Transcript postpartum psychosis

Mood And Anxiety
Disorders in
NICU Families
By
Pec Indman EdD, MFT
The Field of Neonatology Has
Expanded beyond the Primary
Aim of Saving Infant’s Lives to
Minimizing Survivor’s Long-term
Complications, and thus
Extending Clinicians’
Responsibilities beyond the Baby
to the Broader Family.
Meyer EC, Brodsky D, Hansen AR, et al. An interdisciplinary, family-focused approach
to relational learning in neonatal intensive care. J Perinatol 2011; 31: 212- 219.
MYTHS ABOUT PERINATAL
MOOD DISORDERS
© 2012 Pec Indman EdD, MFT
HISTORICAL INFORMATION
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Psychiatric history
History of sexual abuse or trauma
Fertility problems
Perinatal loss
Previous pregnancy, birth, or postpartum
difficulties
© 2012 Pec Indman EdD, MFT
DEPRESSION IN
PREGNANCY
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About 15-21% of women experience depression
in pregnancy up to 38% in low SES (Alfonso DD, et al. Birth
1990;17:121-130)
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50-75% relapse after discontinuing medication
when pregnant (Cohen LS, et al. Psychother Psychosom. 2004 JulAug;73(4):255-8)
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Over 40% resume medication during pregnancy
(Cohen LS, et al.. Psychother Psychosom. 2004 Jul-Aug;73(4):255-8)
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Most are undetected and under treated (Marcus, S.,
Depression during Prengnancy:Rates, Risks, and Consequences. Can J Clin Pharmacol
Winter 2009 Vol 16 (1)
© 2012 Pec Indman EdD, MFT
DEPRESSION/ANXIETY IN
PREGNANCY
Depression in pregnancy associated with:
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Low birth weight (under 2500 grams)
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Preterm delivery (less than 37 weeks) up to
2X risk (Li D, Liu L, Odouli R, Hum Repod. 2009 Jan;24(1):146-53. Epub
2008 Oct 23, Straub H, Adams M, Kim JJ, et al. Am J Obstet Gynecol 2012;207)
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Small-for-gestational age/IUGR (Grote, N, et al. ARCH
GEN PSYCHIATRY/VOL 67 (NO. 10), OCT 2010)
Severe anxiety in pregnancy associated with:
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Constriction in placental blood supply
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Heightened startle response in newborn
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Newborns more inconsolable, poor sleep
(Bennett HA, Einarson, A. et al. Clin Drug Invest 2004;24 (3)
© 2012 Pec Indman EdD, MFT
POSTPARTUM “BLUES”
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Occurs in 50-80% of postpartum women
Onset usually in first week postpartum
Symptoms may persist from several days
to a few weeks
NORMAL
© 2012 Pec Indman EdD, MFT
BLUES OR BEYOND?
• Severity
• Timing
• Duration
© 2012 Pec Indman EdD, MFT
POSTPARTUM DEPRESSION-NICU
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PPD rates 40% if premature infant
Sustained (up to 52 wks) depression
associated with:
• earlier gestational age
• lower birth weight
• ongoing infant illness/disability
• perceived lack of social support.
• most studies failed to consider depression
in pregnancy as a confounding variable
(Vigod SN, Villegas L, Dennis CL, Ross LE. Prevalence and risk factors for
postpartum depression among women with preterm and low-birth-weight infants:
a systematic review. BJOG. 2010 Apr;117(5):540-50)
© 2012 Pec Indman EdD, MFT
SYMPTOMS OF POSTPARTUM
DEPRESSION/ANXIETY:
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Sad mood, guilt, irritability, excessive worry,
anxiety, or feelings of being overwhelmed
Sleep problems (often insomnia), fatigue
Symptoms or complaints in excess of, or
without physical cause
Discomfort around baby, or lack of feelings
towards baby
Loss of focus and concentration (may miss
appointments)
Loss of interest or pleasure
Appetite changes-poor appetite or weight gain
© 2012 Pec Indman EdD, MFT
NICU MOMS and PPD
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A mom’s perception of of nursing
support and depressive symptoms
were found to be directly related.
