Presentation on theme: "Update on Perinatal Mood Disorders"— Presentation transcript:
1Update on Perinatal Mood Disorders William Watson, MD, FCFPFamily Physician, St. Michael’s HospitalSimone Vigod, MD, MSc, FRCP(C)Staff Psychiatrist, Women’s College HospitalASA, TorontoNovember 30, 2013
2ObjectivesTo learn about updated risk factors for perinatal mood disorders in the family practice contextTo learn about prevention and treatment of depressive and bipolar disorders in pregnancy and the postpartum period
3Faculty/Presenter Disclosure Faculty: Dr. Bill Watson and Dr. Simone VigodProgram: 51st Annual Scientific AssemblyRelationships with commercial interests:NIL3
4Disclosure of Commercial Support Dr. Watson has received some financial support from the OCFP in the form of an honorarium, and has no financial disclosures or conflicts of interest related to this presentationDr. Vigod receives salary support from the Ontario Mental Health Foundation (New Investigator Fellowship), Women’s College Hospital and Research Institute (Shirley-Brown Clinician Scientist), and the Dept. of Psychiatry, University of Toronto• She receives operating funds from the Canadian Institutes of Health Research (CIHR), the Schizophrenia Society of Ontario and the Ontario Ministry of Health and Long Term Care (MOHLTC)• She has no financial disclosures or conflicts of interest to declare relevant to this presentation.Potential for conflict(s) of interest: NIL4
5Mitigating Potential Bias There is no source of potential bias and no support or funding from pharmaceutical companies5
6Case 1: Sarah 29-year-old, married, real estate agent Had a depressive episode 2 years ago where she lost interest in work and quit her job, which negatively affected her interpersonal relationships as wellNo evidence of bipolarity, no history of psychosis or safety issuesYou treated her successfully with sertraline, and she has reached remissionShe and her new husband plan to try to become pregnant imminentlyShe asks you if this is the right time to discontinue her antidepressant
7Case 2: Maria, aged 22 Maria, G1P1, five-day-old baby boy - checkup. Maria, G1P1, five-day-old baby boy - checkup.Normal pregnancy and delivery, baby is healthy but has lost 100 g since birth. Maria is breastfeeding and having difficulty with the baby’s latch, and she thinks she doesn’t produce enough milk. She looks very tired and on the verge of tears.Maria says she hasn't been out of the house since the baby was born, and that she has been crying frequently. She worries about the house being a mess when visitors arrive.John, the baby’s father, accompanies them. John is bewildered by her tears and asks you if her tearfulness is normal. He is concerned about how she is feeling and quietly asks if she is depressed.What is the next step?
8Case 3-Mrs. C A 35 year old teacher Brought to the office by her husband of 10 yearsHe has noticed that since the birth of their one month old daughter, Mrs. C. has not been her normal self-he is worriedMrs. C starts to cry after you ask her about the babyShe feels overwhelmed, a bad mother, and especially guilty about having had a babyMost of the time she is irritable and anxiousPersonal hx of abusive (psychological) motherYou note she is tearful, frustrated, poor mother-infant interaction
9Why know about perinatal mood disorders? An important public health issueRisk of a Major Depressive Episode is up to 10% in pregnancy, 15% postpartum (higher than age-matched point prevalence in the non-pregnant population)Risk of bipolar disorder relapse is high in pregnancy and very high in the postpartum period
10Why know about perinatal mood disorders? Potential Impact of untreated mood disorders on mother, baby and family can be profound:Pregnancy: spontaneous abortion, poor prenatal care, substance use, poor fetal growth, preterm labour, suicidePostpartum: poor attachment/parenting, delayed infant motor, language and cognitive development, child behaviour problems, suicide/infanticide
12Spectrum of IllnessEntire range of psychiatric disorders occur during the perinatal periodPerinatal period generally defined from onset of pregnancy until ~ 1 year postpartumNOTE: DSM-5 defines perinatal onset for mood disorders as being onset during pregnancy or within 4 weeks postpartumManagement often begins at pre-conception counseling for women with a personal history of mental health problems
13Management of Perinatal Mood Disorders PreventionDecision-making related to relapse risk, follow-up plans, psycho-education re: need for sleep and good social supportTreatmentSafety AssessmentRisk-benefit analysis: safety of treatment during pregnancy/lactation vs. risks of untreated illnessOptions: Psychotherapy, Psychotropic Medication, ECT, Novel somatic treatments
