1. POSTPARTUM MOOD DISORDERS
Shazia Malik, M.D. CenterPointe Hospital

2. Disclosure
The content of this presentation does not relate to any product of a commercial interest; therefore, there are no relevant financial relationships to disclose.

3. Disclaimer
The Missouri State Medical Association cannot and does not provide legal advice. This presentation is informational in nature and may not be relied upon for legal advice. Medical practices should contact their legal counsel for assistance.

4. -- Hippocrates, Of The Epidemics
“In Cyzius a woman gave birth to twin daughters with difficult labor and the lochial discharge was far from good. On the sixth day there was much wandering at night; no sleep. About the eleventh day she went out of her mind.”
-- Hippocrates, Of The Epidemics

5. HISTORY OF POSTPARTUM DISORDER
400 B.C. – Hippocrates
Recognized Postpartum Disorder
1958 – Louis Marce (French psychiatrist)
Noted “insanity in pregnant, puerperal and lactating women.”
1961 – R.S. Paffenbarger
Demonstrated admission to mental hospitals was increased during the first month postpartum.
1962 – J.A. Hamilton
Argued puerperal psychosis was a distinct disorder. ’ ’

6. EVOLUTION OF DIAGNOSTIC CRITERIA
DSM II (1968)
Acknowledged Postpartum Affective Disorders
Psychosis related to childbirth was listed as psychosis caused by an organic disorder.
DSM III & III R
Acknowledged Postpartum Psychosis as an “Atypical Psychosis.”
DSM IV & IV TR
In the past decade, increased research has led to many publications on this topic.

7. POSTPARTUM QUESTIONS Is childbirth a major stressor ?
Is the stress-diathesis model applicable?
Are there neurophysiologic changes underlying post- partum mental changes?
If so, can they happen to anyone or only to women who are vulnerable in some way?
How can puerperal emotional disturbances be recognized and treated effectively?

8. OBJECTIVE OF DISCUSSION
Provide an understanding of the
possible etiology
phenomenology
diagnosis
prognosis
and treatment of:
Postpartum Blues (PPB)
Postpartum Depression (PPD)
Postpartum Psychosis (PPP)

9. SUMMARY OF DISCUSSION Disorders Treatment Postpartum Blues
Postpartum Depression
Postpartum Psychosis
Treatment
Psychotherapy
Pharmacotherapy
Social Interventions

10. REPRODUCTIVE JUNCTURES
Reproductive junctures are times for affective monitoring in vulnerable women:
Premenstrum
Assisted Reproductive Technology
Pregnancy
Miscarriage
Postpartum
Perimenopause/Menopause

11. HORMONAL INFLUENCES Progesterone Estrogens Neurotransmitters
Beta-Endorphins
Thyroid Hormones
Lack of Sleep
Neurotransmitters

12. POSTPARTUM BLUES A Case Presentation
A 28 year-old married white female gives birth to a full-term, healthy baby. For the first 3 days she is tired but happy. On the fourth day her mother, who is visiting and helping with the household chores, mentions that the house is a mess.
The new mother bursts into tears saying, “You should be helping me, not criticizing me” The next day while watching a movie, she starts to cry over a romantic scene that would normally not bother her.
Over the next few days she notices herself reacting strongly to minor issues, although overall she remains happy about her baby.

13. POSTPARTUM BLUES Incidence/Prevalence Diagnosis
Common in every culture: 25% - 75 % of new mothers
Acute onset: 3RD - 5TH day postpartum
Short-lived: self-limited recovery complete in 2 weeks with no intervention.
Diagnosis
No well established criteria for diagnosis
DSM IV TR: offers no specific designation for this condition

14. POSTPARTUM BLUES Symptomology
Primary symptom of depression: depressed or anhedonic mood is not typically present
Predominant mood is joyful.
Most characteristic symptom was tearfulness but not related to sadness.
Phenomenologically, the central feature is increased emotional reactivity to stimuli.
Associated with:
Irritability
hypersensitivity to light
anxiety
exaggerated empathy

15. POSTPARTUM BLUES Biological Factors
Current data support: hormone withdrawal hypothesis
However, no consistent correlation has been found for any hormones.
A greater decrease in free estriol postpartum
A precipitous decline in progesterone
Larger decreases in plasma beta-endorphin levels

