2. Perinatal Mood And Anxiety Disorders Pec Indman EdD, MFT

3. Every year, more than 400 000 infants are born to mothers who are depressed, which makes perinatal depression the most under diagnosed obstetric complication in America. Postpartum depression leads to increased costs of medical care, inappropriate medical care, child abuse and neglect, discontinuation of breastfeeding, and family dysfunction and adversely affects early brain development. Every year, more than 400 000 infants are born to mothers who are depressed, which makes perinatal depression the most under diagnosed obstetric complication in America. Postpartum depression leads to increased costs of medical care, inappropriate medical care, child abuse and neglect, discontinuation of breastfeeding, and family dysfunction and adversely affects early brain development. Pediatrics 2010;126;1032-1039 © 2011 Pec Indman EdD, MFT

4. MYTHS OF MOTHERHOOD

5. © 2011 Pec Indman EdD, MFT MYTHS ABOUT PERINATAL MOOD DISORDERS

6. © 2011 Pec Indman EdD, MFT HISTORICAL INFORMATION (risk factors) Psychiatric history (including meds) History of sexual abuse or trauma Fertility problems Perinatal loss Previous pregnancy, birth, or postpartum difficulties

8. © 2011 Pec Indman EdD, MFT IS IT PREGNANCY OR DEPRESSION? Mood is labile, teary Self esteem is normal Mood is labile, teary Self esteem is normal Sleep: bladder or heartburn may awaken. Can fall asleep Sleep: bladder or heartburn may awaken. Can fall asleep No suicidal ideology No suicidal ideology Energy: may tire, rest restores Energy: may tire, rest restores Pleasure: joy and anticipation (appropriate worry) Pleasure: joy and anticipation (appropriate worry) Appetite: increases Appetite: increases Mood: persistent gloom Mood: persistent gloom Low self-esteem, guilt Low self-esteem, guilt Sleep: early a.m. awakening Sleep: early a.m. awakening Suicidal thoughts, plans, or intentions Suicidal thoughts, plans, or intentions Energy: rest does not restore. Fatigue Energy: rest does not restore. Fatigue Anhedonia Anhedonia poor appetite poor appetite Yonkers K. and Little B, eds. Management of Psychiatric Disorders in Pregnancy, 2001

9. © 2011 Pec Indman EdD, MFT DEPRESSION IN PREGNANCY Can J Clin Pharmacol Vol 16 (1) Winter 2009 About 15-21% of women experience depression in pregnancy up to 38% in low SES (Alfonso DD, et al. Birth 1990;17:121-130, Marcus, S. Can J Clin Pharmacol Vol 16 (1) Winter 2009) 50-75% relapse after discontinuing medication when pregnant ( 50-75% relapse after discontinuing medication when pregnant (Cohen LS, et al. Psychother Psychosom. 2004 Jul-Aug;73(4):255- 8) Over 40% resume medication ( Over 40% resume medication (Cohen LS, et al.. Psychother Psychosom. 2004 Jul-Aug;73(4):255-8) Most are undetected and under treated ( Most are undetected and under treated (Marcus, S., Depression during Pregnancy:Rates, Risks, and Consequences. Can J Clin Pharmacol Winter 2009 Vol 16 (1)

10. RISK BENEFIT RATIO Risks of Risks of Risks of Risks of Untreated vs Medical Untreated vs Medical Illness Treatment Illness Treatment © 2011 Pec Indman NO RISK-FREE ZONE!!!

12. © 2011 Pec Indman EdD, MFT

13. MEDICATIONS IN PREGNANCY Studies of Prozac, Zoloft, Paxil, Effexor, Anafranil, Deseryl, Serzone, Tricyclics ( Studies of Prozac, Zoloft, Paxil, Effexor, Anafranil, Deseryl, Serzone, Tricyclics (Bennett HA, Einarson, A. et al. Clin Drug Invest 2004;24 (3), NEJM. June 28, 2007;356;26) No increased risk malformations, miscarriage, neonatal complications or neurobehavioral developmental problems up to 71 mo ( No increased risk malformations, miscarriage, neonatal complications or neurobehavioral developmental problems up to 71 mo (Nulman I, Rovet J, Stewart D, et al. Am J Psychiatry 2002;159:1889-18895, Einarson A, Koren G. Can Fam Physician. 2006 May 10; 52(5): 593–594) Paxil?? Paxil?? >3,000 exposed to paroxetine 1 st tri No increased risk No increased risk (Einarson A. et al. Am J Psychiatry 2008; 165:749–752)

