Transcript Postpartum Maternal Psychiatric Illness

Postpartum Maternal Psychiatric
Illness: Impact on the infant and
role of the pediatrician
Goals of this Presentation:
1. Understand the potential impact of untreated
perinatal maternal psychiatric illness on the infant
2. Be familiar with the presentation of postpartum
maternal psychiatric illness
3. Elucidate the potential role of the pediatrician in
identifying postpartum maternal psychiatric illness
4. Understand the importance and impact of
treatment of perinatal maternal psychiatric illness
We need to start at the beginning….
• Between 10-20% of women will
experience significant depression
during pregnancy
• Routine screening for depression
during pregnancy is uncommon
• Typically depression during
pregnancy is untreated or
incompletely treated
• Anxiety disorders (OCD, GAD)
generally worsen during pregnancy
• Prenatal anxiety, depression, and high
stress lead to increased maternal cortisol
transmitted to the fetus via the placenta
• Fetal exposure to prenatal anxiety and
depression play a role in programming
the fetal HPA axis
• High cortisol results in lowered cognitive
development (measured by the Bailey at
16 months)
• Increasing research indicates that such fetal
exposure to maternal adversity predisposes to:
-cognitive and developmental delays
-childhood behavioral and psychiatric illness
-adult onset psychiatric illness
-medical illness in adulthood(Type II diabetes,
HTN, metabolic syndrome, etc)
• Evidence shows that this can be mitigated by
secure maternal attachment and strong
mothering
• BUT, maternal adversity such as prenatal
depression and anxiety predisposes to
postpartum psychiatric illness which further
disrupts maternal infant attachment
Antidepressant Exposure and the
Neonate: Poor Neonatal Adaptation
• Consistent data: Late trimester exposure to SSRIs
is associated with transient irritability, agitation,
jitteriness, and tachypnea
• Studies do not control for maternal mental
health condition, blinding of exposure in
neonatal assessments
• Effectiveness of discontinuing or lowering the
dose late in pregnancy aimed at reducing the risk
of neonatal toxicity has not been prospectively
studied
• No correlation between measures of umbilical
cord blood levels of SSRIS and the risk if
developing neonatal symptoms
• No difference in symptoms between two groups
compared : infants born to mothers who had
taken SSRIS but tapered 2 weeks prior to delivery
vs. those who continued
• This phenomenon may represent transient
neonatal serotinergic dysfunction rather than
medication withdrawal
Risk for PPHN Associated With Late Trimester
Exposure to SSRI?
Inconsistent Findings:
• One report showed increased risk by 6-fold (Chambers 2006)
(with this highest estimate of 6-fold increase 1% of exposed infants
would be affected)
• Lower association seen with Källén and Olausson, 2008
• NO association seen by Andrade.et al., 2009
Limitations:
• Small number of SSRI exposures
• Recall bias with respect to early versus late SSRI exposure
• Recent data suggests lower risk than Chambers et al
• PPHN correlated with cesarean section, race, body mass index, and
other factors not related to SSRI use**
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• Increasing research indicates that such fetal
exposure to maternal adversity predisposes to:
-cognitive and developmental delays
-childhood behavioral and psychiatric illness
-adult onset psychiatric illness
-medical illness in adulthood(Type II diabetes,
HTN, metabolic syndrome, etc)
• Evidence shows that this can be mitigated by
secure maternal attachment and strong
mothering
• BUT, maternal adversity such as prenatal
depression and anxiety predisposes to
postpartum psychiatric illness which further
disrupts maternal infant attachment
Pediatricians play an important
role in supporting strong infant
mother relationships and
identifying the need for
intervention when maternal
perinatal psychiatric illness puts
infants at risk for negative
outcomes
Spectrum of Postpartum Mood Disorders
Postpartum Psychosis
(0.1-0.2 %)
Postpartum
Symptom
Severity
Postpartum Depression
(Approx 15%)
Postpartum Blues
(50-85%)
None
PPD: EARLY RECOGNITION
• PPD is most often missed despite multiple
contacts with health care providers
• The most significant factor in the duration of
PPD is delay in receiving treatment
• Depression often persists for months to years
after childbirth, with lingering effects on
physical and psychological functioning following
recovery from depressive episodes
PRESENTATION OF PPD
• Usually develops slowly over the first three
months, often beginning within the first 4
weeks, though some women have a more
acute onset
• May affect ability to care for the baby
• Signs and symptoms are those of Major
Depression---depressed mood, irritability,
loss of interest and appetite, fatigue
insomnia.
• Often complain of being physically and
emotionally exhausted
PRESENTATION OF PPD
Some common features:
• Often express concerns about her ability to
care for her baby or anxiety about the baby’s
well being
• Anxiety symptoms are common including
frank panic disorder, hypochondriasis, and
most common, generalized anxiety disorder
• Women are often unable to sleep even when
given the opportunity
PRESENTATION OF PPD
• Frequently have intrusive, obsessional
ruminations
• Usually focused on the baby, often violent in
nature
• Egodystonic , VERY troubling to mothers
• NO problem with reality testing i.e. nonpsychotic.
