1. POSTPARTUM DEPRESSION BEYOND THE BLUES Debby Carapezza, R.N., M..S.N. Nurse Consultant, Reproductive Health Program Utah Department of Health

2. INCIDENCE OF DEPRESSION §Each year, 15% to 20% of adults in the United States experience a major depression §The incidence among women is twice that of men and peaks between 18 to 44 years of age - the childbearing years

3. DEPRESSION IN WOMEN §Women are at increased risk of mood disorders during periods of hormonal fluctuation- l premenstrual l postpartum l perimenopausal

4. THE RANGE OF POST- DELIVERY MOOD DISORDERS §50% to 80% of women experience transient “baby blues” within the first two weeks following delivery §0.1% to 0.2% of women experience postpartum psychosis usually within the first 4 weeks following delivery

5. POSTPARTUM DEPRESSION §6.8% to 16.5% of women experience postpartum depression (PPD) also known as postpartum major depression (PMD) §Onset can be as early as 24 hours or as late as several months following delivery

6. SYMPTOMS OF POSTPARTUM DEPRESSION

7. RANGE OF SYMPTOMS §Symptoms range- l from mild dysphoria l to suicidal ideation l to psychotic depression

8. DURATION OF SYMPTOMS §Untreated, symptoms can last: l several months l into the second year postpartum

9. THE ETIOLOGY OF POSTPARTUM DEPRESSION §Various theories based in physiological changes have been postulated: l hormonal excesses or deficiencies of estrogen, progesterone, prolactin, thyroxine, tryptophan, among others

10. ETIOLOGY OF POSTPARTUM DEPRESSION §Other theories cite numerous psychosocial factors associated with PMD: l marital conflict l child-care difficulties (feeding, sleeping, health problems) l perception by mother of an infant with a difficult temperament l history of family or personal depression

11. POSTPARTUM DEPRESSION IN UTAH What can PRAMS* data tell us? *PRAMS is an ongoing, population-based risk factor surveillance system designed to identify & monitor selected maternal experiences that occur before & during pregnancy & experiences of the child’s early infancy.

12. INDICDENCE OF POSTPARTUM DEPRESSION AMONG 2000 UTAH PRAMS RESPONDENTS §24.1% of PRAMS respondents indicated that in the months after delivery they were moderately to very depressed

13. §When the results of the survey are weighted to represent all 47,331 Utah women who had a live birth in 2000, this means an estimated 11,416 women reported being moderately or very depressed.

14. Higher rates of depression were noted among women who:

15. THE IMPACT OF POSTPARTUM DEPRESSION

16. LONG TERM CONSEQUENCES OF PMD §Negative impact on the infant ‘s social, emotional and cognitive development l 2 month old infants of mothers with PMD had decreased cognitive ability and expressed more negative emotions during testing

17. LONG TERM CONSEQUENCES OF PMD §Babies of mothers with PMD were perceived by their mothers as more difficult to care for and more bothersome.

18. POSTPARTUM DEPRESSION & MATERNAL MORTALITY IN UTAH §In recent years, there have been two maternal deaths due to suicide by women within one year of giving birth. §Neither woman had been screened for postpartum depression

19. RISK FACTORS FOR PMD

20. INTERVENTIONS SCREENING FOR PMD

21. SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY: §Be unable to recognize she is depressed

22. SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY: §Believe her symptoms are “normal” for new moms

23. SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY: §Fear being labeled a “bad mother” if she admits her maternal experience does not meet society’s picture of bliss

24. SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY: §Feel she is going crazy and fears her baby will be taken from her

25. WHEN TO SCREEN FOR PMD §At preconception visit §During prenatal intake & subsequent visits §During postpartum exams §During infant’s WCC & WIC visits §When infant is seen for sick care or in ER §At early intervention home visits §At family planning visits during the first year postpartum §At mother’s visits for routine episodic care

26. SCREENING TOOLS §There are several tools available: l Edinburgh Postnatal Depression Scale (EPDS) l The Mills Depression & Anxiety Checklist l The Center for Epidemiological Studies Depression Scale (CES-D) l Others, often on various websites for mental health

27. A WORD ABOUT SCREENING TOOLS! §Be familiar with the tool - its validity and limitations §Have a referral network available for women screening positive §Document the screening and any referrals made §Follow-up with your client to assure that she received needed assistance

28. EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS) §Designed for home or outpatient use §Consists of 10 questions §Can be completed in approx. 5 minutes §Reviews feelings the previous 7 days §Scored 0-3 depending on symptom severity §Depending on study, cut off is 13 - 9 points

29. SAMPLE EPDS QUESTIONS §1. I have been able to laugh & see the funny side of things l As much as I always could l Not quite so much now l Definitely not so much not l Not at all

