Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 DOI 10.1007/s00737-008-0041-6

ABSTRACTS

The Marce International Society International Biennial General Scientific Meeting September 10–13, 2008 Hosted by the International Marce Society in Sydney, Australia Bryanne Barnett AM, President, 2006–2008

Health Outcomes for Women Following Discharge from a Specialist Inpatient Parent-Infant Unit* J Bilszta1, N Shafira2, N Salam2, AE Buist3 and R Nair4 1

Department of Psychiatry, University of Melbourne and Austin Health Universitas Indonesia, Jakarta, Indonesia 3 Women’s Mental Health, Austin Health and Northpark 4 Austin Health Email: [email protected] 2

There exists within Victoria a system of public parent-infant units that provide acute specialist inpatient psychiatric assessment and treatment for women, and their families, experiencing postnatal mood disorders such as depression, anxiety and postpartum psychosis/bipolar disorder. New mothers experiencing these disorders often need long-term management and support but this is outside the scope of the acute services provided by these units. To assist mothers following discharge, recommendations for follow-up in the community are provided but to date there has been little research evaluating up-take and use of these, or their impact on maternal and infant health outcomes. It is also not known whether once mothers leave the inpatient system whether community services are able to provide adequate inter-and intra-service continuity of care. This project has evaluated the uptake and ongoing use of treatment/support recommendations by mothers admitted to a public parent-infant unit over a 24 month period to determine their impact on health outcomes. It has also explored the barriers and/or incentives to use treatment/support recommendations and levels of consumer satisfaction. This paper will present data on 160 women admitted to a public parent-infant unit with special emphasis on the strengths and weakness in relation to the interface between acute mental health services and primary care providers. It will also suggest areas of improving both the acute and longer-term psychiatric care provided to women and means of achieving this within current service models. * A Mental Health Research Fellowship Grant, awarded by the Mental Health Branch of the Victorian Department of Human Services to Dr R Nair, funded this work. Clinical Issues in the Management of Mothers with Schizophrenia Philip Boyce Discipline of Psychological Medicine, University of Sydney

Schizophrenia is a disabling illness that can have a profound impact on a person’s life, it has its onset during late adolescence and early adulthood when it can affect major life transitions; for women it can effect the transition to motherhood. Many women suffering from schizophrenia become mothers; unfortunately many of these mothers will have their children removed or placed under special care orders. In many cases this is because of lack of understanding, and a sense of therapeutic nihilism about schizophrenia. The perinatal period presents a series of clinical challenges for clinicians looking after women with schizophrenia. In this paper these clinical issues will be reviewed. This will take a broad approach to understanding schizophrenia that is essential to be able to provide appropriate clinical care. This approach takes into account their lifestyle (and the problems that can arise from that), their social relationships as well as the core aspects of the illness of schizophrenia. Schizophrenia presents with a mix of positive symptoms, negative symptoms and neurocognitive deficit. All of these can have an impact on how a mother with schizophrenia is able to care for her infant. These will be reviewed along with current research aimed at identifying how neurocognitive deficits can impact on parenting and what strategies can help overcome this. Meeting the Perinatal Mental Health Care Needs of Women Who Have Conceived Twins or Singletons with the Assistance of Reproductive Technology Janette Brooks Edith Cowan University, beyondblue National Depression Initiative and WA Perinatal Mental Health Unit Email: [email protected] or [email protected] Although over a million in-vitro fertilization (IVF) babies have been born across the world, concern still remains that the rate of development of assisted reproductive technology (ART) has outpaced efforts to investigate the mental health consequences for expectant and new parents. Singleton and twin ART pregnancies are associated with higher obstetric risks. A woman who conceives after prolonged infertility is thought to have a high psychological investment in becoming a parent, which may increase the perceived value of the pregnancy and concomitant anxiety over any threat of pregnancy loss. Similarly, a twin pregnancy poses a higher risk to a woman’s health than a singleton pregnancy, risks to fetuses are also increased and maternal anxiety about the health of the fetuses is subsequently expected to be intensified. Although efforts have been made to reduce

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S2 the incidence of multiple pregnancies, the number of confinements resulting in twins continues to increase. Increased maternal age and ART are considered to be the major contributing factors. There is substantial evidence that maternal anxiety or stress during pregnancy is associated with premature delivery, lower birth weight adjusted for gestational age and adverse cognitive and behavioural consequences for the offspring. Given the continually increasing use of ART, increasing incidence of twin births and the high risks already present in these populations, the prevalence, levels and stability of anxiety, stress and depression for these women require further investigation. This PhD study quantitatively measured state-trait anxiety, pregnancy related anxiety, perceived stress and depressive symptomatology at three time points across the perinatal period in a sample of 53 women pregnant with twins and 53 women pregnant with a singleton (matched on use of assisted reproductive technology). Obstetric outcomes, including gestational age at delivery, birth weight and mode of delivery were also obtained. Results and the implications for policy, planning and effective delivery of perinatal mental health care will be discussed. Research to Shape a Perinatal Service Model or a Western Australian Indigenous Community J Brooks1, L Verrier1, M Mitchell2 1

Western Australian Perinatal Mental Health Unit (WAPMHU) State Indigenous Mental Health Service Email: [email protected]; Leanda.Verrier@ health.wa. gov.au

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Perinatal mental health in Australian Indigenous communities has previously been recognised as receiving limited attention; however, there is sufficient evidence to support the development of culturally appropriate mental health services for Indigenous mothers and families. This has prompted the State Perinatal Reference Group (SPRG) to endorse provision of funding to develop and trial a perinatal mental health service framework, to be undertaken in collaboration with the State Indigenous Mental Health Service. It was proposed that this framework would extend and support the existing services in the Carnarvon region of Western Australia (WA), with the aims of raising awareness of perinatal mental health among Indigenous communities, strengthening support networks for women and families, providing education and information to service providers, and establishing innovative and culturally appropriate approaches for achieving this. Key to the development of this service was the incorporation of a research framework, which serves to monitor and evaluate the service, and allows the service to be guided by the identified community needs over time. Prior to service implementation (baseline), questionnaires, focus groups and a service mapping exercise were used to gather qualitative and quantitative data from the local Indigenous community. Data was also collected from obstetric, medical and mental health services and service providers. Comparable data will be collected again at six months into the project, and at the completion of the 18-month pilot. Findings from the baseline evaluation will be available for presentation, demonstrating the ways in which the service delivery framework has been shaped by these results. Ethical Problems in Perinatal Psychopathology Abram Coen Enghien les Bains, France Email: [email protected]>

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 Périnatal psychopathology is a wide field where mulitiple professionals working in a network encounter around a baby. What about confidentiality, professional secret, deontology? Is there a shared ethics in a work where projections, identifications and burn out are common; we need professionals in good mental health and supervision to maintain their ability to think the clinical situation. Three in One: Effective Delivery of a Group Intervention of High Risk Mothers and Babies Alison Cornish, Karen Asgill and EIP Team Benevolent Society, Sydney Email: [email protected] The Benevolent Society’s Early Intervention Program (EIP) has accumulated significant experience over 18 years of delivering psychodynamically-oriented, infant-parent psychotherapy to high-risk families, through both individual and group work. Previously, we presented the development of our group program into it’s current format, consisting of a graduated stream of three groups (antenatal, baby massage and mother-baby) spanning approximately one year of engagement with the service. An evaluation of the groups has been undertaken in order to ascertain their effectiveness with respect to the levels of depression, anxiety and stress reported by the mothers participating. This paper will present the clinical outcomes for the mothers participating in EIP’s group program from 2005 to 2007. On entry to the group program, the women, on average, reported significant levels of depression and anxiety. Our results from the antenatal group evaluation were able to demonstrate reduced levels of anxiety by the time they completed this first phase of the group program. A comparison of the women’s scores across the progression of the three groups indicated that by the time they reached the end of the mother-baby group, their reported levels of depression and anxiety had reduced significantly to the normal range despite reporting ongoing elevated levels of stress. These results will be discussed in the context of the planning and evaluation of a psychotherapeutically based group program as an effective intervention in a high-risk population of mothers and their infants. Maternal Diet, Lifestyle and Stress, and The Contributions to Epigenetic Disruption in the Newborn: A Prospective Perinatal Twin Cohort Study Jeffrey M Craig, Ruth Morley and Richard Saffery Epigenetics Research Laboratory, The Murdoch Childrens Research Institute, Royal Children’s Hospital, Melbourne Evidence is mounting that predisposition to complex disease originates before birth and that environment can influence the course of fetal development via epigenetics. This refers to specific modifications overlayed onto DNA that regulate gene expression and many developmental processes. Nutrition and maternal lifestyle/behaviour are important aspects of the environment that have been shown to influence DNA methylation and gene expression in animal studies. Twins have proved invaluable for studies of nature via nurture. Studying monozygotic twin pairs controls for genotype and enables us to focus on environmentally induced and stochastic epigenetic changes in newborns. We hypothesise that these begin to emerge from conception and accumulate throughout the lifecourse. Studying dizygotic twins enables us to examine potential contribution of genetic

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 variation to phenotype, controlling largely for environment. We are recruiting 250 mothers pregnant with twins, collecting extensive environmental data and maternal blood at 28 weeks gestation, along with multiple biological samples form newborn twins. A follow up at 18 months is also planned to assess epigenetic change over time. These studies will permit an analysis of the relationship between genetics, epigenetics and maternal environment (including maternal stress and anxiety during pregnancy), on the establishment of the fetal epigenetic landscape.

Prevalence and Correlates of Initmate Partner Violence in Couples Expecting Their First Child Creedy, D1, Halford, K2, and Petch, J2

S3 is currently being implemented with families on Palm Island. Murri story telling involves the elements of history, relationships, symbolism, and hidden language (lip and eye talk). It is a cyclical process, a weaving of life events through the lens of time-not a discrete process. What may require an answer of a few words to a question in the Migaloo way almost always requires a narrative response for a Murri. Ungunmerr-Bauman states Dadirri is a way of listening to one another. It is a special quality, a unique gift of the Aboriginal people; it is inner deep listening and quiet still awareness. Dadirri recognises the deep spring that is inside us. It is something like what you call contemplation. It can be utilised for evidence based policy, planning and effective delivery of perinatal mental health care to an historically underserved population of women. About Helen Psychosis and Pregnancy Gilbert, H., Kulkarni, J., and Gurvich, C.

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National University of Singapore 2 Griffith University, Brisbane, Australia Email: [email protected] Aim: Male-to-female partner violence is believed to often begin or escalate during pregnancy and postpartum and is associated with poor general health, obstetric and reproductive outcomes for women. However, there has been little investigation of female-to-male violence and its association with male-to female violence. Method: We investigated each partner’s report on the Conflict Tactics Scale-II of the extent of reported violence in 246 couples expecting their first child who were recruited for a controlled trial of relationship education. Results: 42% of couples reported at least one incident of physical aggression in the past year. The vast majority of violence was of lower severity (pushing, slapping, or shoving), rates of male-to-female and female-to-male violence were approximately equal, and the most common pattern was of reciprocal aggression between the partners. Even less severe aggression is associated with significant risk of injury particularly for women, and predicts relationship deterioration and separation. Conclusions: This study identifies that high rates of aggression in pregnant couples is a significant problem and describes a psychoeducation strategy to address elements of this problem. Communication strategies to assist couples in the transition to parenthood will be discussed.

Can t We Just Yarn? Exploring the Voices of Perinatal Australian Aboriginal and Torres Strait Islander Women using the Indigenous Dadirri Method Geia, L.K.; Hayes, B.A.; Usher, K.J.; Elston, J. School of Nursing, James Cook University, Townsville Email: [email protected] In February, 2008, the landmark official apology offered by the Australian Prime Minister to the Indigenous Peoples for past injustices was accepted by Elders, on behalf of their Peoples. Prior to this event, a small but critical mass of Indigenous and non-Indigenous health professionals had forged partnerships with perinatal Indigenous women to foster emotional and mental health for the women and their families. As a natural progression, Indigenous methods of research are now evolving. Miriam Rose Ungunmerr-Bauman’s Dadirri Indigenous Narrative Methodology is one such vehicle of knowledge transfer which

Monash Alfred Psychiatry Research Centre, Alfred Hospital, and School of Psychology, Psychiatry and Psychological Medicine, Monash University, Melbourne, Australia Email: [email protected] Case Report Introduction: The desire to reproduce is both a powerful urge and a basic human right for women, regardless of mental health status. Currently, mental illness is treated with antipsychotic medication, however research is limited regarding the effect of this medication upon fetal development and maternal health. The challenge for clinicians, and women in this vulnerable population group, is to balance the risk to the mother’s mental health and wellbeing, against any possible risk of fetal abnormalities and developmental problems in the infant. Aim: We follow the pathway of one woman’s pregnancy, delivery and first postnatal year, as she not only learns to cope with her mental illness, but also to accept that her baby will be put into foster care. Method: Helen, a 39 year old woman with a history of paranoid schizophrenia, is observed on her journey through pregnancy-to gather information on psychiatric and medication history, including any side effects, family, medical and obstetric history-and her progress as her pregnancy advances. Observation continues at delivery, and into her baby’s first year, noting maternal and infant health and wellbeing. Results: The outcomes for Helen and her baby are not optimal. Helen becomes unwell, being deemed unfit to provide the necessary parenting skills required by her baby, while her baby has developed fetal abnormalities. Conclusion: The combination of poor psychosocial history, existing involvement with child protection agencies, psychiatric diagnoses and admissions, medications and substance abuse, present many issues affecting outcomes for both mother and baby during the perinatal period. Our Case Report highlights the great need for continued development of evidence-based clinical guidelines in the form of the National Register of Antipsychotic Medication in Pregnancy. Acknowledgements: This research is proudly supported by AstraZeneca, Janssen-Cilag, Mayne Pharmaceuticals and the Australian Rotary Health Research Fund. Channi Kumar’s Legacy for Perinatal Psychiatry and Mother-baby Joint Care Nine MC Glangeaud-Freudenthal Epidemiological Research Unit, France Email: [email protected]

S4 Channi Kumar joined James Hamilton and Ian Brockington in founding the international Marcé Society in 1980, and was its president between 1984–86. He suggested the name of Marcé Society after that of the French clinician Marcé who was one of the first to describe and study puerperal psychosis. Since 1982, this Society has been growing in many countries. Channi Kumar conducted much research in collaboration with students and researchers from many countries. One project very important to him was a cross-cultural study of postnatal depression, in which 15 countries were to participate, including France, England, Ireland, Sweden, Italy, Switzerland, Austria, Portugal, Uganda, Brazil, the United States, Japan, Canada, the United Arab Emirates and Hong Kong. Many researchers learned from him in this domain of research. Channi Kumar participated in the creation in 1981 of a mother-child unit at Maudsley Hospital in London and carried out several research projects to assess its practice and treatments. Within the Marcé Society, we have continued his work and several important studies were performed on issues from joint mother-baby admissions in different countries. Independent Factors Related to Recovery in Maternal Postpartum Psychiatric Disorders Nine MC Glangeaud-Freudenthal*, Anne-Laure Sutter, Véronique Lafont, Marie-Agathe Zimmermann, Micheline Blazy, Blanche Massari, Odile Cazas, Raphaël Cammas, Christine Rainelli, François Poinso, Michel Maron, Sylvie Nezelof and MBU-SMF research group *Epidemiological Research Unit, France Email: [email protected] Inpatients admitted to mother-baby units in France are mainly women with schizophrenia (25%), Maniaco-Depression (20%), depressive illness (25%). In France only 18% of inpatients are admitted only for evaluations of maternal competences and risk for the child. The French version of the Marcé-Checklist was used for collecting data from 12 mother-baby units in France and 3 in Belgium (2001–2007; more than 1000 admissions). The study included all women who were admitted as inpatients their babies under one year of age, to a participating MBU, with for longer than one week (mean duration stay is more than 2 months). A multifactorial analysis on more than 800 mother-baby inpatient joint admissions to psychiatric mother-baby units in France will be presented to show which factors are related to a significant improvement of women’s mental health. Main factors studied were: past mental health history of both infant’s parents, history of traumatic events during the mother’s own infancy, socioprofessional characteristics of both infant’s parents, treatments during pregnancy and referral characteristics. The relative importance of these factors will be discussed to explain significant improvement of women’s mental health at discharge from the unit. MBU-SMF research group MBU-SMF research group includes psychiatrists and researchers from in-patient mother-baby units in France (13 MBUs), Belgium (4 MBUs) and Luxembourg (1 MBU) who actively participate to research data collection. Some other psychiatrists from in- and out-patient mother-baby care units also participate to research discussion within the group. Since 1999, this group is lead by Ms Nine M-C Glangeaud-Freudenthal, a Senior Researcher at the French National Research Center (CNRS) working in an Epidemiological Research team and is one of the working groups within the Francophone Marcé Society.

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 Effective Delivery From the Receiving End Elaine A Hanzak Cheshire, United Kingdom Email: [email protected] For many people the journey of pregnancy and motherhood is a very delightful and rewarding experience. However, the birth of my son lead to a traumatic route into the mental health services, for the first time in my life. Puerperal psychosis resulted in me being hospitalised for two months, without my baby, as I had spiralled into a selfharming, threatening and fearful status. My illusion of family life was in tatters; my teaching career in jeopardy; my marriage potentially hanging by a thread. However, I did make a complete recovery and I wish to share with delegates what happened to me and the highs and lows of my journey. This will include my experience and reflections upon the healthcare I received. The impact upon all who were involved will be commented upon and the notion of postnatal illness as something to just pull yourself out of will be shattered. Since I have shared my story many others have told me theirs and as their spokesperson I can inform delegates of the most effective ways of delivering the policies and planning that they put in place. This knowledge has been acquired over the last few years from my attendance at many relevant conferences, from readers of my book and by direct communication through those affected by poor mental health. My presentation is illustrated with family photographs to emphasise my points. I am very grateful to all concerned in my treatment as I did finally recover and my overall message is positive and of hope for anyone facing mental ill-health. I want to inspire all those involved in mental illness related to childbearing to make a difference with their current and future work so that more eyes can regain their sparkle and delight in life, as I have done. Ownership and Respect Key Components of Effective Delivery of Perinatal Mental Health Care to Australian Aboriginal and Torres Strait Islander Women Hayes, B.A., Geia, L.K., and Egan, M.E. Email: [email protected] The first stage of thee National beyondblue Perinatal Mental Health Plan (2007–2009) Implementing psychosocial assessment of pregnant women and new mothers Australiawide; Training relevant health professionals in recognition and management of anxiety, depression and related difficulties; Establishing pathways of care appropriate to the various settings covered by the National Action Plan. Underpinning all of these processes are the particular cultural needs of Australia’s Aboriginal and Torres Strait Islander women. One of the Queensland strategies as part of the beyondblue National Postnatal Depression Program (2001–2005) was the translation of the Edinburgh Depression Scale (EDS) into contemporary, locally understood language at three sites in North Queensland: Townsville; Mt Isa; and Palm Island. In addition, after each site-specific screening package was translated, each of the site Reference Groups expressed the desire to translate the booklet–Emotional Health in Pregnancy and Early Parenthood (which was distributed nationally to all women) into their own language and to accompany it with their own symbols and artefacts. The women expressed a sense of ownership of all the materials generated which was

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 based on respect for their connection to country and respect for their choice of language for the experiences of their sisters perinatal emotional and mental distress. Ownership and respect will be explored in relation to the effective delivery of care to this underserved population but only the translation of two of the booklets will be presented. Motherhood: Is It Good for Women’s Mental Health? Sara Holton, Jane Fisher and Heather Rowe Key Centre for Women’s Health in Society, School of Population Health, The University of Melbourne Email: [email protected] Background: Having babies is argued to place women at increased risk of mental health problems. However, this is mostly based on clinical studies. There is little population based data regarding whether motherhood is actually detrimental. Objective: To investigate the relationship between motherhood status and mental health in Australian women of childbearing age. Method: A cross-sectional study of Victorian women aged 30– 34 years in 2005, randomly selected from the Australian Electoral Roll, was conducted. Participants completed a self administered anonymous postal questionnaire which assessed sociodemographic characteristics; health and psychosocial factors salient to childbearing decisions; and past and present health status. Four measures assessed mental health: the SF-12v2 (Mental Component Summary); the Personal Wellbeing Index (PWI); the Satisfaction with Life Scale; and a selfreport lifetime rate of diagnosed depression. Results: 569 of the 1278 potential participants (46.7%) returned completed questionnaires. The sample was broadly sociodemographically representative, and included mothers (61.5%) and women without children (38.5%). There was no significant difference in the mean MCS scores (SF-12v2) of mothers and women without children, indicating mothers mental health is no worse than women without children s. There was no significant difference in the proportion of mothers and women without children who had depression, indicating mothers have a similar rate of depression to women without children. Mothers had significantly higher mean PWI and life satisfaction scores than women without children, indicating greater subjective wellbeing and satisfaction with life. Mothers and women without children had significantly different sociodemographic characteristics. Yet motherhood was associated with women’s mental health even when sociodemographic characteristics were controlled for. Conclusions: We find mothers mental health and rate of depression is no worse than that of women without children, and mothers have significantly greater subjective wellbeing and life satisfaction. The results indicate that being a mother is associated with enhanced mental health for women, and challenge the existing evidence that the childbearing years are a period of diminished psychological wellbeing for women. Postnatal Depression in Mexico Perceptions, Prevalence and Link with Infant Failure to Thrive Saffron Homayoun and Gillian Wainscott Perinatal Mental Health Services, Queen Elizabeth Psychiatric Hospital, Birmingham and Solihull Mental Health NHS Trust, Birmingham, UK Email: [email protected]

S5 The objective of the study was to assess levels of awareness of post-natal depression in Mexico by studying the prevalence of post-natal depression in mothers who had recently given birth and to determine whether this condition was associated with failure to thrive in the child. Method: Eighty five mothers who had given birth within the previous 12 months attending an urban community health centre in Oaxaca Mexico, with their infants for routine vaccination, over a three month period in 2007 were asked to complete the Edinburgh Postnatal Depression Scale questionnaire. This had been translated into Spanish and care was taken that the mother understood all questions before answering anonymously and confidentially. The infants were weighed and measured. Results: Postnatal depression is not a well recognised term in Mexico and there are no specific services dedicated to the detection or management. Oaxaca is the fifth largest of the 31 states of Mexico and is one of the most impoverished ranked as second to last by the United Nations Development Programme. 43.4% of women who completed the Edinburgh Postnatal Depression scale questionnaire had a score of 9 or more with 36.1% obtaining a score of 10 points or more 30.9% of children were below the expected height, and 22.7% were below the expected weight, for their age and sex. There was no significant association between a higher questionnaire score and failure to thrive in the infant. Conclusions: In spite of the limitations of the study there are strong reasons to believe that a large numbers of mothers are suffering from post-natal depression, which is unrecognised and untreated. The conduct of the study stimulated interest in Health care professionals, including Psychologists in Mexico who were unfamiliar with the concept of postnatal depression and shocked by the results. Developing a Sustainable Perinatal Social Support Network Jane Honikman Postpartum Support International, Santa Barbara, California, USA Email: [email protected] Postpartum Support International was founded to represent self-help groups working in the prevention or alleviation of negative emotional reactions to childbearing. A Guide has been developed by a team of individuals who are actively involved with the perinatal social support movement. Their experience, talent, and knowledge have been compiled to help others develop sustainable networks throughout our world. This information based upon their expertise is divided into six topics; 1) Telephone Support, 2) Group Support, 3) Creating Materials, 4) Organizational Structure, 5) Community Presentations, and 6) Longevity and Sustainability. The goal of the Guide is to empower and encourage others to create a new parent support network or strengthen an existing one in your community. The definition of a parent support network is broad. It can mean an ongoing support group, a collaboration between agencies, an informational service, or a clearinghouse. All have in common a commitment to assist families by providing information and emotional support. The objectives of this presentation are: 1) To gain knowledge about the role of social support 2) To review the history and research of social support 3) To learn how to develop sustainable perinatal networks with examples and resources related to social support.

