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Update on Perinatal Mood Disorders

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1 Update on Perinatal Mood Disorders
William Watson, MD, FCFP Family Physician, St. Michael’s Hospital Simone Vigod, MD, MSc, FRCP(C) Staff Psychiatrist, Women’s College Hospital ASA, Toronto November 30, 2013

2 Objectives To learn about updated risk factors for perinatal mood disorders in the family practice context To learn about prevention and treatment of depressive and bipolar disorders in pregnancy and the postpartum period

3 Faculty/Presenter Disclosure
Faculty: Dr. Bill Watson and Dr. Simone Vigod Program: 51st Annual Scientific Assembly Relationships with commercial interests: NIL 3

4 Disclosure 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 presentation Dr. 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: NIL 4

5 Mitigating Potential Bias
There is no source of potential bias and no support or funding from pharmaceutical companies 5

6 Case 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 well No evidence of bipolarity, no history of psychosis or safety issues You treated her successfully with sertraline, and she has reached remission She and her new husband plan to try to become pregnant imminently She asks you if this is the right time to discontinue her antidepressant

7 Case 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?

8 Case 3-Mrs. C A 35 year old teacher
Brought to the office by her husband of 10 years He has noticed that since the birth of their one month old daughter, Mrs. C. has not been her normal self-he is worried Mrs. C starts to cry after you ask her about the baby She feels overwhelmed, a bad mother, and especially guilty about having had a baby Most of the time she is irritable and anxious Personal hx of abusive (psychological) mother You note she is tearful, frustrated, poor mother-infant interaction

9 Why know about perinatal mood disorders?
An important public health issue Risk 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

10 Why 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, suicide Postpartum: poor attachment/parenting, delayed infant motor, language and cognitive development, child behaviour problems, suicide/infanticide

11 Still face experiment

12 Spectrum of Illness Entire range of psychiatric disorders occur during the perinatal period Perinatal period generally defined from onset of pregnancy until ~ 1 year postpartum NOTE: DSM-5 defines perinatal onset for mood disorders as being onset during pregnancy or within 4 weeks postpartum Management often begins at pre-conception counseling for women with a personal history of mental health problems

13 Management of Perinatal Mood Disorders
Prevention Decision-making related to relapse risk, follow-up plans, psycho-education re: need for sleep and good social support Treatment Safety Assessment Risk-benefit analysis: safety of treatment during pregnancy/lactation vs. risks of untreated illness Options: Psychotherapy, Psychotropic Medication, ECT, Novel somatic treatments

14 Context in Family Practice
Hospital/office setting Well baby, well family exam Other family members/relationships Resources

15 Screening 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 things I 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 no very good reason Things have been getting on top of me I have been so unhappy that 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 Scored Scores > 13 associated with 10x likelihood that patient has major depression

16 PHQ 2 and 9 may detect PPD at well baby visits (Cochrane 2013)
82% sensitivity, 84% specificity Compares favorably with EPDS May be effective in screening for PPD PHQ-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

17 Why do postpartum mental health problems go undetected?
Normal vs abnormal? Guilt around depression Little preparation for postpartum Lack of recognition by peers and professionals Some women hide depression very well Postpartum 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.

18 Mood Disorders in Pregnancy

19 Mood Disorders in Pregnancy
Not necessarily a high risk time for new onset Although, in general, the 3rd and 4th decades of life are high risk for onset of mood disorders in women Unplanned pregnancy, marital or financial instability may pose risk Relapse rates of existing disorders are high Risk Factors for Relapse (Viguera 2011) Younger age at onset Previous postpartum episodes Fewer years of illness Bipolar disorder Fewer children, and Not being married The 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.

20 Relapse of Major Depression when Antidepressants are Discontinued
1.0 Maintained Rx (n=82) Discontinued Rx (n=65) 0.9 0.8 0.7 Proportion of Pregnant Women Remaining Euthymic 26% 0.6 0.5 0.4 Risk of recurrence was high when euthymic women discontinued antidepressants around time of conception Studies suggest 68-72% relapse rate vs. ~25% in women who continued treatment Relapses most likely to occur during 1st trimester 0.3 68% 0.2 HR: 5.0 ( ) 0.1 0.0 4 8 12 16 20 24 28 32 36 40 Weeks of Gestation Cohen et al. JAMA 2006;295(5):

21 Unipolar 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 depression Viguera 2011 (N=1132) Yonkers 2011 (16%) Cohen et al., JAMA 2006

