ACCESS TO HE (NHS HEALTH) ACC006WD1A 2016
|The risk of postnatal depression towards the mother and child are known, so how can we reduce its prevalence?|
The purpose of this paper is to discuss the known predictive risk factors to postnatal depression that have been established in studies in the UK and worldwide; the effects that they have on mother and baby and what can be done to prevent them from occurring. PND comes under the term ‘major depressive disorder’ and is a global phenomenon that is becoming a public health concern due to the debilitating effect it can have on those directly involved. In order to help prevent its prevalence, more mental health services need to be funded and protected and resources must be easily accessible to those who are at high risk, especially in areas of socioeconomic vulnerability. By reviewing research online, such as journals, reports and reviews, much of the information reveals that the most commonly cited risk factors are a predisposition to anxiety and depression; a lack of support (either emotional, informational or instrumental) and life stressors. Symptoms such as anxiety, crying, sleeping disturbances and lethargy affect the mother whilst the effects on the child can be evidenced by emotional impairment, cognitive and motor development issues. The conclusion reached is that in order to alleviate the pressure that PND is putting on women, their families and society, a concerted effort needs to be made to spread awareness about the illness. Pregnant women and their families should be educated to spot the signs and symptoms of PND and midwifes require the time and resources to offer support and signpost to the relevant services.
There have been numerous studies conducted concerning postnatal depression (PND); its symptomology, prevalence and risk factors to those most likely to develop it. Most of the information that is streamed to the public is through health-based waiting rooms, media or via the internet and is aimed at helping the mother recognise the symptoms so that she may seek help. (Choices, 2011) What is not documented as frequently and shared so clearly, is the effect that this illness can have on the baby and developing child. PND does not just concern the mother; the repercussions can have ramifications on all those that surround her, notably her baby.
What this research reveals is that along with the pernicious effects of this illness on the mother, the deleterious short and long term consequences to the developing child are of some significance and with rates of depression increasing (Hidaka, 2012), it is vital that there is increased education to the population to reduce the risk factors where possible. Preventative and supportive measures appear to be in place but their efficacy is questionable. With financial cutbacks to mental health services in the UK, it is becoming increasingly evident that despite breakthroughs in awareness of the illness, both in the public domain and in research, not enough is being done to either prevent or treat PND. This presents a very real threat to not only those directly involved but also on a wider scale, as the population grows and resources tighten, the prevalence of mood disorders is only going to increase.
The data collected for the purpose of this paper is of a global origin and not exclusively pertaining to the UK. However, with regards to discussion concerning mental health funding and available services, the sources are from the UK.
For purpose of comparison, the differences between two other postpartum mood affective disorders are briefly discussed. ‘Baby blues’ and PND can be mistaken for each other as they have similar spectrum of symptoms, however, the longevity of PND differentiates the two. Puerperal psychosis is an illness that whilst it, too, can incorporate some of the symptoms of PND and postnatal blues, has severe and potentially life-threatening aspects that will need treatment and potentially hospitalisation. (mind.org.uk, n.d.)
Whilst the causal factors to PND are not conclusive, a topic that has been ascertained by various studies to be verifiable is the affect that PND can have on the child. The purpose of this paper is to 1) discuss a number of recognised, identifiable causal factors whilst also investigating the effects that PND has on the child’s development, 2) to discuss what could be implemented in order to raise awareness and to identify the preventative measures that could be employed in order to halt the increasing prevalence of the condition.
What is known about PND?
Postnatal depression (PND), also referred to as postpartum depression, is a form of depression that is widespread and worldwide. It tends to commence within the first two months of the mother giving birth, however approximately one third of affected women display symptoms which started mid-pregnancy. (Royal College of Psychiatrists, 2014). The World Health Organisation states that “Postpartum non-psychotic depression is the most common complication of childbearing affecting approximately 10-15% of women and as such represents a considerable public health problem affecting women and their families.” (Robertson , Celasun, & Stewart, 2008)
Symptoms are typical of a depressive illness and can include crying, irritability, lethargy, sleeplessness, loss of libido, loss or increase of appetite, anxiety, feelings of guilt and negativity, low confidence as a new mother, suicidal ideation and psychosis. PND can range from mild to severe, lasting from a few weeks to years and has been found to affect not just the mother but also her partner. For the purpose of this paper, only maternal PND will be discussed.
Symptoms will usually manifest within the first couple of months following childbirth and may be mistaken for tiredness and sleeplessness associated with a newborn. However an ongoing exhibition of the above symptoms may herald the onset of depression.
