MAR BASELIOS COLLEGE OF NURSING

BHOPAL

SUBJECT: MENTAL HEALTH NURSING

SEMINAR ON
“WOMEN AND MENTAL HEALTH”

SUBMITTED TO, SUBMITTED BY,

Mrs. Sini Shaji Mrs. Betty Boaz
Professor M.Sc. Nursing I Year

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 WOMEN AND MENTAL HEALTH
INTRODUCTION
In most societies, psychiatric disorders are more common in women. The common reasons for
this include: genetic differences, societal pressures on women, differences in rearing pattern and
cultural expectations.
The mental disorders more commonly reported in females include major depression, neurotic
depression, anxiety states, phobic neurosis, hypochondria sis, dissociative disorders, adjustment
problems, attempted suicide, anorexia nervosa and senile dementia.
PREMENSTRUAL SYNDROME
Menstruation is a normal physiological process in females. The various psychological symptom
is attributed to premenstrual syndrome are: sadness, anxiety, anger, irritability, labile mood,
decreased concentration, in decision, suspiciousness, sensitivity, suicidal or homicidal ideations,
insomnia, hypersomnia, anorexia, craving for certain foods, fatigue, lethargy, agitation, libido
changes, decreased motivation, impulsivity and social withdrawal.
This premenstrual syndrome starts about 5 to 10 days before onset of menses and lasts till the
end of menses. It not only affects social but also occupational functioning, leading to various
degrees of maladjustments.
Management

 The syndrome has been widely treated with progesterone, oral contraceptives,
bromocriptine, diuretics and anti-depressant drugs
 Psychological support and encouragement
 Cognitive behavior therapy

PSYCHIATRIC DISORDERS IN PREGNANCY

Pregnancy is generally thought to be a time of happiness and emotional well-being for a woman.
However, for many women, pregnancy and motherhood increase their vulnerability to
psychiatric conditions such as depression, anxiety disorders, eating disorders, and psychoses.
These conditions are often underdiagnosed because they are attributed to pregnancy-related
changes in maternal temperament or physiology. In addition, such conditions are often
undertreated because of concerns about potential harmful effects of medication.
Depression in pregnancy
During pregnancy, symptoms of depression such as changes in sleep, appetite, and energy are
often difficult to distinguish from the normal experiences of pregnancy. Although up to 70% of
women report some negative mood symptoms during pregnancy, the prevalence of women who

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meet the diagnostic criteria for depression has been shown to be between 13.6% at 32 weeks
gestation and 17% at 35 to 36 weeks gestation. The course of depression varies throughout
pregnancy: most studies report a symptom peak during the first and third trimesters and
improvement during the second trimester. In a recent study, more women became depressed
between 18 and 32 weeks gestation than between 32 weeks gestation and 8 weeks postpartum.
Depression is the most common psychiatric disorder associated with pregnancy. Pregnant
women may also suffer from anxiety disorders, such as panic disorder, obsessive-compulsive
disorder, and eating disorders. While it is rare for women to experience first-onset psychoses
during pregnancy, relapse rates are high for women previously diagnosed with some form of
psychosis.
Several risk factors and psychosocial correlates have been identified as contributing to
depression during pregnancy. The most clearly identified risk factors include a previous history
of depression, discontinuation of medication(s) by a woman who has a history of depression, a
previous history of postpartum depression, and a family history of depression. Several key
psychosocial correlates may also contribute to depression during pregnancy: a negative attitude
toward the pregnancy, a lack of social support, maternal stress associated with negative life
events, and a partner or family member who is unhappy about the pregnancy.
Depression that is left untreated in pregnancy, either because symptoms are not recognized or
because of concerns regarding the effects of medications, can lead to a host of negative
consequences, including lack of compliance with prenatal care recommendations, poor nutrition
and self-care, self-medication, alcohol and drug use, suicidal thoughts and thoughts of harming
the fetus, and the development of postpartum depression after the baby is born. An additional
and important implication of untreated maternal depression is the psychological effect that the
depression may have on the fetus. One study that examined 1123 mother-infant pairs reported
that infants of mothers depressed in pregnancy showed less frequent positive facial expressions
and vocalizations, and that these infants were also harder to console. Thus, the relationship
between maternal depression and early childhood problems may be part of a sequence that starts
with depressive symptoms during pregnancy.
Treatment of depression in pregnancy relies on the same therapies used for depression at any
time in life, with the added need to ensure the safety of the fetus. Psychotherapies that have been
recognized as effective treatment for depression include cognitive behavioral therapy and
interpersonal psychotherapy. Education and support are also important, particularly as pregnancy
is a unique experience for women, some of whom may not know what to expect.
Pharmacological therapies are also recognized as effective treatment for depression. However,
full disclosure of both the risk and benefits of various antidepressant medications should be made
to the patient and, if possible, her partner prior to starting any pharmacological treatment.

