Transcript Depressive Disorders in Obstetrics and Gynecology

Depressive Disorders in
Obstetrics and Gynecology
Sheila Marcus, M.D.
Kelsie Thelen, B.A.
Maria Muzik, M.D., M.S.
Copyright © 2011. World Psychiatric Association
Depressive Disorders in Obstetrics and Gynecology
Premenstrual Syndrome (PMS)
• 50%-80% of menstruating women experience mild symptoms; 20% severe1,2
Premenstrual Dysphoric Disorder (PMDD)
• 3%-8% of menstruating women meet diagnostic criteria for PMDD3,4
• Symptoms: depressed mood, anxiety, tension, irritability, lethargy, food cravings, physical
symptoms (breast tenderness, headaches)4
• Risks: history of depressive disorders, cultural attitudes toward menstruation, cognitive style,
neuroticism, personality5,6
• Treatment Options: lifestyle/stress management, cognitive behavioral therapy (CBT),7
antidepressants (SSRIs improve affective symptoms)8
Oral Contraceptive Use
• Possible familial risk of developing depressive disorders during contraceptive use9
• High-dose progestin associated with depressive mood, hypersomnia, weight gain, and
gastrointestinal symptoms10
• Pyridoxine (vitamin B6) supplementation and lower dose oral contraceptives may alleviate
depressive symptoms associated with contraceptives11
1 Deuster et al., Arch Fam Med 1999; 2 Perkonigg et al., J Clin Psychiatry 2004; 3 Wittchen et al., Psychol Med 2002; 4 DSMIV-TR 2000; 5 Bancroft et al., Psychosom Med 1994; 6 Bancroft et al., Psychol Med 1993; 7 Freeman, Pharmacoeconomics
2005; 8 Halbreich et al., Obstet Gynecol 2002; 9 Kendler et al., J Nerv Ment Dis 1988; 10 Rush et al., Biol Psychiatry 2003; 11
Adams et al., Lancet 1973
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Depressive Disorders in Obstetrics and Gynecology
Pregnancy-Related Depression
• During pregnancy 10% of women experience mood disorders;1 up to 18% suffer subsyndromal
depressive symptoms2
• Risk factors: higher number of previous pregnancies,3 previous depressive disorders, single marital
status or marital conflict, alcohol use during pregnancy,4 bereavement in 2nd or 3rd trimester5
• Consequences of untreated depression
– Pregnancy: difficulty obtaining prenatal care, poor weight gain, increased alcohol and
drug use6
– Birth: lower birth weight, decreased APGAR scores, prematurity, and smaller head
circumference in infants7,8,9
– Infant outcomes: higher cortisol and lower dopamine and serotonin levels; poor
performance on neonatal behavioral assessments;10,11 negative impact on infant sleep,
feeding, and crying12
1 Cohen et al, Psychosomatics 1989; 2 Marcus et al., J Womens Health 2003; 3 O’Hara, Arch Gen Psychiatry 1986; 4 Marcus et
al., Postgrad Obstet Gynecol 2000; 5 Kumar & Robson, Br J Psychiatry 1984; 6 Miller, Psychiatr Med1991; 7 Sandman et al.,
Ann N Y Acad Sci 1994; 8 Steer et al., J Clin Epidemiol 1992; 9 Zuckerman et al., J Dev Behav Pediatr 1990; 10 Field et al., Int J
Neurosci 2004; 11 Lundy et al., Infant Behav Dev 1999; 12 Diego et al., Psychiatry 2004
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Depressive Disorders in Obstetrics and Gynecology
Treatment of Depression in Pregnancy
• SSRIs: not likely to contribute to major congenital anomalies above baseline risk;1 may be associated
with difficulties in neonatal adaptation, such as irritability and feeding/sleeping problems2
– First trimester SSRI use may lead to preterm delivery, minor malformations3
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Lithium (for bipolar illness): linked to teratogenicity, especially cardiac malformations; though risk of
