The transition to motherhood is multifaceted, with many biological, physiological, social and psychological changes occurring simultaneously. Although the majority of women make the transition to motherhood successfully, some experience perinatal mental health problems, as they attempt to psychologically adjust to the radical changes that childbirth and parenting brings. In their primary role, midwives hold responsibility for recognising, assessing, and referring perinatal mental health problems when delivering maternity care to women. Missing or providing an incorrect diagnosis of a mental health problem can have many implications for the woman, infant, and wider family. Perinatal mental health problems are a major cause of maternal morbidity and, in some cases, mortality, with 17% of recorded maternal deaths of UK childbearing women dying directly or indirectly from mental health problems between 2012 and 2014 (Knight et al, 2016). Consequently, the midwife's role is crucial for the initial recognition, referral for diagnosis, and treatment of perinatal mental health problems. This article will focus upon the more commonly experienced conditions of post-traumatic stress disorder (PTSD) and postnatal depression (PND); however, there are many mental health problems that childbearing women can experience.
Midwives' knowledge of PND is reported to be high. However, there is a dearth of similar understanding of allied mental health conditions, such as post traumatic stress disorder-post childbirth (PTSD-PC). The consequences are that many midwives are unsure of how to recognise and differentiate between different types of perinatal mental health problems, and how to find the appropriate referral pathway upon recognition (McGlone et al, 2015; Noonan et al, 2016). In response, recognising variance in diagnoses between PTSD-PC, PND and other perinatal mental health problems can result in unsuitable referral and treatment (National Institute for Health and Clinical Excellence (NICE), 2015), with an incorrect diagnosis augmenting distress for the woman and family (White et al, 2006). Zauderer (2014) provides a long list of negative sequelae for woman experiencing perinatal mental health problems, which include failing to bond with the baby, substance misuse, panic disorder, phobia, marital breakdown, and suicide.
The rationale behind this article is, therefore, to provide midwives with important information to improve their confidence in recognising, referring and supporting treatment of PTSD-PC. The confusion in diagnostic and treatment differences between PND and PTSD-PC will be addressed, noting that midwives are not expected to formally diagnose and treat women. However, it is important for midwives to be aware of the differences in clinical features, which are clearly defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association (APA), 2013). Having this knowledge could make the difference between a correct or incorrect diagnosis, and a successful or unsuccessful recovery for the woman.
PTSD-PC: symptoms, diagnosis and treatment
PTSD-PC: symptoms
PTSD-PC is characterised by a reaction to a stressful event that causes a pathophysiological alteration in the hypothalamic-pituitary-adrenal axis (Zauderer, 2014). Resultant clinical features of PTSD-PC are similar to those experienced in non-childbirth PTSD, and can affect between 1-6% of women following childbirth (O'Donovan et al, 2014). The DSM-5 (APA, 2013) places symptoms of PTSD into four categories:
A woman with PTSD-PC will display many of these symptoms with varying severity. Symptoms need to be present for more than 1 month after the event for a diagnosis of PTSD-PC to be given. When clinical features have only been present for between 3 days and 1 month, a diagnosis of acute traumatic stress disorder is appropriate (APA, 2013). Epidemiological research on PTSD suggests that it may be acute or chronic, onset immediately or be delayed, remit and re-occur (Blank, 1993). Symptoms may persist for 5, 10 or even 40 years post the traumatic event (White et al, 2006). To view the associated signs and symptoms of PTSD see Table 1.
| Signs and symptoms of PTSD-PC | Signs and symptoms of PND |
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PTSD-PC: diagnosis
Many symptoms of PTSD-PC are difficult to recognise in a new mother. For instance, it is usual for new parents to experience lack of sleep, and therefore midwives should use considered clinical judgement and the DSM-5 as a guide. In addition, the recently developed City Birth Trauma Scale (City BiTS) (Ayers, 2017) is a new, psychometrically robust self-reporting instrument consisting of 31 questions that relate to the four categories of symptoms. It is anticipated that the City BiTS may, in the future, be added to the schedule for diagnosing PTSD-PC, but is as yet a fairly new development. When the woman answers positively to the following questions, the midwife should consider screening for PTSD-PC using CityBiTS (Ayers et al, 2017).