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Anxiety disorders in pregnancy
Data are available on some of the disorders that affect pregnant women (panic disorder and
obsessive-compulsive disorder) but very little information exists regarding others (generalized
anxiety disorder and social phobia).
Panic disorder
The course of panic disorder during pregnancy is variable and remains unclear. While case
reports of pregnant women with pre-existing panic disorder have suggested a decrease in
symptoms during pregnancy, large-scale studies have reported that there is no decrease in
symptoms for women with pre-existing panic disorder.
In addition, a subgroup of women may experience first-onset panic disorder during pregnancy.
Women presenting with panic attacks for the first time should be screened for thyroid disorder.
The possible effects of anxiety and panic on the course of the pregnancy and the health of the
fetus are not well understood. One study showed a correlation between increased anxiety and
increased resistance in uterine artery blood flow. The correlation between plasma levels of
cortisol in the mother and in the fetus may have implications for the developing fetal brain.
Treatments for panic disorder in pregnancy may include pharmacological therapies, particularly
benzodiazepines for nighttime sedation and symptomatic relief, and antidepressants, as well as
non-pharmacological therapies such as cognitive behavioral therapy, supportive psychotherapy,
relaxation techniques, sleep hygiene, and dietary counseling.
Obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD) is characterized by thoughts that cannot be controlled
(obsessions) and repetitive behaviors or rituals that cannot be controlled (compulsions) in
response to these thoughts. Several reports suggest that women may be at an increased risk for
the onset of OCD during pregnancy and the postpartum period. In one study of women with
diagnosed OCD, 39% of the participants reported that their OCD began during a pregnancy.
Treatments for OCD in pregnancy are the same as those in non-pregnant adults and include
cognitive behavioral therapy and pharmacotherapy. Women with severe OCD can become quite
incapacitated and will require treatment.
Generalized anxiety disorder
There are no data on the prevalence or course of generalized anxiety disorder (GAD) through
pregnancy. Most women, naturally enough, worry about the health of the fetus and how they will
cope with labor and bodily changes. Excessive worrying, however, may be a symptom of GAD
or depression.

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Social phobia
There are no data on either first-onset social phobia or pre-existing social phobia in pregnancy. A
very small number of women experience tocophobia, an unreasonable dread of childbirth. These
women are more prone to postpartum depression if denied the delivery method of their choice
(i.e., cesarean section).
Eating disorders in pregnancy
The prevalence of eating disorders in pregnant women is approximately 4.9%. While studies
have suggested that the severity of symptoms may actually decrease during pregnancy, there are
many negative consequences for both the mother and her infant. One recent study reported that
pregnant women with active eating disorders appear to be at greater risk for delivery by cesarean
section and for postpartum depression. In addition, eating disorders during pregnancy have been
linked with higher rates of miscarriage and lower infant birth weights.
Psychoses in pregnancy
The occurrence of new episodes of psychosis during pregnancy is extremely rare. However, for
women with a history of psychosis, particularly psychosis in previous pregnancies, the relapse
rates are high, with the most common manifestations being bipolar illness, followed by psychotic
depression and schizophrenia.
Bipolar mood disorder
The information regarding the course of bipolar disorder in pregnancy is limited. It appears that
some women with bipolar disorder may experience a relief from symptoms during pregnancy,
but that the risk for relapse in the postpartum period is high. One recent study reported that
pregnancy had no impact on the course of bipolar disorder in women who discontinued lithium
prior to conception, with the relapse rates for either depression or mania in the pregnant women
being the same as in non-pregnant matched women. In another study, pregnancy appeared to
have a protective effect against an increase in symptoms in women with lithium-responsive
bipolar I disorder who had discontinued their lithium during pregnancy; however, there was a
14% rate of relapse in the last 5 weeks of pregnancy. In both studies, the risk of relapse in the
postpartum period was very high, ranging from 25% to 70%. In women with a history of bipolar
mood disorder, the decision whether to use mood stabilizers must be made following an
assessment of risks and benefits. Factors to consider include number and severity of previous
episodes, level of insight, family supports, and the wishes of the woman. Careful monitoring of
psychological symptoms throughout the pregnancy is of paramount importance.
Schizophrenia
The limited data on schizophrenia in pregnancy suggest that this disease has a variable course,
with some women experiencing an improvement in symptoms, while others experience a
worsening of their illness. Regardless of the course of the illness, women with a history of

