PERINATAL AND MATERNAL MENTAL HEALTH: INTERNATIONAL ISSUES

Judith Bass, PhD, MPH Department of Mental Health

Johns Hopkins Bloomberg School of Public Health

Overview

What is Mental Health? Mental health problems during

pregnancy and new motherhood Effects of mental health problems on

women, children, and families Risk factors Prevention and treatment

Overview

What is Mental health? Mental health issues during pregnancy

and new motherhood Effects of mental health on women,

children, and families Risk factors Prevention and treatment

What is mental health?

World Health Organization “Health is a state of complete physical,

mental and social well-being and not merely the absence of disease or infirmity.”

Not simply the lack of mental illness Complete and general state of well-being,

functionality and productivity Ability to contribute to self, family and

community

What is mental illness?

Can include: Emotional distress Sense of hopelessness or despair Anxiety and restlessness Inability to perform basic tasks

Symptoms can be both physical and emotional

Mental Health/Psychosocial Paradigms

Some use them interchangeably Others differentiate

Mental health – clinical illness/clinical care Psychosocial – distress/support services

Alternative option Continuum of needs and issues Varying over time and across populations Selection based on population needs and

resource availability

Overview

What is mental health? Mental health issues during pregnancy

and new motherhood Effects of mental health on women,

children, and families Risk factors Prevention and treatment

Terms and Timeframes

Perinatal period: Pregnancy and the 12 months following childbirth (Gavin et al., 2005) Antenatal period: Pregnancy Postpartum period: Definitions have ranged

from a few days up to twelve months following childbirth

MCH period: Services through child age 5

Mental Health Issues - Distress

Fears sleeplessness Too many thoughts Concerns about the future Confusion

Unexpected body changes and experiences for women having first child

Social pressures Changes in role – whether its first/multiple Additional burden – economic, social

Shame (if unwanted) Isolating in some cultures

Mental Health Issues - Disorders

Depression Major Depressive Disorder Dysthymia

Anxiety Generalized Anxiety Disorder Specific Phobias

Post-traumatic Stress Severe Illness - psychoses

Schizophrenia Bipolar Disorder

Substance use disorders Alcohol Drugs

Overview

What is mental health? Mental health issues during pregnancy

and new motherhood Effects of mental health issues on

mothers, children, and families Risk factors Prevention and treatment

Effects of maternal mental health problems on the women and children

Maternal health Strong link between mental health and chronic

illness For HIV-infected women, depression linked to

adherence Child health and development

Increased rates of infant malnutrition, illness and growth problems

Early childhood a sensitive period for neurocognitive development – need attentive, available mother

Attachment in childhood relevant throughout the life-course

Effects of maternal mental health problems on the family

Relates to functioning – as a member of the family, as a member of the community

During pregnancy Change in capacity – especially if complications

Motherhood Husband/other children need attention Responsibilities to home/community Mental health problems can be

stigmatizing/isolating to the individual and the family

Overview

What is mental health? Mental health issues during pregnancy

and new motherhood Effects of mental health issues on

mothers, children, and families Risk factors Prevention and treatment

Risk factors

Prior history of disorder Trauma – including gender-based violence Pregnancy/birth complications/miscarriage STDs and HIV Age Parity (primi/multi) Social status Gender preferences Substance abuse

HIV-infection

HIV and mental health Elevated rates of mental health problems among

HIV-infected people Particularly Depression and Anxiety problems Depression linked to reduced treatment adherence

Risk factors that are related to both HIV infection and to mental health problems Example: poverty and violence

Neurologic consequences of HIV infection

Trauma

Trauma exposure Prevalent in low-resource countries Causes: war, economics, gender-issues Related to depression, anxiety, post-traumatic

stress, stigma, distress Gender-based violence

Physical complications – can complicate the woman’s ability to have children/keep their pregnancy

Burden of having a child from rape Potential for rejection from husband/family – and

abandonment

Overview

What is mental health? Mental health issues during pregnancy

and new motherhood Effects of mental health issues on

mothers, children, and families Risk factors Prevention and Treatment

Prevention

Often lack of specialized services Where services exist, generally inadequate to

meet population needs Types of programs

Psychoeducation – ‘what to expect when expecting’ Social support groups – for sharing experiences

General and specialized (i.e. rape survivors, HIV-infected)

Family services Economic assistance Child care

Treatment

Psychosocial programming Social support groups Social/economic resources

Psychological services Individual therapy Group therapy

Psychiatric services Pharmaceutical treatment In/out patient care

Example of an Innovative Prevention Program

Caregiver training program to improve neurocognitive development in at risk young children (ages 2-5) Trial currently underway in Uganda with

HIV-infected and affected children Uses home health care visitors to ‘train’

caregivers to be more attentive, responsive, and proactive

Preliminary results show impacts child development AND caregiver mental health

Example of an Innovative Treatment Program

Cognitive Processing Therapy (CPT) to treat severe distress among survivors of gender-based violence in Eastern Congo Many reported rejected by husbands/family –

high stigma Group treatment provided by local

psychosocial workers Preliminary results

Reduced symptoms Improved functioning – within family and social

contacts

Conclusion

Problems are real – range from distress to disorder

Impact full range of the woman’s life: self, child, family

Recognized risk factors are common in low-resource contexts

Prevention programs can be simple – integrated into existing services

Treatment programs – possible, need supervision structure but with task-shifting can be implemented in low-resource settings

Acknowledgements

Collaborators within the Applied Mental Health Research Group (AMHR) Paul Bolton, MBBS; Laura Murray, PhD

Department Faculty/Students Tamar Mendelson, PhD; Andrea Vazzano,

MPH