• One study showed 50% of women with PPD
had these obsessional thoughts
VERY IMPORTANT TO DISTINGUISH
OBSESSIONAL THOUGHTS FROM PSYCHOSIS
• NOT associated with psychotic symptoms
• Experienced as inside the head
• May be experienced dramatically as images in
the mind, e.g. as knives or bloody babies, etc
• Are often accompanied by protective or
avoidant behaviors, e.g. hiding all the knives,
refusing to bathe the baby, similar to the hand
washing used to neutralize the anxiety of fears
that accompany OCD
• DO NOT increase the risk of harm to the baby
• DO NOT necessitate separating mother and baby
Treatment of Postpartum Depression
• Mild to moderate– psychotherapy
• Other modalities: bright light therapy, exercise,
omega 3 FA
• More severe may warrant medication
– SSRI’s are first line
– Benzodizepines in low dose may be needed
transiently as adjunctive treatment
POST PARTUM PSYCHOSIS
• A PSYCHIATRIC EMERGENCY WHICH
REQUIRES IMMEDIATE INTERVENTION
• Typical onset is within 2 weeks after delivery,
first symptoms often within 48-72 hours
• Earliest signs are restlessness, irritability and
insomnia
• Often very labile in presentation
• Often looks “organic” with a lot of confusion
and disorientation
• Most often consistent with mania or a mixed
state
POST PARTUM PSYCHOSIS
• Includes agitation, paranoia, delusions,
disorganized thinking and impulsivity
• Thoughts of harming the baby are frequently
driven by delusions—Child must be saved from
harm, child is malevolent, dangerous, has special
powers, is Satan or God
• Auditory hallucinations instructing the mother to
harm herself or the child are common
• Rates of infanticide associated with untreated
postpartum psychosis have been estimated to be
as high as 4% and suicide as high as 5%
Treatment of Postpartum Psychosis
• A psychiatric emergency
• Requires hospitalization
• Treated as affective psychosis (i.e. bipolar
disorder) with antipsychotics and mood
stabilizers (+/- antidepressants) Typical
regimen might be zyprexa and lamictal
Other Considerations
• The onset or worsening of OCD, PTSD and
panic disorder can also occur postpartum.
There can be considerable overlap with PPD.
• PTSD can develop in response to a traumatic
birth experience or pregnancy loss
• PTSD can emerge in pregnancy when past
physical or sexual trauma is reexpereinced
• Often are intermingled with symptoms of
PPD
Impact of Untreated Postpartum
Maternal Depression on the Infant
• Poor weight gain
• Sleep problems
• Less breastfeeding-depressed mothers more
likely to discontinue breastfeeding
• Impaired maternal health and safety practices
• Increased risk of child abuse and neglect
• Disruption in the attuned infant-caregiver
interactions which promote brain neurological
“wiring”:
– Future , hyperactivity, conduct disorders and school
behavior problems
– Delays in language and social development
– Increased risk of depression and anxiety disorders
– Maternal depression is an “Adverse childhood
experience” ACE, often it is not the only adversity
– MATERNAL POST PARTUM MOOD IS ONE OF THE
STRONGEST PREDICTORS OF NEUROCOGNITIVE
DEVELOPMENT IN CHILDREN MEASURED UP TO AGE SIX
Public Health Issue
• Over four million live births in the US each
year.
About 15% will have postpartum
depression
• About 10% are teen mothers
About 30% will have PPD
• 660,000 Babies at risk for being affected by
PPD alone each year
Need for Patient Education
• The greatest barrier to treatment for PPD in women
is lack of knowledge
• Lack of knowledge about PPD, treatment options,
and community resources is common in postpartum
women and their families, and frequently leads to
delay in seeking treatment
• Delay in treatment for PPD results in a longer illness
• Information about PPD should be provided to
women in the prenatal period, soon after delivery,
and further encounters with healthcare providers in
the first postpartum year.
Postpartum Depression Screening
• There is tremendous societal pressure for women to
present as happy and well functioning during these
times.
• Despite contact with multiple healthcare providers
PPD is usually not diagnosed
• Postpartum depression is often not recognized– when
formal screening methods are not utilized detection
rates are as low as 2%
• Despite the availability of validated screening tools,
routine screening for PPD is not widespread
• Lack of recognition often means untreated depression
and poor outcomes for the mother, her infant, and
family
Postpartum Depression Screening
• American Academy of Pediatrics (AAP) released a
recent report which recommends that
pediatricians screen mothers for postpartum
depression at baby’s one-, two-, and four-month
visits.
• Recommends screening with either the EPDS or a
2 question screener
• EPDS:
o 10 question self administered screening test
o Well validated
Cut-off point of 10 as an indicator of risk for
depression
Postpartum Depression Screening
• Two-question Screener (PHQ-2)
1. Over the past two weeks have you ever felt
down, depressed or hopeless?