14. © 2011 Pec Indman EdD, MFT SSRI’s in PREGNANCY: PPHN? 25,214 deliveries reviewed: Congenital cardiac disease? Congenital cardiac disease? 0.4% exposed babies (mom’s on SSRI) 0.4% exposed babies (mom’s on SSRI) 0.8% Non exposed babies 0.8% Non exposed babies PPHN? PPHN? 16% non exposed babies 16% non exposed babies 0 in exposed group. 0 in exposed group. (Mayo Clin Proc. 2009;84(1):23-27) No increased rate! (. No increased rate! (Antidepressant medication use and risk of persistent pulmonary hypertension of the newborn, Andrade, S, et al. Pharmacoepidemiol. Drug Saf. 2009 January 15., Wilson, K. et al. Persistent Pulmonary Hypertension of the Newborn Is Associated with Mode of Delivery and Not with Maternal Use of Selective Serotonin Reuptake Inhibitors. Amer J Perinatol. 2010, July 6)

15. © 2010 Pec Indman EdD, MFT NEONATAL ABSTINENCE SYNDROME-SSRI’s Can occur in up to 30% neonates exposed in utero Can occur in up to 30% neonates exposed in utero Should monitor/observe up to 48 hrs Should monitor/observe up to 48 hrs Sx: tremor, GI,respiratory, and sleep disturbance ( Sx: tremor, GI,respiratory, and sleep disturbance (Rachel Levinson-Castiel, Arch Pediatrics & Adolescent Medicine, 2006;160:173-176) No evidence discontinuation affected neonatal outcome No evidence discontinuation affected neonatal outcome (Warburton W. Hartzman C. and OberlanderT., Acta Psychiatr Scand 2010:121: 471–479)

16. PRENATAL ANXIETY TREATMENT Psychotherapy and adjuctive therapies Psychotherapy and adjuctive therapies SSRI’s (usually need higher dose) SSRI’s (usually need higher dose) Benzo’s (lorazapam 1 st choice) Benzo’s (lorazapam 1 st choice) “exposure to a benzodiazepine does not significantly increase the risk for birth defects” “exposure to a benzodiazepine does not significantly increase the risk for birth defects” Calderon-Margalit R, Qiu C, Ornoy A, Siscovick DS, Williams MA.Am J Obstet Gynecol. 2009 Dec;201(6):579

17. PRENATAL MEDICATIONS As blood volume increases in pregnancy, medications are diluted. As blood volume increases in pregnancy, medications are diluted. Dosage may need to increase in 3 rd Dosage may need to increase in 3 rdtrimester

18. © 2011 Pec Indman EdD, MFT OTHER TREATMENTS Light Therapy ( Light Therapy (Oren, D, et al.. Am J Psychiatry, April 2002,159:4) 49% improvement in scores in 3 weeks 49% improvement in scores in 3 weeks No adverse effects noted No adverse effects noted Omega 3 Fatty Acids Omega 3 Fatty Acids (Freeman MP, Evidence-Based Integrative Medicine 2003:1(1):43-49) Up to 3 gm daily improved EPDS scores Up to 3 gm daily improved EPDS scores ECT ECT (Yonkers K. and Little B, eds.,Management of Psychiatric Disorders in Pregnancy, 2001) Few complications in pregnancy based on large body of literature Few complications in pregnancy based on large body of literature May be best choice for depression with psychosis May be best choice for depression with psychosis

19. © 2011 Pec Indman EdD, MFT PSYCHOTHERAPY FOR PRENATAL DEPRESSION Interpersonal Psychotherapy (IPT) Cognitive-Behavioral therapy (CBT) Group Therapy/Support Couples counseling

