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Mental State Baby

Mode of referral

Voluntary admission to Mater Hospital due to shortage of beds in Downshire Hospital. Transferred back on 16/05/2008 for further assessment of mental state.

Presenting complaints

• Difficulty to cope

• Low mood

• Thoughts of life is not worth living

*The onset of the symptoms begins when she was in the hospital with the baby and further deteriorates when she was discharged home due to no security of nurses and doctor for the child.

History of Presenting Complaint

Mrs. M, 28-year old lady, 7-week postpartum, was on voluntary admission to the Finneston House, Downshire hospital on 16^th of May 2008 for further assessment of the mental state. She gave birth to baby boy H, in Daisy Hill hospital and the delivery was uneventful. During her stay in the hospital, one of the nurses notices that baby H turned to blue and it was found out by the paediatrician that baby H had congenital heart defect. She and her baby were transferred to Royal Victoria Hospital (RVH) in Belfast the next day.

In RVH, the baby H had to stay in Neonatal Intensive Care Unit (NICU) for three days due to atrial flutter and had an open heart surgery after 2 weeks of delivery. It was found out that baby H had total anomalies of the heart where there is a mixing of the blood and it was not circulating effectively. At the moment, baby H is fit and healthy and patient's husband and sister are taking care of the baby at home.

Mrs. M felt really depressed during her stay in the hospitals. She worried about the safety and the health of baby H and she cried most of the time. She mentioned that it was a very big shock to her to found out that baby H had a congenital heart problem. She also mentioned that during her stay in the RVH, she felt really anxious when baby H had to be taken to the NICU due to atrial flutter. During her stay in the hospitals, she desperately missed home and kept thinking about it.

When she and baby H were discharged from the hospital, her mood further deteriorated and she thought that it was because of no security of nurses and doctors for her child at home. She felt that she had to take care of the baby all on her own now. She also had a thought of inability to bring up the child due to the problem that baby H had in the hospital. One of the things that she worried the most is whether she feed baby H enough and very particular about the amount of milk that baby H has. All this thought and worries also started to interfere with her daily life routine. On one occasion, a couple of family members came over to pay a visit and they bring a pie for her. She tried to bake the pie in the oven and taking care of the baby at the same time and she thought that she can't manage. She ended up burning the pie in the oven while taking care of baby H.

She states that during that time, she lost her appetite and her sleeping pattern has become erratic. After a couple of days, she started to have thoughts of life is not worth living. On further questioning, she was having thought of taking a drug overdose that will end her life. However, she never attempted it. Relating to the baby, she had no hatred feeling towards baby H nor thinking of harming him. At the moment, she does not want to see her child because she feels really guilty that she cannot take care of her child like any other mothers would.

Prior to the admission to the Downshire hospital, she was prescribed fluroxetine by out-of-hour GP but it did not give any effect at all. She was started on cipralex during her stay in Mater hospital before she was transferred back to Downshire hospital.

Past Medical History

No significant medical and surgical history

She denies any ongoing physical illness

Past psychiatric history

Nil

Family psychiatric history

Nil

Personal history

• Childhood: had a happy childhood. She was born with normal vaginal delivery. She had normal developmental milestones and denies any serious illness in childhood. Additionally, she denies any kind of abuse during childhood.

• School: liked school very much. She passed GCSE with average grade for Kilkeel High School and A-level from the same school. She denies any incident of bullying while she was studying there. Attended Stransmillis teaching college for training but left the college after a year.

• Employment: she works as a shop assistant in Kilkeel for the last 9 years.

• Marital/psychosexual/children: Married for 2 years. She has a happy relationship with the husband, Mr M. Had a miscarriage last year. Has a newborn baby at home, H.

• Social: Currently, she is living with her husband. Denies any socio-economic problem. Enjoy her friends company and enjoy listening to the music.

• Benefits: At present, she does not receive any benefits.

Drugs and alcohol history

She is a non-alcoholic and non-smoker. Denies ever taking any illicit drugs.

Forensic history

Nil

Personality history

Pre-morbid: She described herself as an outgoing person and cope well with any problems that she had. For instance, she mentioned about her parent death and she as the eldest in the family was taking care of everything including the mortgage, and she managed to get through it fine compared to other siblings. She also enjoys taking care of other children before she had her own. In this case, even though she enjoyed taking care of the child, she didn't want to feel like she had to do it. She wanted to do it because she wanted to enjoy it as much as she was taking care of other children.

Interest: listening to the music. Enjoy the company of others.

Temperament: She described her temperament is normal pre-morbidly.

Standard and value: Basically, her standard value is just as same as everybody else.

