team; and global cultural practices.

1

Women’s mental health: from Hippocrates to Kumar

Blessings on the hand of women!
Fathers, sons, and daughters cry,
And the sacred song is mingled
With the worship in the sky –
Mingles where no tempest darkens,
Rainbows evermore are hurled;
For the hand that rocks the cradle
Is the hand that rules the world.

William Ross Wallace 1819–1881

An overview of perinatal mental health

It is stating the obvious that childbirth is not a new phenomenon, nor has the study of it been neglected over the years. For the most part, and up until recent years, research has focused more on the actual physical side of childbearing, with little regard given to any psychological or emotional factors. There is now a growing body of researchers who suggest that there is overwhelming evidence to recommend that the good mental health of mothers be maintained during the perinatal period. This is because it is now believed that it is crucial to secure a happy outcome for the mother, her infant, and her family, and it is through this research that methods and management strategies may be discovered in order to achieve these outcomes. Despite the evidence of risk to infant development and factors which could harm the mother and her family, the study of maternal and infant mental welfare remains a subject that is often misunderstood and misrepresented.

Criticism has been levied about the weakness and lack of rigour of some pieces of research into perinatal mental health. It seems that few research projects concentrate on producing the results from randomised control trials and there are very few of the type of ‘gold standard’ research. The reasons for the failure to conduct rigorous research may be many, but not least that it is the overall sensitivity of the condition together with the reluctance of ethics committees to grant permission for such studies. There is apprehension that any enquiries into a mother’s mental health may endanger her mental state even further by having the potential to resurrect thoughts and feelings of a mother’s previously depressed state of mind. These objections make it difficult to carry out sufficient studies of research into the subject. Many of the studies, particularly of a qualitative nature, have had to be carried out retrospectively, capturing the thoughts and feelings of an event which has passed.

A recent UK Government commissioned report: the Darzi Plan –, High Quality Care for All (Darzi, 2008), which is set to revolutionise the vision of the future of health care, highlighted the necessity for services to be focused on individual needs, with the choice for services being centralised. It advocated integrated partnerships, maximising the contribution of the workforce and an intention to prevent policies on health inequalities and diversity. Nowhere, however, did it mention the importance of, or even refer to, perinatal mental health. Even in this enlightened document the mental health needs of mothers were overlooked. Mental health has, historically, been an area of contention when discussing the next priority for government funding. It would appear that those perceived as the more common biological diseases of cancer and the heart override any need for the solution of problems incurred in mental ill-health. The alleviation of mental illness, coupled with the stigma, remains as big a problem in the twenty-first century as it ever was, even though dealing with mental illness and its concomitant dilemmas involves a great deal of the work force and even the finances of the country.

Opinions as to whether postnatal depression is a specific disease have been debated since the time of Hippocrates. From the time of Louis Marcé (1858) the theories of its origin, ranging from hormonal (Dalton, 1985), to social (Guscott & Steiner, 1991; Oakley, 1975) have been considered and disputed. However, it is only in the last thirty years or so that in-depth study of the subject has revealed the high incidence of this distressing complaint (Gerrard et al., 1993). It has been argued that there are still too many women, who, together with their families, are suffering in silence (Kelly, 1994). Recent television and newspaper coverage has stimulated some interest in postnatal depression. However, much remains to be done to educate the public at large, ensuring that a greater awareness of the prevalence of this condition and its damaging symptoms can be recognised and managed.

The debate, however, is not new. It is reputed that the incidence of postnatal depression, as a major mental disorder following childbirth, has been the subject of medical observation since the days of Hippocrates. This ancient Greek philosopher recognised that health and disease are interdependent upon the interplay between human actions and the environment of man. The customs, values, climate, diet, and modes of life and age determined the characteristics of each disease. The additional requirements which determined a person’s health status included the whole of the persona and were involved with the examination in detail of a person’s innermost thoughts, their speech patterns and the silences contained within them. The reasons for the mannerisms were

thought to be peculiar to that person. There was intricate examination of sleeping habits to establish whether they were fitful, filled with dreams and what those dreams consisted of and when those dreams occurred.

This approach encompassed the person as a whole and recognised the importance and effect of the integration of environmental and socio-economic living conditions as well as individual and collectivist lifestyles on the health of the person. Although this philosophy is still largely advocated in primary care, and health care professionals are urged to apply this approach, this is often marginalised by the more scientific approach that is advocated by the medical profession.