20. PSYCHOTHERAPY MODELS Interpersonal Psychotherapy (IPT) Interpersonal Psychotherapy (IPT) http://www.psychology.uiowa.edu/labs/idcrc/Library/IPT.pdf and http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2234626/) http://www.psychology.uiowa.edu/labs/idcrc/Library/IPT.pdf Cognitive-Behavioral Therapy (CBT) Cognitive-Behavioral Therapy (CBT) (Yonkers, K. et al. Obestet Gynecol 2011:117:961-77) Couples Therapy ( Couples Therapy (Apfel R and Handel M in Miller L. ed. Postpartum Mood Disorders 1999) Group Group (http://www.jppr.psychiatryonline.org/cgi/content/abstract/10/2/124 and http://ajp.psychiatryonline.org/cgi/content/abstract/158/4/638)http://www.jppr.psychiatryonline.org/cgi/content/abstract/10/2/124 © 2011 Pec Indman EdD, MFT

21. MATERNAL OUTCOMES ASSOCIATED WITH PRENATAL DEPRESSION Functional impairment Functional impairment Poor nutrition Poor nutrition Inadequate weight gain Inadequate weight gain Adverse behaviors Adverse behaviors Smoking (20.4%) Smoking (20.4%) Alcohol use (18.8%) Alcohol use (18.8%) Drug use (5.5%) Drug use (5.5%) (Bonari L. et al. Can J Psychiatry, Vol 49, No 11, November 2004)

22. © 2011 Pec Indman EdD, MFT DEPRESSION/ANXIETY IN PREGNANCY Depression in pregnancy associated with: Low birth weight (under 2500 grams) Low birth weight (under 2500 grams) Preterm delivery (less than 37 weeks) up to 2X risk ( Preterm delivery (less than 37 weeks) up to 2X risk (Li D, Liu L, Odouli R, Hum Repod. 2009 Jan;24(1):146-53. Epub 2008 Oct 23, Bonari L. et al. Can J Psychiatry, Vol 49, No 11, November 2004 Small-for-gestational age Small-for-gestational age Severe anxiety in pregnancy associated with: Constriction in placental blood supply Constriction in placental blood supply Heightened startle response in newborn Heightened startle response in newborn Newborns more inconsolable, poor sleep Newborns more inconsolable, poor sleep (Bennett HA, Einarson, A. et al. Clin Drug Invest 2004;24 (3)

23. © 2011 Pec Indman EdD, MFT DEPRESSION IN PREGNANCY RISK Women depressed at 18 wks gestation had 3x risk of PPD Women depressed at 18 wks gestation had 3x risk of PPD Depression at 32 weeks-6x risk Depression at 32 weeks-6x risk Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy and Postpartum. American Psychiatric Publishing, Inc., 2005

24. © 2011 Pec Indman EdD, MFT POSTPARTUM “BLUES” Occurs in 50-80% Occurs in 50-80% Onset usually in first week Onset usually in first week Symptoms may persist from several days to a few weeks Symptoms may persist from several days to a few weeksNORMAL

25. © 2011 Pec Indman EdD, MFT BLUES OR BEYOND? Severity Timing Timing Duration Duration

27. © 2011 Pec Indman EdD, MFT POSTPARTUM DEPRESSION 15-20%, and 26-32% teens 15-20%, and 26-32% teens ( (Currie ML and Radenmacher R, Pediatr Clin N Am 2004, 51:785-810, Gaynes BN, et al. Evid Rep/Technol Assess (Summ) 2005:1–8. Symptoms often peak at 3-6 months Symptoms often peak at 3-6 months Can become chronic Can become chronic Untreated, 25% still depressed at one year postpartum Untreated, 25% still depressed at one year postpartum (Leopold KA and Zoschnick, LB., The Female Patient. Aug 1997;22(8):40-49)

