3Spectrum of Perinatal Mood Disorders Antepartum depressionPostpartum depressionPostpartum psychosis
4DEPRESSION DURING PREGNANCY Between 10-20% of women will experience significant depression during pregnancyThis will be a first episode for one third
5Antenatal Risk Assessment Do you have a history of depression, bipolar disorder or anxiety?Have you ever been treated with antidepressant medication or other psychiatric medication?Did you recently stop your antidepressant or other psychiatric medication?Do you have a family history of depression or bipolar disorder?Are you currently struggling with or being treated for depression or anxiety?Are you feeling a lack of support during your pregnancy or worry that you will be without enough support after the baby is born?
6JAMA STUDY February 2006“Relapse of Major Depression During Pregnancy of Women Who Maintain or Discontinue Antidepressant Treatment”Lee Cohen et al. at MGHWomen from 3 specialty centers who were not depressed for at least 3 months prior to pregnancy and on antidepressant treatment.43% had a relapse in their major depression26% of those who continued their medication had a relapse (50% in first trimester)68% of those who discontinued their medication had a relapse (50 % In the 1st trimester, 90% by the end of the 2nd trimester)
7JAMA STUDY February 2006 CONCLUSIONS: Pregnancy puts women with a history of depression at higher risk of recurrence and is not protective.Women who are stable on antidepressants at the time of pregnancy need to be aware that there is a much higher risk of relapse associated with discontinuing their antidepressant medicationThese issues should be part of the discussion with women when weighing the risk/benefit ratio of using antidepressants during pregnancy
8PREGNANCY IS NOT A TIME OF “PROTECTION” FROM MOOD OR ANXIETY DISORDERS
9SIGNIFICANCE Untreated depression during pregnancy is associated with serious risks for mother andher baby.
10OBSTETRICS AND GYNECOLOGY April 2008 "Advising a pregnant or breastfeeding woman to discontinue medication exchanges the fetal or neonatal risks of medication exposure for the risk of untreated mental illness." Untreated or inadequately treated maternal mental illness "may result in poor compliance with prenatal care, inadequate nutrition, exposure to additional medications or herbal medicines, increased alcohol and tobacco use, deficits in mother-infant bonding, and disruptions within the family environment.” .
11OBSTETRICS AND GYNECOLOGY April 2008 GuidelinesLevel A evidence (from good and consistent scientific evidence):Lithium exposure in pregnancy may be associated with a small increase in congenital cardiac malformations, with a risk ratio of 1.2 to 7.7.Valproate exposure in pregnancy is associated with an increased risk for fetal abnormalities and should be avoided if possible, especially during the first trimesterCarbamazepine exposure during pregnancy is associated with fetal carbamazepine syndrome and should be avoided if possible, especially during the first trimester.Maternal benzodiazepine use shortly before delivery is associated with floppy infant syndrome.
12OBSTETRICS AND GYNECOLOGY April 2008 Level B evidence (from limited or inconsistent scientific evidence):Paroxetine use in pregnant women and women who are planning to become pregnant should be avoided, if possible, and fetal echocardiography should be considered when fetuses are exposed to paroxetine in early pregnancy.Prenatal benzodiazepine exposure increased the risk for oral cleft (absolute risk increased by 0.01%).Lamotrigine is a potential maintenance therapy option for pregnant women with bipolar disorder and has a growing reproductive safety profile relative to alternative mood stabilizers.Untreated or inadequately treated maternal psychiatric illness may have various negative consequences.
13OBSTETRICS AND GYNECOLOGY April 2008 Level C evidence (primarily from consensus and expert opinion):Multidisciplinary care management involving the patient's obstetrician, mental health clinician, primary health care provider, and pediatrician is recommended whenever possible.Use of a single medication at a higher dose is favored vs the use of multiple medications to treat psychiatric illness during pregnancy.Close monitoring of lithium during pregnancy and postpartum is recommended.
14OBSTETRICS AND GYNECOLOGY April 2008 Measuring serum drug levels in breast-fed neonates is not recommended.Treatment with selective serotonin-reuptake inhibitors, selective norepinephrine reuptake inhibitors, or both during pregnancy should be individualized.A fetal echocardiogram examination should be considered when the fetus is exposed to lithium during the first trimester of pregnancy.