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psychosis require close monitoring by health care professionals during pregnancy. Psychosis
during pregnancy can have devastating consequences for both the mother and her fetus,
including failure to obtain proper prenatal care, negative pregnancy outcomes such as low birth
weight and prematurity, and neonaticide or suicide. Treatment of acute psychosis in pregnancy is
mandatory and includes mobilization of supports, pharmacotherapy, and hospitalization.
Electroconvulsive therapy may be used for psychotic depression.

PSYCHOLOGICAL CHANGES DURING PUERPERIUM

The postpartum period, or puerperium, refers to the period beginning immediately after the birth
of a child and extending for about 6-to- 8-week period after delivery during which the mother’s
body returns to its pre-pregnant state. Many psychological changes occur in the mother during
this time. Nursing care should focus on helping the mother and her family adjust to these
changes and on easing the transition to the parenting role.

 Adjustment to all the new changes, new roles the family will play; this may cause many
different emotions.
 Postpartum blues: Occurs in some women in different degrees, as a temporary depression
lasting usually 1 to 2 weeks after birth, and may be not be afraid to talk out your feelings
with someone, family, friend, or health care provider. It often helps.
 Cultural influences: Different cultures have different rituals they follow after mother has
the baby.
 Attachment: The process of interaction and bonding between mother & baby.

PSYCHOLOGICAL ADAPTATION DURING POSTPARTUM

Mother typically undergo psychological adjustments during the postpartum period.Reva Rubin, a
researcher who examined maternal adaptation to childbirth in the 1960s, identified three phases
that can help the nurse understand maternal behavior after delivery.
Historically, each phase encompassed a specific time span and women progressed through
phases sequentially.
Rubin’s Stages of maternal psychological adaptation
1- Taking in phase(dependent phase):-

 First 3 days post-partum.

 Focused on self not infant, on her own needs for sleep & rest.
 Passive, dependent & can’t make decisions.
 Need to discuss labor experiences.
 Sense of wonderment when looking at the neonate.

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2-Taking hold phase (dependent to independentphase):-

 Last from the 3rd to 10th day postpartum.

 Focus on infant.
 Active, independent & can make decisions.
 Initiates self-care activities, focus on bowels, bladder & breastfeeding.
 Responds to instruction about infant care & self-care.
 May express lack of confidence in caring for the neonate.

3-Letting go- (interdependent phase):-

 Last from 10 days to 6 weeks postpartum.

 The woman finally redefines her new role.
 See self as separate from infant.
 Gives up fantasized image of her child and accepts the real one.
 Readjustment.

Maternal Concerns & Feelings duringPostpartum period:-

 Abandonment: Only hours before, she was the center of attention, with everyone asking
about her health and well-being. Now suddenly, the baby is the chief interest. The woman
may feel confused by a sensation very close to jealousy. Shared responsibility for infant
care can help alleviate these feelings.
 Disappointment: It can be difficult for the mother to feel positive immediately about a
child who does not meet their expectations. Handle the child warmly. Comment on the
child good points.
 Bonding (attachment): It’s the process by which the mother forms an emotional
relationship with her infant over time. Mother explores the infant first with fingers, then
palms and finally enfolding the newborn with whole hands and arms. Holds infant in face
to face position.