An exploration of the history of the mother’s mental health

In 460 BC Hippocrates described ‘puerperal fever’, also recognised as puerperal sepsis. The name was derived from the Latin puer – meaning a boy or child. It was discovered in more recent times that the condition is caused by the Streptococcus A bacterium. Symptoms include a high fever of sudden onset with resulting delirium. Hippocrates, however, credited the cause as the suppressed lochial discharge, which was transported to the brain, where it produced ‘agitation, delirium and attacks of mania’.

Over time, determining health by exploring the body and the environment became compromised as medicine strove to understand the pathology of life. Once it became possible to study cadavers, the expertise on the functioning of particular body parts provided great insight into their operative modes. Anatomical studies performed by Leonardo da Vinci determined an understanding of the locomotion of the human body.

The eleventh-century writings of the gynaecologist Trotula of Salerno noted that ‘if the womb is too moist, the brain is filled with water, and the moisture running over to the eyes compels them to involuntary shed tears’.

Descartes was a mathematician and physicist who is considered the founder of modern philosophy. In 1637 he published Discourse on the Method in which he expressed his disillusion with traditional philosophy and the limitations of theology. He respected the certainty of algebra and geometry but as they depended purely on hypothesis he felt it was impossible for the interpretation of reality and to determine what the world was actually like. He recognised the radical difference between the physical and mental aspects of the world and the reality of his own mind. ‘I think, therefore I am.’ In 1649 The Passions of the Soul further suggested that the human body was split into the biological body and the psychological or spiritual mind and defined the relationship between the body brain and mind:

Regard this body as a machine which, having been made by the hand of God, is incomparably better ordered than any machine that can be devised by man, and contains in itself movements more wonderful than those in any machine[e]… it is for all practical purposes impossible for a machine to have enough organs to make it act in all the contingencies of life in the way in which our reason makes us act.

(Descartes)

Descartes suggested that the human body is purely a vehicle for the mind and it is only able to function because the mind instructs it to do so: ‘the mind is not immediately affected by all parts of the body, but only by the brain, or perhaps just by one small part of the brain, namely the part which is said to contain the “common sense”.’ This philosophy gave an entirely different perspective on medicine and the regard for the mind and body working independently of each other.

Louis Marcé

In 1858, Louis Marcé recognised that recently delivered mothers and nursing mothers were prone to disturbances of the mind which, whilst they were similar to the more common forms of mental illness, were, however, different in the organic conditions amidst which they develop. He compared the various descriptions of puerperal psychosis, concentrating on the condition of the blood and its effects on ‘those ailments of a special nature that affect recently delivered women’. He considered that the important period ‘is limited to the thirty or forty days in which the uterus is in the condition of a suppurating organ’.

The functions of maternity are discussed in his Treatise; the dangers involved in too frequent pregnancies and repeated miscarriages are recognised and the differences in the physical and mental symptoms are exposed. Whilst discussing the types of psychosis Marcé discovers there are ‘present certain differences which it is too good to highlight’. He differentiates between general paralysis of the insane found in tertiary syphilis, and other types of psychoses. Marcé concludes his treatise by stating that ‘our aim is not to study the various mental illnesses for their own sake but rather, with the help of clinical documents, seek out the special modifications which these ailments/affections undergo’.

Twentieth century opinions and interpretations

Many twentieth-century writers have written about the effects of depression and the torment suffered by women. Sylvia Plath, the twentieth-century American writer and poet is no exception. She speaks of her tormented life, besieged by the wrath and pain of depression and as she plummeted even further into the mire, she describes the pain she experiences as:

Look at that ugly dead mask here and do not forget it. It is a chalk mask with dead dry poison behind it, like the death angel. It is what I was this fall, and what I never want to be again. The pouting disconsolate mouth, the flat, bored numb expressionless eyes, symptoms of the decay within. I smile, now, thinking: we all like to think we are important enough to need psychiatrists. But all I need is sleep, a constructive attitude, and a little good luck.

(Kukil, 2000, p. 155)

Her pain was so intense that she was acquainted with the awfulness of suicidal thoughts which she describes as: ‘with the groggy sleepless blood dragging through my veins, and the air thick and gray with rain and the damn little men across the street pounding on the roof with pick and axes and chisels, and the acrid hellish stench of tar’ (Stevenson, 1990, p. 35).

Sylvia Plath describes her own feelings of the struggle to be creative while over-whelmed with depressive thoughts: ‘You are frozen mentally – scared to get going, eager to crawl back to the womb. First think: here is your room – here is your life, your mind: don’t panic’ (Plath, 2000, p. 186).