15RISKS OF UNTREATED DEPRESSION DURING PREGNANCY Lack of adequate prenatal careHigher use of alcohol and drugsObstetrical and neonatal complicationsHigher rates of premature laborHigher rates of miscarriageHigher incidence of placental abruptionIncreased bleeding during gestationIncreased risk of preeclampsia (five-fold in one large study)
16RISKS OF UNTREATED DEPRESSION DURING PREGNANCY More painful labor and higher use of analgesiaSmall for gestational age infantsLower APGAR scoresLow birth weightNeonatal growth retardationIncreased rate of stillborns (six times in one study)Increased admissions to neonatal ICU
17RISKS OF UNTREATED DEPRESSION DURING PREGNANCY More likely to have colicky, irritable babiesSuicideSubsequent Postpartum Depression or recurrent depression
18TREATMENT OF DEPRESSION DURING PREGNANCY Mild to moderate depression may respond to supportive, cognitive or interpersonal therapy or other non-pharmacolologic treatmentsMore severe depression warrants medication use
19BIPOLAR DISORDER75% of women with bipolar disorder experience recurrent illness if they discontinue treatment during pregnancy
20Postpartum Depression Peak lifetime prevalence for psychiatric disorders and hospital admissions for women occurs in the first 3 months after childbirth (Kendall et al, 1981, 1987)
21Epidemiology of Postpartum Episodes 10203040506070Admissions/MonthPregnancy–2 Years– 1 YearChildbirth+1 Year+2 YearsKendell RE et al. Br J Psychiatry. 1987;150:
22THE MOST COMMON COMPLICATION OF CHILDBIRTH IS DEPRESSION
23BABY BLUES Baby Blues usually develop 3-5 days after delivery Hallmark is emotional reactivityOccur in % of all new mothersNormal reactions to the hormonal changes and stress of having a baby
24POSTPARTUM DEPRESSION Prevalence15% of postpartum women (1 out of 7 new mothers)Higher-risk groupsYoung, low socioeconomic status, poor social supportFamily history of mood disordersPast depression 25-40% risk of PPDPrior PPD 30-50% risk recurrenceGaynes et al, 2005; Wisner K et al. N Engl J Med. 2002;347:
25PRESENTATION OF PPDUsually develops slowly over the first three months, most often beginning within the first 4 weeks, though some women have a more acute onsetMore persistent and may affect ability to care for the babySigns and symptoms are those of Major Depression---depressed mood, irritability, loss of interest and appetite, fatigue insomnia.Often complain of being physically and emotionally exhausted, but unable to sleep.
26PRESENTATION OF PPDCLASSIC SYMPTOMS OF DEPRESSION WITH SOME TYPICAL FEATURES:Often express concerns about her ability to care for her baby or anxiety about the baby’s well beingAnxiety symptoms are common including frank panic disorder, hypochondriasis, and most common, generalized anxiety disorderWomen are often unable to sleep even when given the opportunity
27PRESENTATION OF PPDFrequently have intrusive, obssessional ruminations, usually focused on the baby, often violent in nature, but they are egodystonic and there is not a problem with reality testing i.e. non-psychotic. One study showed 50% of women with PPD had these. Such obsessional thoughts do not increase the risk of harm to the baby and are important to distinguish from psychosis.
28Duration of PPDUntreated depression often persists for months to years after childbirth, with lingering effects on physical and psychological functioning following recovery from depressive episodes (England, Ballard & George, 1994).25%-50% women have episodes lasting 7 months or longer (O’Hara, 1987).The most significant factor in the duration of PPD is delay in receiving treatment (England, Ballard & George, 1994).