POSTPARTUM DISORDERS
Some of the most common emotional and mental health issues that arise during the postpartum
period are:-
Postpartum blues (Baby Blues)
The baby blues generally show up 3 to 4 days after birth and may last for the few weeks after
delivery.

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Signs:

 50% of women experience some feelings of overwhelming sadness.

 Mood swings, sudden crying episodes, irritability, anxiety, loneliness
 Feeling of happiness and love for the newborn may be accompanied by feelings of
helplessness, sadness and anxiety.
Causes:

 Sudden & quick change in the hormones.

 The emotional &physical stress of giving birth.
 It may be a response to dependence and low self- esteem caused by exhaustion.
 Many new mothers tend to have an increased sense of anxiety and tension assuming by a
new role.
 The fatigue and lack of sleep that affects all new mothers only serves to compound the
problem.
Some helpful tips:

 Advice woman to exercise regularly.

 Advice woman to eat a healthy, well-balanced diet.
 A woman needs assurance that sudden crying episodes are normal.
 Allow time to verbalize feelings.
 Make time each day for herself to enjoy.
 Join a support group for new mothers.
 Talk with her partner about dividing up the parenting responsibilities so she don’t feel
like she is doing everything by herself.
Postpartum depression
It is moderate to severe depression in a woman after she has given birth. It may occur soon after
delivery or up to a year later.
Causes

 Women commonly have mood changes during pregnancy, especially after delivery.
 These mood changes may be caused by changes in hormone levels.
 Many non-hormonal factors may also affect mood during this period.
 Changes in your body from pregnancy and delivery.
 Changes in work and social relationships.
 Having less time and freedom for yourself.
 Lack of sleep.
 Worries about your ability as a mother.

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Symptoms

 Irritability.
 Changes in appetite.
 Feeling depressed the majority of the day, almost every day of the week.
 Feeling of worthlessness or guilt.
 Feeling withdrawn or unconnected.
 Lack of pleasure or interest in most or all activities.
 Significant weight gain or weight loss.
 Extreme insomnia or sleeping all the time.
 Loss of energy.
 Problems doing tasks at home or work.
 Negative feelings toward the baby.

Some helpful tips

 Ask the partner, family, and friends of the woman for help with her baby.
 Advice the woman doesn’t hide her feelings. Talk about her feeling with her partner,
family, and friends.
 Don’t make any major life changes during or right after giving birth.
 Advise her to take time to go out, visit friends, or spend time alone with her partner.
 Advise her to rest as much as she can. Sleep when the baby is sleeping.
 Talk with other mothers or join a support group.

Delivery-related Anxiety, Stress Reactions, and Trauma

Postpartum depression is one of several emotionaland psychological issues that a woman
mayexperience during the postpartum period. Inaddition to postpartum depression, delivery-
relatedanxiety and stress reactions may be experienced bysome women, due to unexpected or
traumaticsituations during the delivery. Any given birthexperience, itself, might also trigger the
recollectionand re-experiencing of post traumas (e.g., domesticabuse, rape) for a woman.
Given this, symptoms of obsessive-compulsive(OCD) and Post-traumatic stress disorder (PTSD)
may be experienced during the post-partum period for some women. These post-partum
experiences become impairments when the degree of anxiety is beyond what might be
considered a typical response to the delivery of a new baby (e.g., excessive worry about baby’s
welfare, feeding. Sleeping patterns; excessive concerns about the ability to care for a baby
properly)may experiencing symptoms of anxiety disorder.Specifically, anew mother who is
experiencingunwelcome, persistent, and uncontrollable thoughts about herself or baby may
beexperiencing symptoms of OCD.
Some women in the postpartum periodexperience the following symptoms of PTSD:-

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  Intense fear, horror, or feelings of helplessness in response to experienced trauma.
 Re-experiencing of the traumatic event through recurrent and distressing recollections
(thoughts, images, perceptions, and dreams).
 Acting and feeling like the trauma is occurring again (flashbacks, hallucinations, reliving
the event).
 Extreme psychological distress or physical reaction when exposed to anything resembling
the traumatic experience.
 Continued avoidance of thoughts, feelings, activities, people, and places related to the
trauma.
 Increases in arousal level (can’t fall asleep, irritability, anger outbursts).