S6 The Outcomes of PANDA’s Integrated Peer to Peer and Professional Perinatal Depression Helpline Belinda Horton PANDA (Post and Antenatal Depression Association, Victoria), Melbourne Email: [email protected] The PANDA, (Post and Antenatal Depression Association) helpline provides biopsychosocial assessment of risk and symptoms, mapping of quality pathways to care and ongoing support and follow up important for positive recovery outcomes for women with perinatal depression. The education provided to empower women and their families to become informed consumers of medical, community and mental health services is a significant part of PANDA’s services. PANDA’s helpline model is peer to peer support within highly trained and professionally supported practices, making it a unique service provider in perinatal mental health. PANDA supports two significant groups of people. The first is women, their partners and families, who are experiencing or are at risk of experiencing mild through to severe perinatal mood disorders who contact PANDA’s helpline for information, support and referral. The second group is those women and men who enter into PANDA’s volunteer recruitment and training programs to undertake the roles of telephone support work and public speaking. All callers to the helpline talk to qualified staff and trained volunteers who have personally experienced and recovered from perinatal mood disorders, thus providing powerful peer to peer support. This paper presents the results of an evaluation of the outcomes for PANDA’s service users. This includes their understanding of perinatal depression, building their hope for recovery and knowledge about the steps needed for recovery and the importance of speaking to someone with similar experiences. Outcomes for the volunteer participants are also presented, including the impact of volunteering at PANDA on career goals and personal fulfillment. The importance of the provision of peer to peer support for recovery and growth for both callers and volunteers will be demonstrated by the information gathered from online and mailed questionnaires. The evaluation highlights the importance of the partnership between the peer to peer and professional services within PANDA and with the perinatal mental health sector. providing important input into policy development and service planning for effective perinatal mental health care.

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 grief that is associated with the birth of a stillborn baby and the effect upon the family. My portfolio includes:- - An extensive literature search related to nursing research of perinatal loss.-An over view of the grief models and related theory and there relevance to the topic.-A review of historical case studies & personal accounts of a stillbirth.-A small research project using a qualitative narrative life story approach concerning 2 women’s lived experiences of a still birth. During this presentation I will discuss the topic of grief and loss as related to stillbirth, and present an over view of the findings concerning clinical practice. Prescribing in Pregnancy: Helping Mothers without Harming Babies T Everett Julyan, Jonathan Cavanagh and Roch Cantwell NHS Greater Glasgow and Clyde, Scotland, UK Email: [email protected] Introduction: Psychotropic prescribing in pregnancy remains fraught with uncertainty. While guidance exists, there is no strong research base to inform practice. Decision making must be based on individual circumstances and take into account a range of factors related to the woman, her illness and effects on the fetus. There remains a dearth of knowledge regarding long-term neurodevelopmental effects of psychotropic medication. The Glasgow Perinatal Mental Health Service has developed a database of psychotropic prescribing in pregnancy to inform practice and facilitate research into long-term outcomes. Methods: The database was interrogated to examine the prevalence and nature of prescribing in pregnancy for women referred to the service from primary care, maternity and general psychiatry services. Results: Approximately half of all women were prescribed medication, either periconceptually, after the first timester, or throughout pregnancy. SSRI antidepressants were the most commonly prescribed. Conclusion: Women with mental health problems are often taking psychotropic medication at the time of conception. More require treatment during their pregnancy. Greater awareness is required among primary care physicians and psychiatrists regarding the need for prepregnancy advice and counselling. The relatively small numbers of women attending specialist services should mean that data is collected at regional or national level in order to facilitate high quality research into long-term effects of medication on child development.

Stillbirth: A Review of the Grief and Loss Issues Associated with a Perinatal Loss

Perinatal Depression and the HPA Axis

Leone Joyce

Martin Kammerer, Alyx Taylor and Vivette Glover

Early Intervention Maternal Mental Health. Specialty Services, Mental Health, Waikato District Health Board, New Zealand Email: [email protected]

Imperial College London Email: [email protected]

Over the past 5 years several women have been referred to the Early Intervention Maternal Mental Health Service (Waikato, NZ) for emotional support following an intrauterine death or still born and this has provoked an increased awareness of a need to understand how women cope with the loss of their baby and what effect does this loss have upon the family members. For my Masters of Nursing degree I chose to complete a research portfolio to explore The lived experience of women who have suffered the death of a baby either through an intrauterine foetal death in the second/ third trimester or during labour. The aim was to seek a deeper understanding of the phenomenon and

Aim: To characterise the effect of pregnancy on the symptoms and diagnoses of melancholic and atypical depression in pregnancy (1) and on some functions of the hypothalamic-pituitaryadrenal axis (2) perinatally. Method: 1. A consecutive series of 449 women were asked about all their symptoms of melancholic and atypical depression in pregnancy using the Structured Clinical Interview for DSM (SCID) irrespective of whether they qualified the entry criteria for melancholic and/or atypical depression or not. 2. The diurnal variation of saliva cortisol (a) and the saliva cortisol reactivity to a physical stress test (cold test)(b) were measured with non depressed and depressed samples perinatally.

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 Result: 1. Most of the melancholic and atypical symptoms did not discriminate between these two diagnoses. 2. (a)Saliva cortisol reactivity to physical stress was blunted at week 36 gestation and significant again at weeks six and eight postnatally. The depresseed and the non depressed samples postnatally showed no difference in cortisol reactivity to the physical stress test. (b) Fifteen healthy pregnant women at week 36 antenatal, 14 healthy postnatal women at week six postnatal and 14 healthy non perinatal women at mid cycle showed that the shape of the diurnal variation was not different between the three groups. These findings suggest that the awakening rise, in contrast to physical stress response, is not confounded by pregnancy and the postpartum. Postnatally depressed women (n=18) compared to postnatally non-depressed women (n= 23) showed differences in shape of the diurnal variation of saliva cortisol. Conclusion: Melancholic and atypical depression seem to be confounded by pregnancy. The profile of diurnal variation of saliva cortisol, but not reactivity to a physical stress test detects differences betwen depressed and non depressed women postnatally. Limitation: Absence of a non perinatal control group in study (1) and small sample sizes of study (2) are main limitations for the above reported findings. Boodjarri Business: Perinatal Mental Health Training for Aboriginal Health Workers R Kinsman Western Australian Perinatal Mental Health Unit (WAPMHU) Email: [email protected] Aboriginal Health Workers (AHWs) are in a prime position to raise awareness of perinatal mental health in the Aboriginal community and to coordinate the care of women experiencing emotional difficulties during pregnancy and postnatally. Thus, to ensure better outcomes for Aboriginal women during the perinatal period, appropriate education and support must be provided. For four years, the WAPMHU has worked to enhance the knowledge of perinatal mental health among AHWs and foster their capacity to provide assistance to Aboriginal mothers and their families. In a series of workshops, AHWs in rural and metropolitan Western Australia (WA) discussed their knowledge of perinatal mental health, their perceived role in addressing this issue, and the training and resources required to assist them in this role. Following this, a steering committee with representation from a range of Aboriginal stakeholders was established to guide the development of appropriate training and resources for AHWs in WA. The Boodjarri Business training module was developed in collaboration with Marr Mooditj Aboriginal Health Training College, and covers material such as identifying signs and symptoms, risk and protective factors, ways to support families, and ways AHWs can take care of themselves while providing care to communities. This workshop-style module allows participants to recognise and contribute their existing knowledge from their personal, professional and cultural experiences. Participants can then apply this knowledge to understanding the more specific details and definitions of perinatal mental health as recognised by other (western) health professionals. Although originally designed for implementation with students studying at Marr Mooditj, the Boodjarri Business training has been adapted for other audiences, including current practicing AHWs and community members. The module’s structure and content will be discussed in this paper, highlighting the lessons learned during its development and its delivery in a variety of settings.

S7 On Being a Good Mother: Reasons Women Give for Contemplating or Undergoing Abortion Maggie Kirkman1, Shelley Mallett1, Heather Rowe1, Annarella Hardiman2, and Doreen Rosenthal1 1 Key Centre for Women’s Health in Society, The University of Melbourne, Australia 2 Royal Women’s Hospital, Melbourne, Australia Email: [email protected]

Background and Aim: Despite considerable public debate about abortion there is little research on women’s experiences. The research reported here aimed to increase understanding of the woman’s perspective, including the reasons women give for contemplating or undergoing an abortion. Method: Sixty women who had contacted a public pregnancy advisory service in Victoria, Australia, seeking information, advice, or appointments in relation to an unplanned or unwanted pregnancy, were recruited into the study. Recruitment targeted three categories: women aged 16–18, from rural or regional areas, and presenting at 12–18 weeks gestation. The first two groups are known to be disadvantaged in gaining access to reproductive health services, and women who present for termination after 12 weeks gestation prompt concern about personal or service restrictions on earlier presentation. In-depth telephone interviews were conducted and recordings transcribed. Thematic analysis of reasons discussed by participants was performed, drawing on narrative theory to guide insights into explanation and meaning. Results: About a third of the participating women were aged 16–18, a third were from rural or regional areas, and another third presented at 12–18 weeks gestation. Some women fitted more than one category. Women described complex influences on their decisions to have an abortion (or to continue a pregnancy) that were usually contingent and multiple, conveyed throughout the interview rather than in a brief statement. Reasons given for contemplating or undergoing abortion can be summarised as relating to the woman herself, the potential child, existing children, her partner and other significant relationships, and economic matters, most of which contribute to what it means to a woman to be a good mother. Conclusion: Reasons described by the women revealed the extensive context within which reproductive events must be understood. Parenting Capacity: Assessment through Observation (PCAO) K. Knights1; A.W. Harris1,2; P.M. Boyce1,2; J. Barton2 1

Discipline of Psychological Medicine, University of Sydney Westmead Perinatal Psychiatry & Clinical Research Unit, Sydney West Area Health Service Email: [email protected]

2

Women with schizophrenia experience difficulty when entering motherhood. Clinical observation shows that positive symptoms of schizophrenia (eg; hallucinations, delusions) can cause chaotic behaviour in the mother, compromising the safety of the nurturing environment. Negative symptoms (eg; amotivation, blunted affect, limited motoric expression of facial cues) impact negatively upon mother-infant interaction and bonding. The cognitive deficits associated with schizophrenia may also affect parenting capacity. Empathy and social cognition are also impaired in schizophrenia, adding further insult to interaction and the emerging attachment

S8 relationship. A tragic outcome of this clinical reality is that approximately half of the new babies of mothers with schizophrenia are removed after childbirth (Howard et.al., 2003; Joseph et.al., 1999; Kumar et.al., 1995; Kumar et.al., 1996). However the decision to remove these infants is too often influenced by parenting capacity ratings that are neither appropriate nor specific to the schizophrenia population. Parenting capacity assessments in their current form are not sensitive to illness-related aspects of schizophrenia that impinge upon the ability to parent. It is essential that decision-making in the child protection setting is based upon assessments of parenting capacity that are reliable and validated for use with this cohort. A specifically designed assessment is urgently needed in order to reliably index the infant caregiving capacity of postnatal mothers with schizophrenia. The Parenting Capacity: Assessment through Observation (PCAO) was designed to address this clinical need. The PCAO is the first instrument of its kind, designed specifically for the assessment of mothers with schizophrenia in the time that follows childbirth. The PCAO generates a rating that is representative of essential parenting dimensions (including protection, provision, diligence, proficiency, focus, strategy, management, precision, adaptability, self-efficacy, affection, interaction and empathy), reflecting difficulties experienced as a result of illness-related factors in new mothers with schizophrenia. Pilot data suggests good face validity for this instrument and a protocol that is acceptable to the mothers being assessed. It is hoped that the PCAO will provide an appropriate, sensitive, reliable and valid assessment of the core caregiving tasks of a mother in the postpartum period. This instrument will place the assessment of parenting capacity of mothers with schizophrenia on a scientifically rigorous basis and will assist in the development and assessment of interventions designed to treat functional impairments in mothers with schizophrenia. Postnatal Depression-The Social Construct Viewed Through the Lived Experience Catherine Knox Gidget Foundation, NSW Email: [email protected] Perinatal mental health issues represent a complex black package of physical, psychological and social factors. Affecting nearly 20% of perinatal women, the diagnosis and treatment of antenatal depression and postnatal depression has been a relatively recent occurrence. Seen as a mental illness with the associated stigma, women have suffered silently for generations unwilling or unable to give voice to their feelings. This presentation will have a personal perspective, looking from the inside out, through the eyes of someone who has lived through and recovered from postnatal depression. The perinatal period is one of heightened observance of women, and the representations of mothers during this period will be examined. This will include a discussion on how motherhood is portrayed in our society and the current western sentimental view of motherhood. There are a number of challenges in the diagnosis and treatment for antenatal and postnatal depression. Women may struggle to articulate their often complex feelings and feel unclear about how and where to seek help. If a diagnosis is made there can be confusion by both health professionals and women over referral and negotiating available options. The process of recovery and the importance of an integrated approach will be examined in some detail. This will include a look at psychosocial support and treatment for women and their families, while examining the concepts of loss, grief and identity. Long held beliefs and practices will be explored in this presentation. It will

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 consider alternative notions for understanding the experiences of women passing through pregnancy, childbirth and early motherhood. The impact of perinatal mental illness on the woman’s partner, her family and her community will also be given critical consideration. The social construct of perinatal mental illness will be examined through the lived experience. The National Register of Antipsychotic Medication in Pregnancy (NRAMP) Kulkarni, J;1,2 Gilbert H;1,2 Marston, N;1,2 Gurvich C;1,2 McCauley, K,2,3 De Castella, A

1,2

1 Monash Alfred Psychiatry Research Centre, Alfred Hospital, Melbourne, Australia 2 School of Psychology, Psychiatry and Psychological Medicine, Monash University, Melbourne, Australia 3 School of Nursing and Midwifery, Monash University, Melbourne, Australia Email: [email protected]

Introduction: Current data on antipsychotic use in pregnancy is limited. Aim: The aim of this research is to establish the National Register of Antipsychotic Medication in Pregnancy, to provide evidence-based clinical guidelines for the safest use of antipsychotic medication during pregnancy and for the first year of the baby’s life. Method: Participation will include women with a history of mental illness, who are taking antipsychotic medication and who become pregnant. Participants will be sought Australia-wide. Following provision of informed consent, data will be gathered via telephone and/or face to face interviews during pregnancy, following delivery, and for the first year of the baby’s life. Information will include demographics, medical, psychiatric, medication and obstetric history, and information on general health and wellbeing for mother and baby. A standard database will be used to collate data and generate any trends. Results: This study is current and ongoing, with a minimum proposed target of 100 participants. Several time point analyses are possible and include the antenatal period, immediately postpartum, and at predetermined stages for the first year of the baby’s life. Preliminary results to date will be presented. Discussion: The collection of ongoing data, and the resulting guidelines, have the potential to provide regular contemporary updates to clinical treating teams for evidence-based management of women in this vulnerable population group. The overall benefit of this study goes far beyond any numerical reference. The Monash Alfred Psychiatry Research Centre works to enhance and improve the quality of life for those among us who live daily with mental illness, both now and into the future. Acknowledgements: This research is proudly supported by AstraZeneca, Janssen-Cilag, Mayne Pharmaceuticals and the Australian Rotary Health Research Fund.

Prevalence and Risk Factors of Postnatal Depression among Chinese Men in Hong Kong Beatrice P. Y. Laia, Dominic T. S. Leeb, Alan K. L. Tangc, Tony K. H. Chunga a Department of Obstetrics & Gynecology, The Chinese University of Hong Kong b School of Public Health, The Chinese University of Hong Kong c Department of Psychiatry, The Chinese University of Hong Kong Email: [email protected]

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 Background: Postnatal depression in fathers has a unique detrimental effect on the behavioral and emotional development of young children. However, research on paternal depression has remained largely neglected. Aims: The objectives of the study were to examine the prevalence and psychosocial risk factors of postnatal depression among Chinese men in Hong Kong. Method: A total of 536 men were assessed immediately after delivery and 8 weeks postpartum. At 8 weeks postpartum, the prevalence rate of depression was estimated with a two-phase design. All high scorers on the Beck Depression Inventory or the Edinburgh Postnatal Depression Scale and 40% of low scorers were assessed with the Structured Clinical Interview non-patient version for DSM-IV (SCIDNP). The prevalence rate was measured by reverse weighting. The risk factors of postnatal depression (as defined by the Edinburgh Postnatal Depression Scale) were identified by using logistic regression analysis. Results: The prevalence rates for major and minor depression at 8 weeks postpartum were 2.20% and 2.24% respectively. Perceived stress, life events, difficulty in infant care, lack of social support, antenatal depression, and partner’s postnatal depression independently predicted postnatal depression in men. Conclusions: Postnatal depression is evident among Chinese men. A postnatal screening program is recommended for early detection and intervention. The findings have implications for clinical practice and future research. Validation of the Edinburgh Postnatal Depression Scale among Chinese Men in Hong Kong Beatrice P. Y. Laia, Dominic T. S. Leeb, Alan K. L. Tangc, Tony K. H. Chunga a Department of Obstetrics & Gynecology, The Chinese University of Hong Kong b School of Public Health, The Chinese University of Hong Kong c Department of Psychiatry, The Chinese University of Hong Kong Email: [email protected] Background: Postnatal depression affects a substantial proportion of fathers and it has a unique contribution to child development. Detection and research are important but there are few validated instruments for screening for postnatal depression in Chinese men. Aims: To examine the validity of the Edinburgh Postnatal Depression Scale (EPDS) for screening for postnatal depression among Chinese men in Hong Kong. Method: A prospective cohort of 235 men completed the EPDS, Beck Depression Inventory (BDI), and the Patient Health Questionnaire Depression Module (PHQ-9) at 8 weeks postpartum. Clinical diagnosis of depression was established with the Structured Clinical Interview for DSM-IV, non-patient version (SCID-NP). The criterion validity of the EPDS was evaluated against this clinical diagnosis, and the concurrent validity against the BDI and PHQ-9. Results: The psychometric properties of the Chinese EPDS for men are satisfactory and a cutoff of 10/11 yielded optimum receiver operating characteristics. The Cronbach’s standardized alpha of the EPDS was 0.86. The EPDS correlated with the BDI and the PHQ-9 (Spearman s r=.77 and.76 respectively, p<.01). Conclusions: The Chinese EPDS is a reliable and valid instrument for screening for postnatal depression in men.

S9 Childhood Sexual Abuse: Implications for Pregnancy, Birthing and Mothering Gerri C. Lasiuk Women Health Research Unit, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada Email: [email protected] Background: While there are clear associations between childhood sexual abuse and a range of health problems in adulthood, the implications of childhood sexual abuse for pregnancy, birthing, and the early postpartum period have not been fully described. The literature that does exist suggests that women with histories of childhood sexual abuse may be reluctant to seek health care; have poor relationships with caregivers; have more anxieties and fears about the birthing experience; be (re)traumatized by the birth experience itself; experience emotional problems postpartum; and have more difficulties with breastfeeding, bonding with their infants, and parenting. Method: This interpretive inquiry addressed the question: What is the lived experience of pregnancy and birthing of women with histories of childhood sexual abuse? It was guided by an approach to human science research described by van Manen (1997) and grounded in the philosophical traditions of phenomenology and hermeneutics. Eight English speaking, Canadian women participated in conversational interviews about their experience of pregnancy and birthing. The interviews were audiotaped and transcribed, and the resultant text was thematically analysed. Findings: The inquiry revealed how childhood sexual abuse insinuates itself into a body and a life, often causing long-term disruptions in mood and affect, perceptions, beliefs, behaviour, and systems of meaning. Women’s circumstances at the time they became pregnant influenced their perceptions of their selves and their response-abilities to motherhood. Those who were safe, stable, and supported, spoke of a visceral Yes! to being pregnant. When those things were absent however, women were more apt to be uncertain about pregnancy or to experience it as an invasion. Carrying, birthing, and caring for a child also opened some women up to their own lost innocence and to the delights and joys of childhood, which in turn offered them new opportunities for wholeness and healing. Validation of Edinburgh Postnatal Depression Scale for Adolescent Mothers M Cynthia Logsdon1, Wayne Usui2 and Michael Nering3 1

School of Nursing and Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, University of Louisville, Kentucky, USA 2 Department of Sociology, University of Louisville, Kentucky, USA 3 Measured Progress, Dover, New Hampshire, USA Email: [email protected] Introduction: The Edinburgh Postnatal Depression Scale (EPDS) has widespread use internationally to screen adult women for symptoms of postpartum depression, but the psychometric properties of the instrument have not been established in adolescent mothers in the United States. Psychometric data on the EPDS is needed to advance

S10 the science of postpartum depression in adolescent mothers and to recommend a screening tool that can be used confidently by clinicians to identify symptoms of postpartum depression in adolescents. Purpose: The purpose of this paper is to provide preliminary psychometric data on the EPDS from a sample of 149 adolescent mothers who live in an urban area in the southern United States. Method: The sample for this descriptive study was recruited from two community hospitals and a teenage parent program, an option of the public school system. On average, the adolescents were 16 years of age and most were of low income. The sample was ethnically diverse, and all adolescents were 4–6 weeks postpartum. Results: The mean score on the EPDS was 7.4 (SD=6.1), and the score did not vary by race. Internal consistency reliability was high (.88), as were item to total correlations with all values being larger than .44. There was a mid level correlation between the EPDS and CES-D (r=.62), which was used as a measure of criterion related validity. Exploratory factor analysis (Principal components analysis) with varimax rotation supported a two factor structure of the EPDS. Each factor had an eigenvalue greater than one and accounted for 30% of variance. Additionally, item response theory (Rasch analysis) was used to explore item-testee interaction and to provide empirical evidence to support claims of validity. Conclusions: Preliminary psychometric data from our analysis suggests that the EPDS can be used with confidence to screen adolescent mothers for symptoms of postpartum depression. Fathers Involvement in Swedish Child Health Care: Nurses Attitudes and Practice Pamela Massoudi1,2, Birgitta Wickberg3 and Philip Hwang1 1

Department of Psychology, Gothenburg University, Sweden Research and Development Centre, Kronoberg County Council, Sweden 3 Research and Development Unit, South Bohuslän County Council, Sweden Email: [email protected] 2

Objectives: To explore how Swedish child health nurses perceived working with fathers, and to what extent they detected and offered support to distressed fathers. Subjects and methods: A random sample of all 2580 nurses in Swedish Child Health Services (CHS), 499 nurses, were asked to complete a postal questionnaire. A response rate of 70% was achieved. Results: A majority of the nurses found working with fathers important and rewarding. Fathers participation in CHS activities had increased over the years but many nurses wished for fathers to participate more. Questions reflecting attitudes to fathers as parents, however, revealed that around 50% of the nurses had an ambivalent attitude towards fathers innate caring capacities as compared to mothers. Only one out of four nurses expressed that they attempted to in some way identify fathers that were distressed. None of these nurses used systematic methods or screening scales. Almost 90% of the nurses estimated that it only occasionally or practically never came to their attention that a father was distressed. Less than one out of five nurses had offered supportive listening visits to distressed fathers in the previous year. The odds of giving supportive listening visits to fathers was three times greater for nurses who had regular supervision in their psychosocial work and six times greater for nurses with paediatric specialization.