14Context in Family Practice Hospital/office settingWell baby, well family examOther family members/relationshipsResources
15Screening tools National Institutes for Clinical Excellence (NICE) During the past month, have you often been bothered by feeling down, depressed or hopeless?During the past month, have you often been bothered by having little interest or pleasure in doing things?If the woman answers 'Yes' to both questions a further question should be asked:Is this something you feel you need or want help with?Edinburgh Postnatal Deperssion Scale (EPDS)In the past seven days:I have been able to laugh and see the funny side of thingsI have looked forward with enjoyment to thingsI have blamed myself unnecessarily when things went wrongI have been anxious or worried for no good reasonI have felt scared or panicky for no very good reasonThings have been getting on top of meI have been so unhappy that I have had difficulty sleepingI have felt sad or miserableI have been so unhappy that I have been cryingThe thought of harming myself has occurred to meScored Scores > 13 associated with 10x likelihood that patient has major depression
16PHQ 2 and 9 may detect PPD at well baby visits (Cochrane 2013) 82% sensitivity, 84% specificityCompares favorably with EPDSMay be effective in screening for PPDPHQ-2=During the past 2 weeks, how often have you been bothered by:Little interest or pleasure in doing things (0-3)Feeling down, depressed or hopeless (0-3)If score > 3, use PHQ-9
17Why do postpartum mental health problems go undetected? Normal vs abnormal?Guilt around depressionLittle preparation for postpartumLack of recognition by peers and professionalsSome women hide depression very wellPostpartum mental health problems frequently go undetected for several reasons (Misri, 1995): Some characteristics of “normal” adjustment may be difficult to distinguish from the early symptoms of an emotional disorder. These include anxiety, insomnia, fatigue, episodes of crying, and, in some cases, dysphoria. Many women experiencing symptoms of postpartum emotional distress may be reluctant to reveal them to those around them. At a time when they are expected to feel elated and happy, such symptoms may lead to embarrassment and shame. In turn, this shame may cause affected women to remain silent about their distress, even when they are asked about it directly. Parents-to-be receive considerable preparation for the physical aspects of birth. Unfortunately, they are rarely prepared for the emotional challenges of parenthood, or given information about the stressors they may face. Thus, when disturbing feelings and events arise during the postpartum period, they may conclude that their reactions are unusual and reflect their own inadequacies as parents. Peers and professionals alike may dismiss postpartum women’s emotional concerns. Distressing feelings may be attributed to “hormones” and passed off as irrelevant and unimportant. Like affected women themselves, peers and professionals may also feel that such feelings reflect some weakness in the woman. Some women hide postpartum depression extremely well. They are afraid and ashamed to reveal how they feel, in case someone will think they are crazy or will take their child away.
19Mood Disorders in Pregnancy Not necessarily a high risk time for new onsetAlthough, in general, the 3rd and 4th decades of life are high risk for onset of mood disorders in womenUnplanned pregnancy, marital or financial instability may pose riskRelapse rates of existing disorders are highRisk Factors for Relapse (Viguera 2011)Younger age at onsetPrevious postpartum episodesFewer years of illnessBipolar disorderFewer children, andNot being marriedThe overall risk of at least one recurrence in pregnancy was 71%. Among women who discontinued versus continued mood stabilizer treatment, recurrence risk was twofold greater, median time to first recurrence was more than fourfold shorter, and the proportion of weeks ill during pregnancy was five times greater. Median recurrence latency was 11 times shorter after abrupt/rapid versus gradual discontinuation of mood stabilizer. Most recurrences were depressive or mixed (74%), and 47% occurred during the first trimester. Predictors of recurrence included bipolar II disorder diagnosis, earlier onset, more recurrences/year, recent illness, use of antidepressants, and use of anticonvulsants versus lithium.
