Co-morbidity is the presence of additional disorders or illnesses that magnify the effects and burdens of the other. Here, Peta Marks of the Australian College of Mental Health Nurses examines co-morbid mental health illnesses in pregnancy.
In the field of eating disorders, psychiatric co-morbidities, such as mood disorders, are commonly presented with eating disorders or symptoms of eating disorders. Depression and anxiety are included in these and may be present along with an eating disorder or disordered eating behaviours before, throughout or after a pregnancy. For this reason, the NEDC has sought advice on the impact of motherhood on women and their mental health, where this may include occurrence of depression, anxiety or other mood or psychological disorder along with an eating disorder.
It’s important to recognise that pregnancy and motherhood impact on women in different ways.
For some women, the experience of motherhood is joyfully planned and happily anticipated. For others, a pregnancy may be an unwelcome shock that causes emotional distress and creates confusion. Some women, regardless of whether they have planned a pregnancy or not, will have concerns about pregnancy related issues – such as genetic abnormalities, previous stillbirth or fear of labour. Or, they will be confronted with other issues affecting them physically, emotionally or psychologically and might benefit from seeking counselling e.g. domestic violence, adjusting to the role of motherhood.
The impact that this experience has on each woman is unique and will be impacted by her current and past experiences, her long and short-term life goals, and her relationships and support networks. Regardless of the circumstances surrounding the pregnancy, as soon as every woman becomes pregnant, her body will begin to change so that it is able to support the growth of the foetus:
- Women often feel physically exhausted
- Their metabolic rate increases by 10 to 25 %;
- Heart rate and output rises by up to 40%;
- Breathing rate increases;
- Breasts become sensitive and increase in size;
- Some women experience nausea and vomiting, fainting or dizziness,
- Polyuria is common.
Emotionally, the normal range of feelings associated with pregnancy is vast – from excitement and joy, to weepiness, irritability, anxiety and fear (or a combination), to name just a few (Lees et al 2002). In addition to these common physical and emotional changes, some women will be faced with any number of other stressors, resulting in the need for a referral for pregnancy-related counselling.
The perinatal period is an at-risk period for anxiety, depression and other mental health problems for women and their partners.
There are three main mental health issues associated with the postnatal period:
- Post-partum blues – also known as the 'baby blues' – which occurs in 80% of new mothers, most commonly on days 3–5 after birth. This is a 'transient, self-limiting condition lasting hours to days’ (Davies, 2000) Women generally cry and get upset more easily and they may be irritable.
- Puerperal psychosis is a rare occurrence (0.1%) emerging during the first month after childbirth and is considered a psychiatric emergency requiring hospitalisation.
- Postnatal depression is the most common medical complication of childbirth (Henshaw 2000) occurring in almost 16% of Australian women (Cooper et al 2003; Beyond Blue website). It can onset up to six months following childbirth and includes anxiety symptoms and major depressive symptoms such as depressed or irritable mood, anhedonia, suicidality, helplessness and hopelessness (Davies 2000). Postnatal depression causes severe distress for the patient and her family and may affect the bonding relationship between mother and baby, so treatment is important (Cooper et al 2003).
Postnatal depression is considered a major depression which includes symptoms of sleep and appetite disturbances, physical agitation or slowing, diminished interest or pleasure in activities, fatigue and lowered energy, feelings of guilt or worthlessness, decreased concentration or ability to make decisions, and recurring thoughts of death or suicide, which occur nearly every day for two weeks or more (American Psychiatric Association, 2000). PND generally emerges within the first few weeks after delivery, but can develop up to three months after (Horowitz and Goodman 2005; Wisner, Parry and Piontek, 2002), and women may have a heightened vulnerability to depression for at least six months after the birth (Hendrick, 2003). The duration of PND can extend for more than two years (Goodman, 2004).
Risk factors for antenatal depression (during pregnancy), postnatal depression and parenting stress (difficulties with adjustment to the role of parenting) are different, but they are interrelated. Significant risk factors for antenatal depression include low self-esteem, antenatal anxiety, low social support, negative cognitive style, low income, history of abuse and major life events. Significant risk factors for postnatal depression include antenatal depression and a history of depression.
Vulnerability factors for postnatal depression include depression during pregnancy, previous major depressive disorder, mood disorder, or family history of same; past history of post-natal depression, anxiety, or birth-related crisis; a history of pre-menstrual syndrome and complications during the birth. Additional risk factors include difficulties with close relationships (partner or family) – including the quality of the couple’s functioning within the relationship (Stein et al 1999 In Cramer 1993) and men’s ambivalence during pregnancy (Cowan and Cowan 1992 In Cramer 1993), social stressors such as moving house, leaving work, or personal or familial illness.