RD Laing in his definitive book The Divided Self describes his thoughts during his depressive psychosis as being trapped in a deep cave: ‘It is getting tighter and tighter in here, I am frightened. If I get out of here, it may be terrible. More of these people would be outside. They would crush me, altogether, for they are even heavier that those in here. I think’ (p. 169).

Spalding (1988) in her book Stevie Smith states that Stevie had the symptoms of clinical depression, which were tiredness apathy and irritability, all of which forced her to cut one of her wrists (p. 213).

Depression in women can occur at any age, but it is that which happens at and around the time of childbirth that arouses the most interest today, not only because research is increasing, but also because that same research is uncovering facts about which society was ignorant. Societal changes and attitudes make this a challenging condition. Previously it was postnatal depression that dominated research, but this has been superseded by perinatal mental health, to include all mental health disorders that occur around the time of childbirth, both in the ante and postnatal period and up to one year following the birth of the infant. In some instances it is considered in the pre-conceptual stage.

In the early eighties, Channi Kumar, one of the definitive researchers into perinatal mental health commented that postnatal depression might seem of relatively minor clinical importance when compared with the more florid mental illnesses. However, this insidious and chronic condition that can be responsible for the impairment of both personal and family life could be substantially even more severe and longer lasting. He stressed that as it is over one hundred times greater in terms of breakdown, in purely statistical terms, postnatal depression merits very serious attention.

Depression as a concept in itself is physically inexplicable and appears too complex and difficult to understand – so much so that it is easier to use a ‘standard one fits all’ diagnosis. Most general practitioners (GPs) will accept the responsibility for front line psychiatry and will make commendable efforts to relieve patients of their problems. What is becoming clearer about depression, however, is not that the cure, if indeed there is one, relies on antidepressant medication, but that it requires time and patience from the GP, as well as from others who are concerned about that person. Time is a precious commodity that medical practitioners rarely have, and in today’s rationing of time to patients, it becomes even more crucial that time is given to the depressed patient, and perhaps even more so to the woman who has recently given birth. It is probably reasonable to suggest that only those who have suffered from, or experienced mental illness and depression per se are in a position to understand what it means to feel the plethora of negative thoughts and how mental illness can be more painful than any physical pain.

Unfortunately, society demands explanations for every illness and the diagnosis of depressive conditions is not alone. The nomenclature of depression in itself is interesting. Is it a depressive ‘illness’? To be ill is defined as being ‘out of health’, ‘sick’, ‘unsound’ or ‘harmful’ and illness is a state of being ill. Some philosophers have defined physical illness as a condition where organic systems do not function according to normal standards. In contrast, the problems of mentally ill individuals are located within the minds of the sufferers. Someone who is mentally disordered is simply ‘out of his mind’.

Is depression a condition which is seen either as a state of physical fitness or an ailment or abnormality, as in a ‘heart condition’? The word ‘disease’ is rarely used but it is synonymous with distress. ‘Dis’ implies the reversal of an action or state. Dis-ease literally means someone who is not at ease, distress someone who is overly stressed. ‘Mental health disorder’ appears to be the latest label. Disorder interpreted as a lack of order, disease or ailment.

Women’s health and welfare in general has been taken into account by many researchers. The impact a mother has, both on and in society, is becoming more relevant. It is an interesting concept to question whether depression and in particular postnatal depression is determined by the society in which a woman lives, or whether it is indeed a physiological manifestation.

In order to pursue the notion that social expectations and evaluations influence the conception of the self and behaviour, it is pertinent to consider the various types of theoretical explanations for ill health. It was Parsons (1951) who originally considered the view of illness as a social state and provided a functionalist analysis of the sick role. This theory has been developed by sociologists and philosophers and allows conditions like postnatal depression to be viewed from a theorist’s, non-medical perspective, which questions whether depression is the result of a sociological deterioration rather than a purely physical reaction?

Others have postulated that there is a fundamental distinction between physical illness and mental illness. Each type of illness is interpreted with the use of commonsense frameworks. The body is seen as a part of the physical world in which we live, and as such, it is affected by the laws of cause and effect. Things may happen but fundamentally there is no control over when and how they happen. The mind, however, is viewed in more of a cultural framework of actions, meanings and motives (Horowitz, 1982). In this way perinatal mental health may be observed as a manifestation of social difficulties, as well as a malfunction of the mental processes, since the social difficulties encountered by the mother will have an adverse effect on her mental status.