PND is not recognised as a separate diagnosis but instead is classified as a major depressive episode that includes the criteria that the episode had its onset either within the prenatal period or within 4 weeks of delivery. The criteria for clinical diagnosis of a major depressive episode as classified by The American Psychiatric Association’s Diagnostic & Statistical Manual of Mental Disorders, currently in its 5th edition, includes a range of symptoms such “depressed mood, worthlessness or guilt, recurrent thoughts of death or suicidal ideation, psychomotor retardation or agitation (observed)” (See Appendix..). The International Classification of Disease 10 (ICD-10) similarly does not classify postnatal depression as a separate diagnosis and in order to be classified as having a postnatal onset, must be experienced within 6 weeks of delivery. (BMJ Best Practice, 2016) (Appendix …)
Postpartum Affective Mood Disorders – Postpartum blues, nonpsychotic postpartum depression and puerperal psychosis
There are three recognised mood affective disorders; postpartum blues, nonpsychotic postpartum depression and puerperal psychosis. Data collected by Nonacs and Cohen, 1998, (see Appendix …) reveal the prevalence rates, typical periods of onset and duration and forms of treatment that are typical for each disorder. The data shows that the prevalence for postpartum blues is much higher at 30 – 75% in comparison to postpartum depression 10 – 15% and rates of puerperal psychosis at a significantly lower 0.1- 0.2%.
Commonly known as ‘baby blues’ typically occur within the first week after childbirth. Baby blues affect up to 80% of mothers and will manifest as a loss of appetite, worry, fatigue, mood swings, irritability, sadness, anxiety and feeling overwhelmed. (Womens Health, 2016). These symptoms will usually subside within a week or two and will not require treatment. It is thought that the baby blues is a result of a change in hormones once the baby has been born (Max-Planck-Gesellschaft, 2010); and sleeplessness combined with the realisation of the massive responsibility that is now part of the mother’s life. In figure (1) Appendix … the table demonstrates how on day 5 the oestrogen plasma concentration levels have an acute drop immediately after delivery which coincides with the lowest level of mood. Oestrogen levels are linked to serotonin, a monoamine neurotransmitter (5-hydoxytryptamine) that has a direct effect on mood. (Rosling, n.d.)
This is the most severe mental health illness that can affect women in the postpartum period. It affects approximately 1 in 1000 women and will begin within the first few days or weeks of childbirth. Symptoms may include high or low mood swings that can change rapidly. Psychotic symptoms are often manifested and can include both visual and aural hallucinations whilst having delusional or intrusive thoughts and beliefs. Puerperal psychosis is more likely to present to women who have already had previous episodes of a severe mental illness (namely bipolar), especially if they have experienced an episode postnatally prior. (Royal College of Psychiatrists, 2014)
What are the identifiable causative factors?
Findings from two meta-analyses which were conducted on over 14,000 subjects, in addition to more recent subsequent clinical studies, illustrated that the following factors carried weight as the strongest predictors of postnatal depression: Perinatal depression or anxiety and/or a previous history of depression; low levels of social support; the experience of stressful life events during pregnancy or early postnatal period (Robertson , Celasun, & Stewart, 2008).
Historically the expectation that culture and social structure in different countries had an impact on the propensity to develop PND, was evident (Kumar, 1994)pg 250 – 251 and PND was thought to be a Western phenomenon (Robertson , Celasun, & Stewart, 2008). Anecdotal observations in both Africa (Kelly, 1967), (Chalmers, 1988) and India (Gautam, Nijhawan & Gehlot 1982) report that nonpsychotic depression was a rarity in these societies. It could be hypothesised that PND would be far more prevalent in countries such as the UK where it is common for new mothers to be living apart from their families, with little support and potentially a lack of maternal knowledge being passed down from mothers, grandmothers and aunts. In the same context, this would give weight to the notion that in countries where there are still strong tribal cultures, such as in places like Africa, the presence of PND would be less. In these foraging hunter-gathering societies children are known to be brought up in a more supportive crèche-like environment (University of Notre Dame, 2010) and different generations of families still live in close proximity of each other. Therefore, it could be deemed that there would be more support (informational, instrumental and emotional) and therefore less risk of developing PND.