22 Unipolar Depression in Pregnancy
In a sample that included women who were less severely ill Yonkers et al., 2011 Relapse rate = 16% Women with 4 or more episodes before pregnancy were at highest risk of depression in pregnancy Discontinuation of antidepressants in pregnancy did not have a strong effect on the development of a major depressive episode

23 Unipolar depression in pregnancy
Take Home Points: History of recurrent depression increases risk of depression in pregnancy Severity may be an effect modifier with respect to medication discontinuation: In women with severe and/or recurrent depression, discontinuation of medication represents risk of relapse In women with less severe histories of depression, the impact of medication discontinuation may not be as dramatic

24 Psychotropics Pregnancy Lactation 3 theoretical risks of meds
Teratogenesis (1st trimester exposure usually) Neonatal toxicity or withdrawal (3rd trimester) Developmental effects with latent childhood manifestations Lactation Passage into breast milk and theroretical risk of toxicity in the infant

25 Risk/Benefit Primer Maternal Depression SSRI/SNRI Medication
(likely class effect) Negative effects of depression on daily function, sense of well being, experience of pregnancy Factors associated with depression that may impact fetal outcomes: reduced antenatal care attendance, smoking, substance and alcohol use Increased risk of postpartum depression Possible negative effects on child in infancy and early childhood Evidence for marginally increased risk of: Spontaneous abortions (TM1) Preterm birth (no high risk of < 36 weeks) Lower birthweight (only by g) Lower APGAR scores Cardiovascular malformations (TM1) ARI 5/1000 to ~ 8/1000 Likely class effect despite early focus on paroxetine Neonatal persistent pulmonary hypertension AOR~2 in cohort studies (6 in case- control) for TM 2 exposure ARI 1.2/1000 to ~3/1000 Lack of evidence for any lasting neurodevelopmental effects BMJ 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,

26 Neonatal Adaptation Syndrome
Set of neurobehavioral signs occurring ~ 30% of SSRI/SNRI exposed full term babies vs. 10% of non exposed babies Possible symptoms Usually mild: Insomnia or somnolence ; Agitation , tremors, jitteriness, shivering and/ or altered tone; Restlessness, irritability & constant crying; poor feeding, vomiting/diarrhea Severe 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 lived Median 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 related Management supportive Women 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;

27 Psychotherapy in PMD In general, psychosocial and psychological treatments without meds are recommended as first-line treatment of antenatal depression Evidence 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 illness Need access and resources! In general, psychosocial and psychological treatments without medication therapy are recommended as first-line treatments for women with mild or mild–moderate depressive illness.5 Behavioral studies have examined the effectiveness of various psychosocial and psychological interventions for minor depressive disorder and major depressive disorder during pregnancy and the postpartum period. Tested interventions include antenatal and postnatal classes,76,77 group psycho-education, 78–81 postpartum debriefing before leaving the hospital or clinic,82–84 nondirective counseling,85,86 interpersonal psychotherapy,87–91 and cognitive behavioral therapy.92–97 Despite methodologic insufficiencies in some studies,122 these data indicate that individual psychotherapy is helpful for both pregnant and postpartum women with mild–moderate depression. A limitation is that evidence is strongest forstructured psychotherapies, particularly interpersonal psychotherapy and cognitive behavioral therapy.97,98 These treatments may not be feasible or readily available for some patients. In areas where such resources are not accessible, other psychotherapeutic interventions also may prove useful.

28 Antidepressant Medication
SSRI or SNRI is first line treatment for moderate to severe depression No evidence for preferred treatments based on effectiveness or safety, but most safety data on older SSRI/SNRIs Usually no need to change dose for pharmacokinetic reasons Sertraline and Paroxetine usually undetectable in serum of breastfed infants, Others < 10% passage but no adverse events reported < 20% of women accept treatment Misinformation about risks (untreated illness and treatment) Stigma/Pressure from family, friends, media and providers

29 Other antidepressants
Other first-line antidepressants E.g. Bupoprion, Mirtazapine Much less data than SSRI/SNRIs, but nature and magnitude of risks likely similar Tricyclic Antidepressants No clear concerns about teratogenicity, but withdrawal syndromes occur in neonates Blood 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

30 Benzodiazepines May be required for concurrent management of anxiety and/or sleep in severe cases Contradictory data on increased risk of cleft palate/lip with 1st trimester exposure Best to avoid in 1st trimester Theoretical risk of neonatal withdrawal and of toxicity in breast-feeding Use shorter half-live drugs – lorazepam, clonazepam Monitor infants