20Relapse of Major Depression when Antidepressants are Discontinued 1.0Maintained Rx (n=82)Discontinued Rx(n=65)0.90.80.7Proportion of Pregnant Women Remaining Euthymic26%0.60.50.4Risk of recurrence was high when euthymic women discontinued antidepressants around time of conceptionStudies suggest 68-72% relapse rate vs. ~25% in women who continued treatmentRelapses most likely to occur during 1st trimester0.368%0.2HR: 5.0 ( )0.10.0481216202428323640Weeks of GestationCohen et al. JAMA 2006;295(5):
21Unipolar Depression in Pregnancy But….In the Cohen et al. study, the overall relapse rate was 43% and ~ 75% of the women had 3+ prior episodes of depressionViguera 2011 (N=1132)Yonkers 2011 (16%)Cohen et al., JAMA 2006
22Unipolar Depression in Pregnancy In a sample that included women who were less severely ill Yonkers et al., 2011Relapse rate = 16%Women with 4 or more episodes before pregnancy were at highest risk of depression in pregnancyDiscontinuation of antidepressants in pregnancy did not have a strong effect on the development of a major depressive episode
23Unipolar depression in pregnancy Take Home Points:History of recurrent depression increases risk of depression in pregnancySeverity may be an effect modifier with respect to medication discontinuation:In women with severe and/or recurrent depression, discontinuation of medication represents risk of relapseIn women with less severe histories of depression, the impact of medication discontinuation may not be as dramatic
24Psychotropics Pregnancy Lactation 3 theoretical risks of meds Teratogenesis (1st trimester exposure usually)Neonatal toxicity or withdrawal (3rd trimester)Developmental effects with latent childhood manifestationsLactationPassage into breast milk and theroretical risk of toxicity in the infant
25Risk/Benefit Primer Maternal Depression SSRI/SNRI Medication (likely class effect)Negative effects of depression on daily function, sense of well being, experience of pregnancyFactors associated with depression that may impact fetal outcomes: reduced antenatal care attendance, smoking, substance and alcohol useIncreased risk of postpartum depressionPossible negative effects on child in infancy and early childhoodEvidence for marginally increased risk of:Spontaneous abortions (TM1)Preterm birth (no high risk of < 36 weeks)Lower birthweight (only by g)Lower APGAR scoresCardiovascular malformations (TM1)ARI 5/1000 to ~ 8/1000Likely class effect despite early focus on paroxetineNeonatal persistent pulmonary hypertensionAOR~2 in cohort studies (6 in case- control) for TM 2 exposureARI 1.2/1000 to ~3/1000Lack of evidence for any lasting neurodevelopmental effectsBMJ Jan 12;344:d8012. doi: /bmj.d8012.Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the newborn: population based cohort study from the five Nordic countries.Kieler H, Artama M, Engeland A, Ericsson O, Furu K, Gissler M, Nielsen RB, Nørgaard M, Stephansson O, Valdimarsdottir U, Zoega H, Haglund B.Yonkers, K. A., Wisner, K. L., Stewart, D. E., Oberlander, T. F., Dell, D. L., Stotland, N., … Lockwood, C. (2009). The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. American Psychiatric Association, 114,
26Neonatal Adaptation Syndrome Set of neurobehavioral signs occurring ~ 30% of SSRI/SNRI exposed full term babies vs. 10% of non exposed babiesPossible symptomsUsually mild: Insomnia or somnolence ; Agitation , tremors, jitteriness, shivering and/ or altered tone; Restlessness, irritability & constant crying; poor feeding, vomiting/diarrheaSevere syndrome that consists of seizures, dehydration, excessive weight loss, hyperpyrexia (poor temperature control), or intubation (due to tachypnea/respiratory distress) is rare in term infants (1/313 quantifiable cases)*Duration Usually short livedMedian duration of 3 days, and 75 % complete resolution by 5 days (max 4 weeks)’Premature babies are more vulnerable to NAS, and are more likely to develop signs, which may be more