However, these conclusions carry a risk of cultural stereotyping and fail to take into account that under-reporting may be caused by factors such as higher maternal mortality rates or a lack of knowledge surrounding the illness. Certainly, the means by which research is conducted and data extracted differ between cultures and there is a lack of cited research from countries that are not Western economically developed. Differences in reporting styles, socio-economic environments and perception of reporting styles depending on culture give weight as an explanation to the variability in how PND is reported. (Uriel. Halbreich, 2006).
Most recently it has transpired that the most exciting lead to identifying causal factors to PND lie in the area of genetics. Due to its incipiency however, this area needs to be further studied in order to identify definite links.
Antenatal depression/anxiety/previous history of depression
O’Hara and Swain’s meta-analyses in 1996 and Beck’s 2001 meta-analyses established that the associations between postnatal depression and a previous history of depression were found to be strong. The combined meta-analyses covered 25 studies, which in total included approximately 4000 subjects, and whilst there was no discernible link between a family history of depression and PND, the studies did reveal that a depressed mood and anxiety were strong to moderate indicators of the illness. These findings were also replicated in subsequent studies (Johnstone et al., 2001; Josefsson et al., 2002; Neter et al., 1995). In the study “Risk factors for antenatal depression, postnatal depression and parenting stress” by Bronwyn Leigh and Jeannnette Milgrom (2008), the authors concluded that “antenatal depression was the strongest predictor of postnatal depression”. The study focussed on primipara and multiparae women as part of a national programme in researching depression in Australia.
It would be logical to consider that if the factors, which influence a person’s propensity to become depressed in the first instance, have already been established either prior to or during pregnancy, there is a strong likelihood that symptoms will surface postnatally (Robertson et al. 2008. pg.39). O’Hara and Swain’s study in 1996 researched the psychological constructs that potentially determine the maternal personality characteristics which present within those women who develop PND. A particular disorder is neuroticism, a condition which has been found to be present in women antenatally and postpartum. Neurotic disorders are no longer referred to within psychiatric classification systems but are still used as a measure of psychological distress in questionnaires. Neuroticism is defined as a condition which can cause distress and worry to the person but does not interfere with functions or rationalisation and definite links between neuroticism, assessed during pregnancy and the onset of postpartum depression, have been found by O’Hara and Swain. (Roberston et al, 2008. Pg. 39, 40).
Low levels of support
Types of support such as emotional, instrumental and informational have been found to be pivotal in protecting women from developing PND. ‘Emotional support’ was expressed as being compassionate and boosting self-esteem; ‘informational support’ by way of offering advice and guidance and ‘instrumental support’ whereby practical help is given. (Robertson , Celasun, & Stewart, 2008)pg.42.
In “Social support during the postpartum period: mothers’ views on needs, expectations, and mobilization of support”, a study carried out at the Mount Sinai School of Medicine in New York, USA by Negron R, Martin A, Almog M, Balbierz A, Howell EA (2013); the authors concluded via focus group discussions that support was a principal factor postpartum. Not only did the mothers believe that support was essential but that it should be proffered by their partners and families without prompting. Interestingly, the way in which the women mobilised instrumental support from their support networks differed according to race and ethnicity. The Latina and African American groups of women were very direct in their approach to ask for help from their partners and family members whilst the mothers in the white/other group preferred not to, instead preferring to hire other caregivers in order to prevent disagreements with their own mothers and mothers in law concerning the baby’s care. One aspect that was present across all of the racial/ethnic groups was the barrier to asking for support, as there was a sense of embarrassment and fear of judgement in case they were considered incapable of looking after their own child.
Age has been indicated by various studies (Bottino, P, Moraes, Reichenheim, & Lobato, 2012) (Plataforma SINC, 2009) to be an increasing contributing factor the older the mother is. According to Spanish researchers who studied data on 1397 Spanish women, age presented as a protective factor against the risk of PND and the older women were less likely to have depression. In the study “Reappraising the relationship between maternal age and postpartum depression according to the evolutionary theory? Empirical evidence from a survey in primary health services” Bottino et al 2012, 811 participants who were 5 months postpartum were scored using the Edinburgh Postnatal Depression Scale (EPDS) of which 197 women were classified as being postnatally depressed. The results indicated that maternal age was a significant factor and for each additional year, there was a 4% reduction in risk of developing PND. These findings were independent of other factors, including relationship status, substance consumption, reproductive characteristics or socioeconomic status. Neither were the results altered by the number of children already at home.