31 ECT Efficacious, but has side effects and requires general anesthetic
Risk is minimal but not non-existent Case reports suggest potential associations with adverse cardiovascular events and some adverse neonatal outcomes Use in pregnancy usually limited to: severe treatment-resistant depression, acute suicidality, psychotic depression, or severe dehydration/malnutrition secondary to a depressive syndrome

32 Alternative Treatments
If there is benefit, then it is likely for women with mild depressive illness Limited support for some non-pharmacologic alternatives to psychotherapy: Dietary calcium, Exercise, Massage therapy, Bright light therapy Early enthusiasm for omega-3 fatty acids Most randomized clinical trials to date have failed to show that the active treatment differs from placebo There is limited support for some nonpharmacologic alternatives to psychotherapy, including dietary calcium, 113 exercise,114 massage therapy,115,116 and bright light therapy.117,118 If there is benefit, then it is likely for women with mild depressive illness and should not be recommended as the standard of care for women with moderate to severe major depressive disorder. There was early enthusiasm for omega-3 fatty acids, although most randomized clinical trials to date have failed to show that the active treatment differs from placebo.119–121 Electroconvulsive therapy has been used to treat major depressive disorder and bipolar disorder in pregnant women and has been shown to be highly efficacious. It requires a general anesthetic and is associated with side effects for patients such as memory loss. A review of the literature of electroconvulsive therapy use in pregnancy shows that it has been associated with adverse cardiac effects, as well as some adverse neonatal outcomes.111 As such, its use in pregnancy is usually limited to severe treatmentresistant cases of depression, acute suicidal tendencies, depression with psychotic features, or severe dehydration or malnutrition that can occur as part of a depressive syndrome. Although it is unlikely that an obstetrician will initiate electroconvulsive-therapy treatment, he or she likely will be involved in the decision to use it and in the comanagement of care for patients who require it. Techniques such as repetitive transcranial magnetic stimulation are being investigated widely for the treatment of severe or treatment-resistant major depressive disorder. Because magnetic fields have been associated with increased risk of miscarriage, there is a theoretical risk to administering transcranial magnetic stimulation in pregnant women.112 Although it is not yet recommended for pregnant women, it is an experimental treatment that is undergoing study in pregnant populations.

33 Alternative Treatments
Repetitive Transcranial Magnetic Stimulation (rTMS) Investigated widely for severe or treatment-resistant depression Magnetic fields have been associated with increased risk of miscarriage --- there is a theoretical risk to administering transcranial magnetic stimulation in pregnant women However, it is under study in pregnant populations There is a clear need for safe and rapidly effective treatments for women with depression in pregnancy

34 Bipolar disorder in Pregnancy
Relapse risk high 25-75% depending on population studied Up to ¾ episodes depressed/mixed and ½ in 1st trimester (for women euthymic at conception) (Viguera 2007) … and related to medication discontinuation Recurrence risk two-fold greater in those who discontinued medication with median time to recurrence 4x shorter Median time to recurrence 11 times shorter if meds discontinued abruptly vs. gradually The 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.

35 Risks of Continuing medication
Weigh risk/impact of relapse vs. Potential risks of medication use

36 Mood Stabilizers Lithium
Only slightly increased risk of cardiac defects (e.g. ebstein’s anomaly) when used in pregnancy Need to attend to ECF changes in pregnancy AND massive ECF contraction at delivery Some recommend discontinuation of Lithium with onset of labour and restart day 2 postpartum Passes into breast milk and toxicity can be substantial therefore CLOSE monitoring if used

37 Mood Stabilizers Valproate Lamotrigine
Teratogenic (neural tube defects - NTD) Recent reports of developmental delay in breastfed infants Lamotrigine Risk of NTD Passes into breast milk (up to 30% of maternal levels)  theoretical risk of rash

38 Anti-psychotics Minimal data in breast-feeding Pregnancy:
Haloperidol best studied – not thought teratogenic Main Issue with newer anti-psychotics is potential for weight gain and gestational diabetes FDA warning re: Extra-pyramidal symptoms (EPS) in newborns Minimal data in breast-feeding Clozapine and Olanzapine not recommended due to risk of blood abnormalities and EPS respectively Due to risk of blood abnormalities and some case reports of EPS

39 Summary re: management in pregnancy
There are substantial risks to untreated mood disorders in the pregnancy Choice of treatment involves a risk-benefit analysis unique to each patient Do not underestimate effect of decisional conflict, stigma and lack of support for women faced with these decisions about medication use