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 Conclusion: Despite having good intentions, many child health nurses in Sweden still have traditional views on mothers versus fathers innate caring capacities and do not detect and support distressed fathers to the same extent as they detect and support distressed mothers. Regular supervision and paediatric specialization seem to be important factors that promote nurses support to fathers. Adequate methods and routines to increase support to fathers need to be developed. The Overpathologising of Motherhood Stephen Matthey Infant, Child & Adolescent Mental Health Service, Sydney South West Area Health Service, Australia Email: [email protected] The rate of postnatal depression in English-speaking women is now well established, at around 10–20%. Many studies also cite figures suggesting the rate in pregnancy is equivalent, or even higher. Additionally, investigators are now advocating for better identification of anxiety disorders, which will increase these disorder rates further. The impression given in many studies is that unless all these women receive professional help, the consequences for themselves, their infant, or their family, are dire. This presentation will challenge some of these notions by considering: i) The validity of diagnostic criteria for perinatal women; ii) the erroneous understanding that all high scorers on validated self-report measures would meet diagnostic criteria for a mood disorder; iii) the difference between enduring and transient distress, and how researchers and clinicians often fail to differentiate between these two; iv) the use of incorrect selfreport cut-off scores, and the impact this has on reported rates of high scorers; and v) whether all women identified as having a mood disorder need professional help if their condition is to improve. The discussion will also consider why such overpathologising may occur. The Complexities of Delivering Family Care Centre Services Karen Myors and Debbie Nemeth Karitane, Sydney Email: [email protected] Child and Family Health Nurses (C&FHNs) are specifically trained to identify the health issues of children, from birth till 5 years of age. Their practice incorporates a model of wellness, predominantly within a primary health care setting. Many C&FHNs, however, also work in Family Care Centres (FCCs). FCCs are secondary referral services for families experiencing difficulties requiring more intensive consultations. In recent years, C&FH Nursing has had an increased focus on the psychosocial aspect of families with young children. Likewise, evidence suggests that many families who access FCC services have complex issues, such as isolation, anxiety and depression, which impact on the parenting relationship. The significance of these complexities is often not identified until consultation. Karitane is a specialist organisation providing a wide range of services to support families with young children, including multidisciplinary FCCs. Karitane has undertaken a project to review the appropriate model of care for service delivery within FCC services. This project included the development of a survey in consultation with representatives from FCCs across NSW to gain a greater understanding of the complexities of the

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 work undertaken by C&FHNs in FCCs. The survey was distributed to the 32 FCCs throughout the State. The questions explored the preparedness of C&FHNs to support the families presenting with often complex psychosocial issues, staff skill mix, qualifications and specialist training, support requirements and appropriate referral pathways needed to meet the needs of the families accessing their services. This presentation will outline the results of this survey. Specific reference will be made to: training and preparation for the development of appropriate skills support mechanisms, such as clinical supervision and case conferences models of care appropriate to common presenting issues access to allied health professionals and referral pathways. Positively-Anchored Fathers Timothy O Leary Father’s Time Program, Frances Perry House, Melbourne Email: [email protected] Whilst pre-natal groups for fathers are an opportunity to reduce men’s birthing-related anxieties and encourage them to be in a supportive role for their partner, the most significant benefit may be felt in the longer term. Pre-natal groups for fathers are a chance to educate fathers about child development issues and to help them to avoid gender traps associated with the transition to parenthood. The transition to parenthood tends to result in a decrease in marital satisfaction and an increase in stress associated with financial and lifestyle sacrifices. How men cope and react to these changes is critical. Healthy strategies include fathers who begin parenthood with realistic expectations which can prevent misunderstandings between them and their partner and allow them to be guided by their deeper values in how they make the transition to parenthood. Destructive reactions range from increased substance abuse, over identification with work and withdrawal from the domestic sphere or the use of violent behaviour within the home. A major problem with both parenthood and relationships is the reactivity and associated negativity that occurs when partners or parents become stressed. At these times, the strategies that work during calmer states of mind can be elusive and replaced by blaming and punitive practices. Fathers in pre-natal groups are highly interested in being positively anchored during times of stress with either their partners or expected children. Most people have sound values, they just need strategies to assist them to connect with these values and take valued action during stressful times. A frank, open discussion about these issues leaves pre-natal fathers feeling much more purposeful about their transition to parenthood than simply encouraging fathers to get involved. Prevention of Major Mood Disorders through Perinatal Networking

S11 vulnerability to be detected before the episode sets in. Such a collaboration opens new perspectives for prevention if it includes frontline professionnals (often midwives). We will present an example of such networking involving a mood disorder clinic, community midwives and maternity units of 3 surrounding general hospitals in the south of France. Progressively put in place since 1998, this network has given access to psychiatric evaluation and ambulatory care to several hundreds of women who had never met a psychiatrist before and wouldn’t have imagined doing so during their pregnancy. These consultations were made possible through the decisive orientation proposed by the midwife closely involved in the obstetrical follow-up. We will discuss particular challenges met during the building of this network and underline new clinical dimensions that we discovered, illustrating them with examples from several cases. Finally, a brief numerical analysis of this highly selected group of patients will be presented: it reveals several salient common points such as family history of suicide and exposure to mental disorder in one of the parents. Emphasis on these points may be of considerable strategic importance as they may be easily noticed by the community midwives. Gender Differences in Depression and Anxiety: Is Anatomy Destiny? Gordon Parker School of Psychiatry, University of New South Wales It has been long recognized that rates of depression in the general community are higher in females from early adolescence onwards, with numerous studies pursuing artefactual and true causes. It is less well recognized that rates of anxiety show a similar pattern. Such findings allow the possibility of a higher order variable accounting for the gender difference in both conditions. This paper will consider the nature of that higher order mechanism (limbic cortex hyperactivity) and consider its evolutionary importance, before arguing that it is best viewed as a diathesis factor therefore predisposing but not necessarily dictating to higher rates of anxiety and depression in women. Plasma Melatonin Circadian Rhythms in Pregnancy and Postpartum Depression Barbara L Parry, Charles J Meliska, Diane L Sorenson, Ana M Lopez, Luis F Martinez, Sara Nowakowski, Jeffrey A Elliott, Richard L Hauger, and Daniel F Kripke Department of Psychiatry, University of California, San Diego and San Diego Veterans Healthcare System, La Jolla, California, USA Email: [email protected] Preferred format: paper (30 minutes)

Oguz Omay Psychotherapy Clinic “La Cerisaie” and French Marcé Society (SMF), Tain l’Hermitage, France Email: [email protected] In perinatal psychiatry, preventing the episodes of major mood disorders is a specific challenge. If already diagnosed, bipolar disorder has the highest episode risk during the postpartum period. A first episode may also occur in a patient without known personal psychiatric history, though close attention may reveal a family history of the disorder. A solid link between obstetrics and psychiatry teams is necessary for this particular

Objective: To test the hypothesis that disturbances in plasma melatonin distinguish pregnant and postpartum patients with major depression (DP) from matched healthy comparison (HC) women. Method: In 25 pregnant (15 HC, 10 DP) and 24 postpartum (11 HC, 13 DP) women, we measured plasma melatonin every 30 minutes from 18:00–11:00 hours (h) in dim (<30 lux) light. The values were log-transformed and calculations made for standard and synthesis onset and offset time, duration, peak concentration and area under the curve (AUC). Groups were compared by analyses of covariance, using age, weeks pregnant or postpartum, breastfeeding status and body mass index (BMI) as covariates.

S12 Results: Pregnant DP had significantly lower (p=.01), whereas postpartum DP had higher plasma melatonin values (p = .02), especially in the early morning hours, compared with matched HC women. Pregnant (but not postpartum) women with a personal or family history of depression, regardless of current diagnosis, had significantly earlier melatonin synthesis offset (p=.002) and standard offset (p=.007) than those without such a history. In pregnant DP vs. HC women, sleep onset was significantly delayed relative to melatonin onset (p=.01), and synthesis offset (p=.002) and standard melatonin offset (p=.004) were significantly advanced relative to sleep onset. Conclusions: Plasma melatonin concentrations during sleep, especially in the morning hours, were lower in depressed pregnant, but elevated in depressed postpartum women, compared with HC women. Melatonin timing measures are advanced in pregnant women with a personal or family history of depression. It is not currently known whether such differences in the timing and amount of melatonin secretion are causal in DP. Confirmation of Subscales within the Edinburgh Postnatal Depression Scale (EPDS) Jane Phillips, Margaret Charles, Louise Sharpe, and Stephen Matthey Karitane/University of Sydney Email: [email protected] The Edinburgh Postnatal Depression Scale (EPDS) is a well validated and widely used 10-item self-report measure for depressive symptoms in the perinatal period. Although the EPDS was originally was described as a uni-dimensional measure of depression, there is a growing body of evidence to suggest that it is comprised of distinct anxiety and depression subscales. This paper will provide an overview of previous studies that have looked at the factor structure of the EPDS and will report results from a recent study that further investigated this issue. In this study, 310 postnatal women with infants aged 0–12 months completed the EPDS, the Beck Depression Inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI), and were interviewed using the Structured Clinical Interview for DSM-IV Diagnosis-II (SCID-II) (depression and anxiety disorder modules). A principal components analysis was conducted to examine the EPDS’s factor structure, followed by a confirmatory factor analysis to test four models derived from previous research. The concurrent validity of the subscales identified in each of the models were then assessed by examining correlations between subscale scores and other self report measures of depression and anxiety symptomatology, and by examining the correspondence between EPDS subscale scores and DSM-IV diagnoses. Results from this study support the view that the EPDS is comprised of distinct anxiety and depressive subscales, which raises a number of issues relating to interpretation and best use of the EPDS in clinical practice. Development and Delivery of a National Multiprofessional Education Course for Perinatal Mental Health A Poat and E Forrest Nursing Midwifery and Community Health, Glasgow Caledonian University, Scotland Email: [email protected]

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 Objective: To describe the development and delivery of perinatal mental health education modules for multi professional groups to aid in the planning and effective delivery of perinatal mental health services Background: Following review by the World Health Organisation (WHO) in 2000 and in the U.K, The Confidential Enquiry into Maternal and Child Health (2004) the importance of recognising factors contributing to the poor mental health of women nationally and internationally was highlighted. The need for radical expansion of both perinatal services and education provision was recommended. After much consultation with relevant stakeholders, the Perinatal Mental Health Curricular Framework (2006) was devised in Scotland. This informed a pilot project for a national multi professional education package.This original innovative course was created by Glasgow Caledonian University in conjunction with the University of the West of Scotland and NHS Greater Glasgow and Clyde. Method: A multidisciplinary working group developed the educational material to ensure a culture of topic and discipline specific relevance. The project team worked in subgroups and identified key clinicians and educationalists to contribute to each learning outcome. The educational material will be reviewed and evaluated by a national steering committee and student cohort to certify discipline, educational and topical relevance. Evaluation: The development process, implementation and evaluation of this course will be presented showing the preliminary findings of the project as to its outcomes regarding educational value, interdisciplinary working and effective perinatal mental health service provision. The blended approach to teaching and learning using both face to face and Elearning will be evaluated for its effectiveness in achieving learning outcomes and overall suitability for a geographically spread student cohort. In addition the use of inter-professional mentoring as an innovative practice will also be evaluated. Up Scaling a Perinatal Mental Health Intervention in a Low-income Country: Challenges and Opportunities Atif Rahman University of Liverpool, Royal Liverpool Children’s Hospital, Liverpool, UK Our previous work indicates that the rate of perinatal depression in Pakistani women is between 23 to 28%. We have also shown that perinatal depression in women is associated with undernutrition, increased rates of diarrhoea and low rates of immunization in their infants. Thus, perinatal depression is a major public health problem in developing countries like Pakistan. In such non-literate and poor communities where depression is not recognised and where there are no specialists, developing a culturally acceptable, deliverable psychological intervention that community members find useful, presents special challenges but also opportunities. We conducted a multi-method formative study to develop and deliver a psychological intervention to depressed mothers and their infants through non-specialist village based health workers.. The intervention, called the Thinking Healthy Programme (THP), used CBT techniques of active listening, collaboration with the family, guided discovery (style of questioning to both gently probe for family’s health beliefs and to stimulate alternative ideas) and homework (trying things out in between sessions, putting what has been learned into practice), and applied these to health workers routine practice of maternal and child health education. The intervention was integrated into existing health systems in a rural area of Pakistan. We tested the effectiveness of this intervention using a cluster

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 randomized control design. The main findings of these studies will be presented and the challenges in scaling-up such interventions in a country like Pakistan will be discussed. Two Year Outcomes for Mothers Detected as Probably Depressed by an Early Detection Program Reay, R1, Matthey, S2, and Ellwood D3 1

Academic Unit of Psychological Medicine, ANU Medical School, Canberra, Australia 2 Sydney South West Area Health Service, Sydney, Australia 3 School of Clinical Medicine, ANU Medical School, Canberra, Australia Email: [email protected] Background: The National beyondblue Postnatal Depression Program was implemented in the Australian Capital Territory (ACT) to assist health professionals in the early detection and referral for treatment of mothers affected by perinatal depression (Buist et al., 2005). This paper reports on the findings from a 2 year follow up study into the mental health outcomes of participants in the ACT. Few screening programs have documented the incidence of distress and depression beyond the first few months and rarely beyond the first postnatal year. Objectives: We assessed the effectiveness of the early detection program by examining the incidence of probable depression, uptake of treatments, perceived helpfulness and obstacles to treatment and support over the course of 2 years. Methods: During April December 2004, 984 women from the ACT participated in the National beyondblue Postnatal Depression Program and were assessed for symptoms of depression in pregnancy and 6– 8 weeks postpartum. At 2 years postpartum, all the participants who were screened as probably depressed were invited to participate. A random sample of an equivalent number of mothers who screened as not depressed were also invited to participate. This study compared their outcomes on such variables as depressive symptoms, mother-infant bonding, reasons for distress, access to and satisfaction with treatment. Results: 99 probably depressed and 102 not depressed mothers completed and returned the questionnaire package. The most notable finding was a more than three fold increase in the rates of depression at 2 years for mothers detected as probably depressed by the program compared to the not depressed cohort. Despite the fact that maternal depression was detected by health professionals in the screening program and effective treatments were available, 41% of depressed mothers did not access treatment. This paper will discuss aspects of early detection programs that could be targeted to improve treatment uptake rates of high risk women. Evidence for Planning Improved Services for Australian Women Contemplating Abortion after Unplanned or Unwanted Pregnancy Heather Rowe1, Maggie Kirkman1, Annarella Hardiman2, Shelley Mallett1, and Doreen Rosenthal1 1

Key Centre for Women’s Health in Society, Melbourne School of Population Health, The University of Melbourne 2 Royal Women’s Hospital, Melbourne Email: [email protected]

S13 Introduction: Prevention of unwanted pregnancy and provision of safe abortion services remain public health priorities in Australia and internationally. However there is little reliable information available about women who seek pregnancy counseling, the circumstances which led to the unwanted or unplanned pregnancy, the contextual factors in decision making or their specific service needs. The aim of this project is to describe the characteristics and circumstances of women who contact Victoria’s largest public pregnancy advisory service. Methods: Staff in the Pregnancy Advisory Service at the Royal Women’s Hospital in Melbourne, Australia enter details of women who contact the service in a comprehensive database designed to assist record keeping, service provision, and provide links to hospital patient records. Numeric, tick-box, and free-text data record demographic and personal information disclosed by women during the consultation. An audit of these records was conducted for the period 1 October 2006 to 30 September 2007. Data were de-identified and descriptive statistics collated. Results: 3827 women who made contact became registered with the hospital; the mean age was 27 (range 13–49); mode 20 years; 90% had pregnancies under 12 weeks gestation; 72% were referred by a General Practitioner; 42% had at least one child; 51% were on low incomes; 16% disclosed experience of violence and 10% disclosed mental health problems. Data regarding circumstances of pregnancy, barriers to access, special needs, contraceptive practices and their reasons for seeking options abortion will be presented. Conclusions: These findings contribute substantially to the evidence about the psychosocial circumstances and service needs of women with unwanted and unplanned pregnancy. They will inform policy development and planning for improved pregnancy advisory services, assist the development of a systematic data collection instrument and inform sex education program development, abortion service provision, and political debates about abortion. The Postnatal Depression Initiative The First Six Months Ben Samuel and Michele Dykman Southern Health, Melbourne, Australia Email: [email protected] The Postnatal Depression Initiative is a new initiative taking place in 3 regions of Melbourne, Victoria. It’s purpose is to increase the ability of Maternal Child Health Centres to assist clients they have with mental health problems. It has 2 components: a direct consultation/ support of the enhanced Maternal and Child Health teams in 3 municipalities (involving primary, secondary and tertiary consultation); and an education program for Universal and Enhanced teams throughout the south-east. The authors have been involved in the initiative in the south east of Melbourne, under the auspices of Southern Health. This paper outlines the experiences of the first six months of the program. In particular it focuses on the need for the service, how the PND initiative was resisted by the MCH teams, possible explanations for this resistance and how we attempted to overcome these difficulties. We will propose theories about the work of Maternal Child Health professionals and how this impacts on them and creates a culture wherein thinking about mental health issues can be difficult. We will also look at lessons we have learned and mistakes we have made in the early part of the project.

S14 Continuity of Care Utilising Coping Skills Training for Women with Postpartum Mental Illnesses Mary Samuhel, Ken Jones and Bruce Tonge Monash University, Melbourne Email: [email protected] The treatment of women with mental illness following childbirth has a long history. Research has shown that treatment within hospital and the community can be efficacious for women. Less research has looked at continuity of care from hospital to home, which is the focus of the present study. Forty women participated in this research after discharge from the Mother-Baby Unit at Monash Medical Centre. The women in the experimental group participated in a 4 week coping skills program of cognitive behavioural strategies. The control group filled in questionnaires at one week, 5 weeks, and 3 months post discharge. It was hypothesised that women in the experimental group would perform better on self-report measures, would be more likely to return to work and would positively evaluate the program. The results demonstrated that women in the experimental group had significantly lower scores on the Edinburgh Postnatal Depression Scale (EPDS) and showed a significant increase in selfefficacy as measured on the General Perceived Self-Efficacy Scale (GPSES). The experimental group positively evaluated the program, were more likely to return to work, and had fewer readmissions to psychiatric hospitals. The research showed that continuity of care can be of assistance to women in the post-partum period. Promising areas of future research include adapting this program to normal clinical practice, possibly in the antenatal and postpartum periods. Also, it was found that more research in the area of postpartum anxiety disorders is warranted in terms of the possible construction of an assessment tool and as an important area to target in treatment. Understanding Professional Collaboration: A Key to Successful Integrated Perinatal Care Virginia Schmied1, Pat Brodie2, Terri Bell3, Jeremy Bunker4, Stephen Mcnally1 and Annemarie Hennessy5 1

School of Nursing, University of Western Sydney Sydney South West Area Health Service and University of Technology, Sydney 3 Maternity Services, Fairfield Hospital, Sydney, NSW 4 General practice Unit, Fairfield Hospital, Sydney, NSW 5 School of Medicine, University of Western Sydney Email: [email protected] 2

The purpose of this paper is to describe the nature and characteristics of professional collaboration within one model of integrated perinatal and infant care in NSW, Australia. Integrated perinatal and infant care (IPC) is a collaborative initiative across a number of health and related services in NSW, Australia. IPC provides a framework of promotion, prevention, early intervention and treatment for mothers, infants and their families. It involves universal psychosocial risk assessment as part of a comprehensive assessment in the antenatal and postnatal periods. Women and families in need of support are linked to a coordinated network of support and health-related services in the antenatal and postnatal periods. Proponents of service integration argue that collaboration across professions and traditional service boundaries and integration of service delivery results in enhanced access to

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 services, improved health outcomes, a wider choice for consumers; and, a reduction in the use of inappropriate or unnecessary services. However, establishing integrated service models and achieving collaboration is complex and challenging and to date, there has been limited exploration of what collaboration and integration mean at the level of service delivery. In this paper we report on a study that investigated how primary care services, such as midwifery, child and family nursing and general practice form integrated and sustainable service models and work collaboratively to meet the needs of disadvantaged and vulnerable women and infants through pregnancy and following birth. Data were collected through observations of the IPC meetings, interviews with ey stakeholders and focus groups with midwives and child and family health nurses. We will describe the strategies that this multidisciplinary team have used to develop IPC, the factors that facilitated collaboration particularly for those who deliver the services and current challenges in collaborative across many agencies. Train-the-Trainer: A Community Partnership Model for Disseminating Maternal Depression Screening Lisa S. Segre1, Michael W. O Hara1 and Jane Engeldinger2 1

Department of Psychology, University of Iowa, USA Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, USA Email: [email protected] 2

Introduction: Maternal depression, affecting as many as 18.4% of new mothers, is undetected and untreated in 50% of cases. Detection significantly increases with the systematic use of a screening tool. While providers who have frequent contact with pregnant and postpartum women (e.g., home visitors, social services staff, ob-gyn and pediatric nurses) are ideally situated to screen, they usually have not had adequate training about this disorder. The goal of Train-theTrainer (TTT) is to develop a network of certified trainers among these accessible professionals who are educationally prepared to train their staff, implement depression screening in their programs, and provide community education. This presentation will describe TTT and program results. Method: Representatives from primary care and social service agencies participate in two workshops to learn about perinatal depression, screening, and treatment. To become certified, trainees (1) develop their own training materials using a template and guidance from a TTT mentor, and (2) develop a screening protocol that is tailored to their program. Certified trainers then train their staff, implement depression screening in their program, and provide community training. Results: TTT has effectively established maternal depression screening across the State of Iowa. There are currently 31 certified trainers and 18 trainees. The certified trainers have positively evaluated the TTT workshops. The evaluation of the presentations of certified trainers has also been very favorable. The screening results from several demonstration sites indicate that the trainers have effectively established maternal depression screening in their programs. Results from additional sites will be available at the time of the presentation. Discussion: TTT is a promising model for disseminating maternal depression screening to settings that have frequent contact with new mothers. Establishing on-site certified trainers enhances the sustainability of maternal depression screening in programs once it has been jointly established by the trainer and the mentoring team.

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 Pre-existing PTSD and the Childbearing Outcomes of Survivor Moms: Confirming the Need for Integrated Maternity Care Services Julia Seng Institute for Research on Women and Gender, School of Nursing, and Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA Over the past decade, much-needed attention to perinatal depression has led to increased mental health care for pregnant women. Current research is finding that posttraumatic stress disorder (PTSD) affects the childbearing experiencing and early parenting of many gravidas, a significant proportion of whom also are experiencing depression. This presentation will provide an overview of perinatal PTSD research to date, focusing on a range of qualitative, epidemiological, biological, and now clinical studies conducted by the speaker’s team. Together these data indicate that PTSD is prevalent in community maternity care settings and is associated with increased risk and morbidity in terms of physical, mental health, and early parenting outcomes. Data also indicate that affected women welcome trauma-informed and PTSD-specific, integrated mental health services that are delivered via maternity care settings. Implications for case-finding, design of interventions, new research, and service delivery policy will be considered.

S15 Interpersonal Psychotherapy (IPT), an intervention which has been empirically validated for postpartum depression, has great promise for the treatment of psychopathology at other times during the puerperium. There has been, however, very little research into treatments for depression during pregnancy, despite the fact that psychotherapeutic treatments are likely to be effective and appealing to pregnant women. This paper presentation will describe the results of a recent treatment trial in which 92 women with depression during pregnancy were randomized to receive either a 12 week course of IPT or treatment as usual. Women were recruited from publically funded Maternal Health Centers as well as a large academic medical center. All were treated by community-based therapists who were experienced in IPT. The results of the study indicate that though IPT is moderately effective for depression during pregnancy, its benefits were not as significant as those which occurred in previous trials of IPT for postpartum depression. The implications of these findings will be discussed, including the impact of socio-economic status and the need for different models of treatment delivery which more effectively address barriers to care. A brush with death. Women’s Experience of Significant Primary Postpartum Haemorrhage (PPH) Thompson JF1, Ellwood DA2, and WHA PPH Study Project Reference Group 1

Utilizing the Team Process to Enhance Clinical Work Cindy Smith Specialist Maternal Mental Health Service, Capital and Coast DHB, Wellington, New Zealand Email: [email protected] There are powerful dynamics around pregnancy, reproduction, birth, early attachment and our own experience of being parented, which create tensions for maternal mental health clinicians working within a public health system, which is increasingly preoccupied with managing risk and measuring outcomes. Working effectively in such a context requires a good multi-disciplinary team process, incorporating an understanding of the subjective experiences of team members, as a key tool to enable creative and non-defensive work in such a risk-averse climate. This presentation explores the way in which attending to the capacity for reflective function, sense-making, resilience, and emotional self-regulation of Teams, and the clinicians within them, influences the corresponding capacity of parents to hold, contain, and regulate both themselves and an infant in their care. The presenter draws on Team process experience from her own practice context to exemplify the direct impact of the capacity of teams to grapple with these ideas and experiences on outcomes for clients. Interpersonal Psychotherapy for Depression during Pregnancy Scott Stuart, Michael W O Hara and Jane Engeldinger University of Iowa, USA Email: [email protected]

Women's Hospitals Australasia, Canberra, Australia The Australian National University Medical School, The Canberra Hospital, Canberra, Australia Email: [email protected] 2

Inclusion criteria: Estimated blood loss of 1500 ml in 24 hours postpartum, or, peripartum fall in haemoglobin to 7 g/dl or less or of 4 g/dl. Quantitative data: Breastfeeding; satisfaction with care; postpartum fatigue; anxiety; postnatal depression (EPDS); post-traumatic stress (PCL); hospital readmission; health service use; physical health. Qualitative data: Written responses to open ended questions about labour and birth, satisfaction with care and physical health concerns. Results: 224 women were recruited at baseline and 206/224(92%) completed baseline data. 160/206(78%) women completed all phases of the study. 130/205(64%) exclusively breastfed at baseline while 174/205(85%) hoped to (p<.001). 100/171(58%) were exclusively breastfeeding at 2 months and 76/167(46%) at 4 months postpartum. 9/171(5%) and 5/167(3%) met post-traumatic stress disorder symptom criteria (PCL>44) at 2 and 4 months respectively. 19/171(11%) and 21/166(13%) scored>12 on the EPDS at 2 and 4 months respectively. 17/169(10%) participants had complications requiring readmission to hospital in the first 2 months postpartum and 4/167(2%) between 2 and 4 months. The hysterectomy rate was 8/205(4%). In written comments, women reported fear and trauma; heightened anxiety; sense of failure, loss and disappointment; disempowerment. Postpartum symptoms included excessive fatigue and fear of future pregnancy/birth. Women also questioned clinical decisions and care. Women reported some post-traumatic stress symptoms, particularly re-experiencing and avoidance symptoms. Conclusions: Women experiencing significant PPH are at risk of hysterectomy, readmission to hospital in the 4 months postpartum and

S16 report symptoms of post-traumatic stress. They may need clinical review and follow-up. Emotional Well-being of Childbearing Women: A Comparison of Nationals and Foreign Brides in Taiwan

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 CD of recordings of interviews with women. These recordings were of clients who have dealt with significant emotional difficulties in pregnancy and/ or early parenthood. The programme introduces a brief counselling framework designed to be utilised by clinicians with high demands on their time. Evaluation results and implications for practice and research will be discussed.