16. POSTPARTUM BLUES Predisposing Psychosocial/Obstetric/Gynecological Factors
Not associated with major depressive disorder
Not associated with current stressers/ obstetric complications
Not associated with marital status
All social climates among all cultures
History of severe premenstrual symptoms
Younger age at menarche
Menstrual irregularities
Primipara
Ambivalent attitudes towards pregnancy/fear of labor

17. POSTPARTUM BLUES Prognosis Treatment Recovery is complete in 2 weeks.
20% experience major a depressive episode in the first post-natal year.
If symptoms persist beyond 2 weeks, evaluate for Postpartum Depression.
Treatment
Education
Reassurance
Support
Adequate sleep and rest breaks
PRN short-acting benzodiazepines

18. POSTPARTUM DEPRESSION

19. POSTPARTUM DEPRESSION A Case Presentation
A 26 year-old married female, G:2 LB: 2, has a 2 year-old boy who is hyperactive. She has a family history of depression in mother and sister and postpartum depression in the mother. However, she has had no previous episode of mood disorder. She did suffer postpartum blues after her first pregnancy and gives a history consistent with symptoms of premenstrual dysphoria. Her husband loses his job when she is 6 months pregnant. She delivers healthy twin baby girls.
She complains of fatigue and mild insomnia, but does generally well when in the 3rd week, her husband notices her to be:
Withdrawn and displaying decreased appetite
not taking care of self and baby
feeling guilty and unfit in her role as a mother
not wanting to get out of bed.

20. POSTPARTUM DEPRESSION
Incidence: 10% --15%
16% in adult females in first year after pregnancy
26 % in adolescents
Onset: 2 weeks to 6 months postpartum
Incidents rise in 30 days postpartum
Can occur up to one year postpartum
Can be insidious and unrecognized
Duration: 6 months to 1 year

21. POSTPARTUM DEPRESSION
Etiology
Biological: no one emergent biological factor
Low levels of estrogen and progesterone
High levels of prolactin
Thyroid dysfunction can be a minor association

22. POSTPARTUM DEPRESSION Psychosocial/Obstetric/Gynecological Factors
Social/Cultural Factors
First episode of bipolar illness can present in postpartum.
Stressful life events during pregnancy
Marital discord
Lack of social support/single parent
Family history of mood disorder: increasing from 8% - 16%
Family history of alcoholism
Personal or family history of Postpartum Depression

23. POSTPARTUM DEPRESSION Psychosocial/Obstetric/Gynecological Factors
Prenatal Depression
Personal History of Bipolar Disorder
History of depression not associated with pregnancy
Depression or anxiety during index pregnancy
Unwanted or unplanned pregnancy
Pregnancy loss in past 12 months
Twin births
Infant medical problems

24. POSTPARTUM DEPRESSION
Diagnosis
DSM IV TR uses postpartum onset specific to affective disorders.
Screening for women while they are pregnant may identify those at risk for PPD.
Edinburgh Post-Natal Depression Scale (see handout)
10-item self-report questionnaire
Does not include somatic symptoms
Specifically validated for detection of depression postpartum
Maximum score of 30, score of > identifies woman with postpartum
Postpartum Depression Checklist used by health care professionals

25. POSTPARTUM DEPRESSION
Differential Diagnosis
Postpartum Blues
Duration greater than 2 weeks
Mood Disorder secondary to general medical condition
Hypothyroidism
HIV Infection
Systemic Lupus Erythematosus
Substance-Induced Depressive Disorder
Illicit Drugs
Prescription Drugs
Alcohol
Sympathomimetics

26. POSTPARTUM DEPRESSION
Symptomatology
Period of well-being followed by gradual onset of depression
Exaggerated vegetative symptoms
Significant anxiety and/or panic attacks
Intense anger or irritability
Unable to care for self or baby
Feelings of failure as a mother
Feelings of guilt: inadequacies, real or imagined, regarding the baby
Obsessive thoughts

27. POSTPARTUM DEPRESSION
Prognosis
If not properly treated, future depressive episodes both associated and unassociated with pregnancy, worsening of future premenstrual symptoms and menopausal depressive symptoms.
Depression in the spouse in the first-year postpartum
Difficulty bonding with infants leading to behavior, cognitive, and social developmental delays in infants
Most serious complications of untreated Postpartum Depression
Progression to delusional depression
Suicide
Infanticide