28. © 2011 Pec Indman EdD, MFT SYMPTOMS OF POSTPARTUM DEPRESSION/ANXIETY: Sad mood, guilt, irritability, excessive worry, anxiety, or feelings unable to cope Sad mood, guilt, irritability, excessive worry, anxiety, or feelings unable to cope Sleep problems (often insomnia), fatigue Sleep problems (often insomnia), fatigue Symptoms or complaints in excess of, or without physical cause Symptoms or complaints in excess of, or without physical cause Discomfort around baby, or lack of feelings towards baby Discomfort around baby, or lack of feelings towards baby Loss of focus and concentration (may miss appointments) Loss of focus and concentration (may miss appointments) Loss of interest or pleasure Loss of interest or pleasure Appetite changes-poor appetite or weight gain Appetite changes-poor appetite or weight gain

29. © 2011 Pec Indman EdD, MFT FREQUENT SYMPTOMS IN PRACTICE Review of 133 women 1. “felt really overwhelmed” 2. “felt like my emotions were on a rollercoaster” 3. “have been very irritable” 4. “felt all alone” 5. “felt like I wasn’t normal” (Beck C and Indman P., JOGNN, Sept/Oct 2005:34(5):569-576)

32. © 2011 Pec Indman EdD, MFT THYROIDITIS OCCURS IN ABOUT 10% Lab work to rule out thyroiditis: Lab work to rule out thyroiditis: Free T4 Free T4 TSH TSH Anti-TPO Anti-TPO Anti-Thyroglobulin antibodies Anti-Thyroglobulin antibodies Best time to test 2-3 mo postpartum Best time to test 2-3 mo postpartum (Stagnaro-Green A., Best Pract Res Clin Endocrinol Metab. 2004 Jun;18(2):303-111.

33. © 2011 Pec Indman EdD, MFT TREATMENT FOR POSTPARTUM DEPRESSION/ANXIETY Individual/couples therapy, group Individual/couples therapy, group CBT or Interpersonal Therapy (IPT) Antidepressant and/or antianxiety medication, Sleep meds Antidepressant and/or antianxiety medication, Sleep meds (Wisner KL, et al., N Engl J Med. July 2002;347(3):194-199) Treat thyroiditis Treat thyroiditis ECT, TMS (?) ECT, TMS (?) INADEQUATE TREATMENT CAN LEAD TO CHRONIC DEPRESSION OR RELAPSE

34. © 2011 Pec Indman EdD, MFT POSTPARTUM OBSESSIVE- COMPULSIVE DISORDER (OCD) 3% to 9% of new mothers may develop obsessive symptoms 3% to 9% of new mothers may develop obsessive symptoms Chaudron, LH and Neha Nirodi. Arch Womens Ment Health, March, 2010;1434-1816.) (Abramowitz JS, et al. Anxiety Disorders 2003. 17:461-478, Chaudron, LH and Neha Nirodi. Arch Womens Ment Health, March, 2010;1434-1816.)

35. © 2011 Pec Indman EdD, MFT SYMPTOMS OF POSTPARTUM OCD Intrusive, repetitive, and persistent thoughts or mental pictures Intrusive, repetitive, and persistent thoughts or mental pictures Thoughts often are about hurting or killing the baby Thoughts often are about hurting or killing the baby Tremendous sense of horror and disgust about these thoughts (ego alien) Tremendous sense of horror and disgust about these thoughts (ego alien) Thoughts may be accompanied by behaviors to reduce the anxiety Thoughts may be accompanied by behaviors to reduce the anxiety Repetitive counting, checking, cleaning Repetitive counting, checking, cleaning (Abramowitz JS et al. Arch Womens Ment Health (2010) 13:523–530 )

36. © 2011 Pec Indman EdD, MFT TREATMENT FOR OCD Psychotherapy and psychoeducation Psychotherapy and psychoeducation Medication (SSRIs, anxiolytics, antipsychotics), usually need higher doses of SSRI Medication (SSRIs, anxiolytics, antipsychotics), usually need higher doses of SSRI

37. © 2011 Pec Indman EdD, MFT POSTPARTUM PANIC DISORDER May occur in about 10% of postpartum women May occur in about 10% of postpartum women