Religion: She goes to the church sometime.

Medications

At the moment, Mrs J is on medication as listed below:

Mrs. M is also known to be allergic to penicillin.

Mental state examination (22/05/2008)

• General appearance and behaviour: Casually dressed and well kempt. Very tearful during the interview.

• Speech: normal in volume and rate. Spontaneous.

• Mood: low subjectively and objectively. Concentration is good. Poor appetite and mild sleep disturbance.

• Thought content: no evidence of any formal thought disorder. Improvement in thought as there is no longer thought of life is not worth living but the mood is still low, since the admission.

• Perception: She denies of having any hallucinations or paranoid thoughts.

• Cognition: Conscious: Fully alert

Orientated time/place/person: Good

Attention and concentration: Can subtract 7 from 100.

Memory: long term memory intact. Registration is good. Recall is 3 out of 3.

Language: all performed well.

Overall score of Mini Mental State Examination: 30/30

• Insight: Very good insight. She admitted that she has a problem and has a very positive attitude towards her condition. She wants to get better so that she can go home to take care of her child.

Physical examination

On general appearance, she doesn't appear to be jaundice nor have cyanosis, anaemia, lymphadenopathy, finger clubbing and any signs of dehydration.

BP: 114/64 Pulse Rate: 84

Respiratory rate: 16 breaths per minute

Temperature: 36.8 °C

On further physical examination, the findings are unremarkable.

Summary

This is a 28 year old female, 6-week postpartum, who was on voluntary admission to Finneston House, Downshire Hospital for further assessment of the mental state. She gave birth to baby H in Daisy Hill hospital where they found out that he had a congenital heart defect. They were transferred to RVH for close observation and preparation for the heart surgery. During the stay, baby H had to be taken to the ICU for 3 days due to atrial flutter and 2 weeks after delivery, baby H had an open heart surgery and it was successful. Mrs M felt really depressed, in low mood, missed home and cried most of the time during her stay in the hospitals. To her, it was a big shock that her baby had congenital heart problem. Her condition further deteriorated when she was discharged from the hospital and according to her, was due to no security and help from the nurses and doctors like what she had in the hospital. She felt really anxious about the feeding, the baby's well-being and kept feeling guilty that she might not be able to cope with taking care of her baby. Her condition slowly interfered with her ability to function at home and affected her sleep pattern and appetite. She started to develop a thought that life is not worth living. The way that she imagines of ending her life is through drug overdose. However she never attempted it. She had no feeling of hatred towards her baby nor of having any thought of harming him. She had a miscarriage 15 months ago and her father passed away 18 month back. She claimed that she coped really well during these incidences. Other than these facts, there is no significant medical and psychiatric history.

Differential diagnosis

F53.0 Mild mental and behaviour disorders associated with the puerperium, not elsewhere classified- Postnatal depression

From the classification obtained from ICD-10 manual of the diseases, postnatal depression is characterized by depressed mood sustained for at least 2 weeks, anhedonia, and fatigability. This is the most likely diagnosis in this case as it occurred within the puerperal period and the descriptions fit Mrs M's condition. Other symptoms include loss of confidence or self esteem, tearfulness, inability to cope, inappropriate guilt, diminished ability to think and concentrate, insomnia, loss of appetite and suicide thought. Furthermore, these symptoms interfere with Mrs M's ability to care for herself and her baby.

F53.1 Severe mental and behavioural disorders associated with the puerperium, not elsewhere classified- Puerperal psychosis

This differential diagnosis is almost similar to the diagnosis above with the exception of other serious symptoms such as delusions, hallucination, odd behaviour and irrational thought. Some affected mothers might not recognise that they are ill. Puerperal psychosis is the most severe form of postnatal psychiatric illness. In this case, Mrs M denies of ever having any of these symptoms and based on her past psychiatric history, this diagnosis is not likely.

F53.8 Other mental and behaviour disorders associated with the puerperium, not elsewhere classified- Postnatal anxiety/panic disorder

Postnatal anxiety/panic disorder usually involved mixed anxiety and depressive disorder. The symptoms, along with differential stated above are hot flushes or cold chills, restlessness and inability to relax, muscle tension, difficulty in getting to sleep because of worrying, feeling light headed, fear of losing control etc. Even though there are some elements of anxiety and panic in this case, they are not clear enough to make this diagnosis. Furthermore, it shows more of the depressive symptoms that would suggest something else. Therefore, this diagnosis is less likely.