these anomalies small, it is 10 to 20 times higher than in general population4,5
Anticonvulsants: substantial risk for major fetal malformations (neural tube defects), pregnancy
complications, infant irritability, feeding difficulties and arrhythmia6,7,8,9,10
Lamotrigine: has been approved for treatment of bipolar, but implicated in risk for cleft
anomalies6,9,10,11
Antipsychotic agents: research has not confirmed the presence/absence of teratogenicity beyond
the baseline rate12
ECT: if patient is severely depressed or has psychotic symptoms; little evidence of adverse effects
on fetus or mother but may precipitate premature labor or antepartum hemorrhage
1 Cohen et al., Biol Psychiatry 2000; 2 Nordeng et al., Acta Paediatr 2001; 3 Chambers et al., N Engl J Med 2006; 4 Cohen, J
Clin Psychiatry 2007; 5 Pinelli et al., Am J Obstet Gynecol, 2002; 6 Cohen et al., J Clin Psychiatry 2007; 7 Jager-Romen et al., J
Pediatr, 2986; 8 Kennedy and Koren, J Psychiatry Neurosci 1999; 9 Viguera et al., J Clin Psychiatry 2007; 10 Worley, 2007; 11
GlaxoSmithKline, 2006; 12 Waldman and Safferman, J Psychiatry 1993
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Depressive Disorders in Obstetrics and Gynecology
Postnatal Depressive Symptoms (Baby Blues)
• 50-75% of women experience minor mood swings in the first week after delivery1
Postnatal Depressive Disorders
• 10-15% of childbearing women2
• Clinical Features: similar to other depressive disorders in terms of symptomatology, course,
duration, and outcome
• Effects on infant: difficulties in social and cognitive domains, failure to thrive, attachment difficulties3
• Treatment Options:
– Interpersonal Therapy (IPT) and Cognitive-Behavioral Therapy (CBT) have proven effective4
– Re-establishing the mother’s circadian rhythm, getting more sleep
– Transdermal estrogen in severe cases5
– SSRIs are commonly used by lactating women6
• Sertraline has shown no ill effects
• Fluoxtine use was found to be associated with infant colic
– Lithium should be avoided while breastfeeding7
1 Glover et al., Br J Psychiatry 1994; 2 O’Hara and Swain, Int Rev Psychiatry 1996; 3 Murray and Cooper, 1997; 4 O’Hara et al.,
Arch Gen Psychiatry 2000; 5 Gregoire et al., Lancet 1996; 6 Stowe et al., Am J Psychiatry 2000; 7 Kumar and Robson, Soc
Psychiatry Psychiatr Epidemiol 1984
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Depressive Disorders in Obstetrics and Gynecology
Postnatal Affective Psychosis
• 1:500 to 1:1000 births across cultures1
• Women with a personal or family history of bipolar disorder or puerperal psychosis are at higher
risk2 ; biological risk factors are more important than psychosocial3
• Most women require hospital admission4 but respond well to adequate treatment5
Menopause
• Prevalence of depression does not seem to increase during menopause6
• Psychosocial risk factors: history of depression during postpartum/premenstrual phases, stressful
life events, lack of social support, low socioeconomic status
• Conventional treatments are recommended, such as antidepressants and psychotherapy7
– Hormone Replacement Therapy (HRT) may improve well-being but little evidence to show that
HRT improves depressive disorders during menopause8
1 Kumar, Soc Psychiatry Psychiatr Epidemiol 1994; 2 Kendell et al., Br J Psychiatry 1989; 3 Brockington et al., 1982; 4 Oates
and Gath, Clin Obstet Gynecol 1989; 5 Blehar et al., Psychopharmacol Bull 1998; 6 Hunter, BMJ 1996; 7 Sherwin and
Gelfand, Psychoneuroendocrinology 1985; 8 Morrison et al., Biol Psychiatry 2004
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