Ying Tsao1, Debra Creedy2 and Jenny Gamble2 1

Department of Nursing, Tajen University, Taiwan, Republic of China 2 School of Nursing & Midwifery, Griffith Health, Griffith University, Queensland, Australia Email: [email protected] Aim: This study investigated the emotional well-being of Taiwanese childbearing women in comparison to a cohort of Vietnamese foreign brides recently immigrated to Taiwan. Method: A total of 162 Taiwanese and 44 foreign-born Vietnamese women in four antenatal clinics located in Pingtung County, the south Taiwan, provided demographic details and completed various standardized measures, including Difficult Life Circumstances (DLC), Social Support (SSA), Rosenberg Self-Esteem (RSE), General Health Questionnaire-12 (GHQ-12), Depression Anxiety Stress Scale-21 (DASS-21), and Edinburgh Depression Scale (EPDS). Recruited women were followed up to 6 weeks postpartum. Results: A high prevalence of probable depression in Taiwanese national women during pregnancy (17%) and postpartum (24%) was found. Comparatively, the EPDS prevalence rates estimated for foreign-born Vietnamese women were remarkably higher than that of Taiwanese counterparts, with about 32% and 26%. Women who experienced more difficult life events (DLC) during pregnancy were more likely to suffer postnatal depression (i.e., EPDS 13). Also, higher levels of psychological distress (DASS-21 & GHQ-12) during pregnancy were associated with higher levels of postnatal depression. Women with low social support during pregnancy were more likely to report higher EPDS scores than well-supported women. All correlations mentioned above were virtually identical for Taiwanese and foreign-born Vietnamese women separately. Conclusions: Relatively high rates of reported depressive symptoms among childbearing women, especially among Vietnamese immigrant women, were identified. There are several contributing factors that place women at risk of postnatal depression. Routine psychosocial assessment of expectant mothers for depression or risk of depression is strongly recommended in clinical practice. Meanwhile, outreach health services for recent immigrant women should start early to prevent harmful influences and/or return to state of well-being. Listening To Voices: Supporting Emotional Care in Midwifery Practice Neil Underwood and Phillipa Rasmussen Child Youth and Women’s Health Service (CYWHS), Women’s and Children’s Hospital, Adelaide, South Australia Email; [email protected] In 2007, The Perinatal and Infant Mental Health Service at CYWHS collaborated with the Centre for Continuing Education to trial an innovation in midwifery support and education. A three session programme was developed that steered away from a more didactic and illnessknowledge approach. Instead, the aim was a jargon-free and interactive experience that focussed on existing strengths and reflective practice. The programme produced and distributed an audio

Rejecting Raging Hormones: The Socio-Cultural Construction And Experience Of Reproductive Distress Jane M Ussher Gender, Culture and Health Research Unit, School of Psychology, University of Western Sydney For centuries, expert explanations for women’s reproductive distress have centred on the corporeal body, with the wandering womb, and more recently raging hormones or neurotransmitter imbalances, being positioned as to blame. This has resulted in a narrow biomedical conceptualisation of the causes and treatment of disorders such as premenstrual syndrome (PMS), peri-natal depression (PND), and climacteric syndrome, and the positioning of the reproductive body as the epitome of the monstrous feminine. This paper will present a historical and contemporary overview of the limitations of this narrow bio-medical approach, which has resulted in a neglect of socio-cultural factors associated with the construction and experience of women’s distress. It will be argued that a multi-factorial model, which acknowledges socio-cultural context, as well as intrapsychic, relational, and corporeal factors associated with reproductive distress, is needed. Drawing on clinical case examples and empirical data from a series of qualitative and quantitative research studies, the implications of this multifactorial model will be considered. In conclusion, examples of effective interventions which adopt this model will be provided, demonstrating the effective delivery of mental health care in the premenstrual, peri-natal and menopausal stages of women’s lives. How Mothers with Schizophrenia Respond to their Infants: A Fine-Grained Analysis and Preliminary Functioning Imaging Work Ming Wai Wan, Katherine Warren, Margaret P Salmon and Kathryn M Abel Centre for Women’s Mental Health Research, The University of Manchester, United Kingdom Email: [email protected] Background: The low responsiveness of mothers with schizophrenia towards their infants may contribute toward developmental risk, but little is known about whether they lack responsiveness or show impaired responses. The main objective was to identify whether their responses were fewer, less positive, more negative, and more abnormal compared with mothers with affective disorder, and whether their infants lacked activity or initiation to which mothers could respond. We will also discuss preliminary work from an fMRI study on the neurocorrelates of maternal responsiveness in this group. Method: Forty-five women with severe perinatal illness (schizophrenia n=14; depressive disorder n=23; bipolar disorder n=8) and their infants were observed in mother-infant interaction during admission to a mother and baby unit at M=15 weeks postpartum. Fine-grained coding of maternal response type to each infant behavioural event was made from videotaped interactions, blind to clinical information.

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 Results: Mothers with schizophrenia were as responsive as mothers with affective disorder, but exhibited markedly low positive responsiveness. Behavioural abnormality and nonresponsiveness associated with psychological withdrawal were observed exclusively in mothers with schizophrenia. Infants in both groups showed similar levels of activity, initiative and negativity. Conclusions: Despite some artificiality of the study context, mothers with schizophrenia tend to show particular patterns of impaired responsiveness when interacting with their infant that may inform intervention development. Further research is needed to examine the contribution of maternal response impairments to the developmental vulnerability of this genetically high-risk group. We will also describe, an fMRI study of how mothers with schizophrenia respond to viewing video clips of their infant compared with healthy controls. The Ripple Effect of Perinatal Loss on Families: Research Findings Jane Warland1, Joann O Leary2, Helen McCutcheon1 and Victoria Williamson1 1

University of South Australia, Australia University of Minnesota, USA Email: [email protected]

2

It is now well known that bereaved parents in their subsequent pregnancy after the death of a baby often delay emotional attachment to their new baby for fear of another loss. It is also understood that the child born after a sibling’s death, may be subject to increased risk of psychopathology because of parental anxiety. However little is known about whether this anxiety extends into the parenting period and if it does what long term effect it has on emotional wellbeing and parenting style. Early childhood literature suggests children born after the loss of an infant are at risk of attachment disorders. Similarly, research in the area of mental health has shown that overprotective parenting style can impact on children’s later mental health. A group of parents who may be vulnerable to developing an overprotective parenting style are those who have been bereaved through perinatal loss. This paper will present and discuss the literature reporting the impact that overprotective mothering and poor mother/child affectional bonds can have not only on the mental health of both the subsequent child and parent, but also on the child as an adult. Themes drawn from eighteen adults born after the loss of a sibling give meaning to why attachment disorders can result and provide a strong case for intervention around infant loss and the subsequent pregnancy. This will follow with presentation of data and a discussion of findings from interviews conducted from bereaved parents descriptions of their parenting experiences of subsequent children. This paper aims to improve understanding of mental health issues and parenting styles for bereaved parents and the impact of that parenting on the subsequent children themselves. This knowledge is expected to facilitate many opportunities for intervention at various levels of healthcare, with the anticipated outcome of reducing mental health problems in both bereaved parents and subsequent children. Failelegau or the Acceptable Face of Post Partum Distress Sara Weeks and Sulita Smith Lotofale Pacific Island Mental Health Service, Auckland, New Zealand Email: [email protected]

S17 In many pacific cultures psychiatric illness is considered shameful and stigmatised. A recent community mental health survey in New Zealand (Te Rau Hinengaro) revealed that rates of minor mental illness amongst pacific people are higher than in the general population, and that treatment seeking is low. Another large study (Pacific Island Family Study) found very disparate rates among different pacific island groups when screening with the EPDS (ranging from 7% for Samoan to 30% for Tongan). Pacific women attend the health board Maternal Health services at a significantly lower rate than one would expect given their high birth rate, generally low socioeconomic status, and percentage of the general population. In December 2007 I was asked by an NGO to provide a 2 day workshop in Apia, Western Samoa to educate volunteers around post natal depression. The meeting was boycotted by some groups and seen as a political hot potato, as Samoan women are too strong to get post natal depression however the infanticide/neonaticide statistics tell a different story (one or two cases coming to court each year in a population of 220,000). Clearly something is going on but what??? This paper intends to cover some of the challenges in both research and education in pacific people, as well as a brief discussion of Samoan culture around female sexuality and childbearing. Directions for possible research will be discussed. Major Depression and Antidepressant Treatment: Impact on Pregnancy and Neonatal Outcomes Katherine L Wisner1, Dorothy KY Sit1, Barbara H Hanusa1, Eydie L Moses-Kolko1, Debra L Bogen1, Diane F Hunker1, James M Perel1, Sonya Jones-Ivy1, Lisa M Bodnar1, Lynn T Singer2 1

The University of Pittsburgh Case Western Reserve University Email: [email protected]

2

Context: Initial studies of serotonin reuptake inhibitor (SRI) use during pregnancy did not reveal an increased risk for major malformations; however, other adverse reproductive outcomes have been reported. Objectives: To determine whether the following are adversely impacted by exposure to SRI or major depressive disorder (MDD) during gestation: 1) number of minor physical anomalies (MPA) in the infant, 2) maternal weight gain and infant birth weight, 3) rate of premature birth, and, 4) neonatal adaptation. Design and Setting: Prospective observational study in a perinatal psychiatry program. MDD was diagnosed by the Structured Clinical Interview for DSM-IV. Maternal assessments were done at 20, 30 and 36 weeks gestation. Neonatal outcomes were obtained by blinded review of delivery records and physical examinations. Patients: Pregnant (N=239) women with exposures categorized as: 1) neither SRI nor MDD (N=131); 2) continuous SRI (N=49), 3) continuous MDD (no SRI; N=14), 4) partial SRI (N=23), and 5) partial MDD (no SRI; N=22) participated. Main Outcome Measures: MPA, maternal weight gain, infant birth weight, pregnancy duration, and neonatal characteristics (NICU admission; APGAR scores; and the infant problem subscale- Peripartum Events Scale). Results: Neither SRI nor MDD exposure significantly increased the number of MPA or reduced maternal gestational weight gain. Mean infant birth weight and proportion of small for gestational age newborns were equivalent across groups. Infants exposed to either SRI or MDD continuously across gestation were more likely to be born preterm than infants in the comparison groups. Other neonatal outcomes were similar after controlling for gestational age with one exception: less favorable 5 minute Apgar scores in the continuous SRI exposed compared to unexposed infants.

S18 Conclusions: Preterm birth was significantly associated with both SRI and MDD exposures. MPA, maternal weight gain, and neonatal outcomes (except 5 minute Apgar scores) did not differ among exposure groups.

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 Planning the Effective Delivery of Ante-Natal Maternal Health Care in an Inner City Environment Results From the First Five Years Implementation Marjorie Allen, Di Baines, and Gillian Wainscott

Desired Assistance versus Care Received for Postpartum Depression: Access to Care Differences by Race in Buffalo, New York Kimberley Zittel-Palamara1, Julie R. Rockmaker2, Kara M. Schwabel3, Wendy L. Weinstein4, and Sanna J. Thompson5 1

Buffalo State College, Buffalo, NY 14222 AmeriCorp: AIDS Community Services 3 Creativision 4 Buffalo Medical Group 5 University of Texas at Austin Email: [email protected] 2

Introduction: Postpartum depression(PPD) affects 10%–20% of women (Moses-Kolko & Roth, 2004), yet care remains scarce. This study examines access-to-PPD-care in Erie County, NY by race. Methods: 45 women over age18 who had/currently experiencing PPD were interviewed by telephone using a questionnaire. Results: Average age was 30-years-old(Range=18–48, M=29.8, SD + 7.23); 51.1%(n=23)were Caucasian and 48.9%(n=22)were non-Caucasian. Non-Caucasians: 90.5% (n=19) lived in urbansettings and 72.7% (n=16) received Medicaid. Nearly 20% (n=4) were hospitalized for PPD compared to 0.0% of Caucasians (2=4.590). Most Valued Care (in-order-of-preference): individual counseling, spiritual assistance/direction, in-person support group, hospitalization, medication, and online support group. Most Frequent Professionals Who Provided Care: primary care physicians, OB/GYNs, psychiatrists, psychologists, social workers, and midwives. None received pediatrician assistance. Most Frequent Type of Care Received: individual counseling treatment, medication, hospitalization, spiritual assistance/direction, and online/in-person support groups Caucasians: Most lived in suburban-settings (n=17,77.3%) and almost 80% (n=18) had private insurance. Most Valued Care: individual counseling, medication, in-person/ online support groups, hospitalization and spiritual assistance/direction. Most Frequent Professionals Who Provided Care: OB/GYNs, primary care physicians, midwives, psychologists, psychiatrists, social workers, and pediatricians. Most Frequent Type of Care Received: medication, spiritual assistance/direction, individual counseling, in-person and online support groups. None were hospitalized. Access-to-PPD-care: 44.4% (n=20) reported fair-poor access-to-care and 26.7%(n=12) needed care at time of interview. Factors Impeding Access-to-PPD-Care:15.6%(n=7) were not sure who to speak to, the same number tried to find help, but were unable to find it. 13.3%(n=6) reported lack of education, the same number said her symptoms made it difficult to take action, pressure from family and friends did not help, and comments from professionals prevented access-to-care. Conclusions: There a need to improve access-to-care for women experiencing PPD, but evidence shows PPD care is not equally reachable by all. Women who are non-Caucasians, impoverished, and living in urban-areas have more difficulty getting preferred care as well as needed care. More attention needs to be given to services to proactively address this population.

Mother and Baby Unit, Queen Elizabeth Psychiatric Hospital, Birmingham, UK Email: [email protected] Maternal mental health is recognised as being as important as physical health during pregnancy with respect to the outcome of pregnancy, the development of the infant, and promotion of motherinfant interaction starting in utero. Successive Confidential Enquiries into Maternal Deaths in the United Kingdom have drawn attention to the fact that psychiatric causes are the single most frequent contributory factor to maternal death in late pregnancy and the first year post-partum. Birmingham is a city whose inner areas carry a high index of deprivation. In 2002, two maternal deaths were reported. Following these events and in keeping with other recent research findings, the maternity department of a hospital located within the inner city collaborated with the Perinatal Psychiatry service in Birmingham and devised a Care pathway whereby vulnerable mothers could be identified during the ante-natal period and Care plans put in place to ensure that their mental health needs are catered for during pregnancy and the immediate post-partum period. Method: Training was given to mid-wives, and mothers at risk were seen by mental health workers including community psychiatric nurses and consultant psychiatrists within the antenatal department without the need for a formal referral. Results: During the five years since implementation, increasing numbers of mothers, with varying mental health needs have been seen in the clinic; now around 200 new patients present each year. This presentation enumerates the demographics and clinical features of the mothers seen and the interventions provided. Conclusion: The results and success of the clinic is evidenced by the absence of any fatality due to psychiatric cause, no development of unexpected crisis situations and the smooth access to continuing psychiatric care when this has been indicated. A Pilot Self Management Program For Mothers With Postnatal Depression Admitted To A Mother And Baby Unit Jodie Armstrong, Anne Passmore, Philippa Brown, and Maree Brice-Pozzi Mother & Baby Unit, King Edward Memorial Hospital, Perth Email: [email protected] Self-management is founded on three principles, symptom control, participation in activities that promote and protect health and the management of the emotional consequences of having an illness/ disease. Self management is becoming more widely accepted within the health care system and has been adopted as one of the 5 strategies employed by the Australian Government in the allocation of funds to assist in the manage chronic conditions (any condition lasting longer than 3 months as defined by W.H.O.). Postnatal depression is a condition that affects 12–15% of childbearing women. Residual symptoms of this illness are common with 50% of affected women still meeting the criteria for major depression at 6 months post natally. Untreated the condition can last 2 years. This pilot study aims to

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 develop and test a self management program for women suffering from moderate to severe post natal depression. The program is to be implemented at the Mother & Baby Unit in Perth, Western Australia and run in the form of group modules as part of an inpatient program. The content of the self management program will focus on making progressive steps towards managing their daily life roles. This pilot study will assess the program content, delivery and evaluation tools. Outcomes will be measured in the terms of self-efficacy, empowerment and satisfaction. Effective Delivery of Maternal Mental Health Care in an Inpatient Setting Di Baines, Mary McGuinness, Debbie Mills, Gillian Wainscott, and Judith Williams Mother and Baby InPatient Unit, Queen Elizabeth Psychiatric Hospital, Birmingham and Solihull Mental Health NHS Trust, Birmingham, England, UK Email: [email protected] It has long been recommended from various strategy documents including in the United Kingdom, successive Confidential Enquiries into Maternal Deaths that if a mother suffers from a mental illness during the first year post-partum, of a severity that justifies In Patient admission, this admission should be arranged on a conjoined basis, the mother being admitted together with her infant. Although the evidence base for such admissions is limited, the rationale is that the bond between mother and baby is allowed to develop and is not disrupted by a prolonged separation. Such a policy has been operational in Birmingham for the past 15 years but it is only in more recent years that the importance of engaging service users in decisions about their care has been prioritized, and their views considered an essential indicator in service evaluation and improvement. The Birmingham & Solihull Perinatal Mental Health In Patient Unit comprises nine In Patient beds. On average 50 mothers are admitted with their babies each year. The average length of stay is 42 days. Method: An In-Patient Satisfaction Questionnaire was developed by a multi-disciplinary working group, including a Member of User Voice, to evaluate patient’s perception of all aspects of their stay on the unit including treatment, activities and staff support. The questionnaires were divided into twelve sections each consisting of 67 multi-choice questions. They were sent through the post to each mother immediately after her discharge from In patient stay. Results This presentation incorporates the initial results from the first six months. the action taken as a consequence of these results an evaluation of the following 6 months. Conclusion: All mothers admitted were glad that they were not separated from their babies whilst their illness was treated. The Satisfaction Questionnaire is a useful tool to identify any perceived shortfalls or problems that were often easily rectified. The questionnaire has also proven to be helpful in tailoring our service according to our patients needs. Supports and Services for Early Parenting in Hamilton, New Zealand: An Exploration of the Experiences of Mothers and Fathers Carol Cornsweet Barber Department of Psychology, University of Waikato, Hamilton, New Zealand Email: [email protected]

S19 This paper will discuss a project designed to describe and explore the experiences of new parents in Hamilton, New Zealand, with respect to the services available, their experiences with pregnancy, childbirth, and support during infancy, and their levels of stress and distress during this time. The project included focus groups for mothers of infants, individual interviews with mothers, questionnaires from mothers and fathers, and interviews with health care providers on their observations of the service system and informal supports for parenting. The goal of the project was to understand the range of experiences parents have in the process of bearing and caring for their infants, and the services, and barriers to service, that they encounter during this time. Focus groups included women who were receiving services from a family support centre, some of whom were participating in a support group for women with postnatal depression and anxiety, as well as women who did not access those services and were not receiving formal support. Women in the focus groups completed a set of questionnaires, including the Edinburgh Postnatal Depression Scale, the Depression, Anxiety and Stress Scale, and a measure of quality of life; they also asked their partners to complete a similar set of questionnaires, in order to provide at least an initial view of father’s perspectives and levels of distress. A subset of these women were interviewed in more depth in order to follow up on themes and issues touched on in the focus groups. The goals of the research were hypothesis generating, and implications and directions for future research will be discussed. A Case for a Tertiary Care Specialist Perinatal Mental Health Service Lorrie Bennett Maternal Mental Health Team, Waitemata District Health Board, Auckland, New Zealand Email: [email protected] Since it was first established in 1995, Waitemata District Health’s Maternal Mental Health Team has evolved into being a tertiary health care provider as a specialist perinatal mental health service, Maternal Mental Health provides assessment and intervention to women who are in the second trimester of pregnancy or have a baby up to 1 year of age, who have an existing mental illness or who have developed a mental illness during pregnancy or the postpartum period. The team consists of 8.90 clinical FTE. A range of treatment options are offered, that include groups, psychotherapy, acute care (respite), case management and pharmacology. Waitemata District Health Board (WDHB) has a youthful population, and a growing birth rate. In 2003 WDHB had the second highest birthing rate in the country (Ministry of Health, 2006). In 2006 there were 6,918 births to women living in the Waitemata region. Maori and Pacific women are over-represented in the more deprived deciles of the region. In April 2006 an evaluation of the Maternal Mental Health Team was proposed to: 1. Address concerns expressed by clinicians about the interface between Maternal Mental Health and the Adult Mental Health Teams. 2. Develop an understanding of the expectations from other services of Maternal Mental Health 3. Investigate whether the service delivery model adopted by Maternal Mental Health was consistent with best practise 4. Investigate whether Maternal Mental Health was meeting the needs of the population. 5. Identify the resources and systems required to meet the increasing demands on the service. The evaluation covered a 15 month period, 1 October 2005-31 December, 2006. A report at the conclusion of the evaluation produced 28 recommendations. This poster presentation highlights some of the challenges that confront a

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specialist perinatal mental health service with limited resources with the delivery of a service to a target group living in a large designated semi rural/urban area.

for professional development: Collaborating with development of community resources: Identify key assessment tools and data collection for evaluation/research: Evaluation of strategy

Obsessional Symptoms in Postnatal Women: Adaptive or Pathological?

Anxiety in Women with Medical Disorders of Pregnancy

Vivienne Blackhall and Roch Cantwell

Jennifer Chambers, Kieran O Donnell, Samantha Jayaweera, Catherine Williamson, and Vivette Glover

NHS Greater Glasgow and Clyde, Scotland, UK Email: [email protected]

Imperial College London Email: [email protected]

Introduction: It has been reported that obsessional symptoms are more severe in postnatal depression, and that relapse of pre-existing obsessivecompulsive disorder is more common in the postnatal period. What is not known is whether the greater prevalence of obsessionality is directly related to mental illness, or whether the postnatal period is a time when obsessional symptoms have an adaptive function, aiding increased vigilence and attendance to childcare. This pilot study aims to examine the prevalence and nature of obsessional symptoms in a nonclinical postnatal sample. Methods: Postnatal women, and a comparison group of non-postnatal women were interviewed using the YBOCS, EPDS and HADS to determine the prevalence of current and past obsessional symptoms, and current depressive symptoms. Results: Obsessional symptoms were more common in the postnatal group and were related to cleaning and arranging of baby items. There was a correlation between obsessional and depressive symptoms. Conclusion: Increased obsessionality is present in non-clinical postnatal women when compared with non-postnatal women. Although the nature of the obsessional symptoms appear adaptive in nature, there was a correlation with depressive symptoms. More research, with larger sample sizes, is required.

It is generally accepted that stress and anxiety in pregnancy may have a detrimental effect on both mother and baby. The mother is at increased risk of post natal depression and the developing child may be affected by behavioural problems such as ADHD. One group of women that may have a high predisposition towards stress and anxiety are those suffering from medical disorders of pregnancy. In this study we are comparing anxiety and saliva cortisol levels in such women with a control pregnant population at 32 weeks gestation. Women have been asked to complete self evaluation questionnaires and take part in a semi-structured interview. The women with medical disorders had higher total Spielberger State Anxiety scores (39.0±10.5) compared with controls (31.6±9.5). They scored significantly highly in some of the specific questions I feel frightened, I am worried and I am presently worrying over possible misfortunes but not on the others. The group difference remained after a regression analysis including socio-economic factors that could affect anxiety. The two groups were similar for Spielberger Trait Anxiety with the medical disorder group 34.5±4.7 and the controls 35.9±7.8. These results suggest that more attention should be given to help ease the fears of women with medical disorders of pregnancy.

Collaborative Partnerships in Early Parenting

Does Social Support Reduce the Likelihood of Postnatal Depression in Australian Mothers?