38. © 2011 Pec Indman EdD, MFT SYMPTOMS OF PANIC DISORDER Episodes of extreme anxiety: excessive or obsessive worry or fears Shortness of breath, chest pain, sensations of choking or smothering, dizziness Hot or cold flashes, trembling, palpitations, numbness or tingling sensations Restlessness, agitation, or irritability Fear she is going crazy, dying, or losing control Attack may awaken her from sleep Often no identifiable trigger for panic (Sichel D and Driscoll JW. Women’s Moods, 1999)

39. © 2011 Pec Indman EdD, MFT TREATMENT FOR PANIC DISORDER Psychotherapy SSRIs (higher dose to tx anxiety) Antianxiety medication PRN

40. © 2011 Pec Indman EdD, MFT POSTTRAUMATIC STRESS DISORDER (PTSD) 1-6% of postpartum women 1-6% of postpartum women (Beck CT. Nursing Research. July/Aug 2004; 53(4):216-224)

41. © 2011 Pec Indman EdD, MFT SYMPTOMS OF PTSD Recurrent nightmares Recurrent nightmares Extreme anxiety Extreme anxiety Reliving past traumatic events Reliving past traumatic events sexual sexual physical physical emotional emotional childbirth childbirth

42. © 2011 Pec Indman EdD, MFT TREATMENT FOR PTSD Psychotherapy Psychotherapy SSRIs and/or antianxiety medication SSRIs and/or antianxiety medication

43. © 2011 Pec Indman EdD, MFT 50% bipolar women who discontinued meds relapsed in first 3 months of pregnancy, 50% bipolar women who discontinued meds relapsed in first 3 months of pregnancy, 70% relapsed by 6 months ( 70% relapsed by 6 months (Am J of Psychiatry, 2007 Dec;164(12):1817-24 ) Valproic Acid has up to 5% risk neural tube defects Valproic Acid has up to 5% risk neural tube defects Lithium has 0.05% risk of Ebstein’s anomaly in 1st trimester. Best choice for bipolar disorders Lithium has 0.05% risk of Ebstein’s anomaly in 1st trimester. Best choice for bipolar disorders Preconception counseling is critical Preconception counseling is critical

44. © 2011 Pec Indman EdD, MFT POSTPARTUM BIPOLAR DISORDER In women with BD rates range up to 82% In women with BD rates range up to 82% Time of increased vulnerability for relapse Time of increased vulnerability for relapse Closely associated with postpartum psychosis Closely associated with postpartum psychosis (Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy and Postpartum. American Psychiatric Publishing, Inc., 2005. Sharma, V. et al. Am J Psychiatry 2009; 166:1217–1221) Up to 21.6% of primary care patients dx’d with unipolar depression may have an undiagnosed bipolar disorder. Up to 21.6% of primary care patients dx’d with unipolar depression may have an undiagnosed bipolar disorder. (Smith, DJ. Et al., Br J Psychiatry 2011 10.1192/bjp.bp.110.083840f)

45. © 2011 Pec Indman EdD, MFT SYMPTOMS OF BIPOLAR Mania or hypomania (“moody”) Mania or hypomania (“moody”) Depression (PPD “imposter”) Depression (PPD “imposter”) Rapid and severe mood swings Rapid and severe mood swings

46. © 2011 Pec Indman EdD, MFT TREATMENT OF BD Prophylaxis with a mood stabilizer or neuroleptic is recommended at the end of pregnancy (36 weeks gestation) Prophylaxis with a mood stabilizer or neuroleptic is recommended at the end of pregnancy (36 weeks gestation) Careful observation for symptoms Careful observation for symptoms High Risk postpartum mania/psychosis High Risk postpartum mania/psychosis ( Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy and Postpartum. American Psychiatric Publishing, Inc., 2005)

47. © 2011 Pec Indman EdD, MFT POSTPARTUM PSYCHOSIS Occurs in 1-2/1000 Occurs in 1-2/1000 50% of 1 st time moms with no previous psych hospitalization ( 50% of 1 st time moms with no previous psych hospitalization (Valdimarsdóttir U. et al. 2009. PLoS Med 6(2): e1000013) 5% suicide and 4% infanticide rate 5% suicide and 4% infanticide rate (Sit, D. et al. Journal of Women’s Health 2006: 15(4), Doucet, S. et al, JOGNN 2009, 38, 269-279) Melanie Blocker-Stokes Andrea YatesJennifer Mudd Houghtaling

