Pregnancy is when a woman’s mental health can be most at risk

This was the last note from psychiatrist Dr Daksha Emson, who took her own life in London in October, 2000. That same day, she also took the life of her daughter Freya, aged three months.

Between 2013 and 2015 seven new mothers died in Ireland within one year of the birth of their baby – four by suicide.

Suicide is now the leading cause of direct maternal death in Ireland occurring between six weeks and one year after pregnancy.

Up to 20 per cent of women in Ireland will suffer from a depressive disorder in the antenatal (before birth/in pregnancy) and post natal (after birth) period.

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Pregnancy is not a protective factor for mental illness. On the contrary; it is a time in a woman’s life when her mental health and the wellbeing of her baby can be most at risk.

Prof Anthony McCarthy, consultant perinatal psychiatrist at the National Maternity Hospital in Holles Street, Dublin, says there is a lot of pressure on new mothers to be immediately, wildly excited about their baby and this is not always the case.

“There is a myth out there that women are supposed to love their babies instantly and have this wonderful passionate close bond. We know that if we interview women three days after the birth of a baby, 15 per cent will describe an ecstatic reaction, 45 per cent will say they love the baby but they are tired and quite happy for someone else to look after them, and 40 per cent, three days later, will still feel a bit numb, hollow, surreal, not really bonding in a really intense way yet and often feeling very guilty already, for not having that. The poor woman is tired, she hasn’t slept for three days, she is exhausted.”

Suicide in pregnancy or the postpartum period is thankfully rare, but it does happen and it is estimated that one in 500,000 women will take their own lives while pregnant.

The majority who take their own lives in pregnancy or as a new mother die by violent means, and in some cases their baby dies too.

Mistaken views

For the mother of a young baby to take her own life goes very much against the grain of what many misguidedly perceive is the reality of pregnancy and motherhood for all women. Pregnancy and the postpartum period is often mistakenly viewed as a time when all women are glowing, ecstatic and elated when the reality for many is that they are in pain and exhausted. A small number of women may also develop a serious mental health difficulty.

Prof McCarthy explains that the most common psychiatric diagnosis in women who take their own lives in the ante natal and post natal periods is a bipolar illness or puerperal psychosis. This can be either a first episode or a recurrence of a bipolar illness.

Puerperal psychosis is a severe episode of mental illness which begins suddenly in the days or weeks after giving birth. Symptoms can include high mood, depression, confusion, hallucinations and delusions. It can happen to any woman and often occurs “out of the blue”.

“The majority of women, not all, who kill themselves, have a serious mental illness and the most common is bipolar illness . . . for 95 per cent of those who have puerperal psychosis it is actually an episode of bipolar illness,” says Prof McCarthy. “One in 500 women gets puerperal psychosis. For one in 1,000 that is their very first episode, for the others they are much more likely to either have had a puerperal psychosis before or have an episode of bipolar illness before.

The most important thing to realise is that women are experiencing serious mental health problems in pregnancy and afterwards

“That is why it is so important when women who are pregnant present to a maternity hospital that a history of particularly puerperal psychosis or bipolar illness as well as any other major mental illness is sought, because those are the people who are most likely to get a further puerperal psychosis and they are the ones who are at a very high risk of suicide.

“The most important thing to realise is that women are experiencing serious mental health problems in pregnancy and afterwards. All of them need to be treated seriously. And the question of do they have suicidal thoughts? Do they have suicidal intentions and taking that seriously? . . . women will say, ‘I have the baby, I wouldn’t kill myself because of the baby’, and we know that can change after a relatively short period of time to saying ‘I am so down I am a bad influence on that baby’.

“She may well love her baby, but she may say . . . the child would be better off without me . . . and it switches from I wouldn’t do it because of the baby, to the baby would be better off without me.”

Distress and despair

According to Prof McCarthy, the psychosis women can develop in pregnancy and after the birth of their baby causes intense distress and despair which frequently leads to the woman developing hugely irrational and terrifying thought patterns.