Philippa Brown and Maureen Rushe

Catherine Chojenta1, Jayne Lucke2 and Deborah Loxton1

Mother and Baby Unit and Women and Newborns Health Unit, Perth, WA Email: [email protected]

1

The Mother and Baby Unit (MBU) functions as a state-wide inpatient treatment centre for acute perinatal psychiatric conditions. We became operational in June 2007 and treat mental health issues ranging from mild post natal depression and anxiety through to acute psychiatric conditions such as severe depression, anxiety or a psychotic illness such as a bipolar mood disorder or schizophrenia. In working with our mothers we found many of them needed assistance in parenting skills and decided to form a relationship with Ngala which is an Early Parenting Centre who have a passion for supporting and guiding families and young children through the journey of early parenting. We found many commonalities in presenting problems and formed our partnership which allows: An increase the capacity and resourcing for both services: the provision Of seamless and consistent services for clients within Western Australia: Similar workforce issues existing between services: Both services requiring similar ongoing professional development needs: Similarities of client group and issues of presentation. Nine months down the track we are currently monitoring our partnership protocols and standards for early parenting: planning

Research Centre for Gender, Health and Ageing, University of Newcastle 2 School of Population Health, University of Queensland Email: [email protected] This study examined the relationship between social support and postnatal depression. Longitudinal data was analysed, collected through the Australian Longitudinal Study on Women’s Health (ALSWH). The ALSWH started in 1996 when the younger cohort were aged 18–23, and participants have completed follow up surveys on a three yearly basis. Almost 6800 younger women have completed the second (2000), third (2003) and fourth (2006) follow up surveys, and of these women 9.8% reported being diagnosed or treated for postnatal depression in the three years prior to completing the fourth survey. Among other measures of health and lifestyle, participants were also asked a series of items derived from the Medical Outcomes Study (MOS) Social Support Index from Survey 2 onwards in order to measure perceived social support. This analysis compared the self-rated social support for mothers who have experienced PND with those who have not reported experiencing PND at the fourth survey. While significant results were not evident for some subscales of social support, the strongest association was found with affectionate support and positive social

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 interaction, with mothers who rated their support as being available only some of the time significantly more likely than other women to experience postnatal depression. These results indicate that having positive social supports prior to and around the time of the birth of a child has a significant impact on the mental health of mothers. Experiences in Perinatal Prevention and Health Promotion in the Community Abram Coen Enghien les Bains, France Email: [email protected] Perinatal psychopathology is an important topic: we need specially in our old european countries-for our demography more children and in good health. We then need to import foreigner workers. Perinatality become a political problem; specially If 15 to 20% women may experience a PPD then it is a wide public health problem at a moment where we lack money and must think about unexpensive solutions for a huge probleme. We will speak about the French experience of maisons vertes and clubs (baby club, new mothers club, new parents club) Medico-legal Perinatality Abram Coen Enghien les Bains, France Email: [email protected] We speak a lot about Post Partum Depression(PPD), Psychosis (PPP) but we are more silent about foeticide, infanticide, homicide as a possible consequence of perinatal psychopathology” More frequently child abuse and neglect must be considered as a variety of maternel depression. What about the legislation on those accidents is it a crime or madness? We are far of the harmonisation of laws in Europe and elswhere. When a citizen of one country commits, after delivery, such a crime which law must be considered the one of his homeland or the one of the country where he lives? Baby, Baby. A Study of Depression after Childbirth: Recovery, Resilience and Relapse Second Time Round Sue Cowie Department of Psychology (Tamaki), The University of Auckland, New Zealand Email: [email protected] Depression following birth has wide ranging impacts on the woman, her new baby and her family. Studies indicate that treatment has been effective in shortening the duration of depression but does not prevent the increased risk of experiencing depression following another birth. This study explores in detail women’s and practitioners understandings of first time mother’s experiences of and recovery from depression and then focus on how the women prepare for and make sense of the experience of second time pregnancy and motherhood. It is hoped to develop strategies to reduce recurrence and impact of depression in women with young children. Results are presented of interviews with 25 women who had previously experienced post natal depression. Interviews were conducted 3–6 months before birth,

S21 focusing firstly on how the women make sense of their transition to first time motherhood and coping with/recovery from depression and secondly, on their expectations of second time birth and motherhood. The second interview, completed 3 months after birth, focused on their experience of the pregnancy, birth, and life with another child. Qualitative methodologies were employed. Of particular interest were the things that women described as helpful and unhelpful, their understanding of the help/treatment (e.g. Home help, CBT, support group, Arapax) they had gained and how this influenced their decisions and coping second time round. Preliminary analyses, particularly of time one data (collection complete), are reported and issues related to the study design and implementation are discussed. Development and Implementation of a Scale of Parenting Confidence Rudi Crncec, Bryanne Barnett2 and Stephen Matthey1 1 Infant, Child, and Adolescent Mental Health Service Research Unit, Sydney South West Area Health Service 2 Karitane, Caring for Families Email: [email protected]

Once we believe in ourselves, we can risk curiosity, wonder, spontaneous delight, or any experience that reveals the human spirit. e. e. cummings. Background: Research over recent decades has established that a parent’s confidence in their parenting ability (PCon) is 1) a key element of the subjective parenting experience; 2) a strong predictor of parenting competence; and 3) a protective factor against stress and depression. Clinically, the measurement of PCon could be useful in screening for parenting difficulties, targeting interventions, and evaluating outcomes. Indeed, services working with parents of infants commonly aim to improve PCon. At present however, there are few scales of PCon suitable to this clinical context. That is, many available tools are lengthy and/or lack sensitivity to tasks facing parents of infants. PCon is analogous to Bandura’s concept of perceived selfefficacy. Research findings spanning a range of tasks and populations consistently have shown that individuals with high self-efficacy in a given area tend to trust their own abilities in the face of environmental demands, conceptualise problems more as challenges than as threats, experience less emotional arousal when engaged in challenging tasks, and persevere in the face of difficulty. The study: The research to be presented drew upon self-efficacy theory to guide the development of a new scale of PCon for parents of infants: The 15-item Karitane Parenting Confidence Scale (KPCS). The KPCS validation sample comprised 187 mothers with infants aged under 12 months and consisted of a no-problem control group and three clinical groups. The KPCS showed acceptable psychometric properties and a clinical cut-off score was determined. We contend that the KPCS may prove a useful addition to tools for the assessment of parents and infants presenting to clinical services. Discussion will include issues related to the dissemination of the KPCS amongst practitioners in Australia. Incidence of Patients at Risk for Postpartum Depression (PPD) Using Early Screening Deirdre Doyle, Jenefar Slusher and Cheryl Lefaiver Advocate Christ Medical Center, Illinois, USA Email: [email protected]

S22 Introduction: Postpartum Depression screening typically occurs in the outpatient setting; however screening in the immediate postpartum period affords a multidisciplinary team to provide supportive services to patients at risk before discharge. The purpose of this study was to describe the incidence of positive screening for risk for PPD within 48 hours after delivery. Methods: A retrospective chart review was conducted including all deliveries from February through April 2007. Data collected included maternal age, delivery type, history of emotional problems, psychiatric medications, breastfeeding, and PPD risk screening scores. The Boyer screening instrument was administered prior to discharge. Patients responded yes or no to 15 items; a score greater than 3 or a positive answer to one of four trigger questions indicated risk for PPD. All at risk patients identified by the Boyer risk tool were referred to social services for further psychosocial assessment and referral to psychiatric liaison if necessary. Descriptive statistics and Spearman Rho correlations were used for analysis. Results: The sample included 827 females with a mean age of 28.3 years. The majority were Caucasian (52%) or African-American (22%) with spontaneous vaginal delivery (56.3%). A history of emotional problems was self-reported by 10.5% and 72% were reportedly breast feeding. The PPD risk screenings showed that 23% of the sample scored higher than 3, or 20% responded positively to a trigger question. Significant (p<0.05) correlations were found between the risk for PPD and a history of emotional problems and taking psychiatric medications. Conclusion: This study is the first to examine PPD risk within 48 hours after delivery. These results suggest that PPD risk may be associated with a history of emotional problems and support may be warranted in the prenatal period. Additional research is needed to examine the relationship between early PPD screening and subsequent monitoring in the postpartum period. Creating Links within a Fragmented System-Evolution of the Parent Infant Mental Health Initiative (pimhi) South East Victoria Michele Dykman, Ben Samuel and Mina Tolat Southern Health, Parent Infant Mental Health Initiative, Monash Medical Centre, Mother Baby Unit, Melbourne Email: [email protected] Background: In recognition of the significance of perinatal mental health, the Victorian Government recently funded the Parent Infant Mental Health Initiative (pimhi). Southern Health pimhi operates in conjunction with the Mother Baby Unit at Monash Medical Centre and serves the South East Melbourne and Gippsland catchment area. The pimhi service aims to promote knowledge, understanding and skills via a direct clinical outpatient service, as well as network building and linkages with existing mental health and community services to ultimately provide timely and appropriate interventions to mothers with serious mental illness and their infants so that outcomes are improved in this group. Objectives: To introduce pimhi and the evolution of this new outpatient service in South East Victoria. To highlight the challenges faced by pimhi in establishing links and improving the information flow and referral pathways between services so that perinatal mental

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 health assessment and care is more readily accessible to women with mental illness in the perinatal period. Method: The authors will provide a brief introduction about the Southern Health pimhi service followed by presentation of two clinical cases that compare and contrast the challenges in establishing linkages within what appears to be a fragmented system of care for women with mental illness in the perinatal period. Conclusions: The pimhi service is an exciting new initiative that has great potential to improve outcomes for women with mental illness in the perinatal period and their infants. There are many challenges in improving linkages and access to care for this patient group but we are heading in the right direction. Ongoing pimhi data collection and analysis of outcome measures will hopefully justify the existence of pimhi and hopefully attract further funding and resources to optimise the service’s full potential. The Associations of Depression, Anxiety, Anger and Self-Efficacy with Smoking in Pregnant Adolescents Kathleen Feltes, Thelma Patrick, Donna Caruthers, Thomas Zullo, and Susan Albrecht School of Nursing, University of Pittsburgh, Pennsylvania, USA Email: [email protected] Objective: To determine the associations between depression, anxiety, anger, and self-efficacy with smoking dependence behaviors and smoking consumption in a sample of pregnant adolescent smokers. Methods: Participants were recruited for a randomized controlled smoking cessation intervention study from five hospital-based and two community-based clinics in the Pittsburgh area. Inclusion criteria fosr study participation required pregnant teenagers to be between the ages of 14 and 19 years and smoking at least one cigarette per day. One hundred eight adolescents with complete baseline information were analyzed for their responses to the following instruments: Modified Center for Epidemiological Studies Depression Scale (CES-D), Modified State/Trait Anxiety Inventory (STAI), Modified State/Trait Anger Expression Inventory (STAXI), Confidence and Temptation Scale, and the Fagerstrom Tolerance Nicotine Dependence Test (FNTD). In addition, smoking consumption was measured by selfreported average number of cigarettes smoked per day. Results: Depression, anxiety, and anger were highly prevalent in the study sample (93%, 48%, and 73%, respectively). In addition, depression, anxiety and anger were significantly correlated with one another (r=0.55, 0.40, 0.39, respectively; all p<0.01). However, depression, anxiety, and anger were not significantly associated with smoking dependence behaviors or smoking consumption. In contrast, although self-efficacy was not significantly associated with smoking consumption, self-efficacy was significantly inversely associated with smoking dependence (p=0.006). Conclusion: Pregnant adolescent smokers with greater confidence in their ability to quit smoking reported less smoking dependence behaviors. In studies of pregnant adult smokers, self-efficacy has been reported to predict smoking cessation. Future research should more closely examine the relationship between self-efficacy and smoking cessation in pregnant adolescent smokers. Integrating selfefficacy into smoking cessation intervention programs for pregnant

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 adolescents may improve cessation success rates and improve the health and wellness of teenage mothers and their newborns. A Perinatal Anxiety Training Module for Health Professionals J Foley1, S Somerville2, E Oxnam2, J Jones2 1

Western Australian Perinatal Mental Health Unit (WAPMHU) Department of Psychological Medicine, King Edward Memorial Hospital, Perth, WA Email: [email protected]

2

Research into perinatal mental health has largely focused on the postnatal period and on depression in particular, resulting in the potential for the term postnatal depression being perceived to cover a host of mood disturbances including anxiety. Recently there has been a shift to identify anxiety in the perinatal period (hereafter referred to as perinatal anxiety) as separate and distinct from depression and worthy of its own body of research. Widespread acceptance of screening for depression in the perinatal period may fail to differentiate anxiety disorders which can have significant clinical consequences. Perinatal anxiety is known to affect fetal development and impact upon a child’s long-term social, emotional and psychological wellbeing. Furthermore, antenatal anxiety has been identified as a significant risk factor for postnatal depression and anxiety disorders. There is a distinct need for health professionals to learn about perinatal anxiety, how it can present, what effects it can have, and how it can be managed. The WAPMHU and the Department of Psychological Medicine at KEMH have collaborated on the development of a Perinatal Anxiety Training Module, possibly the first of its kind in Australia. The half-day training module has been designed for health professionals who will have contact with pregnant women, mothers and infants including general practitioners, child health nurses, midwives, social workers and mental health practitioners. The module aims to raise awareness and promote an understanding of perinatal anxiety; increase confidence and competence in screening for anxiety; and improve skills for engaging with anxious women, and referring them to appropriate services The presentation will provide an overview of the training module, describe the process of collaboration in it’s development and report the challenges involved in creating an innovative training module based on an emerging body of research. The Use of Art Therapy in a Group Program within a Mother Baby In-patient Unit Patricia Galante and Natalie Metherill Monash Medical Centre, Mother Baby Unit, Melbourne Email: [email protected] In Australia, the last eight years has seen Art therapy move from a relative unknown quantity, to an acceptable form of therapy in all areas of mental health. The following paper reflects on the recent introduction of Art Therapy, within a group setting, at the Monash Medical Centre, Mother Baby In-patient Unit. In this instance, the group work covers all aspects of Mother/Baby care: The Mother,

S23 her mental health and related issues; The Baby-its mental health as well as its social and physical developmental milestones; and The Mother Baby Relationship itself, which includes (potentially) confronting and disturbing realizations for the Mother. Herein, specific aspects of Art therapy have predominately been utilised, such as metaphor, collage, and spontaneous line and symbol, to promote a safe, constructive, interactive and inclusive approach to this difficult area of mental health promotion. Specifically, this paper examples a variety of Art Therapy approaches to specific groups, by exploring the actual art work of past patients, together with the aims and structure of the various topics. In these cases the process of producing the art work, is of equal importance as the product produced, where-by this safe, non-threatening, at times self directional form of therapy, has the added benefit of increasing self esteem of the participant, due to acceptance of, and pride with the (permanent) finished product. Getting it Right from the Start for Mothers and Babies Di Hurt, Kerrie Jennings, Jenny Johnson, and Sally Gorringe ACE Service, John Hunter Hospital, Newcastle, Australia Email: [email protected] The Getting it Right from the Start for Mothers and Babies Project consisted of a service evaluation of the ACE Service; a hospital based home visiting programme which supports women experiencing depression in the antenatal and postnatal periods. A service evaluation was conducted with data collection between July 2006 and December 2007 with the aim to identify a best practice model of care for antenatal and postnatal women who experience depression or anxiety. The project was funded through the 2006 NSW Nursing and Midwifery Innovation Scholarships. A format based on Stepped Care as a model of healthcare delivery was chosen. The two fundamental features of this model are: that the intervention should be the least restrictive but still likely to provide significant health gain, and; the stepped care model is self-correcting. This means that changes are made (stepping up) if indicated by the current intervention not achieving significant gain. The types of interventions provided by ACE caseworkers were face to face interactions (via home visits or hospital appointments) or telephone support. Women recruited into the project completed 3 questionnaires (the Edinburgh Depression Scale, The Beck Inventory of Depression and the Kessler 10) on 3 separate occasions at initial assessment, 3 months after joining the service and between 6–8 months after their initial contact with the service. Data was completed for 48 clients and analysed to identify characteristics of the clients in relation to the interventions and pattern of care provided. With the awareness that acceptability of interventions can have a direct effect on engagement and compliance, the evaluation also enquired about client satisfaction with the service. This included the acceptability of home visits and phone calls, and provided an opportunity for clients to identify areas of dissatisfaction. The client responses were coded and categorised into themes to identify what was valued about the service as well as areas that could be improved. This poster/presentation will demonstrate the salient information that was obtained from client feedback in the evaluation and the implications for future practice. The data collected from the Edinburgh, Beck and Kessler 10 questionnaires is being analysed and it is hoped to be able to present this data as well.

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Midwives Knowledge of Antenatal and Postnatal Depression: A National Survey Cindy Jones1,2 , Debra Creedy

2,3

and Jenny Gamble

1, 2

1

School of Nursing & Midwifery, Griffith University, Gold Coast, Australia 2 Research Centre for Clinical and Community Practice Innovation, Griffith University, Gold Coast, Australia 3 Alice Lee Centre for Nursing Studies, National University of Singapore Email: [email protected] Emotional care provided by midwives can improve health and wellbeing; reduce stress, trauma and depressive symptoms; and enhance maternal outcomes in childbearing women. Midwives are wellpositioned to provide information and basic counselling services to women with emotional disturbances by assisting them to make informed choices in relation to their treatment, resources and options. However, midwives are reported to provide poor intrapartum and postpartum emotional care to childbearing women which could stem from knowledge inadequacies. This study aims to assess Australian midwives knowledge of antenatal depression and postpartum depression. A postal questionnaire survey was sent to all members of the Australia College of Midwives (n=4000). The survey consisted of 20 Likert-type questions drawn from the literature and Beyondblue’s National Baseline Survey Health Professional Knowledge Questionnaire. On average, midwives (n=813) correctly answered 13 out of 20 questions (SD=2.17). While 50.4% of midwives were aware of the diagnostic criteria for antenatal depression, few midwives (28.6%) knew about the adverse impact of antenatal depression on the physical health of mothers. 98.3% of midwives underestimated the percentage of antenatally depressed women that subsequently attempt suicide in the postpartum period. Many midwives were also not aware of the risk factors (70.6%) and common treatments (35.5%) for antenatal depression. In relation to postpartum depression, 44.4% of midwives were unaware of the incidence rate, 71% did not know the onset period and 32% were unsure about treatment options. Furthermore, midwives have a flawed perception in the used of antidepressant medications (56.4%) and incorrectly believed that the Edinburgh Postnatal Depression Scale (EPDS) could be used to assess psychotic depression symptoms (43.8%). Findings suggest a need to develop and evaluate an educational resource designed to improve midwives knowledge of antenatal and postpartum depression to enhance their provision of effective emotional care to childbearing women. Acknowledgement: This study was funded by a Griffith University New Researcher Grant. Special thanks to the Australian College of Midwives for permission to include the Phase 1 study postal questionnaire in the College Journal. Perinatal Practical Support Service: Trialing In-Home Support for Western Australian Families R Kinsman1, J Brooks1, J Robins2, L Crumlin2

Scale (EPDS) scores, indicating depressive symptomatology. Various dimensions of social support, including practical help, have been proposed as a means to decrease postnatal depression, however the number of social support randomised controlled trials investigating practical support and maternal mental health outcome measures is limited. Given the potential for a practical support service to impact positively on women’s psychological health during the perinatal period, the State Perinatal Reference Group (SPRG) proposed funding a trial of a practical support service for Western Australian (WA) mothers experiencing, or at risk of, perinatal mental health difficulties. The WAPMHU, in conjunction with the Red Cross Society WA Division (SPRG funding recipient), has developed a framework for an in-home practical support service for delivery at two WA sites one rural and one metropolitan. The service can be tailored to meet individual client needs and goals, while providing them with assistance with domestic duties, basic childcare and the development of practical skills, such as time management and accessing with community supports. This service is currently being trialled over a two year period with the aim of demonstrating a reduction in depressive symptomatology, an increase in perceived social support, and development of key practical skills in the client group. A thorough evaluation framework has been incorporated into the trial, with the hope that the service can be expanded into other metropolitan and rural sites in WA in the future. This paper will present on the service delivery and evaluation frameworks, as well as the preliminary data collected. The Specialist Perinatal Psychiatric Unit: How Does it Work? Kerry Lockhart St. John of God Health Services, Sydney Email: [email protected] This presentation will introduce St. Benedict Unit; the 8 bed, discrete specialist perinatal psychiatric unit which is part of St. John of God Health Care; a private 86 bed psychiatric hospital situated in the inner western suburbs of Sydney, Australia. The main emphasis of this presentation will be to highlight the benefits and flexibility of the group program; the interplay of the environment and the planning processes for inpatients admitted to the mother baby unit. This will include how the admission and clinical risk assessments are undertaken as well as how the discharge process for patients begins and develops. This talk will describe the common postnatal psychopathologies, which are treated in the unit, while challenging the myth that postnatal depression is the umbrella diagnosis for all. The over riding goal is to prepare our mothers and their partners to leave the unit better able to cope with life at home. To do this we will show how we incorporate the benefits of a multidisciplinary team approach which also encapsulates some of the clinical skills used in perinatal and infant mental health, and the support offered to fathers, plus some of the lessons learnt over the 13 years since the unit welcomed its first patients. Infant Mental Health Training: What Is It and Why It Is Necessary

1

Western Australian Perinatal Mental Health Unit (WAPMHU) Red Cross Society WA Division Email: [email protected]

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Sarah Mares1 and Beulah Warren2 1

Researchers have long reported the strong association between perceptions of low social support and high Edinburgh Postnatal Depression

Infancy and Early Childhood Studies, NSWIOP Infant Mental Health Training, NSWIOP Email: [email protected]

2

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 The perinatal period is a time of enormous developmental and relational change for all family members. Early development occurs in the context of relationships and relationships past and present act as risk and protective factors during the perinatal period. Skills and confidence in infant and relational assessment and intervention are central to competent perinatal mental health practice. Professionals with these skills are therefore essential to comprehensive service development and delivery. This presentation describes why and how these skills can be further developed by outlining the development of Infant Mental Health education and training in NSW Australia. This post graduate course is available by distance delivery to students across Australia and New Zealand who come from a wide range of professional disciplines and social and professional contexts. There will be a focus on the principles that underpin and inform the NSW Graduate Diploma and Master of IMH, and an outline of the course content, structure, and delivery. The aspects of the course that facilitate reflective processes and practices in graduates are also outlined. Evaluation of a Quiz to Enhance Empathy in New Parents: An International Collaborative Study Stephen Matthey1, Francesca Agostini2, and Fiorella Monti2 1

Sydney South West Area Health Service, Australia Department of Psychology, University of Bologna, Italy Email: [email protected]; francesca.agostini4@ unibo.it

2

Background: Empathy in new parents is known to buffer against distress. New mothers, when struggling to cope, often state it is more helpful if their partner shows he understands how she feels than if he just tries to fix the problem. Empathy development is usually encouraged by written advice in pamphlets (eg., listen to your partner first don t try to fix the problem), there is no evidence that such an approach actually works. An alternative approach to empathy facilitation was taken by the first author. A quiz was developed (The Great Parent’s Quiz), where each parent has to guess how the other is experiencing parenthood (eg: She feels isolated or lonely). Method: This quiz was evaluated in two countries, Australia and Italy, with parents of infants. Participants (Australia: n=52; Italy: n=54) were randomly allocated to either receiving the quiz or not. The Australian participants were recruited from early childhood clinics, while the italian participants were recruited in pregnancy and given the quiz shortly after giving birth. Interviews (Italy: faceface; Australia: face-face or telephone) were conducted with the women and men approximately 4 weeks after receiving the quiz (Australian participants) or 8–12 weeks after leaving the hospital (Italian participants). Results: Results will compare the two countries for: participants perception of the usefulness of the quiz; its impact on perceived partner support and understanding; and its impact on maternal mood. Additionally the percentage of couples who might be susceptible to low empathy, and who might therefore benefit most from the quiz will be reported. Finally, a difference in the interpretation of intended humorous items on the quiz will be reported. Conclusion: The data to be reported show that the great parent’s quiz is seen as being extremely useful by couples in both countries, with women and men reporting their partner found out new things about them. In some cases this is associated with the women feeling more supported by their partner.