28. POSTPARTUM PSYCHOSIS

29. POST PARTUM PSYCHOSIS A case study
A 24 year-old primiparous female who gives a history of her mother being hospitalized after each of the two younger siblings were born. One of the siblings has a diagnosis of Bipolar Disorder. The patient has never been diagnosed or treated. She has a healthy baby after a C-Section with uncomplicated recovery. She complains of irritability with a decreased need for sleep. Three days after the birth of the baby, she has a decreased appetite. She exhibits extreme mood labiality and insists that the baby is dead. Further evaluation reveals that she is hearing voices which are telling her that her baby is dead. She exhibits poor insight.

30. POSTPARTUM PSYCHOSIS Incidence:
Infrequent: 1-2 in 1000 births
Previous episode of postpartum psychosis is 1 in 3.
Consistent across cultures
Onset: can occur within 2 weeks of delivery and up to 3 months postpartum
Severe in intensity
Risk for hospital admission:
First 30 days: 21.7%
Within 90 days 12.7%
Risk generally increased in two years post-delivery

31. POSTPARTUM PSYCHOSIS Etiology Biological Factors
Primary etiology is between psychotic disorder in childbirth
Lack of causal relationships between postpartum psychosis and psychosocial stressers.
Biological Factors
Most of these associations are hypotheses.
Estrogen increases dopamine receptor binding
Sudden decrease in estrogen postpartum leads to dopamine receptor sensitivity triggering psychosis
Sleep deprivation

32. POSTPARTUM PSYCHOSIS Psychosocial/ Obstetric/Gynecological Factors
Life events and stress did not differentiate women who developed Postpartum Psychosis from a control group.
First episode is in 36% who have bipolar disorder
Primiparous – 77% on index cases with a mean maternal age of 26 years
After C-Section – 20%
Personal history of Bipolar Affective Disorder (BAD) - 50%
Severity of past psychotic episode
Past history of schizophrenia – 20%
Previous history of postpartum psychosis
Family history of mood disorder - 50% of first degree relatives had affective illness
Family history of postpartum psychosis – 40%

33. POSTPARTUM PSYCHOSIS Diagnosis Differential Diagnosis
DSM IV TR: not a diagnosis
Postpartum Onset is a specifier to Bipolar Affective Disorder and Postpartum Psychosis is a psychotic disorder not otherwise specified (NOS).
Differential Diagnosis
Substance-Induced Psychotic Disorder
Recreational Drug
Sympathomimetics
High-Dose Metronidazole

34. POSTPARTUM PSYCHOSIS Differential Diagnosis (cont.)
Schizophrenia/Schizo Affective Disorder
Psychotic Disorder secondary to Thyroid Disorder
Psychotic Disorder secondary to Systemic Lupus Erythematosus
First six months postpartum
Serum antinuclear antibodies (ANA) to screen
Psychotic Disorder secondary to HIV
Psychotic Disorder secondary to Neurologic Disorder
Psychotic Disorder secondary to Metabolic Disorder

35. POSTPARTUM PSYCHOSIS Symptomatology
Asymptomatic period of 2-3 days followed by severe onset of days postpartum; 77% of cases in the first two weeks
Prodromal symptoms – sleep disturbance/restlessness
Delirium-like picture of cognitive disorganization
Subjective experience of confusion
Extreme affect instability
Bizarre behavior: hallucinations, delusions
Homicidal and suicidal ideations
70% of these patients are diagnosed Bipolar Affective Disorder (BAD) or Major Depressive Disorder (MDD) with psychotic features.

