1. Peripartum Depression Laura J. Miller, M.D. Women’s Services Division University of Illinois at Chicago

2. Risks from untreated major depression during pregnancy n Decreased prenatal care n Insufficient weight gain n Increased use of addictive substances n Increased risk of being a victim of violence n Decision to abort due to depression n Suicide (although risk may be lower than in non-pregnant women

3. Obstetric & neonatal complications of depression n Fetal growth retardation n Pre-eclampsia n Premature labor n Placental abruption n Newborns more inconsolable (independently of addictive substance use, weight gain, length of labor, method of delivery and Apgar scores)

4. Types of postpartum mood disorders n Postpartum “blues” n Postpartum depression n Postpartum psychoses

5. Postpartum “blues” n Central features: tearfulness, lability, reactivity n Peaks 3-5 days after delivery n Present in 50-80% of women n Present in all cultures studied n Unrelated to environmental stressors n Unrelated to psychiatric history

6. Postpartum “blues” : hormone withdrawal hypothesis n Ovarian steroid receptors in CNS are heavily concentrated in the limbic system n The magnitude of the postpartum drop in estrogens and progesterone correlates with presence of “blues”; absolute levels don’t n Neuroactive steroids (pregnanolone, allopregnanolone) decrease postpartum, affecting GABA

7. Postpartum “blues”: biological attachment hypothesis n Neurobiological systems foster attachment between mammalian mothers & infants n Oxytocin activates limbic structures (e.g. the ACG) that mediate the interface between attention & emotion n Postpartum reactivity may stem from this n With stressors, depression may result

9. Clinical features of postpartum depression n Despondency n Sleep disturbance, fatigue, irritability n Anorexia n Poor concentration n Feelings of inadequacy n Ego-dystonic thoughts of harming the baby

10. Characteristics of postpartum depression n Begins within 4 weeks of baby’s birth n Clinical presentation peaks 3-6 months after delivery n Present in 10% of new mothers in U.S. n Much less prevalent in some cultures n Related to psychiatric history n Related to environmental stressors

11. Consequences of untreated postpartum depression n Disturbed mother-infant relationship (elevated cortisol found in both) n Psychiatric morbidity in children later (depression, conduct disorder, lower IQ) n Marital tension n Vulnerability to future depression n Suicide/homicide

12. Postpartum cultural influences n Ceremonies n Cleansing rituals n Seclusion n Rest n Solicitude n Return to home of origin

13. Postpartum psychoses n Usually related to a mood episode n More disorientation, agitation, lability n Peaks within 3 weeks of birth n Affects 1/1000 women overall, but 25 - 35% of women with bipolar diathesis n Predicted by absence of depression/anxiety in third trimester n Unrelated to environmental stressors

14. Treating postpartum mood disorders n Psychotherapy – Interpersonal psychotherapy – Couples therapy n Somatic treatments – Antidepressant medication – Hormone therapy – ECT n Self help networks

15. Interpersonal psychotherapy for postpartum depression n Focus on role transition n Integrate new role with established roles n Explore feelings & ambivalence about roles n Assess satisfaction with relationships n Define patient’s expectations of others n Renegotiate relationships n Maintain specific problem focus

16. Couples therapy for postpartum depression: evaluation n Evaluation begins with family, then each parent individually, then couple together n Relevant history – parents’ families of origin – history of parents’ relationship – parents’ expectations about the baby – circumstances surrounding becoming pregnant, pregnancy, labor, delivery, postpartum

17. Couples therapy for postpartum depression n Create accepting atmosphere n Educate about wide range of normal feelings postpartum n Establish common ground n Articulate “ideal family” n Find compromises to approximate the ideal and replace fantasies with a real family

18. Antidepressants: teratogenicity n Morphologic: none for SSRI’s, tricyclics & venlafaxine; not enough systematic data about newer agents (e.g. nefazodone, bupropion, mirtazapine) n Behavioral – none for fluoxetine, tricyclics – fluoxetine protects against brain effects of maternal separation in rats

19. Antidepressants: fetal & neonatal side effects n SSRI’s: “colic”, decreased weight gain; tremor; tachypnea; motor automatisms; increased bleeding diathesis n Tricyclics: tachycardia; (rare) tachyarrhythmia, urinary retention n All antidepressants: – neonatal withdrawal – questionable association with prematurity

20. Guidelines for antidepressants during pregnancy n Consider better-studied agents n Agents to avoid during pre-eclampsia: bupropion, maprotiline n Vitamin C with SSRI’s n Dosing considerations – increase sometimes needed in 2nd trimester – consider reduction during last month

21. Postpartum pharmacotherapy: side effect concerns n Sedation n Insomnia n Weight gain n Decreased sexual desire n Effects on breastfeeding infant

22. Antidepressants & lactation: relative doses to nursling n Sertraline: 0.4% - 1.0% n Fluvoxamine0.5% - 1.6% n Paroxetine: 0.1% - 4.3% n Fluoxetine:1.2% - 12.0% n Venlafaxine:5.2% - 7.4% n Citalopram:0.7% - 9.0% n (% of weight-adjusted maternal doses)

23. Antidepressants & lactation: reported side effects n Usually none n Fluoxetine case report of “colic” -- e.g. crying, restlessness, decreased sleep, vomiting, watery stools n Citalopram case report of uneasy sleep n Doxepin case report of pallor, hypotonia, respiratory depression

24. Prescribing during lactation n Explain potential risks & benefits, ideally to both parents n Obtain description of baby’s baseline behavior n For possible infant side effects, check serum level & confer with pediatrician n Some mothers pump breast milk prior to each dose & use pumped milk after dose

25. Postpartum estrogen treatment n Effective in placebo-controlled studies n Dose: 200 micrograms as transdermal patch, changed twice weekly, or sublingual 1mg QID n Contraindications: breast cancer, hypercoagulability, pregnancy n Efficacy & safety relative to antidepressants not yet established

26. Preventing peripartum depression n Discuss family planning & reproduction n Identify women at risk during pregnancy n Psychosocial prevention n Mood stabilizer prophylaxis for bipolar disorder n Antidepressant prophylaxis for depression n Estrogen prophylaxis (experimental)