Conversely O’Hara and Swain (1996) and Beck (2001) concluded that maternal age was not a significant factor with the development of PND in mothers aged 18 years and above. However other research has shown that mothers aged between 14 – 18 years, did show a much a higher proportion of illness (Troutman & Cutrona, 1990). Due to the limitations in this research, such as not accounting for other age related risk factors (adolescence, peer pressure), it is considered that more research is needed for this age group to gain a truer representation of results.
Whether the age of the mother impacts their propensity to develop PND is debatable. As a younger mother there is the likelihood that her physical resilience is stronger and her need for sleep less. If the baby is her first and she still lives at home then she may have more support, less financial responsibility and more energy to deal with sleepless nights and therefore, potentially less likely to become as fatigued or overwhelmed. Whilst an older mother may have other children or responsibilities that stretch her mentally, physically and financially. However, it could be argued that a younger mother has less knowledge and confidence and indeed may be living in sheltered accommodation and trying to survive on benefits whilst the older woman is in a financially secure position and able to dedicate time, love and experience to her newborn child. Until further research can be more substantial and definitive, it would be worth considering age as only a weak risk factor.
The study of molecular genetics in the role of PND is very current and quickly evolving with articles used in research ranging from 2004 and 2013 (Couto, Brancaglion, Alvin-Soares, & Moreira, 2015). In “Postpartum depression: a systematic review of the genetics involved” Tiago Castro e Couto, Mayra Yara Martins Brancaglion, Antonion Alvim-Soares, Lafaiete Moreira, Frederico Duarte Garcia, Rodrigo Nicolato, Regina Amelia Lopes P Aguiar, Henrique Vitor Leite and Humberto Correa, (2015); the review discusses the genetic links to postnatal depression and how they may occur, whilst also exploring whether or not these are similar to the genes connected to major depression. The review covered 20 studies that had been conducted in 10 different countries (Brazil, Canada, China, Germany, Israel, Netherlands, Spain Sweden, the UK and the USA). What the authors concluded was that the genes studied in both postnatal depression and major depression, were similar in type and pattern. However, the research to date is small and in order to be able to glean a more comprehensive understanding of the genetic relationship to PND, further study needs to be done. An article in the Science Daily “Genetics in depression: what’s known, what’s next” (Wolters Kluwer Health:Lippincott Williams and Wilkins, 2015) discusses the difficulty of genetic factor identification despite using genome-wide analysis techniques. It appears that whilst the hereditary element of depression has been widely acknowledged, due to the multifaceted composition of depression, the researchers also conclude that studies on much larger scales than ones carried out to date, will be needed.
Pregnancy/early postnatal stressor
It has been documented that being susceptible to antenatal or early postnatal stressors contributes to the development of PND. (Bronwyn. Leigh, 2008). A study focusing on the prevalence of antenatal and postnatal depression in Brazil, found that both antenatal and postnatal depressive symptoms were exacerbated by socioeconomic factors. Cited as a methodological limitation, the study explains that the sample of woman they used in the research were using large, urban based primary care clinics as opposed to using privately funded services. This does give rise to the question of whether a person’s financial status is a potential stressor and therefore a predictive risk element, however further studies incorporating women attending privately funded clinic is necessary to cement this theory. The National Childbirth Trust reiterate in their online guide regarding PND that additional strain can contribute to the illness and cite financial worries and being unemployed as examples (NCT). It certainly seems plausible that having a new baby alongside anxiety about finances could significantly increase the risk of depression, especially at a time when a parent feels that they should be providing for their child. Furthermore, it is possible that they are experiencing additional pressures due to a desire to keep up with peers who are in a more stable and affluent position.
Links between major life events such as divorce, marriage, death of a loved one, moving or losing home or job and the onset of depression have been documented (E. S. Paykel, 1980). Conversely, there have also been studies that have found there is no association between postnatal depression and life events, as cited by Robertson et al. A question could also be posed as to whether the person who suffers depression as a direct result of a life event, is predisposed to depression anyway and this is simply a trigger that begins the first episode. To develop depression, it could be disputed that there are more risk factors present than simply a period of stress. It also could be argued that what is considered a ‘stressful’ event for some might be the opposite for others and instead it is the biological and psychological makeup of the individual that determines the likelihood that they develop depression. It is considerations such as these that make pre-empting who will definitely be at risk of developing PND, most difficult. Values are variable when regarding ‘stress’. A divorce for a person who wants it may present as relief, despite the procedures or animosity involved, whilst for another person it might be devastating, triggering episodes of anxiety and overwhelm. These variations may cause anomalies in self-test questionnaires, however it is relative to each person concerned.