2. Over the past two weeks have you felt little
interest or pleasure in doing things?
Considered positive if answered yes to either
question
• A score above 20 on the EPDS or any indication of
suicidality or psychosis warrants consideration for
crisis intervention services.
If not using screening tools, be
specific:
• “Are you been unable to sleep even when your baby
is sleeping?” (“Or do worries and anxiety keep you
awake?”)
• “Have you found yourself crying a lot?”
• “Have you had any thoughts that have been
worrisome or frightening to you?”
• “Have you had any thoughts of harming yourself or
your baby?”
• The suicide rate is increased 70 fold with postpartum
depression necessitating assessment of suicidality as
part of every screening for postpartum depression.
Other considerations
Suspect PPD if:
• Frequent calls with concerns about the
infant seem to reflect maternal anxiety
• Infant fails to gain weight and there isn’t
an explanation
Impact of Treatment on the Infant:
Exposure to Medications via
Breastfeeding
• Antidepressants have more published data in breast
feeding than any other class of medications
• All antidepressants are secreted into breast milk
• Nursing infant serum concentrations are not detectable
by the usual laboratory assays
• Literature review revealed 11 publications of 40 infants
(5 % of published breast feeding cases)with purported
adverse effects from antidepressant exposure during
breastfeeding—majority of symptoms were GI distress
and sleep problems some of which resolved with
discontinuation
Impact of Treatment on the Infant:
Exposure to Medications via
Breastfeeding
Minimize infant exposure by:
• Using a medication of prior response
• Using a medication of prior infant exposure
(i.e. in utero)
• Monotherapy is preferable
• Infant serum monitoring is not recommended
Choice of Antidepressant
•
Antidepressant used during pregnancy should be continued
• Use agent to which patient has responded to in the past
• Caution may be needed with exposure in premature infants
with hepatic immaturity
• Onset of action requires 2-4 weeks
• Exposure for the infant is lowest for sertraline (Zoloft) and
fluvoxamine (Luvox), somewhat higher for paroxetine (Paxil),
higher with citalopram (Celexa) and fluoxetine (Prozac)
• With the current knowledge there is no strong evidence to
recommend one drug over another or rationale to switch from
one SSRI to another to promote safety during breastfeeding
Use of Benzodiazepines During Lactation
• Data is somewhat limited
• When measured, exposure through breast milk is
extremely low
• Some anecdotal reports of sedation, poor feeding,
respiratory distress; pooled data show low
incidence of adverse effects
• Diazepam more likely to accumulate in breast
feeding baby
• Less likely to accumulate—lorazepam (Ativan)
clonazepam (Klonopin)
• Benzodiazepines may be needed transiently whne
maternal anxiety is high and SSRI’s have not yet
begun to work
Mood Stabilizers and Lactation
• Lamictal present in breast milk at variable levels; infant
serum levels 20-50 % of maternal . Only one adverse event
reported with daily maternal Lamictal dose of 850 mg.
• Tegretol and Depakote are approved by the AAP for use in
lactating infants. Need close monitoring for drug levels and
liver function
• Lithium is excreted into breast milk at high levels
– Breastfeeding generally avoided
– Possible as monotherapy with close supervision at lowest possible
dose with close clinical monitoring for signs of toxicity and checking
Li levels, TSH, BUN, Cr
Women with history of moderate to severe bipolar disorder
need to preserve their sleep and should pump and have
someone else do night time feedings if possible
Neurodevelopmental Effects of
Antiepileptic Drugs Study
Effects of breastfeeding during AED therapy
cognitive outcomes in 199 children at age 3
No difference in IQ’s in breastfed (exposed) vs.
non breastfed
Limitations:
All had exposure to AEDs in utero,
No control of women not taking AED’s
Meador KJ, Baker GA, et al Neurology. 2010 Nov 30;75(22):1954-60. Epub 2010 Nov 24
Antipsychotics and Lactation
• Typical Antipsychotics
– Medium to high potency typical antipsychotics rarely
have adverse effects
– Thorazine associated with sedation and developmental
delay
– Clozapine may be concentrated in breast milk– requires
infant blood monitoring
• Atypicals Antipsychotics
– olanzapine, risperidone, and quetiapine-excretion into
breast milk is low
– adverse effects appear to be rare
Role of the Pediatrician
• Have a high awareness of incidence of postpartum
psychiatric illness and the consequences of lack of
treatment
• Play a role in educating mothers (MAPP has
materials)
• Play a role in identifying postpartum illness,
especially depression (routine screening, if possible)
• Be prepared to refer identified mothers to treatment
• Provide support to mothers who are in need
• Collaborate as part of a team in treating maternal
postpartum illness bearing in mind the child’s
wellbeing
TREATMENT OF POSTPARTUM
PSYCHIATRIC ILLNESS FOR A
MOTHER IS AN EARLY
INTERVENTION FOR A CHILD
Maine Association of Psychiatric Physician’s (MAPP)
Postpartum Depression Project