36. POSTPARTUM PSYCHOSIS PROGNOSIS
Excellent if treated rapidly and appropriately
Benign course: rare, 23% of mothers with no psychiatric history
Future Postpartum Psychosis episodes: risk, 25%
Future affective episodes: 64%
Suicide: 5%
Risk Factors:
Postpartum Psychosis admission
Teenage pregnancy
Stillbirth: 70-fold increase in first Postpartum year

37. POSTPARTUM PSYCHOSIS PROGNOSIS
Infanticide: 2% - 4%
Of those who commit infanticide, 62% commit suicide.
1-3 in 50,000 births
Risk Factors:
Maternal age of 15 years at first pregnancy
A year-old mother with her second or subsequent child
Low education
No prenatal care
Andrea Yates

38. POSTPARTUM PSYCHOSIS
Medical Emergency - protection of mother and infant
General Principles:
Early identification
Rapid evaluation
Hospitalization
Coordinated care of mother and infant
Involvement of family and other support

39. POSTPARTUM OBSESSIVE-COMPULSIVE DISORDER AND ANXIETY
Extremely common and often comorbid with depression
Intrusive thoughts or “images” of harming baby or something harmful happening
Terribly distressing and incapacitating
Will not volunteer this information; we must directly ask the mother
Mother is afraid to be alone with baby

40. POSTPARTUM OBSESSIVE-COMPULSIVE DISORDER AND ANXIETY
Antidepressants – must be given at Obsessive-Compulsive Disorder (OCD) dose
Fluoxetine: mg
Sertraline: mg
Paroxetine: mg
Cognitive-Behavioral Therapy (CBT)
Support Groups
Social Support

41. FACTORS CONTRIBUTING TO MATERNAL INFANT BONDING
High-risk Maternal Attitudes
Lack of interest in newborn
Hostile expressions toward infant
Disappointed about gender of infant
Unrealistic expectation about development of infant from birth
Young age of mother
Mother’s experience with rejection/ neglect in her own childhood

42. FACTORS CONTRIBUTING TO MATERNAL INFANT BONDING
High-risk Environmental Factors
Stressful life events
Relationship of mother to spouse/partner
Number of children under mother’s care
Economic resources
High-risk Infant Attributes
The behavioral disposition of the infant
Medical complications relating to the infant

43. IMPACT OF MATERNAL MENTAL ILLNESS ON OFFSPRING
Acute Effects
Mother-infant bond (critical in first year of life) Secure base for child to explore
Negative parenting attitudes in Postpartum Depression, if continued beyond the first week of infant’s life…
Difficulty in mother infant bonding and engagement which if persists leads to…
Infant reciprocating negatively
resulting in decreasing eye gaze during feeding
less content and less playful
more drowsy and fussy
less playful and more squirming.

44. IMPACT OF MATERNAL MENTAL ILLNESS ON OFFSPRING
Long-term Effects
Behavioral functioning: Infants and toddlers
More sleep disturbance
Eating problems
Temper tantrums persisting up to 3 ½ years
Electroencephalogram (EEG) changes in frontal lobe correlating with behavior problems.
Cognitive functioning: less optimal cognitive development in infants
Delay in development of object permanence

45. IMPACT OF MATERNAL MENTAL ILLNESS ON OFFSPRING
Long-term Effects (cont.)
Social/ Interpersonal functioning:
SECURE ATTACHMENT  Sensitive responsive parent
INSECURE AMBIVALENT { Neglectful and rejecting parents INSECURE AVOIDANT { Depressed mothers
INSECURE DISORGANIZED  Fearful experience with caregiver, Postpartum Psychosis, untreated Postpartum depression PRESCHOOL YEARS  Lethargy, sadness, panic, school phobia
Biological:
High Serum Cortisol
Alteration in hypothalamic adrenal axis 

46. TREATMENT Primary Prevention/Secondary/Tertiary Prevention
MEDICAL
Ante- & post-natal care
Pharmacotherapy ECT
PSYCHOLOGICAL
Interpersonal Therapy (IPT)
Couples Therapy
Group Therapy
Mother-Infant Psychotherapy
SOCIAL
Education
Support Groups

47. PRIMARY PREVENTION Professional and Community Education
Identification of Women-at-Risk, antenatal and during pregnancy; Use depression rating scales
Postnatal Screening
Treatment Options
IPT starting with pregnancy and immediately after postpartum
Pharmocotherapy
Postpartum Psychosis with history of Bipolar Disorder; Lithium prophylaxis immediately postpartum
Postpartum Depression; antidepressants immediately upon postpartum
Social Support Groups

48. THE NINE STEPS TO WELLNESS
Education
Sleep (a minimum of 5 hrs)
Nutrition
Exercise and make time for yourself
Sharing with non-judgmental listeners
Emotional support
Practical Support (help with chores)
Referrals to professionals
Hospitalization if necessary

49. PSYCHOTHERAPY
Interpersonal Psychotherapy (IPT): Best documented psychosocial intervention for mild to moderate Postpartum Depression.
Time-limited
12-20 sessions
The focus is on role transitions, interpersonal disputes, and if necessary grief/ interpersonal deficits.