S25 Identifying Yourself on a Self-Report Mood Measure: Does This Effect the Openness of Responding? Stephen Matthey1, Tracey White1 and Sarah Rice1,2 1

Sydney South West Area Health Service, Australia Department of Psychology, Macquarie University Email: [email protected]

2

Background: There is evidence that women may fake good on selfreport mood measures, such as the Edinburgh Depression Scale (EDS), for fear of being thought of as bad mothers (Russell, 2006). If so, rates of high scorers on such measures may differ if women are asked to complete them anonymously, as opposed to putting their name on the form. Such a finding would have serious implications for epidemiological research studies. Method: Women (N=211) attending Maternal and Child Health Clinics completed two self-report mood measures, similar to the EDS. Women were either asked to write their name on the forms, and were told that the research officer would check their forms once completed (Named condition). Or they were specifically asked to leave their name off the forms, and upon completing them they would be put into an envelope without being looked at (Anonymous condition). In addition, mental health professionals (N=44) attending a previous International Marce Conference completed a brief survey asking them what they predicted the study would find. Results Most of the health professionals (77.3%) expected that the Anonymous condition would result in more honest responding by women. To the contrary, however, this was not found. There were no differences between the rates of endorsement of not currently coping on one of the measures by women in the two conditions, nor on their experience of motherhood scores on the other measure. There was a small, but statistically significant, difference in women reporting whether they had a prior history of difficulty coping, with more women in the Named condition endorsing this. Conclusion: Rates of postnatal distress or depression, based upon responses to self-report mood questionnaires, are unlikely to be affected by whether participants are required to put their name on the measures or not. This is an unexpected finding from a non-random sample of mental health professionals interested in the perinatal mental health field. Characteristics of the Intrusive Thoughts Experienced by Pregnant Women and New Mothers? Mary McGuinness1, Chris Jones2 and Jackie Blissett2 1

Birmingham and Solihull Mental Health Trust, UK University of Birmingham UK Email: [email protected]; mary.mcguinness@bsmht. nhs.uk

2

Recent reports have suggested that pregnancy and the puerperium may precipitate or exacerbate OCD in some women. A consistent pattern in the content of obsessions and compulsions in women with OCD symptoms during pregnancy or postpartum is emerging. During pregnancy, women tend to report contamination obsessions and washing and cleaning rituals (Buttolph and Holland, 1990; Diaz et al., 1997). Postpartum women report obsessional thoughts about harming the baby accompanied by avoidance of fear cues, often the

S26 baby (Sichel et al., 1993; Wisner et al., 1999). Contemporary cognitive models of obsessive compulsive disorder propose that clinical obsessions are an extreme variant of normal intrusive thoughts (Rachman and De Silva, 1978). This online study compares the intrusive thoughts of a community sample of pregnant women in the last trimester of pregnancy (n=300) with those experienced by new mothers (n=100) and a never pregnant community sample (n=100). Using a modified version of the Interpretation of Intrusions Questionnaire participants were asked to provide two examples of unwanted mental intrusions that they had experienced recently (OCCWG, 2001). Three approaches to content analysis will be employed. Two raters will independently categorise ITs by theme, symptom dimension (Leckman, Mataix-Cols and do Rosario-Campos 2005) and subtype (Lee and Kwon 2003) to investigate between and within group differences and determine whether the ITs of a non clinical sample are similar to those reported by clinical samples. The implications for clinical practice and research will be discussed Is Pregnancy a Risk Factor for Obsessive Compulsive Disorder? Mary McGuinness1, Chris Jones2 and Jackie Blissett2 1

Birmingham and Solihull Mental Health Trust, UK University of Birmingham UK Email: [email protected]; mary.mcguinness@bsmht. nhs.uk

2

Recent reports have suggested that pregnancy and the puerperium may precipitate or exacerbate OCD in some women. Clinical reports highlight swift onset of postpartum OCD, which is in contrast to typical onset, which is gradual (Buttolph and Holland, 1990; Maina et al., 1999). Sub-clinical symptoms are more common in the nonclinical populations than previously thought (Jennings et al., 1999). Many OCD patients report onset of OCD with major life events that are likely to trigger thoughts about harm or mistakes. From this perspective, pregnancy and the post partum period are fertile ground for the development of OCD concerning responsibility for harm, because it fundamentally involves responsibility for caring for a helpless infant’s well being. OCD in pregnancy is probably under diagnosed and the influence, if any, of pregnancy and the post partum period on the development or exacerbation of OCD is poorly understood. Early diagnosis and treatment of OCD in the puerperium is of particular importance and may minimise long-term family disruption and impairment of the mother-infant relationship. If pregnancy is a high-risk period for OCD onset, then understanding the factors involved has important implications for the detection of women at risk and the development of theory driven, symptomtargeted psychological treatments. This on line study employs a between groups design to address the question of whether pregnancy is a high risk period for the expression of cognitive vulnerability and symptoms of OCD. A group of pregnant women (n=300) will be evaluated by means of self-report questionnaires completed during the last trimester of pregnancy and compared with a group of new mothers evaluated within three months of delivery (n=100) and a group of healthy women (n=100) who have never been pregnant. The between group and within group statistical relationships between intrusions, cognitive biases, maternal bonding, symptomatic status and reproductive history will be investigated.

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 Maternal Depression in Pregnancy Predicts Parenting Stress in the Postpartum Period Shaila Misri1, Tim Oberlander2 and Hongbin Zhang3 1

Reproductive Mental Health Program, Department of Psychiatry, BC Women’s Hospital & Health Centre and St. Paul’s Hospital, Vancouver, British Columbia, Canada 2 Early Human Experience Unit, Centre for Community Child Health Research, Child and Family Research Institute, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada 3 Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada Email: [email protected] Objective: To study the impact of antenatal depression on postpartum parenting stress. Background: Studies have shown that postpartum depression is strongly associated with parenting stress which leads to insecure attachment, negative mother-baby interaction and impaired child development. However, the association between antenatal depression and postpartum parenting stress has not been investigated as of yet. Methods: This study consisted of 95 pregnant women recruited as part of a larger study examining the effects of prenatal SSRI exposure on infants. The 95 subjects who participated in this study comprised three groups: (1) depressed pregnant mothers treated with SSRIs (n= 40), depressed non-medicated pregnant mothers (n=13), and healthy pregnant controls (n=42). Mother’s mood was prospectively monitored at 26 weeks of gestation and 3 and 6 months postpartum using the Hamilton Depression Scale (HamD). Assessments of parenting stress were conducted with the Parenting Stress Index (PSI) at 3 and 6 months postpartum. Results: Regression analysis showed that depressive symptoms at 26 weeks were significantly associated with postpartum parenting stress (p=.001) after controlling for current depression, medication use, age, education, ethnicity and number of children. Furthermore, for each 10-point increase on the HamD in pregnancy there was an average 12.44-point increase in postpartum PSI scores. Conclusions: Antenatal depression is associated with postpartum PSI scores. The greater the severity of antenatal depression the higher the postpartum PSI scores. Human Imprinting Elsie Mobbs Perinatal & Infant Mental Health Service, NSW Email: [email protected] Across the mammalian spectrum a one-teat preference is recorded. In the human mammal this may be a vestigial behavioural remnant and be most evident when the newborn baby fixatedly sucks on only one digit out of ten. The newborn may have a pre-birth fixation on the thumb, finger or wrist, resulting in the baby rejecting the mother’s nipples in preference to its already found mother. When

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 this situation occurs the mother will often say, Baby does not like me. The mother’s feelings of rejection are lessened if it is explained to her that baby has accidentally orally imprinted on a decoy. The newborn may orally imprint on the mother’s nipples, a dummy, or on the self as in thumb-sucking. The newborn baby uses sucking to form a relationship with its sucking object. Thumb-sucking cannot be said to be a need for sucking because if that were the case then baby would suck on anything rather than be calmed only by its recognised sucking object. Correlating with the exhibition of one-teat preference, also known by other terminology such as teat fidelity, teat ownership and teat territoriality, is the autonomous functioning of the breast and in the reduction of cortisol levels by sucking on the fixated object. Postnatal Depression and Mother-Infant Interactions at 12 Weeks Postpartum in an Italian Low-risk Sample Fiorella Monti1, Francesca Agostini1, Isabella Cantagalli1, Leonardo De Pascalis1,2 1

Department of Psychology, University of Bologna, Italy Obstetrics and Gynaecology Unit, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy Email: [email protected]

2

Background: Postnatal depression (PND) has been recognized as affecting the maternal ability to sensitively interact with the infant. Several studies have suggested how poor early motherinfant interactions, associated to PND, can mediate the long-term negative effects on the child development. Different instruments have been developed to evaluate early mother-infant interactions; the Global Rating Scales of mother-infant interaction (GRS; Murray et al., 1996) were created to assess differences in mother-infant interactions between women with or without PND. GRS have also been used with different clinical groups and for cross-cultural comparison on PND, including Italy, even if with a very small sample. The present study was aimed at further investigating depressed mother-infant interactions with GRS in an Italian sample of middle class women. Method: A total sample of 234 women was recruited during pregnancy in hospitals. At 12 weeks postpartum psychologists visited the women at home. During the visit Edinburgh Postnatal Depression Scale (EPDS; Cox et al., 1987) was completed by the mothers and face-to-face mother-infant interactions were videorecorded. Selected dimensions of the GRS were used to analyse mother-infant interactions in relation to maternal depressive symptomatology. Index (N=35) and control groups (N=199) were defined on the basis of the EPDS scores, considering a cut-off value 12/13. Results: Results will compare index and control group on the following dimensions of the GRS: a) for the mother: Sensitivity, Intrusiveness, Remoteness, Depression; b) for the infant: Engagement. Results will also point out any differences in the Italian depressed mother’s interactive style, in comparison to international findings. Conclusion: The data to be reported show that in our Italian sample depressed mood affects maternal interactive style, especially in terms of lower maternal sensitivity and higher intrusive behaviour. Further studies are needed in this sense in order to increase the amount of data present in literature concerning Italian context.

S27 Parental Representations During Late Pregnancy and Early Parenthood Following Assisted Reproductive Technology Fiorella Monti1, Francesca Agostini1, Leonardo De Pascalis2, and Isabella Cantagalli1 1

Department of Psychology, University of Bologna, Italy Obstetrics and Gynaecology Unit, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy Email: [email protected]

2

Background: Mental representations influence the parents perception and interactive behaviour with their newborn baby, proving to be important from an intergenerational, attachment, and child development perspective. The perinatal period is a moment in which maternal representations are strongly activated and, since pregnancy, they can be predictive of parenting styles, influencing the interactive and caring behaviour with the infant. In situations of emotional distress, like in ART (Assisted Reproductive Techniques) pregnancies, a higher incidence of difficulties has been found for mothers in building up representations and adapting to the new (real) situation after birth, which could possibly lead to failures in interaction with the baby. In this study, maternal and paternal representations were investigated in the comparison between spontaneous pregnancies and ART pregnancies, during the gestational period and the infant’s early life. Method: The sample of 87 subjects, 48 ART (25 mothers and 23 fathers) and 39 non-ART mothers, was given interviews and semantic differentials on maternal and paternal representations during pregnancy [IRMAG (Ammaniti et al., 1995) and Rap.Pa.G. (Di Vita et al., 2002)] at 30–32 weeks of gestation, and interviews on maternal and paternal representations after delivery [Pap.Ma.N. and Rap.Pa.N. (Di Vita et al., 2002)], 3 months after the child’s birth. Results: Comparisons between ART women and non-ART women and between ART women and ART men will be shown about: the main socio-demographic and obstetrical variables, the main characteristics of parental representations of oneself-as-parent and of the child, both during and after pregnancy. Conclusion: The data underlined that ART women’s representations are more ambivalent than those of non-ART women, while ART men’s representations are more disengaged than those of ART women. This could indicate, in ART, a much more complex transition to parenthood, not only from a medical, but also from a psychological point of view. Postpartum Depression Screening in the Neonatal Intensive Care Unit Kyle O Mounts, Mary M Kerrigan, and Anne M Weinfurter Wheaton Franciscan Healthcare St. Joseph Hospital, Milwaukee, Wisconsin, USA Email: [email protected] Background: Postpartum depression affects 15 to 20% of women. Having an infant in the neonatal intensive care unit (NICU) is a source of stress for parents and is associated with increased risk for postpartum depression. Evidence suggests that approximately 40% of women who have very premature infants in the NICU suffer from

S28 postpartum depression. Objective: To use a formal postpartum depression screening process to determine the rate of positive depression screens in women with infants in the NICU for greater than three weeks and to determine the rate of referral for follow-up services. Design/Methods: The mothers of all infants who were in the NICU at three weeks postnatal age were offered postpartum depression screening using the Edinburgh Postnatal Depression Scale (EPDS). Screening was performed by the NICU social workers who introduced the idea of screening in the initial intake interview. Women with scores greater than 12 were offered referrals for follow-up services. Women whose infants met criteria for the neonatal follow-through clinic were re-screened in the follow-through clinic. The hospital’s Quality Assurance/Quality Improvement Committee (QA/QI) provided additional oversight for the process. Results: The QA/QI Committee began tracking the screening process in January 2007. Between January 1, 2007 and November 30, 2007, 131 women qualified for screening. Onehundred fifteen women (88%) completed screening and 35 women (30%) had scores greater than 12. Of the women with scores greater than 12, 31 (89%) accepted referrals for further evaluation. At the 6 month follow-through clinic visit 6 women have been re-screened; two have been referred for follow-up services. Conclusions: Women with infants admitted to the NICU are at high risk for developing postpartum depression. A program for postpartum depression screening, including arrangements for appropriate followup for women with positive screens, can be successfully implemented in the NICU. Perinatal Care and Planning for Psychiatrically Ill Women A Model of Care for Western Victoria Fyowna Norton and Klara Szego Mother Baby Services, Mercy Hospital, Melbourne Email: [email protected] Modifying psychiatric care to the maternity context is critical in delivering positive outcomes for women with a mental illness, particularly so in the antenatal period. Women with severe mental illness such as major depression, schizophrenia and bipolar disorder pose significant management challenges when planning for childbirth, pregnancy and the post partum period. Mother Baby Services is the consolidated delivery system for perinatal care of psychiatrically unwell women in Western Victoria. It amalgamates three care streams of mother/baby inpatient unit, mother/ baby outpatient clinic and education and liaison. These services provide effective interventions aimed at decreasing illness relapse as well as promoting the mother infant relationship, parenting skills and consequently the emotional development of the infant. Data on the relevance and appropriateness of interventions provided by these services, including information on current and predictive demographics for this growing number of women indicate the significant implications of this growth for this area. These findings will be considered in the context of clinical practice and management for this highly vulnerable group. How Couples Cope with Crying Infants Timothy O Leary Father’s Time Program, Frances Perry House, Melbourne Email: [email protected]

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 Despite the challenges for couples in making the transition to parenthood, there is very little research on how couples cope with their experience of a crying infant. A small qualitative research project using a modified grounded theory method explored how four couples (two heterosexual and two same-sex) coped with their crying infant. The couples reported experiences of considerable distress in situations with their crying infant, however their highly supportive and respectful relationship dynamics allowed them as a couple to better cope with such stressful parenting situations. The Same-sex couples shared similar processes to heterosexual couples but additionally encountered negative due to homophobia. Analysis of the findings drew out a new way of considering the systemic configuration of couples in the transition to parenthood that has implications for how professionals engage with clients who are in the transition to parenthood. Van Egeren, (2006), suggests that couples are considered to make the transition to parenthood by moving from being a couple to forming two sub-systems: the couple sub-system and the coparenting subsystem. In the process of analysing the data, the use of such binary concepts as parenting processes and couple processes proved inadequate. Drawing upon the notion that the couple and parental subsystems overlap (Carneiro et al, 2006), many findings belonged in a third category that spanned across both categories and which I have termed the Couple-Parenting Interface. This third category is a container for experiences and processes that included elements of both parental and couple domains. It also has a symbolic aspect where meanings are constructed by the couple and each partner that become part of ongoing narratives about both the couple and co-parenting relationships. The outcome of this small research project indicated that couples who positively manage their Couple-Parenting Interface are more likely to make a healthy transition to parenthood. References: Van Egeren, L. A., (2003) Pre-birth predictors of co-parenting experiences in early infancy, Infant Mental health Journal, Vol 24, Issue 3, Pages 278 – 295 Carneiro, C., Corboz-Warnery, A. and Fivaz-depeursing, E. (2006) the pre-natal Lausanne Trilogue Play: A new observational tool of the co-parenting alliance, Infant Mental health Journal, Vol.27 (2) 207–228 (2006) Creative Linking: A Model for a Multidisciplinary Teaching Staff in Perinatal Psychiatry Oguz Omay Psychotherapy Clinic “La Cerisaie” and French Marcé Society (SMF), Tain l’Hermitage, France Email: [email protected] During the perinatal period, the mother and the baby (and also the father) are surrounded by many professionals whose priorities and technical focus differ: the general practitioner, the obstetrician, the mid-wife, the paediatrician, the social worker, the psychologist, hospital vs community care networks… Each professional may work with an implicit culture in his/her domain, in the hospital or the community context, finding it difficult to connect with others working for the same patient. Connections between professionals may become more strained if the pregnancy is associated to a specific vulnerability: antenatal diagnosis of malformation, psychiatric problem of the mother, history of perinatal death, social problems, substance abuse… Developing effective connections between professionals involved in such common but complex situations constitute a major task. This would not only be a more

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 efficient way of allocating resources, but may also have specific therapeutic effects on the mother-baby dyades through prevention of anxiety or even trauma associated with the highly technical modern health care context. With a focus on the prevention and appropriate care of major mood disorders during the perinatal period, we put in place a monthly multidisciplinary workshop in order to develop such creative linking between professionals: by working through in a specific manner the details of the clinical case material presented, they discover their differences and potential complementarities, surpass common mistakes and dead ends in collaborative work. Mutual understanding between professionals focusing on the purely medical or psychological aspects of the case is especially worked on. In interaction with the audience of the workshop, we will present examples of casework and comment on key points of emphasis enabling mutual teaching and attunement between professionals. Subtypes of Postnatal Depression Based on Manifest Symptom Profiles Jane Phillips, Margaret Charles, Louise Sharpe, Stephen Matthey Karitane/University of Sydney Email: [email protected] Following the work of Parker et al, who identified subtypes of nonmelancholic depression, the following study sought to determine whether there are identifiable subtypes of PND based on self reported depression and anxiety symptoms. 125 English-speaking postnatal women (0–12 months postpartum) who had been admitted to the Karitane Residential Family Care Unit (RFCU) and who scored >10 on the EPDS participated in this study. Participants completed a range of self-report measures and a structured clinical interview for psychiatric diagnosis during their admission at the Unit. A K-means cluster analysis (of depression and anxiety symptoms) was conducted. Three and four class solutions were generated, with the three class solution appearing to be the more interpretable. The first cluster was characterised by lower scores on all items, and was labelled a mild depression and anxiety cluster. Compared to the first cluster, the second cluster was characterised by higher levels of depression, but comparable levels of anxiety and was labelled a moderate depression and anxiety cluster. In contrast, the third cluster was characterised by a level of depression similar to that of cluster 2, but a higher level of anxiety (and was therefore labelled a moderate depression, high anxiety cluster). The validity of the cluster solution was confirmed by identification of differential characteristics for each of the clusters (variables included socio-demographics, current and lifetime depressive and anxiety disorders, stressful life events, personality vulnerability, difficult infant behaviour, dysfunctional attitudes, adult romantic attachment style). These results provide evidence that there are identifiable sub-types of PND based on clinical features. The implications of these results in terms of different etiological pathways for different PND subtypes and differential treatment requirements will be discussed. The Perceived Value of Mutual Support of Sufferers and Survivors to Recovery from Post Natal Illness Veritee Reed Hall, Wendy Garner and Voluntary Staff Team at PNI ORG UK Email: [email protected]

S29 This poster presentation will focus on The perceived value of mutual support of sufferers and survivors to recovery from Post Natal Illness. This will be from the perspective of members of the Internetbased UK Registered Charity PNI.ORG.UK (www.pni.org.uk). The ethos of the charity is that members and staff participate as equals. There are no experts, just people with experiences, knowledge and skills which are shared. PNI.ORG.UK is run by sufferers and past sufferers of PNI (survivors) for sufferers and past sufferers of PNI. The charity aims to support women with or who have suffered Post Natal Illness. As part of the work of the charity, there is a Self and Mutual Help & Support Forum-http://veritee.proboards7.com. The basic philosophy is; that no one understands what it feels like to have PNI as well as someone who has or has had PNI, but we understand that at times advice and support can be subjective, so it is not recommended that the forum is EVER used as someone’s only support or help. The Poster will report on findings relating to the central question The perceived value of mutual support of sufferers and survivors to recovery from Post Natal Illness. There will be two sources of data: selected data (using criteria of relevance to central question) from members spanning a time period of 10 years (1998 2008) use of content analysis to hone down key aspects of the value of mutual support in recovery, data collected from current members, through surveying techniques further use of content analysis to hone down key aspects of the value of mutual support in recovery. Findings will detail: A composite view of past and current members perception of the value of mutual support in aiding recovery from Post Natal Illness. The Management of Bipolar Affective Disorder in Women of Childbearing Age Michelle Smith, Justin Earl, Andy Kent South West London and St George’s NHS Mental Health Trust, London, UK Email [email protected] Aims: This study examined the current practice of prescribing in women of childbearing age with bipolar affective disorder and whether contraception and the risks of medication in pregnancy had been discussed by psychiatrists in a university teaching hospital in London, UK. Background: Recent NICE (National Institute for Health and Clinical Excellence) guidelines on Antenatal and Postnatal mental health highlight the importance of discussing contraception and the risks of pregnancy in all women of childbearing age. This guideline also recommends avoiding sodium valproate in women of childbearing age. Methods: We identified all cases of women of childbearing age (18 45 years) with a diagnosis of bipolar affective disorder from seven community mental health teams in southwest London, UK between February May 2007. Retrospective data was then collected from the case files including: medication currently prescribed, documented evidence of discussion of contraception and the risks of medication in pregnancy. Data was analysed using SPSS 14.0. Results: We identified 34 female patients of childbearing age with bipolar affective disorder. The median age was 35 years (range 22 45 years). Of the 34 patients, 10 (29.4%) were prescribed sodium valproate, 3 (8.8%) were prescribed carbamazepine, 8 (23.5%) were prescribed lithium. We found evidence that contraception was discussed by the prescribing doctor in 11 (32%) cases and the risks medication in pregnancy were discussed in 12 (35%) cases.

S30 Conclusions: This study demonstrates current prescribing practice in women of childbearing age with bipolar affective disorder. Despite its well know teratogenic effects, sodium valproate was found to be the most frequently prescribed medication. In only one third of cases were the risks of taking medication in pregnancy and the importance of contraception whilst on potentially teratogenic medication discussed. Do Dormitory Suburbs Make Good Nurseries? The Experience of a Day Stay Program for New Families in Victoria Aileen Thoms, Ruth Keatley, Larry Osborne, and Colleen Coleman Kooweerup Regional Health Service, Victoria Email: [email protected] (Ruth Keatley contact for poster) This poster will illustrate how a small, rural health service in Kooweerup, Victoria provides an innovative approach to early parenting through the provision of a day stay program that engages with parents to provide early intervention from birth to 1 year, through support, health promotion and education. The program enhances the parents ability to manage better common issues in the first year and so enhance the baby’s and parents own experiences of this important stage of life. The poster will illustrate the unique characteristics of how living in a rural, urban fringe area of Melbourne affects the delivery of perinatal mental health services. It will demonstrate how the program complements other services in the area by supporting parents through early intervention with telephone triage, comprehensive screening, risk assessment and referral pathways to additional resources. Follow up is provided and supports given to navigate the health system. A new transition to parenting program is also offered to pregnant women. The program provides a holistic, experiential approach delivered by a multidisciplinary team which supports the parents in understanding and normalising some of the common emotions associated with parenting, i.e. anxiety, stress and fatigue and offer practical suggestions and support in managing these feelings. Parents gain an understanding of their babies temperament and behaviour and how this can impact on relationship dynamics. Conclusion The outcomes show that by providing this model of support, the parents are more confident, have greater skills and knowledge and are more responsive and proactive to their baby’s needs which enhances their enjoyment of their family unit. Inpatient Admissions to the Birmingham Mother & Baby Unit Over a 10-Year Period Gillian Wainscott and Jennifer Whitmore Department of Perinatal Psychiatry, Queen Elizabeth Psychiatric Hospital, Birmingham, UK Email: [email protected] Pregnancy, childbirth and the first year after the birth of a child is a time of increased risk of mental illness. These may present as a new episode of illness specifically related to childbirth, or a recurrence of a pre-existing condition. Three successive confidential enquiries into Maternal Deaths have highlighted that suicide was, up until recently, the most common causes of death during the first year post-partum. They have recommended that, when a mother requires inpatient treatment for mental illness during the first year after birth, admission should be arranged, together with her baby. In this paper we report the

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 experience over a 10-year period (1998–2007) of an inpatient service which offers conjoined admissions of mothers and babies. Method: Admissions to the Birmingham Mother and Baby Unit over a 10 year period were reviewed. Demographic and clinical information of the mother, as well as the outcome for the baby, were collected. Results: 462 mothers were admitted to the Mother & Baby Unit over the 10-year period. The majority of women suffered from a serious mental illness, with 210 (46%) suffering from a serious mood disorder and 104 (22%) suffering from a schizophrenic/psychotic illness. Most women were not separated from their infants. In 45 cases (10%) assessment was terminated prematurely, and mothers left the unit alone. Of the women who left the unit without their infant: 16 (36%) had a schizophrenic/psychotic illness 7 (16%) had a depressive illness 7 (16%) had a personality disorder Conclusions: Mothers with schizophrenia had the poorest prognosis and were more likely to lose their babies, although this was not inevitable. Over the 10-year period, more women with a diagnosis of schizophrenia were being admitted to the Unit. This may be because they are now better identified antenatally through Mental Health Liaison Clinics. The management of mothers who are not able to gain admission to a specialist unit is worrying. These mothers are admitted without their babies to acute psychiatric wards, or are treated at home by Home Treatment Teams. Macro-Level Interventions for Postpartum Mood Disorders: An Education-based Approach Kimberley Zittel-Palamara1 and Wendy L. Weinstein2 1

Buffalo State College, Buffalo, New York, USA Buffalo Medical Group Email: [email protected]

2

Postpartum mood disorders include the experience of depression, anxiety, or psychosis typically six weeks after delivery of a baby. These disorders occur with alarming frequency. It is conservatively estimated that one in seven women will have postpartum depression (Moses-Kolko & Roth, 2004); this is larger than the number of men who will be diagnosed with prostate cancer this year (National Prostate Cancer Coalition, 2004)! Yet, few medical or mental health professionals ever receive specific training on how to assess, diagnose, or treat these disorders (Oates, 2000). The barriers to care have been supported by several researchers in the field, stating that many medical professionals will not assess for postpartum mood disorders because they are unsure what to do if it is detected (Buist, 2003). The majority of U.S. communities lack postpartum mood disorder service providers, leaving limited alternatives such as medication or hospitalization. Making matters more complicated many women who are silently suffering with postpartum mood disorders continue to remain silent out of fear that her children will be removed, that there is something wrong with her, and having experienced unsupportive remarks from professionals or unwanted treatment options (HansonLynn, 2005; Logsdon, Wisner, Billings, & Shanahan, 2006; Small, Brown, Lumley, & Astbury, 1994; Wood & Meigan, 1997). This presentation will discuss an educational model that is being used by a psychiatrist and social worker in Buffalo, New York to improve the availability/quality of care and to improve medical/mental health professionals ability to assess, diagnose, treat, and refer women to appropriate care. These presentations are being made to local obstetricians, gynecologists, physicians, counselors, social workers, and child protection workers. Additionally, this model is being used

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 for continuing education training and is being integrated into a new Masters-level course in a school of social work.

