1. Perinatal Mood Disorders
Presented By: Heidi Haensel, MD, FRCPC
March 20, 2019
Perinatal Mood Disorders

2. Disclosure:
I have not had in the past 3 years, a financial interest, arrangement or affiliation with one or more organizations that could be perceived as a direct or indirect conflict of interest in the content of this presentation.

3. Objectives:
To review the presentation of mood disorders (Depression and Bipolar Disorders) in pregnancy and postpartum
To discuss the impact of mood disorders in pregnancy and postpartum on the mother and infant
To discuss screening and management of mood disorders in pregnancy and postpartum

4. Depression in Pregnancy and Postpartum- a Common Problem
Between 5 and 16% of women will experience major depression at some point during their pregnancy
Between 4.2%–9.6% will experience a major depressive disorder between birth and 3 months postpartum
Estimates vary between 9.3% and 31% for the first year postpartum

5. Baby Blues – Even More Common
occur in 50-85% of women
Peak symptoms 3rd to 7th day after delivery; usually completely gone 3 weeks after delivery
Thought to be reaction to hormone changes post-pregnancy
Main feature is mood lability - “crying at the drop of a hat”; “moodiness”
Also anxiety, insomnia, poor appetite and irritability
Not as severe, persistent or pervasive as postpartum depression

6. Depression in Pregnancy and Postpartum – How to Recognize
Those with a history of depression carry the greatest risk
However, for 50-70% it is the first presentation of depression in their lifetime
If discontinuation of antidepressants near conception,75% relapse (often 1st trimester)
With abrupt discontinuation antidepressants during pregnancy, 70% have adverse effects, suicidality, hospitalization

7. Depression in Pregnancy and Postpartum – How to Recognize
Symptoms:
Sad mood
Crying frequently
Changes in sleep: in post-partum, often not able to sleep when baby is sleeping
Appetite: diminished appetite in breastfeeding a concern
Decreased energy and motivation: not keeping up with baby or self care
Anhedonia: don’t enjoy, feel bonded to the baby
High anxiety frequently seen
May have thoughts of harm to self or to the baby: e.g. “They are better off without me”; smothering baby, leaving baby in a snow bank

8. Risks for Developing Perinatal Depression
Personal history of depression, depression in pregnancy – up to 50% develop postpartum depression
Previous postpartum depression
Family history of depression

9. Risks for Developing Perinatal Depression
Excessive anxiety during pregnancy; Lack of confidence in parenting skills/excess anxiety about baby
Poor social support – social isolation, recent move, poverty, cultural or language issues
Relationship or family conflict; Life/financial stress
Recent adverse life events (e.g., loss of close relative or friend); previous pregnancy loss
Intimate partner violence
Unintended pregnancy/ambivalence towards pregnancy
Infants with health problems or perceived difficult temperaments
Chronic/acute maternal health problems

10. Perinatal Depression - Impact
Impacts of untreated perinatal depression are much greater and farther-reaching than risks associated with antidepressant treatment
Impacts on pregnancy outcomes and child development derive from poorer prenatal care, more substance use in pregnancy, poorer nutrition and self-care, epigenetic effects of chronic stress
Postnatal impacts on relationships with family and spouse; attachment security of infant; confidence in parenting; sustaining breastfeeding; substance use
In turn, these impact the motor, language and social development of infants and children
Suicide and infanticide risks

11. Perinatal Depression - Impact
Impacts for mother
poor self care, inadequate nutrition & weight gain, sleep disturbance, illicit drug use, smoking , alcohol abuse
emotional deterioration, increased anxiety
interpersonal/family conflict
increased risk pre-eclampsia, operative delivery, epidural, NICU
Suicide, attempted suicide, infant harm and infanticide
Impacts for infant
preterm birth
lower birth weight
smaller head circumference
lower APGAR scores
Significant behavioural problems more likely
Sleep and eating disorders
Difficulties in regulating emotions and behaviour eg. temper tantrums
Delayed language development
Lower rates of secure attachment

12. Bipolar Disorder in the Perinatal Period
Rates the same as general population (2.1%)
Pregnancy confers risk for exacerbation of symptoms (45-50% report this)
Many women discontinue medications abruptly in pregnancy; 50% will relapse
Postpartum period conveys increased risk for onset of Bipolar Disorder or relapse
25%–30% recurrence rate in the immediate postpartum and relapse rates at months postpartum of 67%–82%.
Rate of postpartum psychosis is 10–20% among women with bipolar disorder.
In Bipolar Type 2, hypomanic symptoms in pregnancy can be misattributed as “nesting behavior”, and in postpartum they can be attributed to elation about the baby
Diagnosis often missed until mood swings into depression

