The Mental Health Act (1983) | Insanity and the Law
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Child and Adolescent
This section is entitled 'obstetric' for want of a catch-all phrase, and covers mental health issues related to menstruation, menopause, pregnancy and the postnatal phase. Included are Premenstrual Syndrome, postnatal blues and depression, postnatal psychosis, and the effects of pregnancy and menopause on mental health.
Premenstrual Syndrome (PMS) is defined as symptoms recurring prior to menstruation that are absent afterwards, though there is a wide variation in timing. Common symptoms are irritability, depression, fatigue, headache, bloating and breast tenderness. While around half of women asked will report having some symptoms, only one in 20 has symptoms severe enough to cause major problems. Stress, age and number of pregnancies all increase the risk of having PMS, whereas the contraceptive pill and supportive relationships reduce the rate of occurrence. PMS can be treated by reducing stress, avoiding caffeine and alcohol prior to menstruation, eating healthily, exercising, and having counselling sessions. Various drugs may be used in severe cases, though some studies have also shown that PMS responds to placebo treatments too. See the entry on Dealing with Pre-menstrual Syndrome and Period Pain for more details.
Following childbirth, around half of all mothers experience a phenomenon known as postnatal blues or 'baby blues'. This occurs during the first ten days following the birth, and is thought to be due to the change in hormone levels. It may present as irritability, anxiety, mild depression or mood swings, and is worst around the third day. Postnatal blues require reassurance alone in most cases; however, depression that lasts longer than a couple of weeks, or is more than just mild, may represent postnatal depression.
Postnatal depression affects around one in ten mothers and lasts between three and six months. The symptoms are similar to a depressive episode, and include low mood, tiredness, lack of pleasure and suicidal ideation. There may also be a high level of anxiety and guilt regarding the newborn, problems with bonding between mother and child, unpleasant obsessive thoughts about harming the baby, and occasionally even thoughts of infanticide. Treatment is generally supportive counselling, though in some cases anti-depressants are needed. See the entry on Post-natal Depression for more details.
Postnatal psychosis occurs in around one in five hundred births, and occurs more often in mothers with a past history or family history of mood disorder. It comes on rapidly at some time between four days and eight weeks following the birth, with the first symptoms usually being insomnia and restlessness. This is followed by confusion and psychotic symptoms such as delusions, hallucinations and paranoia, with these symptoms varying greatly over a short space of time. The cause of postnatal psychosis is generally unclear except in those cases where there is a medical cause, such as an infection or drug-induced psychosis.
The risk of self-harm or infanticide needs to be determined, and mothers can be treated on a mother-and-baby ward if they are deemed not to pose a threat to their child. Treatment is with anti-psychotics, anti-depressants and mood stabilisers, and special care is taken in breastfeeding mothers where drugs may be transmitted to the infant in the milk. Electroconvulsive therapy can be effective in severe cases, providing a rapid improvement in symptoms.
Pregnancy is generally associated with good mental health, with both recurrences and first episodes of mental illness being uncommon in pregnant women. As suggested by the conditions mentioned above, this period of good health is balanced out by the postnatal period and so overall pregnancy does not alter the risk of mental illness. The exception is those women who suffer a miscarriage, in whom depressive illness and bereavement reaction are understandably common. Interestingly, the same cannot be said for abortion, which has little if any effect on the rate of mental illness. One final consideration with regards to pregnancy is the use of medication in women with known mental illness – as some drugs may have harmful effects on the fetus, it is important to weigh the risks of stopping the medication and continuing it. Some drugs, such as the mood stabiliser lithium, are avoided during pregnancy and breastfeeding if at all possible.
While the menopause may have effects on a person's psychological make-up, it is not thought to be associated with an increased risk of mental illness. There may be an exception in those women suffering from depression, though the use of anti-depressants is preferred over hormone replacement therapy, which is largely a medical treatment.