Durkheim (1858–1917) was concerned about the social processes and constraints that integrate individuals into the larger social community. His belief was that when society was strongly integrated, the individuals who were a part of it were held firmly under control, rather than being allowed to dictate the terms and conditions of that society. From this functionalist perspective, illness can be regarded as a form of social deviance, in which an individual adopts the sick role. Unlike the criminal who chooses to violate social norms, sick persons are considered ‘deviant’ because they have no control over their condition. The sick role is characterised by the exemption of the sick person from normal social responsibilities. Neither blame nor responsibility is attached to being sick, but sick people are expected to seek out medical attention to ‘cure’ the problem quickly, to enable them to return to their place in society. Postnatal depression and other mental disorders can be construed as a manifestation of an illness in that the ‘patient’ in this instance, though lacking any physical signs or symptoms of disease is, or appears to be, ‘suffering’. This makes it clear in many if not all cases, that the sufferer requires as much sympathy and understanding for her needs as any other sick patient does, although it can be argued that consciously, and perhaps subconsciously, the woman believes she is ‘sick’, as do those associated with her. However, it is possible that the woman is subconsciously feigning sickness in order that she may receive that sympathy. The incumbent of a sick role is also expected to comply with the regime prescribed by a competent member of the medical profession (Abercrombie et al., 1984). This obligation of conforming to the sick role ensures this role is not used as an excuse for opting out of normal social responsibilities (Morgan et al., 1991).

Parsons’ (1951) earlier work provides a basis for Morgan’s assumption, as Parsons’ concept of the sick role was based on the premise that a sick person is not in that position because they chose to be, but rather because they had it foisted upon them, either by infection or injury or some other non-deliberate external force. Parsons (1951) argues that being sick is not just experiencing the physical condition of a sick state, but it constitutes a social role, since it involves behaviour based on institutional expectations and is reinforced by the norms of society corresponding to these expectations. In the case of postnatal depression this could mean that women may seek medical permission to vacate the role of ‘caring mother’. Women may on the one hand be constrained by common beliefs and facts that belong to a bygone age, that is from a functional perspective they may believe that they should stay at home to care for the child. On the other hand they may feel obliged to agree with modern day feminist thinking regarding their ‘rights’ to freedom and the need to accept the triple role of wife, mother and worker. Whichever way they turn it appears that women will believe themselves to be disadvantaged.

Whereas many writers have criticised the works of Parsons, some originally offered a viable alternative medical supremacy in controlling role conformity. One exception was Friedson (1970) who reformed the functionalist framework to produce the ‘labelling approach’ (Morgan et al., 1991). In this interpretation a clear distinction was made between disease, which is regarded as a biophysical phenomenon that exists independently of human evaluation and illness, which depends on the social and medical response to disease. This theory explains illness as a deviance not as a product of individual psychology, physiology or of genetic inheritance, but of social control. In respect of this perspective, women with perinatal mental health disorders might be seen as deviant because they reject or cannot cope with the pressures of motherhood. They must therefore be given a label or diagnosis which places them in a socially acceptable category.

During the 1970s, symbolic interactionism was seen as a major alternative to functionalism. Whereas functionalist theory focuses on the influence of the larger society on the individual, symbolic interaction emphasises interpersonal forms of interaction. The intellectual roots of this paradigm are in the concept of self, as developed by Mead (1934) who argued that reflexivity (referring to self) is crucial to the self as a social phenomenon. The individual is seen as a creative, thinking organism responsible for his or her own behaviour that does not react mechanically to social processes. Social life depends on the individual’s ability to imagine how they would react to other people’s situations or roles. The ability to achieve this state depends on the individual’s capacity for internal conversation. Mead (1934) believed that society was conceived by an exchange of gestures involving the use of symbols. Symbols impose particular meanings on objects and events and, as a result, exclude other possible meanings. Without symbols no human interaction or human society would be possible (Haralambos, 1985). However, the theory has been criticised for failing to give sufficient weight to the objective restraints on social action. In recent years, Denzin (1992) has sought to resurrect the theory by refining and developing the finer points and argues that in...

Table of contents

• Cover
• Contents
• Title Page
• Copyright
• 1 Women’s mental health: from Hippocrates to Kumar
• 2 The antenatal period
• 3 Postnatal depression and bipolar disorder
• 4 Puerperal psychosis
• 5 Problems associated with perinatal mental health
• 6 Possible causes of postnatal depression
• 7 Recognition and detection of perinatal mental health disorders
• 8 The effect on the family
• 9 Effects on society
• 10 Management of postnatal depression
• 11 The multidisciplinary team
• 12 Global cultural practices
• 13 An overview of women’s perinatal mental health
• References
• Appendix 1
• Appendix 2
• Index