Peripartum Depression Laura J. Miller, M.D. Women’s Mental Health Program University of Illinois at Chicago

Risks from untreated major depression during pregnancy n Decreased prenatal care n Decreased nutrition n Increased use of teratogenic addictive substances – cigarettes – alcoholic beverages

Effects on offspring of untreated depression during pregnancy n Low birth weight (Federenko & Wadhwa 2004) n Preterm birth (Dayan et al. 2002) n Pre-eclampsia (Kurki et al. 2000) n Neonatal irritability (Zuckerman et al. 1990)

Postpartum “blues” n Features: tearfulness, lability, reactivity n Predominant mood: happiness 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

Clinical features of postpartum depression n Mood predominantly depressed, despondent, anhedonic n Sleep disturbance, fatigue, irritability n Loss of appetite n Poor concentration n Feelings of inadequacy n Ego-dystonic thoughts of harming the baby

Characteristics of postpartum depression n Begins within 4 weeks of birth, but clinical presentation peaks 3-6 months after delivery n Present in % of new mothers in U.S. (Joseffson et al. 2001) n Much less prevalent in some cultures (Wile & Arechiga 1999) n Related to psychiatric history (Steiner & Tam 1999) n Related to environmental stressors (Bernazzani et al. 2004)

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 Family tension n Vulnerability to future depression n Suicide/homicide

Peripartum depression: posited contributory factors n Hormonal flux interacting with stressors n The magnitude of the postpartum drop in hormones correlates with mood changes; absolute hormone levels don’t n The biological mother-infant attachment system may predispose to depression in the context of stress, low social support & limited resources

Peripartum depression: recognition and treatment in primary care settings n Ob/gyn survey (LaRocco-Cockburn et al. 2003) : – Only 32% reported they’d been appropriately trained to treat depression – 73% cited time constraints for screening n Pediatrician survey (Wiley et al. 2004): – 49% not educated about PPD – Only 31% felt they’d recognize PPD – Only 7% were familiar with screening tools

Screening for Peripartum Depression with the Edinburgh Postnatal Depression Scale [EDPS] n 10 item scale; maximum score 30; cut-off n Self report : quick and easy to score n Widely tested – During pregnancy, sensitivity 100%; specificity 87% – Postpartum, sensitivity %; specificity % – Available in over 20 languages; cross-cultural validation n Defines population in need for further assessment n Can be used to monitor treatment progress n IDPA (Medicaid) reimburses for this screening

Assessment of peripartum depression n Conducted by clinician for all women who score above the cut-off score on EPDS n Purposes - to ascertain whether the woman: – has major depression – is suicidal – is at risk of harming her baby – has bipolar disorder

Treating peripartum depression n Antidepressant medication n Interpersonal psychotherapy n Couples therapy n Self help tools & networks n ECT (rTMS) n Hormone therapy n Parenting coaching

Challenges in prescribing antidepressant medications peripartum n FDA categories have limited usefulness (based heavily on animal data) n Wide variation in amount of data for different antidepressants n Optimal dosing changes as pregnancy progresses n Wide variation in amount ingested by breast-feeding babies

Peripartum Depression Disease Management Model n Education (via workshops) n Screening tool n Assessment tool n Treatment guidelines n Self-care tools n Referral networks n Back-up consultation