1. I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation. Practicing Safety Toolkit: Mother/Caregiver Bundle – Maternal Depression, Bonding, Attachment Steve Kairys, MD, MPH, FAAP Practicing Safety Learning Session May 30, 2009

2. Syndromes of the Postpartum Period  Postpartum or maternity “blues”  Adjustment disorder in the postpartum period  Major depression in the postpartum period  Mania in the postpartum period  Psychosis in the postpartum period

3. Cohen LS. Depress Anxiety. 1998:1:18-26. Transient, nonpathologic Medical emergency Serious, disabling Postpartum Blues Postpartum Depression Postpartum Psychosis 50% to 70% 10% 0.01% 2/3 have onset by 6 wks postpartum  risk for MDD 70% are affective (bipolar, MDD) Severity of Postpartum Mood Symptoms

4. Bright. Am Fam Physician. 1994;50:595. Suri and Burt. J Pract Psychiatry Behav Health. 1997;3:67. Maternity blues Adjustment disorder Postpartum depression Postpartum psychosis/ mania Disorder 26 to 85% About 20% 10 to 20% 0.2% Incidence Support and reassurance Support/reassurance Psychotherapy Antidepressants, mood stabilizers & psychotherapy Hospitalization; antipsychotics; mood stabilizers; benzodiazepines; antidepressants; ECT Treatment 80% resolve by week 2; 20% evolve to PPD Excessive difficulties adjusting to motherhood Onset within 1 year Agitated Major depression often with obsessions Onset after PP day 3. Mixed/rapid cycling. Risk of infanticide. Presentation Postpartum Mood Disorders

5. New Jersey Statistics on Postpartum Depression (Annual)  110,000 live births  800 fetal deaths  Assuming a 10-15% incidence of PPD: Between 11,000-16,620 cases of Postpartum Depression would be expected annually Governor’s Work Group on Postpartum Depression, Spring, 2005

6. Myths about Postpartum Depression  Depression in new mothers is not serious  Postpartum depression is more common in white middle class women  Postpartum depression will go away on its own  Women with postpartum depression cannot breastfeed

7. Risk Factors for Postpartum Mood Disorders Major Risk Factors Depression during pregnancy Anxiety during pregnancy Previous history of depression Teen pregnancy Lack of social support Conflict with spouse/significant other Stressful life events outside of pregnancy Minor Risk Factors Socioeconomic factors Obstetrical complications Adapted from Robertson, Grace, et al GenHospPsych 26(2004)289-295 Adapted from Gaynes, Gavin, et al. AHRQ

8. Depressed Mother’s Infant Interaction Withdrawn  Infant first protests, attempts to engage, then over time withdraws Intrusive and over stimulating  Anger/irritation/rough handling 40% of the time  Infant tries to avoid mother, fusses most of the time Remember not all mothers show these behaviors in public

9. How Depression Can Influence Breastfeeding Depression can: Decrease maternal sensitivity and responsiveness Cause a lack of persistence in the face of difficulties Be related to some maladaptive cognitions regarding the baby (e.g., “the baby is sucking the life out of me”)

10. Major Long Term Impact on Children  61% of children of parents with a major depressive disorder will develop a psychiatric disorder during childhood or adolescence.  Offspring of depressed parent are 4 x more likely to develop an affective disorder than if non- depressed parent  40% chance of experiencing an episode of depression by age 20 and 60% by age 25

11. Post-Partum Depression Using the Edinburgh Postnatal Depression Scale (EPDS)  A 10-question screening tool, developed to assist primary care health professionals  Easy to administer.  Proven valid and reliable  Indicates how the mother has felt during the previous week  A woman scoring 9 or more pts. or a 1 or higher on question #10 should be referred for follow-up.  It is important to screen all moms at 1, 2, and 15 month old well-care visits J.L. Cox, J.M. Holden, R. Sagovsky. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 1987; 150: 782-786

12. Ask what the parents do for fun away from child. Discuss the importance of spending time playing with, talking with and cuddling their baby Be sure to mention that the parent cannot spoil their children by holding or comforting too much. Anticipatory Guidance