30. SAMPLE EPDS QUESITONS (Cont.) §*3. I have blamed myself unnecessarily when things went wrong l Yes, most of the time l Yes, some of the time l Not very often l No never

31. SAMPLE EPDS QUESTIONS (Cont.) §*6. Things have been getting on top of me l Yes, most of the time I haven’t been able to cope at all l Yes, sometimes I haven’t been coping as well as usual l No, most of the time I have coped as well as ever l No, I have been coping as well as ever

32. TREATMENT §1. Educate the woman and her support system regarding the diagnosis of postpartum depression.

33. TREATMENT OPTIONS §Pharmacological intervention §Counseling, individual and/or group §Support groups

34. PHARMACOLOGICAL INTERVENTION §Use of tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) may be indicated for both non- nursing and nursing mothers §Have low incidence of infant toxicity and adverse effects during breastfeeding* §Decisions regarding use while breastfeeding must be on a case by case basis

35. OTHER CONSIDERATIONS: §Provider must be familiar with agents and the hepatic function of mother and infant §Client must be informed of risks/benefits of treatment Vs. no treatment for herself and her infant l unknown impact of long-term use of medications on neurodevelopment of infant

36. Other Considerations - Cont. §If the woman chooses to breastfeed while on psychotropics, she should work collaboratively with a psychiatrist and her pediatrician §If the infant experiences insomnia or other behavior changes, his serum should be assayed for the presence of medication §Document all discussions regarding treatment in the client’s chart

37. TREATMENT OF DEPRESSION PATIENT ASSISTANCE PROGRAMS §Pharmacological treatment of depression can be effective. Unfortunately, it can also be expensive. Costs of antidepressants vary depending on the drug, dose and pharmacy. §Paxil® 20mg qd X 30 Days = $85.39 §Prozac® 20mg qd X 30 Days = $67.79 (generic) §Zoloft® 50mg qd X 30 days = $75.00 §Elavil®, at approximately 75mg qd X 30 days = $11.39 (generic) or $37.89 (brand).

38. COUNSELING §Know referral sources in your locale, especially those that: l accept Medicaid l utilize a sliding fee l will develop a payment plan with the client l offer free counseling §Be familiar with indigent drug programs available through various pharmaceutical manufacturers

39. Counseling - Cont. §Any woman with symptoms of psychosis or with serious suicidal/homicidal ideation should be referred for emergency psychiatric evaluation

40. SUPPORT GROUPS §Numerous postpartum support groups are available. Contact: §Local mental health agencies §Hospitals §Websites

41. WEBSITE INFO & SUPPORT §Depression After Delivery - http://www.depressionafterdelivery.com §Postpartum Support International - http://www.postpartum.net/ §The Postpartum Stress Center - http://www.postpartumstress.com/ §Postpartum Education for Parents - http://www.sbpep.org §Office on Women’s Health - http://www.4women.gov-pregnancy-after the baby is born-PPD

42. Websites and Other Resources §Mental Health Association in Utah l http://www.xmission.com/~mhaut/ §For information on medication while breastfeeding, call Pregnancy RiskLine: l In Salt Lake City: 328-BABY (2229) l Outside Salt Lake: 1-800-822-BABY (2229)

43. SUMMARY §Postpartum depression: l is relatively common l may have long-term consequences for mother, infant & family l is easily missed l should be screened for l can be treated successfully

44. References §1. Beck AT, Ward, CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Archives of General Psychiatry. (June 1961). 4:6:561- 571. §2. Cox JL, Holden, JM, Sagovsky R. Edinburgh Postnatal Depression Scale (EPDS). British Journal of Psychiatry. (1987). 150:782-786. §3. Epperson CN. Postpartum major depression: detection & treatment. American Family Physician. (April 15, 1999). 59:8:2247-2254. §4. Mandl KD, Tronick EZ, Brennan TA, Alpert HR, Homer J. Infant health care use and maternal depression. Archives of Pediatric Adolescent Medicine. (1999). 153:(8):808-813. §5. Stowe Z. Depression after childbirth: I it the “baby blues” or something more? Pfizer Inc. January 1998. §6. Stowe ZN, Nemeroff CB. Women at risk for postpartum-onset major depression. American Journal of Obstetrics & Gynecology. (August 1995). 173:2:639-645. §7. Utah Department of Health. (2001). [Untitled]. Unpublished Maternal Mortality Review Program data.

45. References (cont.) §8. Utah Department of Health. (2001). [Untitled]. Unpublished PRAMS data. §9. Whiffen VE, Gotlib IH. Infants of postpartum depressed mothers: temperament and cognitive status. Journal of Abnormal Psychology. (1989). 98:3:274-279.