29RISK FACTORSDepression during pregnancy is the best predictor of post partum depressionPrenatal anxiety also a strong predictor of PPDHistory of depression, especially PPDFamily history of depressionHistory or family history of late luteal phase disorderObstetrical complications at deliveryComplicated pregnancyNeonatal loss or illnessDifficult infant temperament
30RISK FACTORS Ambivalence about pregnancy Marital conflict Lack of social supportNumber of childrenRecent lossHistory of sexual abuseLow self esteemRecent stressful life eventsBreastfeeding difficulties
31Risks of Untreated PPD To mother: Diminished capacity to care for self and babySubstance abuseIncreased healthcare costsStressful impact on relationship between woman and her partner.Suicidal thoughts more likely to be accompanied by homicidal thoughtsKindling phenomenon---development of a chronic low grade depression with more susceptibility to repeated episodes of MDD
32Risks of Untreated PPD To child: Poor attachment, bonding, and less nurturing maternal interactionPoor weight gainSleep problemsLess likely to be breastfedLess likely to receive preventative healthcare and child safety practicesPoor cognitive, language and and motor developmentBehavioral problems—future conduct disorders, hyperactivity, and school behavior problemsFuture depression and anxiety disordersRisk of future medical illnesses as well —maternal depression is an “Adverse Childhood Experience”
33MATERNAL POST PARTUM MOOD IS ONE OF THE STRONGEST PREDICTORS OF NEUROCOGNITIVE DEVELOPMENT IN CHILDREN MEASURED UP TO AGE SIX
34Summary: Impact of PPDDiminished maternal ability to function in many roles particularly the core parenting role with long lasting adverse effects on child’s health, cognitive and emotional development and ongoing risk to mother’s emotional, physical, and social wellbeing.Treatment for mother is prevention or early intervention for child
35POST PARTUM ANXIETY DISORDERS Postpartum Onset Anxiety/Panic Disorder10% of new mothersPostpartum Obsessive/Compulsive Disorder (PPOCD)3-5% of new mothersPostpartum Stress Disorder (PPTSD)1-3% of new mothers may develop. Mothers who have had a traumatic childbirth experience, premature birth and loss of child are at most risk for onset of PPTSD. Mothers who have experienced ahistory of childhood sexual or physical abuse are also at higher risk.
36POST PARTUM PSYCHOSISTypical onset is within 2 weeks after delivery, first symptoms often within hoursEarliest signs are restlessness, irritability and insomniaOften very labile in presentationOften looks “organic” with a lot of confusion and disorientationMost often consistent with mania or a mixed state
37POST PARTUM PSYCHOSISIncludes agitation, paranoia, delusions, disorganized thinking and impulsivityThoughts of harming the baby are frequently driven by delusions—Child must be saved from harm, child is malevolent, dangerous, has special powers, is Satan or GodRates of infanticide associated with untreated postpartum psychosis have been estimated to be as high as 4%.
38Risk Spectrum for Postpartum Psychosis Highest-prior history of psychosis, particularly postpartumModerate --Bipolar disorderAt risk--Previous postpartum depression
39TREATMENT OF POSTPARTUM PSYCHOSIS Postpartum psychosis warrants emergency level care and usually requires inpatient hospitalizationTreat as affective psychosis—i.e. as Bipolar disorderMedication treatment is necessary beginning with an antipsychotic/mood stabilizer such as Zyprexa
40Suicide in the Postpartum Period Any indication of self-harm or suicidal ideation should be taken seriouslyFurther assessment and intervention are urgently required when a woman scores positive on item #10 on EPDS or question # 9 0n the PHQ-9Severe postpartum psychiatric disorder is associated with a high rate of death from natural and unnatural causes, particularly suicideSuicide risk in the first postnatal year is estimated to be increased by 70-fold (Appleby et al 1998)
41Age at Death for Infants Dying From Intentional or Suspicious Causes, US, 1990-97 Source: Centers for Disease Control and Prevention. WONDER, compressed mortality file, 2000.
42All women should be considered at risk for PPD and should be screened DESPITE MULTIPLE CONTACTS WITH MEDICALPROFESSIONALS FOLLOWING THE BIRTH OF A CHILD,POSTPARTUM DEPRESSION MOST OFTEN GOES UNDIAGNOSED.All women should be considered at risk for PPD and should be screened
43Need for Patient Education Lack of knowledge about PPD, treatment options, and community resources is common in postpartum women and their families, and frequently leads to delay in seeking treatmentDelay in treatment for PPD results in a longer illnessInformation about PPD should be provided to women in the prenatal period, soon after delivery, and further encounters with healthcare providers in the first postpartum year.
44Screening for Postpartum Depression Postpartum depression is often not recognizedDespite the availability of many screening tools, PPD remains underAbsence of screening often means untreated depression and poor outcomes for the mother, her newborn, and familyPostpartum depression can be screened for with simple and validated screening tools
46EPDSPlease UNDERLINE the answer that comes closest to how you have felt in the last seven days, not just how you are feeling today.1. I have been able to laugh and see the funny side of things.As much as I always couldNot so much nowDefinitely not so much nowNot at allI have looked forward with enjoyment to things.I have blamed myself unnecessarily when things went wrong.I have been anxious or worried for no good reason.I have felt scared or panicky for not very good reason.