Additionally, it might be considered that the pressure a primaparious or multiparious mother may feel having a newborn, combined with sleepless nights and a lack of support (either perceived or actual) is arguably enough of a trigger to develop postnatal depression.
The effects on the child
There is growing evidence that the consequence of antenatal and postnatal distress affect the biological and neurological pathways concerning foetal and child behaviour and development. (Michael T. Kinsella, 2014). The adverse outcome to the child’s development (Murray & Cooper, 1997) could be attributed to more than one contributing factor, either directly or indirectly. This could be because of exposure to the depressive symptoms displayed by the mother or as a result of the parenting style or interpersonal behaviour; it could also be due to what is referred to as ‘third factor variables’ – the environment that surrounds the parent and child which may be socioeconomically adverse.
Infant cognition, emotional and motor development have been shown to be negatively affected by PND and the paper “Effects of postnatal depression on infant development” by Lynne Murray and Peter J Cooper (1997) reveals that at various stages of infancy, the children exposed to maternal depression were more likely to perform poorly at mental and motor development assessments at 12 to 18 months of age, compared to the control group. Additionally, their emotional development was stunted and the authors found that socialising with strangers, sharing, interaction and concentration were impaired. Behavioural problems, tantrums, sleeping difficulties, eating issues and separation anxiety were also reported to have been more apparent in the children whose mothers had PND.
Theories on the rise of prevalence
The rate at which depression appears to be becoming more prevalent has been discussed by many studies and whether or not this is due to the phenomenon being more widely recognised and therefore more actively reported, is a possibility. The stigma and marginalisation surrounding mental health problems is lessening and the public’s attitudes are slowly adapting. Schools and workplaces are becoming more aware of the dangers of poor mental health and strategies to cope and advise, are being put in place. However, the lack of funding in the NHS halts how far the support can progress. Not only does finance play a part in the treatment of PND, it also features in the prolificacy of the illness, as does the issue of housing. Temporary housing accommodation is cited as a psychosocial risk factor in “Identifying women at risk of postnatal depression: prospective longitudinal study” by Lee DT, Yip AS, Leung TY and Chung TK (Lee, Yip, & Chung, 2000) as does the low quality of accommodation as researched in an Asian study (Shubham. M, 2014). As housing in the developing world becomes less available, more pressure is applied to families bringing up their children, contributing to the escalation of mental health issues; for any member of the family, of either sex and at any age.
In 1997, the Government released a policy to reduce child poverty and to ensure that they were included socially. Sure Start children centres began to be established in 2001 with the emphasis on their placement in deprived areas. Funding was maintained for services that would help families most in need, with the aim to intervene early and help prevent crises from occurring. Through the provision of a ‘hub’ that the local community could access, support can be shared by attending parents enabling a sense of community to build. Elements such as these are a starting point to help in tackling key issues such as postnatal depression (Lord, 2011). Unfortunately, due to recent government cut backs, these are losing out on crucial funding and are having to close (Dugan, 2015).
Equally, in addition to the lack of provision from the NHS and Government, the rise of PND could also be simply because life is becoming more fast-paced and demanding. There is less opportunity to take time out and wind down from the everyday pressures that life brings. Taking a slightly different perspective on this topic, psychology professor Kelly Lambert, suggests that it is how we deal with the changes in lifestyle over the past century that may have contributed to the rise in depression. She theorises that it is due to the lack of physical energetic output needed to realise basic rewards such as food, shelter and water. The specific areas in the brain stimulated and which are essential for reward/pleasure, coping strategies, motivation and problem solving, involve the accumbens-striatal-cortical circuitary system. This system connects physicality, emotion and the cognitive processes. Historically, the activation of these neural areas would have involved some physical exertion in order for humans to survive on a day to day basis. Whilst in today’s climate, we are able to achieve the same goals using technology (banks transfer of money/paying bills/online grocery shopping/supermarkets/cars etc), which requires mental rather physical exertion. With the reduced activation of these areas, it is suggested that mood is affected with the rising prevalence of depression on a global basis as the result (Lambert, 2005).
Denial could also be implicated in the prevalence of PND. An obstacle to diagnosis and treatment can occur if the mother refuses to acknowledge that she is unwell and in need of help. Depression historically carries a deep-rooted stigma and even though through the spread of awareness this is lessening, it still presents as a factor that hinders diagnosis. Stigma combined with guilt at not feeling as happy as she feels she should, or not experiencing the love and bond that is socially expected of a new mother, can also interfere with her acceptance that she might be suffering with depression. (Bilszta, Ericksen, Buist, & Milgrom, 2010).