severe.Weak evidence that severity of symptoms may be dose relatedManagement supportiveWomen taking antidepressants should deliver in a hospital with paediatric support and the baby should have regular cardio respiratory and temperature monitoring for a minimum of 48 hours.Simple supportive measures such as reassurance, frequent feeding and encouragement of skin to skin contact to aid regulation are usually sufficient.Breastfeeding of infants with NAS is not contraindicated, and in fact may alleviate withdrawal syndromes. These infants should continue to be monitored for NAS after discharge from hospital.Neonatal Signs After Late In Utero Exposure to Serotonin Reuptake Inhibitors. Moses-Kolko et al.JAMA 2005; 293;
27Psychotherapy in PMDIn general, psychosocial and psychological treatments without meds are recommended as first-line treatment of antenatal depressionEvidence that individual psychotherapy may be useful in women with mild-moderate symptoms (IPT and CBT have best evidence)Takes time… while fetus may be exposed to effects of illnessNeed access and resources!In general, psychosocialand psychological treatments without medicationtherapy are recommended as first-line treatmentsfor women with mild or mild–moderate depressiveillness.5 Behavioral studies have examined the effectivenessof various psychosocial and psychologicalinterventions for minor depressive disorder and majordepressive disorder during pregnancy and thepostpartum period. Tested interventions include antenataland postnatal classes,76,77 group psycho-education,78–81 postpartum debriefing before leaving thehospital or clinic,82–84 nondirective counseling,85,86 interpersonalpsychotherapy,87–91 and cognitive behavioraltherapy.92–97 Despite methodologic insufficienciesin some studies,122 these data indicate thatindividual psychotherapy is helpful for both pregnantand postpartum women with mild–moderate depression.A limitation is that evidence is strongest forstructured psychotherapies, particularly interpersonalpsychotherapy and cognitive behavioral therapy.97,98These treatments may not be feasible or readilyavailable for some patients. In areas where suchresources are not accessible, other psychotherapeuticinterventions also may prove useful.
28Antidepressant Medication SSRI or SNRI is first line treatment for moderate to severe depressionNo evidence for preferred treatments based on effectiveness or safety, but most safety data on older SSRI/SNRIsUsually no need to change dose for pharmacokinetic reasonsSertraline and Paroxetine usually undetectable in serum of breastfed infants, Others < 10% passage but no adverse events reported< 20% of women accept treatmentMisinformation about risks (untreated illness and treatment)Stigma/Pressure from family, friends, media and providers
29Other antidepressants Other first-line antidepressantsE.g. Bupoprion, MirtazapineMuch less data than SSRI/SNRIs, but nature and magnitude of risks likely similarTricyclic AntidepressantsNo clear concerns about teratogenicity, but withdrawal syndromes occur in neonatesBlood levels can be monitored through pregnancy and will likely require dosage increases as pregnancy progresses, although clinical assessment is a better marker of response than blood levels
30BenzodiazepinesMay be required for concurrent management of anxiety and/or sleep in severe casesContradictory data on increased risk of cleft palate/lip with 1st trimester exposureBest to avoid in 1st trimesterTheoretical risk of neonatal withdrawal and of toxicity in breast-feedingUse shorter half-live drugs – lorazepam, clonazepamMonitor infants
31ECT Efficacious, but has side effects and requires general anesthetic Risk is minimal but not non-existentCase reports suggest potential associations with adverse cardiovascular events and some adverse neonatal outcomesUse in pregnancy usually limited to: severe treatment-resistant depression, acute suicidality, psychotic depression, or severe dehydration/malnutrition secondary to a depressive syndrome