EXPERIMENTAL LABORATORY STRESS AND RELAXATION IN PREGNANCY Convenors: Judith Alder and Johannes Bitzer University Women’s Hospital Basel, Switzerland Email: [email protected] Summary: Psychosocial stress during pregnancy has been associated with adverse obstetric outcome (Alder et al., 2007). Moreover, there is increasing evidence on an association of negative mood and long-term child development. However, as the condition of psychosocial stress is related to a wide variety of interindividual biopsychosocial differences, we are only starting to understand some of the fundamental mechanisms of stress transmission and programming effects. Therefore, experimental stress and relaxation paradigms offer an optimal way to observe mechanisms of stress reactivity and the possible ways of stress transmission from mother to fetus. Only by understanding these mechanisms, effective therapeutic interventions can be developed and tested. The Symposium Experimental stress and relaxation in pregnancy includes work on the maternal-fetal communication during a laboratory stress condition. Second, results will be presented on the maternal psychoneuroendocrine reactivity during two different relaxation conditions and there impact on fetal parameters. Last, some possible clinical implications for obstetric care will be presented in women with premature contractions who are practising progressive muscle relaxation. PAPER 1: The Unborn Child Participates in its Mother’s Emotional Life: the Role of Psychological and Endocrine Factors Nadine S. Fink, Corinne Urech, Johannes Bitzer, Irène Hoesli, and Judith Alder University Women’s Hospital Basel, Switzerland Email: [email protected] Background: Maternal stress during pregnancy can have severe effects on the course of pregnancy and pregnancy outcomes, and hence on infant development. However, effects of maternal stress on the unborn child are not well understood. This study looked at the effects of maternal laboratory stress on the unborn child. For the first time corticotropin releasing hormone (CRH), cortisol and norepinephrine (NE) were investigated as underlying mechanisms in the transmission of maternal stress to the fetus. Methods: 26 healthy pregnant women (aged 18–44 yr) made a single 2-hour visit to our clinic at pregnancy weeks 28–32. We asked them to complete a stressful arithmetic stress test and took blood samples before and after completion to measure maternal stress hormones. We analysed the effects on fetal reactivity (fetal heart rate (FHR), FHR variation, accelerations, mild decelerations and body movements), using a computerized cardiotocogram system (SisPorto® 2.0). Results: The strongest finding of this study is that maternal stress activation has effects on the unborn child. Fetuses of stressed mothers had significant higher FHR (F (1, 19)=5.1, p=.04, p2=.25), less FHR variation (F (1, 19)=2.8, p=.10, p2=.15) and mild decelerations in FHR (F (1, 19)=6.0, p=.02, p2=.30). This suggests that unborn children are influenced by their mothers experienced distress. In addition, maternal baseline stress hormones such as cortisol and

S31 norepinephrine had effects on the unborn child, revealing a potential maternal-fetal pathway of stress transmission. Conclusions: If the same mechanisms operate in daily maternal stresses it means a child is born already having a long history of responding to stress and stress hormones and is a participant in the mother’s emotional life. PAPER 2: Relaxation Exercise During Pregnancy: Impact on Psychobiological Wellbeing Corinne Urech, Nadine Fink, Johannes Bitzer, Irene Hoesli, Judith Alder University Women’s Hospital Basel, Switzerland Email: [email protected] Introduction: Relaxation has an impact on certain psychological functions and leads to a reduction in perceived stress in pregnant women. In addition, relaxation can have positive effects on the course of pregnancy and obstetric outcomes. However, the underlying biological mechanisms are poorly understood. The purpose of the present study was therefore to study the association between different relaxation techniques and psychobiological reactivity of mother and fetus. Methods: A sample of 39 healthy pregnant women (aged 22 to 44 years) recruited at the outpatient department of the University Women’s Hospital Basel, participated in a randomized controlled trial with an experimental repeated measure design. Participants were assigned to a relaxation technique (progressive muscle relaxation (PMR) or guided imagery (GI)) or a control group condition. General endocrine parameters indicating the HPA-activity, subjectively reported mood, as well as fetal reactivity (computerized CTG) were measured at different time points during the trial. Results: The analyses of our preliminary data show a significant superiority of GI technique compared to PMR and the control group condition with respect to subjectively reported mood. Fetal responses indicate a trend towards decreased fetal heart rate in the GI group, increased FHR variability and decrease of fetal motor activity in both relaxation groups. Guided imagery and PMR evoked declining salivary cortisol levels but did not differ to the control group condition. The analyses of ACTH, estradiol and catecholamines are not yet completed but will be presented together with additional obstetric data. Conclusion: According to these preliminary results, relaxation techniques have advantageous effects on pregnant women and their fetus. GI in particular has positive subjective effects, and is associated with fetal behaviour. Further studies will have to explore the benefit of GI in women with psychosocial risk factors.

PAPER 3: Progressive Muscle Relaxation in The Context of Pregnancy Complications Judith Alder, Corinne Urech, Nadine Fink, Irene Hösli, and Johannes Bitzer University Women’s Hospital Basel, Switzerland Email: [email protected] Background: Several studies have shown an association between psychosocial stress and premature labor. However, while relaxation exercises are a standard intervention for different psychopathologies and in stress inoculation trainings, there is limited data regarding its

S32 effectiveness in patients hospitalized for premature contractions. The present study therefore aims at the evaluation of the benefit of progressive muscle relaxation (PMR) on wellbeing, physiologic and obstetric measures. Methods: Intervention study comparing patients with premature contraction with healthy pregnant controls regarding their reactivity to a standardized audiotaped 10-min. relaxation procedure (PMR). To date, eight patients with premature contractions and 13 healthy controls participated and were compared with respect to subjective relaxation ratings, anxiety measured by means of the State-TraitAnxiety Inventory (STAI), blood pressure (BP) and heart rate (HR) before and after the intervention. Results: Preliminary results show that subjective reports on relaxed state are significantly lower in pregnant women with high state and trait anxiety scores. Anxiety and ratings of a relaxed state however, did not correlate with blood pressure or heart rate. Pregnant women with premature contractions showed significantly higher anxiety scores but did not differ with regard to ratings of relaxation. However, compared to healthy controls, patients had higher measures of SBD (103 vs 120 mmHg; T=2.4, p<0.05) before and after the PMR exercise. In both groups, there was a trend for decreased BP and HR decreased and a significant increase in subjective reports of relaxation from pre-to post relaxation. Additional data on obstetric outcome will be presented. Conclusions: Both patients and healthy controls benefit from PMR with regard to subjectively experienced state of relaxation and BP. These preliminary findings point to the potential of relaxation exercise in pregnant women and patients with premature contractions and to the exigency of its implementation in obstetric departments. RECENT DEVELOPMENTS IN PERINATAL MENTAL HEALTH POLICY AND PRACTICE IN THE WESTERN WORLD Convenor: M-P Austin Email: [email protected] Discussant: Anne Sved Williams Perinatal Psychiatrist, Chair National Clinical Practice Guidelines for Antenatal Care (Australia) Rationale for the Symposium It is now well recognised that the perinatal period is a time of both heightened vulnerability for maternal mental health and opportunity for the implementation of prevention and early intervention. Over the last 10 years we have seen significant developments in policy, guidelines and the provision of mental health care for women and their families in the perinatal period across a number of Western countries. This symposium will outline these various developments followed by discussion from the presenters and panel about the relative merits and challenges inherent in the various approaches. PAPER 1: Perinatal Mental Health Policy and Service Development in the UK: Common Aims, Diverging Paths Roch Cantwell Perinatal Mental Health Service, Dept of Psychiatry, Southern General Hospital Email: [email protected]

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 As the nations of the United Kingdom go their separate ways in terms of health policy, their responses to the needs of women with perinatal mental health problems are also diverging. Guideline development in Scotland (Scottish Intercollegiate Guidelines Network) and England & Wales (National Institute for Health and Clinical Excellence) has produced not only evidencebased guidance on detection and management, but also recommendations for service development. Different national approaches to health delivery pose different challenges to regional service provision and, in Scotland, mental health legislation has placed a specific onus on service providers to ensure that the inpatient needs of childbearing women and their families are met. This talk will review changes in both policy and practice across the UK over the past 10 years. PAPER 2: Perinatal Mental Health Policy and Service Development in France: State Guidelines for Better Perinatal Care Catherine Isserlis Dept of Child Psychiatry, Versailles University Hospital, France Email: [email protected] In France, Health policy for the perinatal period recommends a systematic assessment of all pregnant women for an interview (about 45 minutes), with a midwife or a GP, at the end of the fist trimester of pregnancy. The aim of this interview is to allow all pregnant women, or couples, to have a chance to talk to a professional about their fears and difficulties in becoming parent and to be supported if necessary. It also aims to detect personal or familial psychosocial vulnerabilities and to improve the follow up during pregnancy, childbirth and postpartum. The High State Health Authority (Haute Autorité de Santé or H.A.S.) is in charge of the validation of guidelines and procedures that have been submitted by scientific association (such as the Francophone Marcé society) or by multidisciplinary research groups. For instance, there are already guidelines validated on Outpatient cares for patients with depressive disorders and on what a patient file should contents for an inpatient who has try to commit suicide. All French Medical doctors, including psychiatrists, have to use those validated guidelines to report about the improvement of their clinical practice.. This paper will cover the activites of the French Marcé Society in terms of guideline development and training around perinatal psychosocial needs. PAPER 3: Guidelines for the Management of Mental Health Issues in the Perinatal Period: The Current Status in the United States Katherine L. Wisner Women’s Behavioral HealthCARE, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pennsylvania USA Email: [email protected] Several states (notably Illinois, New Jersey and Pennsylvania) have developed state-wide initiatives to improve mental health care for perinatal women. These initiatives focus on screening practices, depression care management, and the development of accessible services for new mothers and families. Policy development has become a national priority with the publication of the Agency for HealthCARE Research and Quality’s evidence report on perinatal depression as well as the passing in the House of Representatives of

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 the MOTHERS Act. Additionally, representatives from the APA and ACOG have collaborated to develop treatment guidelines. The progess of the last decade will be summarized and critically reviewed along with a vision for the next five years. PAPER 4: A National Action Plan for Perinatal Mental Health for all Australian Families: Prevention and Early Intervention in the Primary Health Sector 1

M-P Austin and Carol Bennett

S33 service development in resource-constrained settings drawn from the World Health Organization’s Western Pacific, Easter Mediterranean and South East Asian regions. PAPER 1: Common Perinatal Mental Health Problems in Parents in the North of Viet Nam: Prevalence and Correlates Jane Fisher1, Tran Tuan2, Lu thi Buoi2, and Thach Tran2

1

1

Past director beyondblue PNMH National Action Plan beyondblue PNMH program Email: [email protected]; carol.bennett@ beyondblue.org.au

2

The Australian beyondblue Perinatal Mental Health National Action Plan (NAP) was developed to address the mental health needs of women, partners/fathers and infants during pregnancy and in early parenthood. The Plan followed a four year program of research and focusses on a rationale for the implementation of routine, universal perinatal psychosocial assessment, workforce training and pathways to care in the primary health care sector . The Australian Government has committed $85 million to support the implementation of the Plan which was released in April 2008 and is available on the beyondblue website: www.beyondblue.org.au. PERINATAL MENTAL HEALTH IN RESOURCE-CONSTRAINED SETTINGS: EVIDENCE, PUBLIC POLICY AND SERVICE DEVELOPMENT Convenor: Jane Fisher and Bryanne Barnett While about one in ten pregnant women and mothers of newborns in developed countries have significant perinatal mental health problems, there is increasing evidence that prevalence is two to three times higher in the world’s resource-constrained settings. The presumption that culturally-prescribed postpartum care is available and provides mothers of newborns with an honoured status, mandated rest and increased practical assistance, thus protecting mental health, does not reflect reality for many women. If, in the context of poverty and chronic social adversity maternal caretaking capacity is compromised, child survival, health and development are jeopardized. While mental health problems are a key determinant of maternal and child mortality and morbidity in developing countries, they are not currently recognised in existing initiatives to promote maternal health and improve sexual and reproductive health and child health in developing countries. We believe that the achievement of the Millennium Development Goals to improve maternal health, reduce child mortality, promote gender equality and empower women, achieve universal primary education and eradicate extreme poverty and hunger cannot be achieved unless there is a specific focus on maternal mental health. In doing this it is essential to pay attention to the social determinants of mental health and its key role in maternal health and child survival, health and development, and in increasing the coverage of evidencebased low-cost interventions for maternal mental health problems. Enhancement of maternal mental health requires the involvement of multiple sectors including those dealing with development, poverty reduction, human rights, social protection, education, gender, and security, in addition to health. This symposium will include presentations addressing: the generation of local evidence about the prevalence and determinants of perinatal mental health problems and strategies to incorporate these in health policy and

1 Key Centre for Women’s Health in Society, Melbourne School of Population Health, The University of Melbourne, Australia. 2 Research and Training Centre for Community Development, Hanoi, Vietnam Email: [email protected]

Background: Viet Nam, a low-income country has limited local evidence about perinatal mental health on which to base practice and policy. In 2000, 32% of mothers of newborns in Ho Chi Minh City scored in the clinical range on a translated, but not locally validated version of the Edinburgh Postnatal Depression Scale. The aim of this study was to assess the prevalence and correlates of perinatal mental health problems in women and men in rural and urban North Viet Nam. Methods: Separate cohorts of women in the third trimester of pregnancy and who had recently given birth and their husbands were recruited in a rural (Ha Nam) and an urban (Ha Noi) health district. Data were collected by individual structured interviews to assess sociodemographic and household characteristics, reproductive health, quality of support and exposure to violence and SCID interviews administered separately by a Vietnamese psychiatrist. Results: In total 199 pregnant women and 165 mothers of newborns (64% from Ha Nam) and 235 of their husbands were assessed. Of these, 32.6% of female and 22.7% of male participants from Ha Nam and 24.7% of female and 13% male from Ha Noi were diagnosed with an anxiety or depressive disorder. More than a third of households had at least one parent and in 8% both parents with a mood disorder. Correlates were poverty, unwelcome pregnancy and exposure to violence. Only one person had ever received psychiatric treatment. Conclusion: As in other resource constrained settings, perinatal mental health problems are prevalent in women in Viet Nam. This study provides the first evidence that these problems are also prevalent in men. They are currently unrecognised by local health services. These data suggest that the integration of mental health care into maternity health services must be accompanied by poverty reduction and violence prevention strategies. PAPER 2: What is the Real Prevalence of Postpartum Depression? smet Kirpinar1, Sabahat Gözüm2, Türkan Pasinlio lu2, Nazan Ayd n1 1 Atatürk University Medical Faculty, Department of Psychiatry, Erzurum, Turkey 2 Atatürk University Nursing High School Email: [email protected]

Background: Postpartum depression (PPD) is a term used to describe a heterogeneous group of depressive disorders specific to the postpartum period. In previous studies, the reported prevalence of PPD has shown a wide range, depending on many factors such as diagnostic procedures, cultures, and socio-economic status. Previous

S34 studies have shown that a past history of depression, including a past postpartum episode, increases the risk of postpartum depression. Methods: A prospective, cohort study was conducted in Erzurum, Turkey. There were 571 third trimester pregnant women between September 1, 2001 and November 30, 2001 in Erzurum city center. The women were assessed for PND with Edinburgh Postpartum Depression Scale at 6-weeks postpartum. Finally, the Structured Clinical Interview for DSM-IV (SCID) was used to assign psychiatric diagnoses in mothers who had scores above threshold on the EPDS. Results: In this study, PND prevalence rate of 13% was found at 6 weeks postpartum, using as EPDS criterion a score of 13. But later evaluation showed that only 62% of depressive disorders were postpartum onset cases. Other cases had occurred before pregnancy in 10% and during pregnancy in 12.1% of the depressive mothers. Conclusion: Some of the depressive disorders shown at the postpartum period are not really PND High prevalence of PND in some countries may be a consequence of high depression rates in women. PAPER 3: Young, Single and Not Depressed: Prevalence of Depressive Disorder among Young Women in Rural Pakistan Atif Rahman1, Mansoor Ahmed2, Siham Sikander2, Abid Malik2, Barbara Tomenson3, Francis Creed3 1

University of Liverpool, Royal Liverpool Children’s Hospital, Liverpool, UK 2 Human Development Research Foundation, Islamabad, Pakistan 3 Department of Psychological Medicine, University of Manchester, UK Background: The prevalence of depression is very high (>45%) among adult women, including during pregnancy and after childbirth in Pakistan but it is not known whether such a high prevalence occurs in younger women. The aim of this project was to assess the prevalence and correlates of depression in 16 to18year old unmarried women in Pakistan Method: A population-based survey of all 16 to 18-year old unmarried women in one rural community. Depressive disorder and psychological distress were assessed using the Structured Clinical Interview for DSM-IV Disorders (SCID) and the Self-Reporting Questionnaire (SRQ) respectively. Results: 337 eligible women were identified of whom 321 (95%) were interviewed. Fourteen (4.4%) had depressive disorder; one third scored 9 or more on SRQ. On multivariate analysis a high SRQ score was associated with childhood experience of poverty, father’s education, stressful life events, disturbed family relationships and mother’s depression. Conclusion: Depressive disorder is not common in young women in rural Pakistan though distress appears common and is associated with early and recent adversity and family difficulties. These findings suggest that a rapid role transition accompanied by several potentially difficult life events clustered closely together including marriage, moving in with the husband’s family, pregnancy and childbirth might contribute to the onset of depression in Pakistani women living in rural areas. PAPER 4: What is Needed in Order to Scale-up Maternal Mental Health Care Services in Viet Nam? Tran Tuan1, La Thi Buoi2, Jane Fisher2 1

Research and Training Centre for Community Development, Hanoi, Vietnam 2 Key Centre for Women’s Health in Society, Melbourne School of Population Health, The University of Melbourne

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 Background: Common mental disorders are prevalent in Viet Nam in particular in mothers and children. In 1999 Viet Nam launched a national community based mental health care program, which is now established in about 4000 communes (40%), to supplement the psychiatric hospital system. However, maternal mental health is not included in these programs, the national program of safe motherhood, or in obstetric hospital services. The aims were to investigate why there are no maternal mental health care services in Viet Nam and how these can be scaled up to meet the 2007 Lancet Global Mental Health call to action. Methods: A critical review, using WHO guidelines and the Lancet framework, of national mental health policy and an evaluation of the model of community-based mental health project in two provinces in North Viet Nam. Results: Maternal mental disorders are not considered in the national mental health program or recognized in existing initiatives to improve maternal and child health. The community-based mental health care system was established to manage schizophrenia and epilepsy through local distribution of medications. Anxiety, depression and personality disorders are not included in the national model. Key explanatory factors are (1) mental health care is dominated by psychiatrists who have only one-year of specialist training as undergraduates; (2) there is a lack of appropriate training about mental health in general and primary health care; (3) poor research capacity in the area of mental health and health care system. Current service provision does not meet WHO recommendations. Conclusion: While there is high political will for community-based mental health care in Viet Nam, there is no model of care for maternal mental health problems. Operational and action research is needed to build community-based evidence to help Viet Nam renovate mental health care in general and build up maternal mental health care services to meet WHO guidelines and the Lancet call. PAPER 5: Scaling up Services for Perinatal Mental Health: How to Move to Service Delivery Mark Tomlinson Health Systems Research Unit, Medical Research Council, Cape Town, South Africa, and Department of Psychology, Stellenbosch University, Cape Town, South Africa A recent call in the Lancet Mental Health Series stated that the most important priority for global mental health was the scaling up of services for people with mental disorders. Mental health problems associated with pregnancy and childbirth are highly prevalent, and unless these are urgently addressed, it is unlikely that many low and middle income countries will attain the Millennium Development Goals of improving maternal health, reducing child mortality, promoting gender equality and empowering women. Since the adoption of the Millennium Development Goals in 2000 there have been a number of initiatives aimed at ensuring that countries meet the goals, most notably in the area of neonatal and child survival. This paper will adapt the four step management cycle as a guide for scaling up services for perinatal mental health services. Step 1 involves assessing the situation and creating a policy environment conducive to perinatal mental health. The second step is ensuring optimum care of the mental health of women during the perinatal period within the constraints of the situation. Step 3 is the systematic scaling up of services and Step 4 involves monitoring coverage and measuring effect and cost. Any scaling up of services in LAMI countries is going to depend as

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 much on the strengths of the health systems in these countries as on the epidemiology of perinatal distress. The lack of epidemiological data has to be addressed, but strategies to strengthen health systems are imperative if interventions arising out of epidemiological results are to be considered. The paper will situate the discussion on lessons learned and the development of a strategy for scaling up, using this management framework.

S35 Conclusions: Findings are discussed with reference to the importance of identifying women at risk of ongoing and severe depression.

PAPER 2: Mothers Thoughts and Feelings About Their Relationship with Their Preschooler: The Impact of Recurrent Depression Tania Trapolini1, Catherine McMahon2, and Judy Ungerer2

MATERNAL DEPRESSION IN THE EARLY CHILDHOOD YEARS AND CHILD OUTCOMES: PARENTING, CHILD DEVELOPMENT, BEHAVIOUR AND ATTACHMENT Convenor: Catherine McMahon Psychology Department, Macquarie University, NSW Email: [email protected] PAPER 1: Patterns of Maternal Mood Disturbance from Birth To Seven Years: Predictors Of Recurrent Depression and Anxiety and The Impact On Child Development And Behaviour Catherine McMahon1, Tania Trapolini1,2, Irene Fihrer1, Bryanne Barnett2 1

Psychology Department, Macquarie University Infant, Child and Adolescent Mental Health Service, Sydney South West Area Health Service Email: [email protected]

2

Background: This prospective study followed a sample of mothers and their infants from 4 months after birth until their children were 7 years old. This paper reports on patterns in maternal mood (anxiety and depression) over the duration of the study, factors that predict ongoing depression and overall relationships between depression and child development. Method: At each study contact (4, 12 & 15 mths; 4 yrs, 7 yrs) maternal mood (anxiety and depression) was measured using selfreport questionnaires. The depression module of the Composite International Diagnostic Interview was used to diagnose depressive episodes retrospective to the last assessment point, according to criteria specified in the DSM IV. Children were assessed with respect to their cognitive development on each occasion and parents (as well as teachers at 4 and 7 years) reported on child behaviour. Results: 60% of women met criteria for a major depressive episode in the first 4 months after birth and at least 30% (30–38%) reported recurrence at each subsequent contact. There were moderate to high correlations for depression and anxiety scores over time (>.5) and high correlations (>.7) between depression and anxiety symptoms at each contact. Severity of both anxiety and depression symptom scores at 4 months significantly predicted subsequent recurrences up to 7 years (ps<.025) Controlling for initial symptom severity, maternal attachment state of mind assessed at 12 months was a strong predictor of recurrent depression at 4 and 7 years. Children of mothers with ongoing depression had significantly lower developmental scores at 1 and 4 years and their parents reported more behaviour problems at 1, 4 and 7 years. These reports were corroborated by teachers at 4 and 7 years.