The NICE guidelines in the Quality Standard report (NICE, 2016) have produced a list of statements that covers issues such as pre-conception information; information for pregnant women; asking about mental health and wellbeing; psychological interventions; mental health assessments and specialist multidisciplinary perinatal mental health services. However, it appears that despite the postnatal care plan implemented by the Royal College of Midwives (RCM) to take care of women after they have given birth, both midwifes and mothers report in a survey that care was lacking. The NICE quality standards recommend that a postnatal care plan should be developed with the patient either antenatally or as soon as possible after giving birth. This information would include relevant details from the pregnancy (this would ideally include any depression that had occurred) and details concerning her adjustment to motherhood, the support structures she had in place and her emotional and mental wellbeing. The survey carried out between September and November 2013, interviewed members of the RCM (midwives, student midwives and maternity support workers) about their experiences in delivering postnatal care. The RCM also asked mothers on the internet site netmums.com for their experiences during the postnatal period, however, the generalisability of these results are potentially questionable. The website netmums.com is an online service that offers advice and information to parents, as well hosting forums for parents to voice concerns, ask for advice or share stories. (netmums.com, n.d.). If the users of the website are on the forums regarding PND or other postnatal issues, then it could be that they are more swayed to have negative opinions about their level of care. Whilst the outcome might still be the same, it would be prudent to interview an entire cross-section of society via a number of avenues, such as in GP surgeries, at routine checks with the health visitor as well as through online portals. A question that was asked in the survey, “what is the most significant factor influencing the decision about the number of postnatal visits a woman receives?” revealed that 65% of the midwives stated that the woman’s needs did not influence the amount of input and visits that the mother received. Instead it was determined by the amount of pressure that the service was under (The Royal College of Midwives, 2014). This alone could be interpreted as a public health concern and highlights the enormity of the issues facing those in need. The midwives have been trained to spot risk factors and to signpost vulnerable mothers to professionals who can treat them accordingly. If at this very significant time, they are unable to do this due to time constraints, staff shortages and funding, then signs and symptoms will continue to go unnoticed and preventative measures, such as treatment and support can’t stem the onset of depression. The Royal College of Midwives have previously recommended that maternity services in each trust provide specialist mental health care ante-natally and post-natally, especially in light of the fact that mental health issues in these periods affect 20% of women and that suicide is a significant risk in new mothers. The report (NHS England, 2016) also cites that after cardiovascular disease, suicide is the leading cause of maternal death.
Implementing preventative strategies
In order to help prevent PND, It is advisable to observe the contributing components that cause it. A lack of support, education surrounding the illness and a previous history of depression are among the known risks and therefore it is imperative that our society addresses these issues. This could begin with education; at school, college, in the workplace and in the antenatal clinics. Advice on how to recognise the signs in oneself and others; support groups for those most at risk; educational classes in antenatal clinics; free yoga and relaxation/meditation classes for those identified by GPs, health visitors and midwifes; these are a few strategies that could be implemented.
A relatively recent ‘tool’ that GPs now have in some localities, is the option to ‘socially prescribe’. A non-pharmaceutical and holistic option to empower patients and help them take control of their symptoms. Social prescribing has been described as a ‘mechanism for linking patients with non-medical sources of support within the community’ by the Centre Forum Mental Health Commission (Thomson L.J., 2015). Also known as ‘community referral’, the concept is to steer away from the over-prescription of antidepressants and instead improve mental health and wellbeing. The positive outcomes that social prescribing has had on the patients, as described in the review by Thomson et al, include a rise of self-esteem and confidence, a reduction in symptoms of anxiety and depression, improvements in mental wellbeing and a sense of empowerment. In 2007, the Scottish government produced a document concerning the development of social prescribing for mental health. (Scottish Development Centre for Mental Health, 2007). According to Kessler et al, 2001, as cited by the report, approximately 30% of GP consultations (50% of consecutive attendances) are due to psychiatric issues. Through social prescribing, women with postnatal depression can have access to not only activities of interest such as exercise, gardening and arts but also to offer them the opportunity to gain support with financial, legal or parenting issues that they may face.