Women who are experiencing an eating disorder should also be considered at risk for postnatal problems. For example, research has identified that perinatal and postnatal distress, depression and anxiety is associated with body weight and shape concerns, with disordered eating before and during pregnancy and with vomiting during pregnancy (Abraham et al 2001; Carter et al 2000). Distress is greatest in women who are experiencing an active eating disorder at the time of pregnancy, particularly those with a binge and/or purge type of eating disorder (Abraham et al 2001). Women who are overweight during the postpartum period, and those with bulimia nervosa or binge eating disorder seem particularly vulnerable to developing postnatal depression and anxiety (Carter et al 2000; Mazzeo et al 2006). And those with active bulimia nervosa during pregnancy are also at greater risk for experiencing miscarriage and preterm delivery (Morgan et al 2006).
Eating disorders and disordered eating behaviours as well as distress, depression and/or anxiety in mothers also has a correlation with other issues for mothers and babies – for example, we know that mothers who are depressed are less sensitively attuned to their babies, are less affirming and more negating of their infant’s experience; there is also a significant disturbance in mother-infant attachment. Similarly, mothers who engage in dietary restraint have been shown to use more strong verbal control with their infants (Stein et al 2001). These kinds of disturbance are associated with poorer cognitive outcomes in infants and toddlers (Murray et al 2006).
Because of the impact of these issues on the woman and on the baby, it is important to address them at the earliest possible point.
The 2008 National Perinatal Mental Health Plan recommends that depression screening is acceptable to women and should be part of routine antenatal and postnatal care (beyondblue National Postnatal Depression Program Vol 1: National Screening Program 2005).
In addition (and among other things) it recommends:
The Edinburgh Postnatal Depression Scale is the best available and most practical screening tool.
- Additional key psychosocial questions can assess risk and help to plan perinatal care, in particular focusing on support, previous history of anxiety and depression and the woman’s current stressors.
- Antenatal screening for depression in the third trimester.
- Postnatal screening 6-8 weeks after childbirth.
- All pregnant women be provided with an information and resource booklet on emotional health in the perinatal period.
- Eating disorder specific testing through the SCOFF questionnaire can elicit a discussion about a potential disordered eating problem in pregnancy and postnatal checkups.
All women with a pre-existing mental health issue, including those with an eating disorder or history of an eating disorder, should be considered at risk for developing perinatal mental health problems. Identifying those at risk early, supporting healthy lifestyle choices which may assist with mood such as low intensity exercise during pregnancy, ensuring adequate nutrition and perinatal monitoring, and engaging in treatment for the eating disorder will all be important.
Becoming a mother is a huge life adjustment for any women, so supporting women to adjust to their role, engaging with them around self-compassion and self-care (particularly related to their relationship with their body) and helping them to engage with the support networks that are available to them will be essential for every woman.
Eating disorder specific references
Abraham, S., Taylor, A., Conti, J., (2001) Postnatal depression, eating, exercise, and vomiting before and during pregnancy. IJED 29(4):482-487
Carter, A.S., Baker, C.W., Brownell, K.D., (2000) Body Mass Index, eating attitudes, and symptoms of depression and anxiety in pregnancy and the postpartum period. Psychosomatic Medicine 62:264-270
Mazzeo, S.E., Slof-Op’t Landt, M.C.T., Jones, I., Mitchell, K., Kendler, K.S., Neale, M.C., Aggen, S.H., Bulik, C.M., (2006) Associations among postpartum depression, eating disorders, and perfectionism in a population-based sample of adult women IJED, 39(3):202-211
Murray, L., Fiori-Cowley, A., Hooper, R., Cooper, P., (1996) the impact of PND and associated adversity on early mother-infant interactions and later outcome. Child Development 67(5):2512-2526 1996
Risk of PND, miscarriage, and preterm birth in BN: Retrospective Controlled Study. Morgan, J.F., Lacey, J.H., Chung, E., (2006) Psychosomatic Medicine 68(3):487-492 doi: 10.1097/01.psy.0000221265.43407.89
Stein, A., Woolley, H., Murray, L., Cooper, P., Cooper, S., Noble, F., Affonso, N., Fairburn, C.G., (2001) Influence of psychiatric disorder on the controlling behaviour of mothers with 1-year-old infants: A study of women with maternal eating disorder, postnatal depression and a healthy comparison group. The British Journal of Psychiatry Aug 2001, 179 (2) 157-162; DOI: 10.1192/bjp.179.2.157
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