32Alternative Treatments If there is benefit, then it is likely for women with mild depressive illnessLimited support for some non-pharmacologic alternatives to psychotherapy: Dietary calcium, Exercise, Massage therapy, Bright light therapyEarly enthusiasm for omega-3 fatty acidsMost randomized clinical trials to date have failed to show that the active treatment differs from placeboThere is limited support for some nonpharmacologicalternatives to psychotherapy, including dietary calcium,113 exercise,114 massage therapy,115,116 and brightlight therapy.117,118 If there is benefit, then it is likelyfor women with mild depressive illness and shouldnot be recommended as the standard of care forwomen with moderate to severe major depressivedisorder. There was early enthusiasm for omega-3fatty acids, although most randomized clinical trials todate have failed to show that the active treatmentdiffers from placebo.119–121Electroconvulsive therapy has been used to treatmajor depressive disorder and bipolar disorder inpregnant women and has been shown to be highlyefficacious. It requires a general anesthetic and isassociated with side effects for patients such as memoryloss. A review of the literature of electroconvulsivetherapy use in pregnancy shows that it has beenassociated with adverse cardiac effects, as well assome adverse neonatal outcomes.111 As such, its use inpregnancy is usually limited to severe treatmentresistantcases of depression, acute suicidal tendencies,depression with psychotic features, or severedehydration or malnutrition that can occur as part ofa depressive syndrome. Although it is unlikely that anobstetrician will initiate electroconvulsive-therapytreatment, he or she likely will be involved in thedecision to use it and in the comanagement of care forpatients who require it. Techniques such as repetitive transcranial magneticstimulation are being investigated widely for the treatment of severe or treatment-resistant major depressivedisorder. Because magnetic fields have beenassociated with increased risk of miscarriage, there isa theoretical risk to administering transcranial magneticstimulation in pregnant women.112 Although it isnot yet recommended for pregnant women, it is anexperimental treatment that is undergoing study inpregnant populations.
33Alternative Treatments Repetitive Transcranial Magnetic Stimulation (rTMS)Investigated widely for severe or treatment-resistant depressionMagnetic fields have been associated with increased risk of miscarriage --- there is a theoretical risk to administering transcranial magnetic stimulation in pregnant womenHowever, it is under study in pregnant populationsThere is a clear need for safe and rapidly effective treatments for women with depression in pregnancy
34Bipolar disorder in Pregnancy Relapse risk high25-75% depending on population studiedUp to ¾ episodes depressed/mixed and ½ in 1st trimester (for women euthymic at conception) (Viguera 2007)… and related to medication discontinuationRecurrence risk two-fold greater in those who discontinued medication with median time to recurrence 4x shorterMedian time to recurrence 11 times shorter if meds discontinued abruptly vs. graduallyThe overall risk of at least one recurrence in pregnancy was 71%. Among women who discontinued versus continued mood stabilizer treatment, recurrence risk was twofold greater, median time to first recurrence was more than fourfold shorter, and the proportion of weeks ill during pregnancy was five times greater. Median recurrence latency was 11 times shorter after abrupt/rapid versus gradual discontinuation of mood stabilizer. Most recurrences were depressive or mixed (74%), and 47% occurred during the first trimester. Predictors of recurrence included bipolar II disorder diagnosis, earlier onset, more recurrences/year, recent illness, use of antidepressants, and use of anticonvulsants versus lithium.