It transpires that along with genetics, a previous history of depression, susceptibility to anxiety and a lack of support (both personal and from the health professions), are the strongest risk factors to developing PND. Due to the severity of symptoms and the overall effect that PND can have on the mother, baby and family as a whole, it is abundantly clear and vital that the appropriate support and care is provided, either by the family GP, midwife, health visitor or through a psychiatrist. Treatment options can either be via drug therapy or through talking therapy and there are a myriad of available support groups specifically geared towards giving advice and support on how to cope with PND. Emotional, informational and functional support is equally necessary from family members and friends, as is educating them about the needs of the mothers and how to spot signs and symptoms of depression. If the public are aware that there may be ‘tell-tale’ signs that depression is a possibility then strategies can be utilised to reduce the risk.
It is apparent that a cross society, cross government strategy towards tackling the mental health is imperative and needs to incorporate, self-care, primary and secondary health care. Funding for mental health must be prioritised and instead of closing down institutes, hospitals and centres that are specifically geared towards prevention and treatment, more need to be established. Not only do policies to protect these places and service users have to be in place, there also needs to be breaching penalties applied on each occasion that referral deadlines are not met. These penalties should be fed back down the line from where they were originally issued to ensure that any failings are recognised and audited ensuring no organisation or government, locally or nationally, is devoid of blame. From a socioeconomic point of view, stressors such as poor finances and housing have been established as risk factors and steps must be taken to see that high-risk women in these areas of concern are referred to the appropriate service in order to provide advice and support.
To conclude, in order to establish parity of esteem, mental health needs to be given the same importance as physical health. Access to physical health is available 24 days, 7 days per week and unfortunately mental health services are not. (NHS England, 2016). The research to date has established that postnatal depression is not only prolific but rising, the effects of which impact on not only the wellbeing of families but also on the global economy. This is not just a public concern, it is our public concern.
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Essay from Spring 2016
Outline and evaluate the biological (medical) and cognitive models to psychopathology.
This essay will seek to determine the causes that lie behind the increasing figures of patients being treated for mental health disorders. Biological factors, such as genetics (Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis, 2013), hormones, such as dopamine and serotonin, (Seo D, 2008) and cognitive issues, such as maladaptive behaviours (Ellis 1962) cited by Cardwell, Clark and Meldrum, 2008, will all be explored.
The biological model assumes that all illnesses, including psychological ones, are derived from a physical cause, whether that be genetic or originating with an infection, or emerging out of neuroanatomical, neurochemical, or biochemical phenomena. This assumption, that psychological illness is biologically based, leads to an assumption that the panacea will be medically and chemically based, addressing the person’s physiology by way of treatment. Cardwell M, Clark L and Meldrum C.(2008) Psychology AS for AQA A4 London. Collins 4th Edition. (pp 224 – 225).
From a genetic point of view there is strong evidence from Zimbardo et al (1995) cited by Cardwell, Clark and Meldrum (2008) p.226, in the form of compiled data from family and twin studies, between 1920 and 1987, which shows a high correlation between family members and their risk of developing schizophrenia depending on how they were related. For example, siblings had a 9% chance of developing the illness compared to 17% for dizygotic twins and 48% for monozygotic twins. Discussing biological factors in psychopathology, Cardwell et al (2008) p.226, cite that concordance remains high for depression. Research has shown that depression in reared-together monozygotic twins had a 46 % concordance compared to a lower 20% for dizygotic twins.
A genome-wide analysis on five major psychiatric disorders (autism spectrum disorder, attention deficit-hyperactive disorder, major depressive disorder and schizophrenia) was conducted on over 33,000 cases with over 27,000 controls (Lancet, 2013). By analysing single nucleotide polymorphism, they concluded that molecular genetic risk factors were shared within child and adult onset psychiatric disorders. Currently diagnosing one of the above psychiatric disorders is done via interview and review of symptoms. The efficacy of this may be dependent on the level of expertise the practitioner has and the authors of the study maintain that “These results provide evidence relevant to the goal of moving beyond descriptive syndromes in psychiatry, and towards a nosology informed by disease cause.”
Studies have shown that there is strong evidence to support the hypothesis that changes occurring in neurotransmitter systems (glutamate, serotonin, GABAergic and dopamine) are indicated in psychosis and schizophrenia. There have been numerous studies investigating the dopamine involvement in the pathophysiology and treatment of schizophrenia, however much of this research was carried out on animals (Howes OD, 2009) and therefore generalisability is poor and ethics questionable.