13. Postpartum Psychosis Rare; 1 to 2 per 1000 births
If first onset psychosis, usually is a first presentation of bipolar disorder
Symptoms develop typically 2 to 3 days after delivery, but may develop up to 4 weeks after
Prodrome of worsening insomnia and agitation
Symptoms of lability, disorganized thoughts and behaviour, bewilderment, poor memory
Progresses rapidly
Bizarre thoughts often involve the baby; e.g. the baby is an alien, dead, replaced
Infanticide: 1-3 per 50,000 births; suicide also a risk
Postpartum psychosis is an emergency, and requires hospitalization and psychiatric management

14. Perinatal Mood Disorders - Screening
Bipolar Disorder – no validated tool for perinatal period; rely on diagnostic interview
Depression – Edinburgh Postnatal Depression Scale
See the “new” Ontario Antenatal Record for screening tools and schedule
Screening in pregnancy recommended, as well as 6 weeks postpartum

15. Edinburgh Postnatal Depression Scale
Validated for use in postpartum and pregnancy; self-report
Can be used for partners and adoptive parents as well
Puts less emphasis on sleep and appetite as symptoms, as these are commonly disrupted in pregnancy and postpartum; more emphasis on anxiety symptoms and cognitive symptoms of depression
Is not the “gold standard” – this is still the diagnostic interview

16. EPDS Score
Interpretation
Action
Less than 8
Depression not likely
Continue support
9–11
Depression possible
Support, re-screen in 2–4 weeks. Consider referral to primary care provider (PCP).
12–13
Fairly high possibility of depression
Monitor, support and offer education. Refer to PCP.
14 and higher (positive screen)
Probable depression
Diagnostic assessment and treatment by PCP and/or specialist.
Positive score (1, 2 or 3) on question 10 (suicidality risk)
Immediate discussion required. Refer to PCP ± mental health specialist or emergency resource for further assessment and intervention as appropriate. Urgency of referral will depend on several factors including: whether the suicidal ideation is accompanied by a plan, whether there has been a history of suicide attempts, whether symptoms of a psychotic disorder are present and/or there is concern about harm to the baby.

17. Also Consider: Anxiety disorders
Adjustment disorder with depressive symptoms
Grief
Personality disorders, especially Borderline Personality Disorder
Domestic violence
Stressful life circumstances
Substance misuse

18. Perinatal Mood Disorders - Treatment

19. Bipolar Disorder in the Perinatal Period
Ideally, consultation with a psychiatrist prior to conception to discuss relapse risks and risks of medication
Generally psychiatric management recommended throughout pregnancy; requires close monitoring for emergence of relapse
Consult regarding medications:
Mother Risk
or FRAME Clinic at Victoria Hospital ext
Need high support in immediate postpartum; extended hospital stay (3 to 5 days) recommended
Promote medication adherence and good self-care, especially sleep

20. Perinatal Bipolar Disorder - Medications
Atypical antipsychotics, lamotrigine are safest in pregnancy
Lithium – risks of neonatal toxicity at birth and through breast milk; cardiac risk is less than original estimates
Valproic acid – confers greatest risk of neural tube defects; only use if no other medications work; use 5 mg folic acid daily
Detailed second trimester ultrasound recommended for women on lithium or antiepileptic medications

21. Depression in the Perinatal Period
Treatment should take into account history of symptoms, preferences of woman
Mild to moderate depression – psychotherapeutic interventions first line
Moderate to severe depression – indication for medications

22. Psychotherapy in Perinatal Depression
Psychoeducation
Lifestyle interventions – promoting sleep, nutrition, exercise, social support
Healthy Babies, Healthy Children referral
Strong research evidence on benefit of friendly home visitor

23. Psychotherapy in Perinatal Depression
Evidence-based psychotherapies:
Supportive Psychotherapy
Cognitive-Behaviour Therapy
Interpersonal Therapy
Remember to screen for Employee Assistance Program or Benefits to access community psychotherapy
Postpartum Mood Disorders Support Groups
Elgin PPMD Support Group
Vesta Parenting Centre

24. Medications in Perinatal Depression
Most antidepressant medications in pregnancy have not been shown to confer risks above the baseline risk of malformations
Exception is: Wellbutrin – increased risk of left ventricular outflow obstruction; paroxetine in first trimester – increased cardiac and limb defects
Most antidepressant medications are very compatible with breastfeeding
Fluvoxamine, Effexor and Wellbutrin have increased exposure through breastmilk and require more monitoring

25. Perinatal depression – when to refer
Complex, treatment resistant depression
Very severe symptomatology
Depression with psychosis

26. QUESTIONS?
ext 76673