48. © 2011 Pec Indman EdD, MFT SYMPTOMS OF POSTPARTUM PSYCHOSIS Usually begins 48-72 hours postpartum Usually begins 48-72 hours postpartum Most develop symptoms within 2-4 weeks Most develop symptoms within 2-4 weeks Visual or auditory hallucinations Visual or auditory hallucinations Early symptoms restlessness, agitation, irritability Early symptoms restlessness, agitation, irritability Confusion, paranoia, extreme moodswings Confusion, paranoia, extreme moodswings Delusional thinking (infant death, denial of birth, need to kill baby) Delusional thinking (infant death, denial of birth, need to kill baby) (Sit, D. et al. Journal of Women’s Health 2006: 15(4), Doucet, S. et al, JOGNN 2009, 38, 269-279.)

49. © 2011 Pec Indman EdD, MFT TREATMENT FOR POSTPARTUM PSYCHOSIS REQUIRES IMMEDIATE HOSPITALIZATION REQUIRES IMMEDIATE HOSPITALIZATION Antipsychotics Antipsychotics Mood stabilizers (antidepressants as needed) Mood stabilizers (antidepressants as needed) Psychotherapy Psychotherapy ECT ECT (Sit, D. et al. Journal of Women’s Health 2006: 15(4), Yonkers KA, et al.. Am J Psychiatry. 2004;161:608-620)

50. © 2011 Pec Indman EdD, MFT WHY TREAT MOMS? Increased incidence of childhood psychiatric disturbances Impaired cognitive and language development in children Potential for child abuse and neglect Negative impact on marital/family relationships Increased risk chronic depression and relapse (Field T. et al., Infant Behavior & Development 2004;(27):216-229, Hart S. et al., Infant Behavior & Development 1998; 21(3):519-525, Murray L and Cooper PJ.,. Psychological Medicine 1997;27(2):253-260)

51. © 2011 Pec Indman EdD, MFT BREASTFEEDING AND ANTIDEPRESSANTS AAP now recommends 1 year of breastfeeding. AAP now recommends 1 year of breastfeeding. “Paxil and Zoloft usually produce undetectable infant levels.” ( “Paxil and Zoloft usually produce undetectable infant levels.” (Weissman AM. et al. Am J Psychiatry 2004;161:1066-1078) Studies of exposed infants show no differences in IQ or neurobehavioral development Studies of exposed infants show no differences in IQ or neurobehavioral development (Yoshida K, et al. Br J Clin Pharmacol. 1997 Aug;44(2):210-1) See also M. Freeman, J Clin Psychiatry, Feb. 2009. 70:2

52. BREASTFEEDING Depressed moms breastfed for shorter durations Depressed moms breastfed for shorter durations Experienced breastfeeding more negatively than non-depressed Experienced breastfeeding more negatively than non-depressed (Individual and Combined Effects of Postpartum Depression in Mothers and Fathers on Parenting Behavior. Paulson, Dauber, and Leiferman. Pediatrics, 118(2), Aug 2006:659-668) Increased breastfeeding difficulties Increased breastfeeding difficulties Decreased levels of breastfeeding self- efficacy Decreased levels of breastfeeding self- efficacy (Dennis CL & McQueen K. The Relationship Between Infant- Feeding Outcomes and Postpartum Depression. Pediatrics 2009;123:e736-e751) © 2011 Pec Indman EdD, MFT

53. SCREENING Edinburgh Postnatal Depression Scale (EPDS), 1987 Cox, et. al. Edinburgh Postnatal Depression Scale (EPDS), 1987 Cox, et. al. Score of > 10  refer for evaluation Score of > 10  refer for evaluation Validated in pregnancy, free, many languages Validated in pregnancy, free, many languages PHQ9, PHQ4, PHQ2: not well studied for perinatal use, but frequently used www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/ PHQ9, PHQ4, PHQ2: not well studied for perinatal use, but frequently used www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/ www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/ Postpartum Depression Screening Scale (PDSS), 2002 Cheryl Beck D.N.Sc. www.wpspublish.com Postpartum Depression Screening Scale (PDSS), 2002 Cheryl Beck D.N.Sc. www.wpspublish.com