The biological model has its strengths, the evidence gleaned from studies is quantifiable and continuing medical advances in understanding the neural involvement in psychopathology (Burklund LJ, 2012) via neuroimaging will aid treatment in the future. The availability of treatment is free at point of contact (GP or NHS psychiatrist) and the cost of prescription medicine is relatively low at £8.20 per medicine (nhs.uk, 2015). The treatment for psychosis may vary (nhs.uk, 2015) and can be a combination of both anti-psychotics and Cognitive Behavioural Treatment (CBT). The anti-psychotics work by blocking the effects of dopamine and can take as little as a few weeks to reduce all symptoms which in comparison to CBT is relatively ‘quick’. There can be significant side effects such as drowsiness, constipation, blurred vision, muscle twitches and spasms, drowsiness, shaking and trembling, restlessness, dry mouth and a loss of libido but these don’t affect everyone and severity will differ for each person. (nhs.uk, 2015).
Delays in diagnosis because of long waiting lists and lack of provision as summarised in the Children’s and adolescents’ mental health and CAMHS report (Committee, 2015) means that for these younger groups of society, diagnosis and treatment is often difficult to obtain and preventative measures are not in place to stop the illnesses progress in the first place. By the time a diagnosis is obtained, the disease may have progressed to a much worse state and be more difficult to treat. A medical approach tends to be symptom focused and as such is reductionist. When a patient is given a medicine or treatment such as electro-convulsive therapy (ECT) reduction of symptoms occludes understanding cause and possible prevention.
A key feature of the cognitive approach is the concept of irrational thinking and the resulting behaviour traits that develop (Ellis 1962), as cited by Cardwell et al (2008). Ellis maintained that rational and irrational thinking occurs in everyone and people who develop psychological problems do so because they default to negative thinking, illogical and irrational behaviours. With regards to depression in the study Cognition and Depression: Current Status and Future Directions, (Gotlib IH, 2010), the authors Gotlib and Joormann report that negative attitudes, interpretations and thoughts increase the risk of the person becoming depressed and experiencing further related cognitive issues such as memory impairments and difficulties in concentrating, thus cementing the concept that cognition is the primary cause for the onset of depression. Of interest they also argue that in order to broaden the study of cognitive dysfunction in depressive disorders, integrative investigating of possible contributing neural and genetic factors would give a more comprehensive view of not only the onset of depression but also how to treat it.
Whilst pharmaceutical treatments are easily available and work relatively fast, treatment with CBT is only offered on the NHS for the first 6 – 10 sessions and there is generally a waiting list. In order for cognitively based therapies to work, there needs to be a strong commitment from the patient and whilst effective and non-invasive, it takes a longer time to take effect. Cost after the NHS treatments normally cost in the region of £40.00 – £100.00 and therefore this needs to be taken into consideration when suggesting to patients a choice of treatment. (nhs.uk, 2015)
It could be argued that some mental health disorders are typically biological in their onset, such as dopamine and serotonin imbalances. Whilst others are cognitive in origin and through ‘faulty’ thinking, develop into a mental health disorder. Conversely, it could also be suggested that in fact, both the cognitive and biological models are one and the same. Cognition is performed in the brain by frontal and temporal lobes (www.biau.org) both of which are involved in schizophrenia (Highley J, 2001). In the paper “Frontal and temporal lobe brain volumes in schizophrenia. Relationship to symptoms and clinical subtype” (Turetsky B, 1995) it is explained that on MRI imaging both of these areas of the brain are of a lesser volume than in those people without schizophrenia. The paper “The neurobiology of cognition in schizophrenia” (Tamminga, 2006), reports on the different areas of cognition that are affected by schizophrenia which cements the theory that if there is an issue with impaired or faulty thought processes then this is entwined with biology. The author Carol Tamminga concludes that rather than treating the schizophrenia with just one type of medication, future strategies could include pharmacologic treatments for targeted areas of the brain whilst then focusing on the person’s cognitive symptoms. The cognitive model argues that cognition impairments play a role in the development of psychopathic illnesses such as schizophrenia. Beck and Rector maintain in their study “Cognitive approaches to schizophrenia: theory and therapy” (Beck A, 2005), that the onset of schizophrenia can be caused by a combination of neurobiological effects, cognitive, behavioural and environmental factors.
It would therefore be pertinent when looking forward as to how to treat these illnesses, not just to concentrate on the one model but to approach each case holistically and each person as an individual, tailoring their treatment to their own specific needs and harnessing the mind to enhance the biochemical treatment of the brain. Both models have their merits and whilst one has empirical evidence and the other anecdotal, is important to remember they are both linked and can be mutually supportive. The false separation between mind and body could be said to halt progression into establishing the best line of treatment for the future.
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