What follows is a detailed comparison of symptoms, diagnosis, and treatment differences between PTSD-PC and PND. When using the City BiTS:
To be referred and treated a woman must score as follows on the City BiTS:
If a woman answers positive to question 31; ‘Could any of these symptoms be due to medication, alcohol, drugs or physical illness?’ the woman is to be excluded from diagnostic PTSD-PC. It is important to note that some women will not meet full diagnostic criteria for PTSD-PC, but nevertheless be experiencing distressing symptoms that require further assessment and support.
PTSD-PC: treatment
Although midwives are not expected to treat women with perinatal mental health problems, a working knowledge enables explanations to be given to the woman, her partner and her family. One contemporary treatment for PTSD-PC involves eye movement desensitisation and reprocessing (EMDR) therapy. Shapiro's (2001) adaptive information processing (AIP) model assumes that the human mind has a natural processing system that controls, filters and reacts to incoming information. When confronted with a trauma, this information processing system can become disrupted, and can produce traumatic symptoms as a result. A traumatic birth has potential to overwhelm usual neurological coping mechanisms, with associated stimuli inadequately processed and stored in an isolated memory network. When these isolated memories are repetitively replayed, they arouse associated maladaptive emotions, unpleasant intrusive thoughts, images, and sensations. The goal of EMDR therapy is to unlock and reprocess dislocated memories and integrate them into the body of adaptive recollections, in order to remove the psychopathology. An experienced EMDR therapist will deliver a standardised 8-phase EMDR programme designed by Shapiro (1995) (Table 2).
| Signs and symptoms of post-traumatic stress disorder post childbirth (PTSD-PC) |
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A further treatment for PTSD-PC is emotional freedom technique (EFT) (Karatzias et al, 2011). EFT is an easily administered, self-applied, meridian-based therapy (Craig, 2009) that assumes that emotional disturbance, including PTSD, is a by-product of disturbances in the body's energy field (meridian system) caused by exposure to a traumatic event. EFT involves light manual stimulation of acupuncture meridian points of the face, upper body and hands, while the individual focuses on the traumatic event (Craig, 2009). There are significant therapeutic gains from having received EFT, with a slightly higher proportion of patients in an EMDR group producing substantial clinical changes compared with an EFT group (Karatzias et al, 2011).
PND: symptoms, diagnosis and treatment
PND: symptoms
PND is a non-psychotic major depressive episode that begins within 1 month post childbirth (APA, 2013). The symptoms experienced by a woman with PND are similar to those of depression. PND affects how a woman thinks, feels, and acts, arousing feelings of sadness and loss of interest in day-to-day activities. PND instigates both physical and psychological reactions, such as depleted energy, increased fatigue, difficulty concentrating, feeling worthless, guilt and anxiety. Further symptoms are detailed in Table 1.
For a diagnosis of PND to be secured, clinical features must present for a minimum of 2 weeks (APA, 2013). Risk factors for developing PND are multi-factorial, and include biochemical, genetic (family history of depression), personality, and environmental factors. It is estimated that 10-45% of women experience some symptoms of PND post childbirth in varying intensities (Noonan et al, 2016).
PND: diagnosis
Symptoms associated with PND may be masked by natural characteristics of having a newborn. For example, it is usual for a woman to suffer from sleep depletion, increased fatigue, and low mood as a result of hormonal changes during the postnatal period. Applying clinical judgement, holding strong knowledge of the condition, and using a screening tool such as the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al, 1987), helps midwives distinguish between normality and PND. The EPDS is a psychometrically robust self-reporting questionnaire, and in the UK is the most widely used instrument for initially diagnosing childbearing women. The EPDS consists of 10 questions:
PND: treatment
Treatments for PND are similar to those of non-postnatal depression, and include psychosocial interventions, hormone therapy and pharmaceutical medication. Individualised variants such as efficacy, treatment response, side effects, compliance, patient preference, and breastfeeding should be considered when discussing treatment regimens with women (Scottish Intercollegiate Guidelines Network (SIGN), 2012). NICE (2015) and SIGN (2012) recognise that 4-6 sessions of cognitive behavioural therapy (CBT) is an effective psychosocial treatment for PND. CBT is designed to equip the woman with tools to cope with her new situation and help her build resilience. During delivery of CBT, perceived problems are differentiated into thoughts, feelings, and actions (associated behaviours). Once identified, the therapist discusses skill sets to manage thoughts, feelings, and actions, with the ultimate goal of reducing clinical features. In the event that CBT is unsuccessful, pharmacological management should be considered, with NICE (2015) not recommending any particular pharmaceutical treatment.