40 Postpartum mood disorders

41 Postpartum Mood Disorders
Risk appears to be substantially higher than in pregnancy both for new onset and recurrent mood disorders Formulation? 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 style Social factors: social support, life stressors (e.g. health of baby, financial, intimate partner violence)

42 Copyright © American Psychiatric Association. All rights reserved.
From: Episodes of Mood Disorders in 2,252 Pregnancies and Postpartum Periods American Journal of Psychiatry 2011; 168: doi: /appi.ajp Figure Legend: Episode Occurrence Rates of Major Affective Episodes During Pregnancy and During the Postpartum Period in 1,162 Women With Bipolar I, Bipolar II, or Major Depressive Disordera Date of download: 2/22/2012 Copyright © American Psychiatric Association. All rights reserved.

43 Postpartum Mood Symptom Spectrum
Baby Blues: up to 75%, within days, resolves within first month without treatment, likely hormone-related Postpartum 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*)

44 Post-Partum Depression
Onset: DSM 5 indicates within 4 weeks of delivery, genetics work suggests onset 6-8 weeks and clinically, even later onset observed Risk Factors: Untreated depression/anxiety in pregnancy, poor sleep , poor social support, stressful life events Symptoms: same as major depressive episode 50% with anxiety – panic, obsessive ruminations Themes of incompetence, obsessional harm (differentiate from psychosis)

45 Bipolar Disorder Postpartum
Relapse 30-50% - acute and severe mostly depressive Risk Factors (other than medication discontinuation): Younger age, primiparity, sleep/biological rhythm disturbance Psychosocial risk factors play less of a role Increased risk of postpartum psychosis 90% within 4 weeks of delivery Marked by confusion, thought disorder Small but serious risk of suicide/infanticide

46 Back 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 treatment Consider 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

47 Possible Plans: Sarah Discontinue Continue
Monitor for recurrence of illness If illness recurs in pregnancy: consider non-pharmacologic and pharmacologic treatment strategies and potentially restart medication Plan for prevention of postpartum depression No clear evidence for prophylactic re-start of medication postpartum in euthymic women Continue Pharmacokinetic changes in pregnancy and at delivery Absorption (watch emesis) Distribution (increased ECF during pregnancy – contracts rapidly at delivery) Increased hepatic metabolism Echocardiogram screening Continue to monitor and plan for prevention of PPD Counsel around potential risks of antidepressant use and NAS Counsel patient around antidepressants in lactation

48 Other 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?

49 Case 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?

50 Case 2-Commentary Depression vs Blues PHQ 2 = 2
Ref to Lactation consultant -Early follow-up for mom and baby

51 Case 3-Mrs. C A 35 year old teacher
Brought to the office by her husband of 10 years He has noticed that since the birth of their one month old daughter, Mrs. C. has not been her normal self-he is worried Mrs. C starts to cry after you ask her about the baby She feels overwhelmed, a bad mother, and especially guilty about having had a baby, not sleeping Most of the time she is irritable and anxious Personal hx of abusive (psychological) mother You note she is tearful, frustrated, poor mother-infant interaction

52 Case 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

53 Postpartum Depression Management
Lifestyle and Social Support: Ensure adequate sleep, engage social supports Psychotherapy: For mild and moderate depression, evidence for interpersonal psychotherapy and cognitive behaviour therapy (group and individual) Medication: Same principles as non-postpartum all 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

54 Bipolar 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 strategy Safety Assessment: mother, baby (+/- other kids) Treatment: based on nature and severity of illness Psychotherapy: Strongest evidence for Interpersonal Therapy (IPT) where focus is on role transition to parenthood and improving communication abilities and social support Psychotropic medication: as indicated, consider passage into breastmilk and risk of toxicity Somatic Therapies Evidence for CBT is also good Limited evidence for antenatal and postnatal classes, group psycho-education, postpartum debriefing before leaving the hospital, nondirective counseling

55 Management When to refer (examples)? Diagnostic clarity
Need for specialized psychotherapy Failure to respond to first-line antidepressant medication treatment Postpartum psychosis - a psychiatric emergency Do not leave mother unsupervised Send to emergency department (hospital) for assessment and treatment –Form 1

56 Useful References Hendrick, 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: 72-86,2009 Yonkers 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, 2009 Yonkers 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: 4-9,2007 Einarson A, Boskovic R: Use and safety of antipsychotic drugs during pregnancy. J Psychiatr Pract 15: ,2009

57 Questions/Discussion


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