“For example, thoughts that they are a harm to the baby or imaging that they might harm the baby, even at a time when they are doing everything to protect the baby,” he explains. “They would avoid caring for the baby or refuse to be near the baby, because they imagine they are going to harm the baby, or they could pose some risk to the baby. If they are psychotic, they may have voices in their head or delusional thoughts that they are a harm to the baby, or they are evil in some way, that there is a badness in them, thoughts like that can come out.”

As with any other illness, it is vital that pregnant women or new mothers struggling with mental health difficulties receive early intervention by specialist services – specialist input from a perinatal mental health team can save, not only the woman’s life, but also her baby’s.

Perinatal mental health services have long been under resourced in Ireland. Currently, there is no specialist perinatal mental health service outside Dublin and there are no Mother and Baby Units (MBU) on the island of Ireland. There are approximately 20 such units in the UK.

The first report of the Confidential Maternal Death Enquiry (MDE) in Ireland, stated that the absence of a MBU where a mother who needs inpatient psychiatric care can bring her newborn baby with her, was “a continuing and regrettable deficiency in the Irish health services”.

It also said that “stand-alone psychiatric units are poorly equipped to look after women with medical and obstetrical complications”.

The UK was one of the first countries in the world to admit mothers and their babies together for the treatment of maternal mental health issues as far back as the 1940s.

Having a mother and baby unit is obviously beneficial from the mother’s point of view – and that early relationship with the mother is also of critical importance to the infant’s development and wellbeing.

Prof McCarthy says that while there is a lot of great work being done every day by public health nurses, GPs, psychologists and general psychiatrists throughout the country, there is a definite absence of specialist perinatal mental health care in Ireland.

Thanks to a new development supported by the HSE Mental Health Division, Ireland’s first model of care for maternal mental health was recently established.

Specialist Perinatal Mental Health Services – Model of Care for Ireland proposes a new maternal mental health service for the country. It will take the form of a hub and spoke clinical network model, with a specialist perinatal mental health team located in each hub. The maternity service with the greatest number of births in each of the HSE Hospital Groups will act as a hub and will provide support into the smaller units (spokes).

Specialist service

In each of the HSE’s Hospital Groups, the maternity service with the highest number of deliveries will be the designated hub. Each hub will have a specialist perinatal mental health service. Its staffing will be multidisciplinary and led by a consultant psychiatrist in perinatal psychiatry. In the remaining maternity units the liaison psychiatry team will continue to provide the input to the maternity service. This team will be linked to the hub specialist perinatal mental health teams for advice, regular meetings, training and education.

The project was headed up by Dr Margo Wrigley, former National Clinical Advisor and Clinical Programmes Group Lead Mental Health in the HSE.

According to Dr Wrigley, “while the focus of this specialist service will be women with moderate to severe mental illness, it will play a central role in educating and training all involved in the delivering of services to women during the antenatal and postnatal periods”.

The model of care also recommends that a MBU be located at St Vincent’s University Hospital in Dublin. It will be vital in allowing women to recover while not being separated from their babies, but there is no date yet for the development of the unit .

If the mother does need admission to hospital, Prof McCarthy says that “ideally, it should be to a mother and baby unit where she can be cared for, but also she can have as much and as appropriate exposure to her baby as possible so as not to impair the bonding. It is important to note that sometimes mothers almost need to get away from the baby because what they need is rest and sleep and they can’t manage the baby and the demand of the baby seems too much for them. Whereas, for others, to be separated from the baby may be just torture for them and make them feel much worse about themselves.

“Many mothers, even if we are trying to bring them into hospital . . . they won’t come in because she can’t be with her baby and it can be very painful . . . yet sometimes we have to say the only safe option here is to have her admitted and that can be very difficult.”

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IF YOU NEED SUPPORT
- Call 999 if it is a crisis.
- Your GP will refer you to an appropriate HSE service – eg primary care psychology, child and adolescent mental health, adult mental health.
- You can also access free, 24 hour helpline support: Samaritans: Freephone – 116 123; Text - 087 2 60 90 90 (standard text rates apply); find your nearest branch at samaritans.org.
- Pieta House – 1800 247 247, pieta.ie.
- Women's Aid National Freephone Helpline – 1800 341 900, womensaid.ie.
- For information on mental health support services, see yourmentalhealth.ie.