Discussion
A diagnosis of PTSD-PC or PND can have devastating effects at a psychological, physical and social level. Despite being two separate conditions, a woman with PTSD-PC may proceed to develop a dual diagnosis of PND. It is also important to note that the predisposing trauma that triggers arousal of memory flashbacks may not be regarded as a significant threat by a bystander. The principle is ‘that what the woman experienced as the perceived threat to her own or baby's life’ is what counts, which is easier for the midwife to quantify when the trauma can be visualised. Overt examples include the woman experiencing a third or fourth degree tear, postpartum haemorrhage, poor neonatal outcome, or an obstetric or neonatal emergency. However, more commonly reported trauma experiences include unmanageable pain, lack of control, or feeling mistreated by maternity care staff. Women who have had a straightforward labour and have produced a healthy infant, may therefore still report PTSD-PC symptoms (Borg Cunen et al, 2014). Additionally, the related traumatic experience could simply be a birth that deviated from perceived expectations (O'Donovan et al, 2014).
Women who present with symptoms and describe events surrounding childbirth as traumatic, should be assessed for PTSD-PC and possibly also PND depending on clinical presentation (Table 1). Symptoms of PTSD-PC and PND may possess an element of overlap (Table 1). These intersects may cause a PTSD-PC diagnosis to be overlooked in favour of PND when a dual diagnosis present (White et al, 2006). The cause of a positive correlation between PTSD-PC and PND may be a dose response between the two conditions; that is, as PTSD-PC symptoms exacerbate, those of PND intensify adjacently (White et al, 2006), with figures showing this comorbidity to range from 20-75% (McKenzie-McHarg et al, 2015). When symptoms match PTSD-PC, the City BiTS scale is issued. In contrast, when PND symptoms present, the EPDS is issued and scored. When a self-reported diagnosis of either or both conditions is secured, the woman should be referred down the appropriate pathway for formal diagnosis from a mental health expert.
Management guidelines warn against midwives providing a formal debriefing when mental health symptoms arise (NICE, 2007), with a less standardised postnatal discussion shown to benefit women by allowing them to evaluate their experiences and ask questions. Actively listening to women's experiences with compassion and understanding is helpful (McKenzie-McHarg et al, 2015), although if conducted without referral and treatment, this may be ineffective in terms of accelerating recovery (Borg Cunen et al, 2014). Discussions offer opportunity for midwives to assess women for symptoms of perinatal mental health problems and follow up.
Such ability requires the midwife to:
‘Actively listening to women's experiences with compassion and understanding is helpful, in conjunction with referral and treatment. Such discussions offer opportunity for knowledgeable midwives to assess women for signs and symptoms of perinatal mental health problems and follow up’
Barriers to diagnosis
One problem for midwives using psychometric instruments such as the City BiTS or EPDS, is that they can act as a barrier to detection of PTSD-PC and PND when no well-developed relationship has been established between midwife and woman, partner and family. Continuity of care models are beneficial for increasing recognition of perinatal mental health problems, quite simply because the midwife is more likely to develop a trusting relationship with the women.
Renfrew et al (2014) derived from a new evidence-informed framework that ‘models of midwifery care’ and midwifery interventions during pregnancy promote more positive outcomes. Renfrew et al (2014) identified 50 short-, medium- and long-term outcomes that could be improved by care within the scope of midwifery practice. These included reduced maternal and neonatal mortality and morbidity, reduced stillbirth and pre-term birth, fewer unnecessary interventions, and improved psychosocial and public health outcomes. Developing a one-to-one relationship with the woman will permit the midwife to distinguish between usual behaviour and an emerging mental health problem. ‘The Best Start’ document (Scottish Government, 2017) recommends that a continuity of carer model be rolled out in Scotland over the next 5 years, firmly placing the woman and family at the centre of care.
Conclusion
This paper summarises the differences between PTSD-PC and PND, which is key for a midwife to correctly identify and screen women for appropriate diagnosis, referral, and treatment. This understanding will inevitably improve morbidity and mortality outcomes for childbearing women with PTSD-PC and/or PND. In summary, as the woman's primary carer throughout her childbearing experience, it is the midwife's responsibility to develop knowledge and skills to appropriately assess perinatal mental health problems.