47EPDS Things have been overwhelming me. I have been so unhappy I have had difficulty sleeping.I have felt sad or miserable.I have been so unhappy that I have been crying.The thought of harming myself has occurred to me.Scoring:0-3 points per questionScore > 10 warrants further assessment
49PHQ-9Over the last 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead, or of hurting yourself in some way
52PHQ-2Over the past two weeks, how often have you been bothered by any of thefollowing problems?Little interest or pleasure in doing things.Feeling down, depressed, or hopeless.0 = Not at all1 = Several days2 = More than half the days3 = Nearly every day
53Perinatal Depression Screening When to screen:Antenatal early risk assessment andscreening during pregnancy. ACOG recommendsthe PHQ-2 once per trimesterIf at high risk (prior history, neonatal loss, obstetrical complications, etc):Upon discharge from hospital. Need to assess support plan post dischargeAt early (2 week) follow up appointment
54Perinatal Depression Screening Postpartum OB/midwife visit 6-7 weeksWell child pediatrician visits for the first yearOther possible times:Lactation consultant visitVisiting home nurse
55Perinatal Depression Screening In a national sample, 57% of pediatricians felt responsible for recognizing maternal depression (Olson AL et al. Pediatrics. 2002;110: )Well-child visit is an ideal time to look for signs of PPD in the mother (See pediatric provider frequently first year)“Pediatricians should ascertain the physical and mental health of the parents in their practice and periodically review the importance of parents’ attention to their own mental health needs.”AAP: Report of the Task Force on the Family
56Perinatal Depression Screening Recognition is key: risk factors, warning signs, symptoms, early identificationBe alert for plans or intent to harm self (suicide), infant, othersIndications for emergency intervention: psychosis, risk of suicide or harm to the infantRefer to mental health professional if concomitant substance abuse, bipolar symptoms or history of bipolar disorder, history of psychiatric hospitalization
57Training for Office Staff Familiarize office staff with screening toolsTrain staff to ask the appropriate questions when woman callHave accessible and up to date contact for local emergency mental health careHave up to date information for other mental health resources: outpatient mental health providers, support groups, support associations such as PSI
58Perinatal Depression Screening Selection of treatment:first requires good evaluation, review of prior history, patient education and assessment for sociality/dangerousnessIndividual psychotherapy--CBT /IPTMedication with discussion of risks and benefitsBright light therapySupport groupSupport programsHospitalizationECT
59Obstacles to Screening Lack of familiarity (health care provider and patientLack of trainingLack of protocolsPatient’s reluctance to disclose feelingsLack of easy assess to mental health resourcesLack of timeLack of reimbursement
60What Do Women Need To Talk About? Negative childbirth experiences—especially with traumaConcerns about their infants—their temperaments, health issuesInteractions with their babies and caring for themHow this time differs from their expectationsFeelings of isolation
61What Do Women Need To Talk About? Loss—of prior employment role, closeness with spouse or older childFeelings of frustration , inadequacy in motheringBreastfeeding difficultiesLoss of care and attention received during pregnancyAmbivalence about returning to work and sense of loss when that is a necessity
62Maine LD 792 An Act to Promote Postpartum Mental Health Education Modeled after other state initiatives—i.e. New Jersey
63MAPP PPD PROJECTA statewide project funded by a grant from the American Psychiatric Association for the purpose of collaborating with other medical specialties and other members of the mental health community to promote understanding of postpartum depression as a psychiatric illness with serious consequences to mothers and infants, decrease stigma, and increase recognition and treatment of PPD
64PPD Resources www.postpartum.net Postpartum Support International Crisis hotline for postpartum depression and psychosis: PPD-MOMSNIMH supported websiteExcellent resource, regularly updated9 educational modules aimed at different provider categories offering CME’sMGH Center for Women’s mental Health1-800-PPD-MOMS Crisis hotline for postpartum depression and psychosis:Illinois Perinatal Mental health Consult Service—telephone consultation by perinatal mental health experts for any health care provider with prescriptive authority