50. PSYCHOTHERAPY Couples Therapy Group Therapy Social Support Groups
Birth of baby developmental stage
Marital disharmony
Lack of partner support
Group Therapy
Formalized group therapy found to be superior to social support groups in alleviating signs/symptoms of depression.
Mother-Infant Psychotherapy
Learn by watching in group therapy
Social Support Groups
Not an alternative for therapy or medication!

51. PHARMACOTHERAPY
5% to 17% of all nursing women take pospartum medications
12% to 20% of all nursing women smoke.
No fixed guidelines
Case-by-case approach evaluating risk/benefits
AAP medicines grouped in 4 categories:
Contra-indicated
Effect unknown may be of concern
Give with caution
Compatible
Timing a dose can reduce infant exposure
Just after nursing and/or prior to infant’s longest sleep period.

52. ANTIDEPRESSANTS
Some prefer Tricyclic Antidepressant (TCA) first line; others prefer short-acting Selective Serotonin Reuptake Inhibitors (SSRIs)
Nortryptiline/desipramine when full dose is used
Seen in very small doses in milk and serum levels are undetectable
Monitoring of breast milk and infant serum concentration is not recommended unless side effects are seen in infants.
Adverse effects are colic, gastrointestinal, and sleep disturbance.

53. MOOD STABILIZERS Lithium Valproate
Detectable Lithium levels can be seen in nursing babies.
Acute effects include:
Hypotonia, cyanosis, lethargy, hypothermia
Long-term effects include:
Hypothyroidism and Diabetes Insipidus
Valproate
Present in low concentration in breast milk.
Infant serum level is about 10% of maternal levels.
Safe if maternal serum levels are within normal limits.

54. MOOD STABILIZERS Carbamazapine Lamotrigine
levels in infants is 40% of maternal serum levels.
Effectively cleared by newborns, serum levels in infants are insignificant.
Lamotrigine
Glucuronidation is immature in infants, it should used with care.
Serum concentration in nursing infants is 30% of maternal concentration.
However, no adverse effects have been documented regarding infants when used during nursing.

55. ANTIPSYCHOTICS Olanzapine: 16 infants
No toxicity reported
No plasma concentrations noted in 6 infants during nursing
Median infant daily dose was 1% -1.6% of maternal dose.
Risperidone: Limited case reports
Infant dose ranging from 2.3% - 4.7% of maternal dose
No evidence of complications in nursing infants
Quetiapine: Limited data
Nursing infant dose is 0.09% of maternal dose.
Low-potency antipsychotics can cause sedation and anticholinergic effects.
High-potency antipsychotics are considered safe but no long-term data is available.

56. ELECTROCONVULSIVE THERAPY (ECT)
Indications
Refractory depression
Psychotic depression
Melancholic depression
High suicide Risk
Risks: Not known other than some post-ECT confusion

57. OPTIONS FOR BREASTFEEDING WOMEN
Use non-pharmacologic treatment.
Wean and initiate pharmacologic treatment.
Continue to breastfeed and initiate pharmacologic treatment.

58. TREATMENT SUMMARY Use a medication appropriate for the diagnosis.
Use a medication to which the patient has had a prior response.
Use a medicine to which the infant has had a prior exposure.
Use a medication for which there is a published data.

59. TREATMENT SUMMARY Monotherapy
Infant serum monitoring is not recommended for antidepressants.
Infant serum monitoring is recommended for mood stabilizers.
If adverse effects are suspected, suspend breastfeeding.

60. HAPPY MOTHER! HAPPY CHILD! HAPPY FAMILY!
TREATMENT SUMMARY
Diagnose early and effectively.
Treat aggressively with a multimodal technique.
HAPPY MOTHER!
HAPPY CHILD!
HAPPY FAMILY!