35Risks of Continuing medication Weigh risk/impact of relapsevs.Potential risks of medication use
36Mood Stabilizers Lithium Only slightly increased risk of cardiac defects (e.g. ebstein’s anomaly) when used in pregnancyNeed to attend to ECF changes in pregnancy AND massive ECF contraction at deliverySome recommend discontinuation of Lithium with onset of labour and restart day 2 postpartumPasses into breast milk and toxicity can be substantial therefore CLOSE monitoring if used
37Mood Stabilizers Valproate Lamotrigine Teratogenic (neural tube defects - NTD)Recent reports of developmental delay in breastfed infantsLamotrigineRisk of NTDPasses into breast milk (up to 30% of maternal levels) theoretical risk of rash
38Anti-psychotics Minimal data in breast-feeding Pregnancy: Haloperidol best studied – not thought teratogenicMain Issue with newer anti-psychotics is potential for weight gain and gestational diabetesFDA warning re: Extra-pyramidal symptoms (EPS) in newbornsMinimal data in breast-feedingClozapine and Olanzapine not recommended due to risk of blood abnormalities and EPS respectivelyDue to risk of blood abnormalities and some case reports of EPS
39Summary re: management in pregnancy There are substantial risks to untreated mood disorders in the pregnancyChoice of treatment involves a risk-benefit analysis unique to each patientDo not underestimate effect of decisional conflict, stigma and lack of support for women faced with these decisions about medication use
41Postpartum Mood Disorders Risk appears to be substantially higher than in pregnancy both for new onset and recurrent mood disordersFormulation?Biological factors such as genetic predisposition to rapid change in hormones at delivery…. May also have medical issues (anemia, thyroid)Psychological factors: psychodynamic considerations (e.g. history of trauma, separation-individuation, issues with dependency), personality and coping styleSocial factors: social support, life stressors (e.g. health of baby, financial, intimate partner violence)
43Postpartum Mood Symptom Spectrum Baby Blues: up to 75%, within days, resolves within first month without treatment, likely hormone-relatedPostpartum Depression (PPD): major depressive episode (MDD) with onset in the 1st postpartum year (requires treatment)Postpartum Psychosis: psychotic episode, 90% occurring within first 3 months postpartum, likely a bipolar disorder presentation (*Psychiatric Emergency*)
44Post-Partum Depression Onset: DSM 5 indicates within 4 weeks of delivery, genetics work suggests onset 6-8 weeks and clinically, even later onset observedRisk Factors: Untreated depression/anxiety in pregnancy, poor sleep , poor social support, stressful life eventsSymptoms: same as major depressive episode50% with anxiety – panic, obsessive ruminationsThemes of incompetence, obsessional harm (differentiate from psychosis)
45Bipolar Disorder Postpartum Relapse 30-50% - acute and severemostly depressiveRisk Factors (other than medication discontinuation):Younger age, primiparity, sleep/biological rhythm disturbancePsychosocial risk factors play less of a roleIncreased risk of postpartum psychosis90% within 4 weeks of deliveryMarked by confusion, thought disorderSmall but serious risk of suicide/infanticide
46Back to Sarah Is this right time to discontinue her antidepressant? Consider severity/recurrence of depressive illness (attn: to prior pregnancies/postpartum periods and premenstrual symptoms)Consider how quickly/effectively she responds to non-pharmacological and pharmacological treatmentConsider other risk factors for poor pregnancy outcomes or relapse (e.g. medical and psychiatric comorbidity, psychosocial)Consider gestational age of patient (i.e. planning vs. 1st trimester)Consider her personal preferences
47Possible Plans: Sarah Discontinue Continue Monitor for recurrence of illnessIf illness recurs in pregnancy: consider non-pharmacologic and pharmacologic treatment strategies and potentially restart medicationPlan for prevention of postpartum depressionNo clear evidence for prophylactic re-start of medication postpartum in euthymic womenContinuePharmacokinetic changes in pregnancy and at deliveryAbsorption (watch emesis)Distribution (increased ECF during pregnancy – contracts rapidly at delivery)Increased hepatic metabolismEchocardiogram screeningContinue to monitor and plan for prevention of PPDCounsel around potential risks of antidepressant use and NASCounsel patient around antidepressants in lactation
48Other considerations If she elects to continue: Would you recommend changing to a different antidepressant?Should you reduce her dose or discontinue in 3rd trimester to avoid NAS?What if she had presented already pregnant… at 14 weeks gestation?