Postpartum Psychosis
In comparison to the incidence of depression and anxiety that is experienced by new mothers in
the postpartum period, postpartum psychosis is rare. Nevertheless, when it is experienced by
anew mother, she might be scared or confused, once out of the psychotic state.
A woman experiencing postpartum psychosis requires immediate attention, especially if her
symptoms include thoughts of suicide or other harm to herself or baby.
A new mother with postpartum psychosis may be experiencing the following symptoms:-

 Hallucinations (of hearing, sight, touch, etc.)

 Delusions (false, bizarre beliefs, which are not reality- based).
 Drastic mood swings
 Disorganization of speech(incoherence).
 Disorganization of behavior(extremely inappropriate dress).
 Extreme restlessness.
 Anger & agitation.

Nursing intervention towardpsychological changes & disordersduring postpartum period:-

1- Early detection of any behavioral andpsychological responses changes.
2- Early detection of depression-anger or blues.
3- Early detection of male adaptation inattachment.
4- Refer the client to obstetrician to evaluatephysiological status.
5- Support positive parenting behaviors.
6- Refer the client to: Psychiatrist, Nurse Psychotherapist, Pediatrician, Support group,
Public health nurse.

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MENOPAUSALSYNDROME
Menopause, the cessation of ovulation, generally occurs between 45and 53years of age. The
hypoestrogenism that follows can lead to hot flashes; sleep disturbances, vaginal atrophy and
dryness, urinary problems ,sleep problem and cognitive and affective disturbances like worrying,
depression, anxiety, irritability, difficulty in concentration and decreased self-confidence.
Management

 Hormonal replacement therapy

 Reassurance
 Psychological support
 Early identification of emotional problems and prompt treatment
 Counseling
 Psychotherapy
COUNSELLING- PREMARITAL, MARITAL AND GENETIC

Definition
Counselling entails precision of diagnosis, the estimation of risks, and a supportive role to ensure
that those who are given information are enable to benefit from it and from the interventions that
are available.

Target population
 Couples about to marry.
 The newly-weds.
 Any individual seeking advice

Main functions
 Medical counseling.
 Genetic counseling.
 Family planning counseling.
 Nutritional counseling
 Sex education

1. MEDICAL COUNSELLING
The aim is diagnosis of diseases
 Transmitted to the other partner: STD, TB
 Represent a risk factor during pregnancy: cardiac disease chronic renal disease renal
transplantation
 Affect reproductive function: Female: fibroid, genital hypoplasia, anovulation, menstrual
disorders, hirsutism Male: undescended testes, varicocele, azospermia, physical
disability.

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2. GENETIC COUNSELLING
Aim: Identify individuals at risk of having a child with genetic disorder
Indications
1. Age > 35: Down syndrome: 1/2000 at 20 y 1/500 at 40y 1/32 at 45 y.
2. First cousins: share large groups of identical genes (1/16): increasing the risk of recessive
diseases particularly if there is family history.
3. Chromosomal abnormality in either partner.
4. Family history of genetic disorders
5. Ethnic groups: Blacks: Sickle cell anemia. Mediterranean's: B thalassemia, Glucose 6
phosphate dehydrogenase
6. Pregnancy loss in those previously married.
Steps
 Establishment of a diagnosis.
 Estimation of a recurrent risk.
 Communication of relevant information
 Provision of long term support.
Teratogenic medications: e.g. Anticonvulsant, antineoplastic, oral anticoagulant, isotretinoin
lithium, alcohol, smoking Effects should be explained.

3. FAMILY PLANNING COUNSELLING

I. Encourage pregnancy
 >30 y.
 A cause of possible impairment of fertility: fibroid, PCOS, oligomenorrhea, genital
hypoplasia.
 Chronic medical disease which progress with advancement of age
II. Contraception
Aim reduction the hazards of:
 adolescence pregnancy
 unnecessary resort to induction of abortion
 birth of unwanted child.

