A Depressão Perinatal

Perinatal mental health

Abstract

Perinatal mental health has become a significant focus of interest in recent years, with investment in new specialist mental health services in some high-income countries, and inpatient psychiatric mother and baby units in diverse settings. In this paper, we summarize and critically examine the epidemiology and impact of perinatal mental disorders, including emerging evidence of an increase of their prevalence in young pregnant women. Perinatal mental disorders are among the commonest morbidities of pregnancy, and make an important contribution to maternal mortality, as well as to adverse neonatal, infant and child outcomes. We then review the current evidence base on interventions, including individual level and public health ones, as well as service delivery models. Randomized controlled trials provide evidence on the effectiveness of psychological and psychosocial interventions at the individual level, though it is not yet clear which women with perinatal mental disorders also need additional support for parenting. The evidence base on psychotropic use in pregnancy is almost exclusively observational. There is little research on the full range of perinatal mental disorders, on how to improve access to treatment for women with psychosocial difficulties, and on the effectiveness of different service delivery models. We conclude with research and clinical implications, which, we argue, highlight the need for an extension of generic psychiatric services to include preconception care, and further investment into public health interventions, in addition to perinatal mental health services, potentially for women and men, to reduce maternal and child morbidity and mortality.

Perinatal mental ill-health has been a focus of interest for centuries, but until recently this interest has mainly centered around postpartum psychosis and depression, with relatively little funding for research into individual level treatments as well as for investment in specialist services and public health interventions. This is, however, changing.

In January 2016, the UK Prime Minister announced a strategic >£290 million investment into new specialist perinatal mental health services (services for women with mental disorders in pregnancy and the first year postpartum)1. Since then, additional funds have been promised, with the aim of ensuring that women in all parts of the UK have access to specialist community services and psychiatric inpatient mother and baby units, and extending service provision up to two years postpartum. The ambition is to provide care concordant with the Antenatal and Postnatal Mental Health Guidelines produced by the National Institute for Health and Care Excellence (NICE)2 to all women needing it. In other countries, there have also been -investments in specialist outpatient and/or community perinatal mental health services and/or in mother and baby units3, 4.

Perinatal mental disorders are common – indeed, the commonest complication of child-bearing – and are associated with considerable maternal and foetal/infant morbidity and mortality5-7. In addition, there is a huge cost burden, particularly to health and social care, estimated in the UK to be £75,728 and £34,840 per woman lifetime for perinatal depression and anxiety respectively, with an aggregate cost for the country of £6.6 billion. Around 75% of this economic burden is associated with subsequent childhood morbidity8.

While these estimates inevitably are subject to various assumptions, the World Health Organization (WHO) has highlighted the urgent need for “evidence based, cost effective, and human rights oriented mental health and social care services in community-based settings for early identification and management of maternal mental disorders”9.

The current classifications of perinatal mental disorders are confusing, which partly reflects the debate on whether these disorders are unique in terms of their causes and psychopathology, or the same as mental disorders at other times of a woman's life. Recent evidence suggests that, even within individual diagnostic constructs such as postpartum depression, there are different phenotypes, potentially needing different interventions and services10.

In this paper, we summarize and critically examine the epidemiology of mental disorders in relation to childbirth and their impact on the foetus/infant/child, and then focus on the evidence base for interventions during pregnancy and postpartum, as well as in the preconception period, at the individual and population level. We also review the evidence base on service delivery models and discuss implications for research.

In particular, we explore whether, in view of the current evidence base, investment in services can be expected to make a meaningful and lasting difference for women and their families, how service delivery could be optimized, and what the implications can be for general psychiatric services and research.

PREVALENCE OF MENTAL DISORDERS IN THE PERINATAL PERIOD

The early postnatal period is at high risk for new and recurrent episodes, particularly of severe mental illness5, 11-13, with around one to two women in 1,000 requiring admission in the first few months after birth5.

A seminal study by Kendell et al12 (replicated by several groups) found that women were around 22 times more likely to have a psychiatric admission in the month following birth than in the pre-pregnancy period. This increased postnatal admission risk is found amongst women both with and without prior psychiatric illness, but more so among women with a pre-existing severe mood disorder11. A systematic review of 37 studies (including 5,700 deliveries in 4,023 women) found that 20% of women with pre-existing bipolar disorder experience a severe postnatal mental illness (i.e., psychosis, mania and/or hospitalization)14.

For less severe mental disorders (predominantly mild to moderate depression and anxiety disorders), the evidence for postpartum triggering is less clear6, 11. Some studies have found an increased rate of disorders requiring outpatient contact and/or psychotropic treatment in the postnatal period, particularly for depression and obsessive-compulsive disorder (OCD)15, 16. This may reflect an under-detection and/or under-treatment of these disorders during pregnancy, as studies find that postpartum depressive and anxiety symptoms frequently begin during or before pregnancy17, 18, but women are less likely to receive treatment during pregnancy than postnatally11. Nevertheless, it has been estimated that, for each woman requiring psychiatric admission following birth, 2.5 require outpatient treatment and 12 receive pharmacological treatment in primary care11. Therefore, “common mental disorders” (namely, depression and anxiety) represent a significant component of treatment need in the postnatal period.