54. © 2011 Pec Indman EdD, MFT WHEN SHOULD WE SCREEN? Ideally, preconception counseling Each trimester of pregnancy All well-baby checkups in first year NICU parents and teens high risk

55. CONSEQUENCES OF UNTREATED PERINATAL MENTAL ILLNESS Decreased ability to parent Decreased ability to parent Harsher discipline Harsher discipline Cognitive, emotional and developmental delays and deficits Cognitive, emotional and developmental delays and deficits Poor attachment Poor attachment Depressive disorders by age 15 Depressive disorders by age 15 (Hammen, C and P. Brennan, Arch Gen Psychiatry, 2003;60:253-258)

56. © 2011 Pec Indman EdD, MFT FATHERS In a national studies reported in 2006 and 2010, 10% of new fathers scored in the range of clinical depression. In a national studies reported in 2006 and 2010, 10% of new fathers scored in the range of clinical depression. Maternal depression increased the risk of paternal depression. Maternal depression increased the risk of paternal depression. (Paulson, Dauber, Leiferman, Pediatrics, 2006 Aug;118(2):659-68, Paulson, J and Bazemore, S. JAMA. 2010;303(19):1961-1969)

57. TREATMENT CONSIDERATIONS History of the illness History of the illness Degree of current illness Degree of current illness Risks and benefits of treatment options Risks and benefits of treatment options Patient/patient’s family’s history and preferences Patient/patient’s family’s history and preferences © 2011 Pec Indman

58. © 2011 Pec Indman EdD, MFT TREATMENT GUIDELINES Always r/o bipolar spectrum before starting SSRI’s. Always r/o bipolar spectrum before starting SSRI’s. http://www.psycheducation.org/depression/MDQ.htm http://www.psycheducation.org/depression/MDQ.htm Start at low dose and work up Start at low dose and work up F/U frequently and treat to remission! F/U frequently and treat to remission! Meds work best with therapy Meds work best with therapy Progesterone may worsen mood - caution with progestin only OC’s or IUD Progesterone may worsen mood - caution with progestin only OC’s or IUD

59. © 2011 Pec Indman EdD, MFT RESOURCES Postpartum Support International Postpartum Support International www.postpartum.net (great resources) www.postpartum.net (great resources) www.postpartum.net North American Society for Psychosocial OB/GYN www.naspog.orgApril 22-25, 2012 North American Society for Psychosocial OB/GYN www.naspog.org April 22-25, 2012 www.naspog.org www.mededppd.org (professionals and consumer info) www.mededppd.org (professionals and consumer info) www.mededppd.org www.womensmentalhealth.org (Mass General) www.womensmentalhealth.org (Mass General) www.womensmentalhealth.org

60. © 2011 Pec Indman EdD, MFT RESOURCES UIC Perinatal Mental Health Project UIC Perinatal Mental Health Project 800-573-6121 Free consultation for providers 800-573-6121 Free consultation for providers www.otispregnancy.org 866-626- 6847 (Organization of Teratology Information Specialists-free patient handouts) www.otispregnancy.org 866-626- 6847 (Organization of Teratology Information Specialists-free patient handouts) www.otispregnancy.org www.motherisk.org www.motherisk.org (fetal and breastmilk exposure) www.motherisk.org www.infantrisk.org www.infantrisk.org (fetal and breastmilk exposure, phone app!) www.infantrisk.org Depression During and After Pregnancy: A Resource for Women, Their Families, and Friends, (free booklet Eng/Span) http://ask.hrsa.gov/detail_materials.cfm?ProdID=3924 Depression During and After Pregnancy: A Resource for Women, Their Families, and Friends, (free booklet Eng/Span) http://ask.hrsa.gov/detail_materials.cfm?ProdID=3924