Explain the hazards of:

 uncontrolled fertility
 high risk pregnancy (too early, too many & too close together)
Methods:
 Natural barrier & chemical: not good choices.
 IUCD, injectable& implants: not suitable.
 Pills best choice.
 Emergency contraception (levonorgestrel) may be required.

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4. NUTRITIONAL COUNSELING
 BMI: preferred indicator of nutritional status
 Eating habits: fasting, pica, eating disorders, megavitamin
 Pre-conceptional intake of folic acid

5. SEX EDUCATION
Important {level of sexual knowledge amongst youth is moderate}.
Includes
 Sensitive sexual sites.
 Healthy marital relations.
 Communication skills to reduce the chance of marital difficulties increase marital
satisfaction.
 Safe sex & protection against STD.
 Answers of questions on sexually related issues.
Requirements
 The partners may be counseled separately or together.
 The doctor:
o Good knowledge of different aspects of human reproduction & sexuality.
o Good listening.
o Encourage them to ask questions.

Procedure
A. History
1. Menstrual.
2. Family.
3. Drug intake
4. Past: STD
B. Examination
1. Female: BMI, SSC, hair distribution, galactorrhea
2. Male: External genitalia: undescended testes, varicocele, hydrocele, hypospadias
C. Investigations
I. Routine investigations
 Female: RH typing, Rubella Ab, Toxoplasmosis Ab, Pelvic ultrasonography
 Male: semen analysis Both: urine analysis, CBC, Bl group, blood sugar, . liver function
II. Special investigations
 Hormonal profile: amenorrhea, oligomenorrhea, galactorhea, PCOS, hypogonadism.
 Karyotyping: at risk cases.
 Screening for STD: some cases.

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  Investigations for specific medical diseases: cardiac ECHO, GTT, kidney function, IVP,
CT of skull in galactorrhea, thyroid function test
D. Health education
 Family planning
 Nutritional
 Sex

ROLE OF NURSE
Nurses play an important role in assessing for genetic disorders, in offering support to
individuals who seek counseling, and in helping with reproductive genetic testing procedure. The
nurse can function within a multidisciplinary setting in genetic counseling by assisting with the
family history.
CONCLUSION
Early identification and treatment of psychiatric disorders in pregnancy can prevent morbidity in
pregnancy and postpartum with the concomitant risks to mother and baby. Both psychotherapy
and pharmacotherapy should be considered. In British Columbia, the Reproductive Mental
Health program offers consultation and education services to practitioners and allied health
professionals throughout the province.Nursing care should focus on helping the mother and her
family adjusts to these changes and on easing the transition to the parenting role.

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 REFERENCES

BOOKS
1. Neeraja K.P.. (2008) .Essential of Mental Health and Psychiatric Nursing. volume 1.
New Delhi: Jaypee Brothers Medical Publishers (P) Ltd, Page no: 345-349.
2. Lalitha K..( 2007) .Mental Health and Psychiatric Nursing- an Indian Perspective. first
edition Vmg Book House, Page no.641 to 654.
3. Dr Kapoor, Bimla.(2010).Textbook Of Psychiatric Nursing, Volume 1. NewDelhi: Lotus
Publications Page No 153-156.
4. Ahuja Neeraj (2011). A Short Textbook Of Psychiatry. 7th Edition,NewDelhi: Jaypee
Publishers, ,Page No:217-220.
5. Sreevani R.. (2007). A Guide To Mental Health And Psychiatric Nursing,2nd edition,
NewDelhi: Jaypee Brothers,India .Pp no:315-317.
6. Bhaskara Raj.D Elakkuvana. (2013), Textbook of Nursing Education. Bangalore:
Emmess medical publishers, page no.134-153 .

INTERNET

 www.nimh.nih.gov/health/topics/women-and-mental-health/
 https://www.mentalhealth.org.uk/a-to-z/w/women-and-mental-health
 www.who.int/mental_health/prevention/genderwomen/en
 www.dualdiagnosis.org/mental-health-and-addiction/common-issues-women
 kidshealth.org/en/parents/genetic-counseling.html

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