Postnatal blues

Postnatal blues or ‘baby blues' is a very common in puerperal period and up to 85% of women experience it. It is not a psychiatric disorder and usually resolved within a couple of weeks. The symptoms are mood lability, tearfulness, irritability and anxiety. However the symptoms do not interfere with mother's ability to function and taking care of the baby. In this case, it has clearly shown that Mrs M was unable to do her basic routine activity and taking care of her baby. Hence, it is not likely that postnatal blues is the diagnosis.

Postpartum thyroiditis

One study has shown that postpartum thyroiditis can present in up to 7.5% of patients and can present as depression. However, any organic causes have been excluded during investigation (as will be mention below). Therefore, in this case, there is no link between hypothyroidism and postnatal depression.

Investigation:

The investigations that should be done for Mrs M are physical, social and psychological investigations:

Physical: Routine blood investigation such as full blood picture, iron profile, thyroid function test, serum urea and electrolytes. These tests were done to exclude any organic causes of her condition. The urea was just below the normal range which might indicate that she had mild dehydrated. Other than that, the results were unremarkable.

Social: Collateral history should be taken. One informant has been chosen; Mr M (husband)

Psychological: Mrs J's condition should be assessed and observed in full details and her progress needs to be noted during her stay in the ward.

Collateral history

Informant: Mr. M (husband)

Mr M stated that he realised that there was noticeable mood deterioration of his wife during their stay in the hospitals. It started to affect her appetite and sleeping as well. These symptoms further deteriorate when they were discharge home. She started to loss her concentration of managing herself and the baby and kept feeling guilty of her inability to do so.

When Mr M was asked about how he thinks Mrs M has changed since the admission, Mr M feels that there has been definite improvement of his wife's mood and health condition over the last couple of weeks. She begins to show her interest towards her baby during the visit and her outings and slowly starts to enjoy taking care of her baby. Additionally, she managed to do a bit of the housework while taking care of her baby. Her next goal would be to be able to make dinner for her family as right now, the relatives are bringing food to them and she felt guilty about it. He mentioned that her wife is looking forward for more outings and probably discharged in the nearest time.

Second mental state examination (3/6/2008)

• General appearance and behaviour: casual dressings, well kempt, less tearful compared to the last time. Attitude positive towards her illness.

• Speech: Normal rate and volume. Spontaneous speech.

• Mood: improved since last MSE. Concentration is good. Appetite is fair but still have mild sleep disturbance.

• Thought content: No thought content disorder. No longer thought of life not worth living. No hatred towards the baby. Started to enjoy taking care of her baby.

• Perception: She denies of having any hallucinations or paranoid thoughts.

• Cognition: Good. MMSE; 30/30

• Insight: Very good insight. Looking forward for getting better and discharged so that she can take care of her baby.

Progress report

It is difficult to assess Mrs M's progress by observing her within the period of 2 week, however from the mental state examination and other observation during her stay in the ward, there is a definite improvement in her condition. She stated that she has no longer has any suicide thought and her mood has been lifted and appetite has improved. However, she still have mild sleeping disturbance. Through several visit and outings, she has shown an interest in her baby and started to enjoy him more compared to the time when she was first admitted. Additionally, she stated that she managed do her laundry and taking care of the baby at the same time. To her, she felt that this is the big achievement. She has also find a way to cope with feeding her baby but still be worried about it right now. She is very keen to go for outings back home and looking forwards for her discharge.

Final Diagnosis

From my point of view, the final diagnosis for this case would be postnatal depression. Evidences to support this diagnosis would be the fact that Mrs M has a depressed mood, inability to cope, tearfulness, insomnia, fatigue, appetite disturbance and thought of life is not worth living. Other than that, she also felt anxious and this includes her worries or obsessions about the baby's feeding, health and well-being. The fact that she had all this symptoms within the puerperal period makes the final diagnosis of postnatal depression more likely.

Postnatal depression

Aetiology

The definite aetiology of schizophrenia is still uncertain, however, there are possible risk factors that can be considered as possible cause for this problem.

Biological factors:

Several studies tried explore the role of steroid hormones in women during puerperium, but there is no strong evidence that link these hormones and postnatal depression. Furthermore, there is no significant different between women with postnatal depression and non-depressed women after childbirth with regard to level of progesterone, oestrogen, and cortisol or in a degree to which the hormone level change.

On the other hand, thyroid dysfunction has been found to be responsible to a small number of cases in women with postnatal depression. The childbirth and pregnancy, in some women, can somehow affect the thyroid function which can be linked to mood disorders. It has been suggested that thyroid function test should also be carried out with other blood tests to rule out any possible biological cause.