1 Infant, Child and Adolescent Mental Health Service, Sydney South West Area Health Service 2 Psychology Department, Macquarie University Email: [email protected]

Background: This longitudinal study aimed to explore the impact of early transient and recurrent depression on the caregiving representations of mothers of 4-year-old children. Attachment theory proposes that caregiving representations help determine how a mother thinks and feels about her child, herself as a parent, and her relationship with her child. Method: Ninety-two mothers were assessed for symptoms of depression when their children were 4, 12 and 15 months, and later at 4 years of age. At 4 years of age, mothers caregiving representations of their child and their relationship were examined using the Parent Development Interview (PDI). Results: Caregiving representations of mothers who had been depressed (either early only or recurrent) were distinguished by fewer attempts to understand their child’s internal states and take their child’s perspective into account. Furthermore, caregiving representations of mothers who reported concurrent depressive symptoms tended to be characterized by a decreased capacity to express positive affect (i.e., pleasure), and an increase in the expression of emotional pain (i. e., sadness) in regards to their relationship and caregiving role. Conclusions: The more problematic representations of depressed mothers will be considered in the context of cognitive and attachment theories and the implications on caregiving behaviour will also be discussed. PAPER 3: Impact of Maternal Depression on Child Attachment Representations in Middle Childhood Irene Fihrer and Catherine McMahon Psychology Department, Macquarie University Email: [email protected] Background: This paper examines the impact of maternal depression (both early and concurrent) on attachment representations in middle childhood, assessed by analyzing the children’s family drawings, as well as relations between child attachment at one year and later attachment representations. Given the heterogeneous nature of depression course in this sample, severity and recurrence of maternal depression were also investigated in terms of their respective impact on children’s attachment representations. Method: Seventy-five mothers were assessed for symptoms of depression when their children were 4, 12 and 15 months, and later at 4 and 6–8 years of age. Measures of attachment relationships were obtained from the Strange Situation when the children were 12 months

S36 old. The family drawings were rated according to a theoretically derived attachment-based scoring system (Fury, et al., 1997). Results: There was a trend for the drawings of children whose mothers were concurrently depressed to reflect more insecure attachment and to include more disorganized features. Both severity of maternal depression symptoms averaged over the 7 years of the study and the number of depressive episodes the mother reported predicted insecure attachment representations. Finally, disorganized attachment in infancy was predictive of high scores on the Vulnerability domain in middle childhood. Conclusions: Findings will be discussed in the context of stability/ instability of attachment representations over time. STRESS AND INFANT OUTCOMES Convenors: Jeannette Milgrom and Marie-Paule Austin Discussant: Catherine McMahon Overall Symposium Description: This symposium will offer three papers examining emerging findings of the effect of stress on the developing infant. Professor Glover (London) will review her substantial work in the context of what we currently know and do not know regarding the impact of antenatal stress and the potential mechanism in a key paper. This will be followed by a briefer presentation from the New South Wales team of results from the first phase of a significant prospective study of antenatal anxiety. Finally, the impact of very early stressful experiences on neurobehavioural development of premature infants born <30 weeks of gestation will be presented by the Victorian team, examining environmental and interactional stressors in the NICU. PAPER 1: Antenatal Stress/Anxiety, the Fetal Environment, and the Neurodevelopment of the Child

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 PAPER 2: Prenatal Stress, Maternal Sensitivity, and Biobehavioural Regulation in Infancy Kerry-Ann Grant1,2, Marie-Paule Austin1,3, and Catherine McMahon2 1

Black Dog Institute, Randwick, NSW, Australia Centre for Emotional Health, Macquarie University, NSW, Australia 3 School of Psychiatry, University of NSW, Australia Email: [email protected] 2

The data reported in the present paper are part of a larger prospective study being conducted at the Royal Hospital for Women and Black Dog Institute in Sydney. The aim of the study is to investigate the impact of maternal stress and anxiety in pregnancy on infant and child developmental outcomes. For the purpose of this symposium, we present data from the first phase of the study, exploring associations among maternal antenatal psychological state, maternal postnatal psychological state, and infant behavioural and adrenocortical responses to a mild laboratory stressor. The role of maternal caregiving (particularly sensitivity) as an external organiser of the infants biobehavioural responses is also discussed. A novel contribution of the study is the use of an interactive stress paradigm (the still-face procedure) to measure both maternal behaviour and infant stress reactivity. The findings of this study are expected to contribute to our understanding of mechanisms of risk and to help identify targets of intervention/prevention to benefit mothers and their infants. PAPER 3: Stress, Premature Infant Neurodevelopment and Maternal Mental Health 1,2

Milgrom, J.,

1

Newnham, C.A. and

3

Inder, T.

1

Vivette Glover Institute of Reproductive and Developmental Biology, Imperial College, London, United Kingdom Email: [email protected] There is good evidence from independent prospective studies that if a mother is stressed or anxious while pregnant, her child is substantially more likely to have emotional or cognitive problems, including an increased risk of attentional deficit/hyperactivity, anxiety, and language delay. These findings are independent of effects due to maternal postnatal depression and anxiety, and support a fetal programming hypothesis. We still do not know what forms of anxiety or stress are most detrimental, but there is evidence that the relationship with the partner can be important in this respect. Effects differ with each child, possibly due to gene/environment interactions, and also postnatal care. We are only just starting to explore the mediating mechanisms. There is a strong correlation between maternal and fetal cortisol levels, which is increased in more anxious mothers. This suggests that the emotional state of the mother can affect placental function, possibly by a down regulation of the barrier enzyme 11 b-HSD2, as has been shown in animal models. The magnitude of these effects is clinically significant; the attributable load of emotional/behavioural problems due to antenatal stress and/or anxiety is about 15%. Thus there is the potential for appropriate interventions during pregnancy to prevent some of these problems occurring in the future child.

Parent-Infant Research Institute, Austin Health, VIC, Australia University of Melbourne, VIC, Australia 3 Washington University of St Louis, United States of America Email: [email protected] 2

Children born prematurely are at additional risk for a range of developmental problems. While early medical complications significantly add to the risk of these problems occurring, two broad aspects of environmental stress are recognized as also contributing to these problems: the Neonatal Intensive Care Unit environment, where infants are found to be chronically and acutely stressed, including maternalinfant separation; and the mother-infant interaction as parents are often traumatized and infants who have poor neurobehavioural regulation, develop maladaptive coping patterns such as gaze aversion. We present pilot results of an intervention that teaches parents to detect and sensitively respond to their infant’s stress and availability cues. Our hypothesis is that this increased sensitivity and positive interaction (i.e. not just minimal stimulation) will (i) reduce infant stress and (ii) encourage infant-parent engagement, and as a result (iii) facilitate neurobehavioural development (as measured by MRI) and medical recovery (as measured by gestational age at discharge). The process by which this is thought to occur is via reduced infant stress and enhanced mother-infant attachment. We also hypothesize enhanced maternal adjustment in terms of mental health and parenting stress. The relationship between stress and environment on brain development has been the subject of growing interest but rarely tested directly in human infants.

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 FATHERS ARE IMPORTANT TO MATERNAL AND CHILD ADJUSTMENT Convenor: Michael O Hara PAPER 1: Paternal Depression During Pregnancy and Early Infant Behavior Mijke P van den Berg a,b,c; Jan van der Endeb; Vincent W.V. Jaddoe a,d,e; Henriette A. Molle; Albert Hofmand; Michiel W Hengeveldc; and Henning Tiemeier b,d a The Generation R Study Group, Erasmus Medical Center, Rotterdam, The Netherlands b Department of Child and Adolescent Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands c Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands d Department of Epidemiology & Biostatistics, Erasmus Medical Center, Rotterdam, The Netherlands e Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands Email: [email protected] Background: Up till now no little is known on the influence of paternal depressive symptoms during pregnancy on early infant development. Aims: To investigate whether paternal depressive symptoms during pregnancy are, independently from maternal depressive symptoms, associated with early infant behaviour. Method: In a prospective population-based cohort study from fetal life onwards information was obtained on both maternal and paternal depressive symptoms (Brief Symptom Inventory) at 20 weeks pregnancy and related to excessive crying in 4,426 2-month-old infants and temperament (Infant Behavior Questionnaire-Revised) in 3,346 6-months infants. Results: Paternal depressive symptoms, adjusted for relevant confounders and maternal depressive symptoms, were associated with excessive infant crying and infant sadness. Conclusions: Paternal depressive symptoms during pregnancy, next to maternal depressive symptoms, should be considered a risk factor for adverse infant behavior. PAPER 2: Antenatal Predictors of One-Year Postnatal Outcomes in First-Time Fathers: a Prospective Study John Condon1, Phillip Boyce2 and Carolyn Corkindale1 1

Dept of Psychiatry, Flinders University of South Australia University of Sydney Email: [email protected] 2

A cohort of 311 first-time expectant fathers completed an extensive psychosocial assessment during the third trimester of their partners pregnancies. At the end of the first postnatal year, 220 of them completed a detailed follow-up assessment. Assessments were also carried out at three and six months. A small, but statistically significant, improvement in most measures of mental health and wellbeing occurred in the postnatal period compared to during pregnancy. Late pregnancy would appear to be the most stressful period for first-time fathers. The findings suggest a marked decrease in

S37 sexual satisfaction and activity level compared to pre-pregnancy levels throughout the year following the birth of the first child. However, only retrospective data are available on this as it had already occurred at the baseline assessment in late pregnancy. These men exhibited a striking continuity between antenatal and postnatal assessments across a wide range of measures. For example, high or low paternal-infant attachment at one year could be predicted with approximately 70% accuracy from father-foetal attachment scores. If quality of the (antenatal), partner relationship was also included, the accuracy of prediction increased to over 80%. These findings suggest that men who are strongly emotionally involved in their partners pregnancies are the same men who are highly emotionally involved with their oneyear-old infants (and the converse also applies). If replicated, these findings have significant implications in terms of the desirability of fostering father involvement during pregnancy, and thereby increasing the likelihood of long-term positive father-child outcomes. PAPER 3: Prevalence and Predictors of Depression in Partners of Postpartum Women Robin C. Kopelman, Scott Stuart, Stephan Arndt and Joy Moel University of Iowa Department of Psychiatry, Iowa City, IA, U.S.A. Email: [email protected] Background: Many studies have demonstrated the risk for depression in women during the postpartum period, as well as the negative impact of the depressive symptoms on families. Some evidence suggests that depression in the male partner has negative effects on the family and the potential negative impact of one depressed partner on the other has been noted. Little is known, however, about the rates and predictors of depression in fathers and within postpartum couples. Objectives: Determine the prevalence of depressive symptoms in male partners of postpartum women, examine factors associated with paternal depression and describe the pattern of coexistent depression in postpartum couples. Methods: Depressive symptoms were assessed in a large community sample (N = 807) of partners of postpartum women using the Edinburgh Postnatal Depression Scale and the Inventory to Diagnose Depression at 14 28 weeks postpartum. Both partners also completed measures of psychosocial adjustment, functioning and relationships. Results: Up to 11% of male partners reported significant depressive symptoms in the postpartum period. Factors associated with depression in the male partner included the presence of depression in the mother and relationship status. Coexistent depression occurs in a minority of postpartum couples (2.9%). The coexistence of depression in these couples appears to have an impact on both interpersonal and general functioning. Few of the partners are receiving mental health treatment. Conclusions: Recognition of the occurrence of depression in fathers and within postpartum couples, along with its correlates, may have significant implications for mental health interventions before and during the postpartum period. PAPER 4: Impact of Paternal Depression and Marital Satisfaction on Child Adjustment Sheehan Fisher, Michael O’Hara, and Robin Kopelman University of Iowa Department of Psychology and Psychiatry, Iowa City, Iowa, U.S.A. Email: [email protected]

S38 Background: Depression in fathers has been largely ignored in recent years as contributor to child internalizing and externalizing behaviors. Moreover, fathers marital satisfaction has been similarly neglected. Finally, there has been little effort to follow fathers over time to determine the longitudinal stability of depression from the early months of a child’s life through to the toddler period. Objectives: Determine the association of paternal depression and marital satisfaction with child internalizing and externalizing behaviors as rated by both fathers and mothers at child age 42 months; determine the longitudinal stability of depressive symptoms in fathers over a three year period from child age six months to child age 42 months. Methods: Depressive symptoms were assessed in a sample of 125 fathers and mothers in the first six months postpartum and again at 42 months postpartum using the Edinburgh Postnatal Depression Scale and the Inventory to Diagnose Depression. Also, at 42 months postpartum fathers and mothers completed the Dyadic Adjustment Scale and the Child Behavior Check List as well as other measures. Results: There are significant correlations between levels of maternal and paternal depression. Paternal depression is significantly associated with both maternal and paternal ratings of child behavior problems. Paternal marital satisfaction is significantly associated with paternal ratings of child externalizing behaviors. Mothers and fathers show high agreement in their ratings of child behavior problems. Conclusions: Depression in fathers both in the early postpartum period and later during the child’s development has a significant impact on the child. These findings and findings from other studies confirm the important of considering the family as a whole in studies of perinatal depression. WATCHING, WAITING AND WONDERING Margie Stuchbery, Sarah Mares, Michael, Zilibowitz Jade House, Karitane, Sydney Email: [email protected] A parent’s mental health profoundly affects their relationships. Nowhere is this more critical than when there is an infant or child whose developing attachment and emotional systems depend on a parent’s capacity to relate. Evidence is mounting that treating parental mental illness in isolation does not necessarily result in improved parentinfant or parent-child relationships nor in improved developmental outcomes for children. This workshop will describe an infant-led, parent-infant psychotherapy designed to directly intervene in this crucial relationship. Entitled, Watch Wait and Wonder (WWW), (Muir, 1992) and developed along psychodynamic principles this therapy operates within the behavioural, emotional and cognitive systems of both the parent and the infant or child. WWW promotes an observer stance in the parent, encourages the development of her reflective capacity about the infant and aims to alter a parent’s subjective relational experience of the infant. The infant or child is also offered an alternative experience with the parent, becoming an agent in the relationship and developing an awareness of contingency, a sense of their own autonomy and agency. Following a description of the principles of the WWW model three presenters, a psychiatrist a psychologist and a paediatrician will outline their experience of applying the WWW approach in very different contexts. At the completion of the workshop participants will have been introduced to the theoretical principles that inform Watch, Wait and Wonder as a model for intervening in the mother-infant relationship and will have had some exposure to the application of these principles in clinical practice. References: Muir, E. (1992). Watching, waiting, and

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 wondering: Applying psychoanalytic principles to mother-infant intervention. Infant Mental Health Journal. 13(4), 319–328. Cohen, N. J., Muir, E., Lojkasek, M., Muir, R., Parker, C. J., Barwick, M., & Brown, M. (1999). Watch, Wait and Wonder: Testing the effectiveness of a new approach to mother-infant psychotherapy. Infant Mental Health Journal, 20(4), 429–451. INFANTS OF PARENTS WITH MENTAL ILLNESS: BIOPSYCHOSOCIOCULTURAL APPROACHES TO THE FAMILY Anne Sved Williams1, Bryanne Barnett2, Ros Powrie3, Louise Newman4, Susan Priest, and Mandy Seyfang6 1

Perinatal and Infant Mental Health Services, Children, Youth and Women’s Health Service South Australia, University of Adelaide 2 School of Psychiatry, University of New South Wales, and Sydney South West Area Health Service 3 CYWHS Womens and Childrens Hospital, Adelaide 4 Perinatal and Infant Psychiatry, University of Newcastle 5 University of Newcastle-Perinatal and Infant Psychiatry Program and UNSW School of Public Health and Community Medicine 6 Helen Mayo House, Children, Youth and Women’s Health Service, South Australia, and University of South Australia Email: [email protected] Research evidence has clearly shown compromised outcomes for a significant percentage of infants of parents with mental illnesses. It is also clear that multiple psychosocial factors combine with mental illnesses to impact and often worsen infant outcomes. Women with mental illness wish to parent their infants well but often find the combination of mental illness and adverse life circumstances interferes with their ability to offer goodenough parenting. Thus, to ensure best treatment of those women and optimize outcomes for their infants, a wide range of approaches to their management will be appropriate, with options for management of motherinfant and infant issues in addition to the management of the maternal mental illness. Working across a wide range of agencies and professional groups with a broad biopsychosociocultural approach is likely to be appropriate. This symposium/workshop will bring together professionals who work with different populations of mentally ill women or in different settings, but whose aim is to consider effects of the illness on the infant and how to best co-manage this with optimal management of the mother. Beginning with the effects on infants of maternal anxiety and depression in the antenatal and postnatal period, speakers will then discuss the inpatient management of women with severe (usually psychotic) illnesses where care involves hospitalization of the woman and her infant, and at times her partner too. Management plans always consider parenting practices, mother-infant relationship, infant development and often couple or family therapy and case examples using videos will be shown. Speakers will then describe other major issues impacting on infant outcomes such as the effects of migration, particularly when mental illness combines with incarceration, and also compromised cultural groups such as for many Australian Aboriginal families. Management approaches including advocacy will be described. CLINICAL ISSUES IN PERINATAL MENTAL HEALTH CARE Convenor: Katherine L. Wisner Women’s Behavioral HealthCARE, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pennsylvania Email: [email protected]

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 PAPER 1: Initial Results from an NIMH-funded Study of Screening for Postpartum Depression Katherine L. Wisner Women’s Behavioral HealthCARE, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pennsylvania Email: [email protected] Objective: Offer screening to all new mothers for postpartum depression (PPD) at the University of Pittsburgh Medical Center’s maternity hospital. Methods: Screening is offered to all women 18 years or older. The screening is conducted by phone beginning at 4 weeks with frequent calling day, night and weekends. Calls terminate at 6 weeks post-birth. The Edinburgh Postnatal Depression Screening Scale (EPDS) is utilized. Mothers who score >10 are scheduled for an in-home evaluation, which includes a diagnostic interview to identify psychiatric disorders associated with positive screens and clarify timing of episode onset. Results: As of March, 2008, 13.8% of screened women (N=3912) had EPDS scores >10 (Table). Home visit assessments (N=328) were completed and the subjects primary diagnoses were: 1) Major depression, N=225 (69%); Bipolar Disorder, N=59 (18%); Anxiety Disorder, N=30 (9%); Substance Use Disorder, N=1 (0.3%); Other, N=7 (2%); No diagnosis, N=6 (2%). The onset of the identified episodes was: during pregnancy, N=90 (27%); postpartum (within 4 weeks of birth), N=121 (37%); and prior to pregnancy, N=117 (36%). Conclusions: Although 69% of the women had major depression, a positive EPDS identified other major psychiatric disorders. For any psychiatric disorder, the identification rate was 96%. Post-birth screening identified a majority (63%) of women who had illness onset either during pregnancy or prior to the index pregnancy. Interim Results of Postpartum Screening Study Eligible 7064 Agreed to be called 5392 76.4% of Eligible Before 6 weeks, pending 389 Eligible for Phone Call 5003 Not reached 4–6 weeks 1011 20% of agreed Reached 3992 80% of agreed Screened 3912 98% of reached EPDS <10 3373 86.2% of screened EPDS >10 538 13.8% of screened Refused Home Visits 207 37% of EPDS positive Pending Home Visits 4 1% of EPDS positive Completed Home Visits 328 62% of EPDS positive PAPER 2: SSRI RX: Effects on Efficacy and Maternal Role Function M. Cynthia Logsdon University of Louisville, Louisville, Kentucky, USA Email: [email protected] Aims: The ability to mother her infant is reduced in a woman with postpartum depression. Although antidepressant treatment effectively improves depressive symptoms, various domains of functioning, e.g., work, relationships, do not universally improve with treatment. In this study, we investigated whether mothering improved with antidepressant treatment in women with postpartum depression. Methods: The study was a supplement to a larger study. Women from a randomized clinical trial (double-blind eight week trial of nortriptyline compared with sertraline) completed three outcome measures of mothering: Gratification in the Maternal Role, the Infant Care Survey, and videotapes of maternal infant interaction. The tapes were analyzed using the Child Caregiver Mutual Regulation Coding Scale and Noldus Behavioral Coding Software.

S39 Results: Women whose depression symptoms remitted in the 8 week trial had increases in maternal gratification and self efficacy. The two antidepressants were equally efficacious in decreasing depressive symptoms and improving functioning, gratification with maternal role and self efficacy. Differences between times 1 and 2 in the mother infant interactions were related to time (increasing age of the infant) and not choice of antidepressant or remission of depression. Conclusions: Effective treatment with two antidepressants improves two measures of mothering in women with postpartum depression. Results of the study can help women and their health care providers to understand the benefits of antidepressant treatment in the postpartum period. PAPER 3: Self-Reported Sleep Complaints in Late Pregnancy Predict Post-Partum Depression Recurrence Michele L Okun, Barbara H. Hanusa, Martica Hall, and Katherine L. Wisner Western Psychiatric Institute and Clinic, University of Pittsburgh, Pennsylvania, USA Email: [email protected] Aim: Postpartum major depression (PPMD) is a serious health concern. At the present time, no risk factor has proven superior at predicting neither who will develop PPMD nor when this event is likely to occur. Emerging evidence suggest that poor sleep precedes an incident or recurrent depressive episode. Few studies have evaluated sleep quality during late pregnancy and its relation to recurrence of PPMD. This study evaluated the relationship between sleep quality in late pregnancy and timing of recurrence of PPMD 6 months postpartum. Methods: Participants were 51 pregnant women (age 31.2±4 years) with a history of PPMD, but no current depression, who were enrolled in a study designed to prevent recurrences of PPMD. Participants were randomized immediately after delivery to either nortriptyline or placebo. Sleep complaints as measured by the Pittsburgh Sleep Quality Index (PSQI) were collected at 36 weeks gestation. Sleep complaints were coded as clinically significant if the overall PSQI >5. Recurrence was determined by the 21-item Hamilton Rating Scale for Depression (21-HRSD) and clinical interview. We used Fisher Exact Statistic exact tests to assess differences in time to event. Results: Sleep quality in late pregnancy was related to timing of recurrence. Rapid recurrence (<4 weeks post-delivery) was preceded by few sleep complaints (mean PSQI for recurrers=4.8 versus 8.1 for nonrecurrers, p=0.03). Recurrence >4 weeks postpartum was preceded by prominent sleep complaints in late pregnancy (mean PSQI for recurrers=9.9 versus 7.1 for nonrecurrers, p=0.03) Conclusions: We found that sleep quality in late pregnancy is a relevant risk factor in the timing of PPMD recurrence. These findings have clinical implications for intervention and prevention opportunities. Knowing a woman’s sleep quality in late pregnancy can inform a clinician of the risk of having a recurrence as well as the timing of the event. PAPER 4: Changes in Antidepressant Metabolism and Dosing Across Pregnancy and Early Postpartum Dorothy K.Y. Sit, James M. Perel, Joseph Helsel, and Katherine L. Wisner Women’s Behavioral HealthCARE, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pennsylvania, USA Email: [email protected]

S40 Objective: Little information about the disposition of individual antidepressant drugs during pregnancy has been published. We examined the dose requirements and level/dose ratios of citalopram, escitalopram and sertraline during pregnancy and after birth. Methods: Doses were charted across each week of gestation and postpartum. Samples were collected at 20, 30, 36 weeks gestation, delivery, and 2 and 12 weeks postpartum. Plasma trough levels were obtained 8–15 hours after dose intake. The samples were analyzed for concentrations of stereospecific parent drug and metabolites. Results: Three women received citalopram, two women were treated with escitalopram and six women received sertraline. Across pregnancy and postpartum, the mean dose-corrected plasma concentrations (level to dose-L/D ratios) of S and R citalopram and S-

Arch Womens Ment Health (2009) 12 (Suppl 1):S1–S40 sertraline (SERT), and the corresponding primary chiral metabolites S and R desmethylcitalopram (DCT) and N-desmethylsertraline (DMST) were assessed. In four of five subjects who received citalopram or escitalopram and five of six subjects who received sertraline the L/D ratios for the stereoisomers of the parent compound and primary metabolite decreased between 20 weeks gestation and delivery, which reflects increased drug metabolism. By 12 weeks postpartum the L/D ratios were similar to those detected at 20 weeks gestation. Conclusions: Our cases illustrate that dose requirements frequently increase during the second half of pregnancy to offset increased drug turnover and maintain optimal pharmacotherapy. These findings replicate and extend earlier published data with other antidepressants.