49Case 2: Maria, aged 22 Maria, G1P1, five-day-old baby boy - checkup. Maria, G1P1, five-day-old baby boy - checkup.Normal pregnancy and delivery, baby is healthy but has lost 100 g since birth. Maria is breastfeeding and having difficulty with the baby’s latch, and she thinks she doesn’t produce enough milk. She looks very tired and on the verge of tears.Maria says she hasn't been out of the house since the baby was born, and that she has been crying frequently. She worries about the house being a mess when visitors arrive.John, the baby’s father, accompanies them. John is bewildered by her tears and asks you if her tearfulness is normal. He is concerned about how she is feeling and quietly asks if she is depressed.What is the next step?
50Case 2-Commentary Depression vs Blues PHQ 2 = 2 Ref to Lactation consultant-Early follow-up for mom and baby
51Case 3-Mrs. C A 35 year old teacher Brought to the office by her husband of 10 yearsHe has noticed that since the birth of their one month old daughter, Mrs. C. has not been her normal self-he is worriedMrs. C starts to cry after you ask her about the babyShe feels overwhelmed, a bad mother, and especially guilty about having had a baby, not sleepingMost of the time she is irritable and anxiousPersonal hx of abusive (psychological) motherYou note she is tearful, frustrated, poor mother-infant interaction
52Case 3 -commentary -PHQ2= 6, EPDS=20 -Mrs. C likely has postpartum mood disorder-important to discuss findings with her and her husband-make urgent referral to psych-consider using SSRI/SNRI +/- hypnotic-referral to support group-early follow up
53Postpartum Depression Management Lifestyle and Social Support: Ensure adequate sleep, engage social supportsPsychotherapy: For mild and moderate depression, evidence for interpersonal psychotherapy and cognitive behaviour therapy (group and individual)Medication: Same principles as non-postpartumall antidepressant medications pass into breastmilk at < 10% of maternal dose;use of benzodiazepines is NOT an absolute contraindication for breastfeeding with healthy full-term infant
54Bipolar Disorder Management Prevention: social support, sleep protection, some advise longer stay with rooming out of baby for high risk mothers but evidence limited for this strategySafety Assessment: mother, baby (+/- other kids)Treatment: based on nature and severity of illnessPsychotherapy: Strongest evidence for Interpersonal Therapy (IPT) where focus is on role transition to parenthood and improving communication abilities and social supportPsychotropic medication: as indicated, consider passage into breastmilk and risk of toxicitySomatic TherapiesEvidence for CBT is also goodLimited evidence for antenatal and postnatal classes, group psycho-education, postpartum debriefing before leaving the hospital, nondirective counseling
55Management When to refer (examples)? Diagnostic clarity Need for specialized psychotherapyFailure to respond to first-line antidepressant medication treatmentPostpartum psychosis - a psychiatric emergencyDo not leave mother unsupervisedSend to emergency department (hospital) for assessment and treatment –Form 1
56Useful ReferencesHendrick, V and Gitlin, M. Psychotropic Drugs and Women: Fast Facts, Norton and Company, NY, 2004.Payne JL, Palmer JT, Joffe H: A reproductive subtype of depression: Conceptualizing models and moving toward etiology. Harv Rev Psychiatry 17: 72-86,2009Yonkers KA, Wisner KL, Stewart DE, Oberlander TF, Dell DL, Stotland N, Ramin S, Chaudron L, Lockwood C. The management of depression during pregnancy: A report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry Sep-Oct;31(5):403-13, 2009Yonkers KA, Vigod S, Ross LE. Diagnosis, Pathophysiology and management of mood disorders in pregnant and postpartum women. Obstet Gynecol Apr;117(4): Review.Cohen LS: Treatment of bipolar disorder during pregnancy. J Clin Psychiatry 68 Suppl 9: 4-9,2007Einarson A, Boskovic R: Use and safety of antipsychotic drugs during pregnancy. J Psychiatr Pract 15: ,2009