Psychososial factors:

The role of psychosocial factors has been shown to be consistently associated with postnatal depression. These factors include history of depression, lack of social support, marriage problem, and personal vulnerability. Additionally, stressful life events are also believed to be related to postnatal depression. In this case, baby H has had a congenital heart problem that obviously affects Mrs M's mood and her mental health. Additionally, she also had miscarriage and death of a family member within the last 2 years.

Women who are in postpartum period need a lot of support and encouragement. They are more likely to experience postnatal depression if they received inadequate social support, have marital problem or had recent negative life event. In this case, Mrs M received a lot of support from family members and her husband who keeps helping her with her conditions and taking care of her baby.

Treatment Plan

Physical treatment:

Postnatal depression manifests along a continuum in between postnatal blues and postnatal depression. While some patients may experience the mild to moderate effect of postnatal depression, the others are experiencing a more severe form of depression, characterised by prominent symptoms that interfere with routine daily activities. Due to this reason, the management approach for postnatal depression may vary. The treatment should be guided by the severity of the illness.

In treatment of severe postnatal depression, the main treatment is antidepressant, and in Mrs J's case, she is currently on Cipralex 10mg, which is in the group of Selective Serotonin reuptake inhibitor (SSRIs). SSRIs have been the first-line agent and effective in women with postnatal depression. There is little evidence that SSRIs are secreted into the breast milk for breast-feeding mother, but as pre-cautions, the manufacturer advises to avoid it. In this case, since Mrs. J is not breast-feeding, therefore, it is safe to administer this medication to her.

For treatment of other symptoms that Mrs J has, diazepam 2mg which is a short term treatment for anxiety is commenced. Additionally, for sleeping disturbance, Zopiclone 7.5mg is administered at bedtime.

Furthermore, non-pharmalogical treatment is as important and should be used in conjunction with the medications. The options are psychotherapy, counselling, group approaches and support strategies. A systemic approach is vital to acknowledge the context in which postnatal depression occur, the individual presenting complaints and risk factor, and the impact of treatment on the mother, infant and other family members.

Hospitalization:

Inpatient hospitalisation should be considered for severe postnatal depression particularly for the patient who is at risk of suicide. Additionally, the separation of the mother from the infant should reduce the stress of parenting to some extent and give time for the mother to recover. However, the impact of separation on the mother from her family needs to be addressed, as separation from the baby or family can reinforce the women sense of failure and helplessness and impair mother-baby attachment. In this case, Mrs J did mention that she doesn't want to see her baby because she feels very guilty that she cannot take care of her child. However, she is really keen to get better so that she can go back home to take care of her baby. Therefore, hospital admission is essential for her recovery.

Further treatment plan

Physical:

Current medications should be continued and closely monitor for any improvement in her mental state. If the symptoms doesn't respond well to the medication, the dosage of the medication should be considered to be increased (e.g. Cipralex 10mg to possibly 20mg) or probably a change in medication of a different drug in a same class if seem appropriate. On the other hand, she should be monitored for any side effects that may present. She should also be encouraged to attend occupational therapy or group treatment to improve her mood and provide a coping skill exercise. Liaison with home treatment team is also important to monitor her progress in the community during the outings or even after she is discharged.

Psychotherapy:

Psychotherapy is as important as the medication for patient with severe postnatal depression. Counselling, self-reassurance, support group, and involvement in occupational therapy may be helpful in treating this problem. It provides help to alter maladaptive patterns of coping, relieve emotional disturbance and encourage personality growth.

Long Case Commentary

For this part of the report I would like to explore the aetiological factors that contribute to the postnatal depression. Depression in general involved an interaction between biological, psychological and also social contributing factors. The relation between these factors is complex even though at individual level, only some of the factors might be prominent. Even so, the definite aetiology of postnatal depression is still uncertain. There are several possible risk factors which have been found through research to be associated with postnatal depression and will be discussed in this commentary.

Biological psychosocial

Childbirth is a major life event for mother and this might cause an accumulated stress around this time and might put them to a greater risk of developing depressive symptoms. Through a study done by O'Hara et al, 1982, evidence has been found linking postnatal depression with significant stresses and increased recent negative life events prior to the childbirth. Furthermore, any complications related to the well-being of the baby also contribute to the mental health of the mother. In another study, by Whiffen and Gotlib, 1989, has shown that any problem experience by the infant in term of health complication or behaviour after childbirth has consistently associated with postnatal depression. In this case, we know from the history that Mrs J has had 2 recent negative life events within the last 2 years which was the miscarriage and the death of her father. Additionally, following the birth of her first son, baby H has congenital heart problem which cause a lot of stress to her during the stay in the hospital. All of these negative life events and complication following the childbirth are the risk factors that contribute to the postnatal depression.

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