As the perception of nursing support
decreased by one point, the risk of
depression increased by 6%
(Kyle Mounts, Screening for Maternal Depression in the Neonatal ICU, Clin
Perinatol, 2009;36: 137-152)
© 2012 Pec Indman EdD, MFT
NICU MOMS AT 1 year
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39%-63% depressed at 1 year pp
© 2012 Pec Indman EdD, MFT
RISK FACTORS FOR PPD
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50-80% risk if previous postpartum
depression
50% risk if depression or anxiety during
pregnancy
Personal and/or family history of depression
or other psychiatric disorder
History of severe PMS or PMDD
Social isolation/poor support system/teens
(Suri R and Burt VK. The Assessment and treatment of Postpartum
Psychiatric Disorders. Jrnl Prac Psych and Behav Hlth. March 1997)
© 2012 Pec Indman EdD, MFT
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TREATMENT FOR POSTPARTUM
DEPRESSION/ANXIETY
Individual/couples therapy, group
• CBT or Interpersonal Therapy (IPT)
Antidepressant and/or antianxiety
medication, Sleep meds
(Wisner KL, et al., N Engl J
Med. July 2002;347(3):194-199)
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Treat thyroiditis
ECT
INADEQUATE TREATMENT CAN LEAD
TO CHRONIC DEPRESSION OR
RELAPSE
© 2012 Pec Indman EdD, MFT
POSTPARTUM OBSESSIVECOMPULSIVE DISORDER
(OCD)
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3% to 9% of new mothers may develop
obsessive symptoms
(Abramowitz JS, et al. Anxiety Disorders 2003. 17:461-478, Chaudron, LH and Neha
Nirodi. The obsessive–compulsive spectrum in the perinatal period: a prospective
pilot study. Arch Womens Ment Health, March, 2010;1434-1816.)
© 2012 Pec Indman EdD, MFT
SYMPTOMS OF
POSTPARTUM OCD
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Intrusive, repetitive, and persistent thoughts or
mental picture – different that PTSD flashback
Thoughts often are about hurting or killing the
baby
Tremendous sense of horror and disgust
about these thoughts (ego alien)
Thoughts may be accompanied by behaviors
to reduce the anxiety (such as hiding knives)
Repetitive counting (diapers in the bag),
checking (baby’s breathing), cleaning
(The obsessive–compulsive spectrum in the perinatal period: a prospective pilot
study. Arch Womens Ment Health, March, 2010;1434-1816. Sichel D and Driscoll
JW. Women’s Moods, 1999)
© 2012 Pec Indman EdD, MFT
TREATMENT FOR OCD
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Psychotherapy and psychoeducation
Medication (SSRIs)
© 2012 Pec Indman EdD, MFT
POSTPARTUM PANIC
DISORDER
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May occur in about 10% of postpartum
women
© 2012 Pec Indman EdD, MFT
SYMPTOMS OF PANIC
DISORDER
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Episodes of extreme anxiety: excessive or
obsessive worry or fears
Shortness of breath, chest pain, sensations of
choking or smothering, dizziness
Hot or cold flashes, trembling, palpitations,
numbness or tingling sensations
Restlessness, agitation, or irritability
During attack may fear she is going crazy,
dying, or losing control
Attack may awaken her from sleep
Often no identifiable trigger for panic
(Sichel D and Driscoll JW. Women’s Moods, 1999)
© 2012 Pec Indman EdD, MFT
TREATMENT FOR PANIC
DISORDER
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Psychotherapy
SSRIs
Antianxiety medication
© 2012 Pec Indman EdD, MFT
BIPOLAR DISORDER
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In women with BD rates range up to 82%
Time of increased vulnerability for relapse
Most present with depression
Closely associated with postpartum
psychosis
(Sharma, V. et al. Bipolar II Postpartum Depression: Detection, Diagnosis, and
Treatment. Am J Psychiatry 2009; 166:1217–1221.)Cohen LS and Nonacs RM eds.
Mood and Anxiety Disorders During Pregnancy and Postpartum. American
Psychiatric Publishing, Inc., 2005)
© 2012 Pec Indman EdD, MFT
SYMPTOMS OF BIPOLAR
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Mania or hypomania
Depression
Rapid and severe mood swings
© 2012 Pec Indman EdD, MFT
TREATMENT OF BD
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Careful observation for symptoms
High Risk postpartum mania/psychosis
(Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy
and Postpartum. American Psychiatric Publishing, Inc., 2005)
© 2012 Pec Indman EdD, MFT
POSTTRAUMATIC STRESS
DISORDER (PTSD)
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May occur in 1-6% (Beck CT. Nursing Research.
July/Aug 2004; 53(4):216-224)
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Up to 38% report traumatic
birth
(Beck C & Watson S, Impact of Birth Trauma on Nursing, Nursing
Research 2008(57);4:228-236)
© 2012 Pec Indman EdD, MFT
PTSD in NICU Families
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Up to 70%
Common to experience PTSD, PMADs
(Lefkowitz DS, Chiara Baxt C, Evans JR.. J Clin Psychol Med Settings 2010; 17: 230–237)
© 2012 Pec Indman EdD, MFT
SYMPTOMS OF PTSD
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Recurrent nightmares
Extreme anxiety
Reliving past traumatic events
• sexual
• physical
• emotional
• childbirth
© 2012 Pec Indman EdD, MFT
TREATMENT FOR PTSD
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Psychotherapy
SSRIs and/or antianxiety medication
May require sleep medication
Social support
© 2012 Pec Indman EdD, MFT
POSTPARTUM PSYCHOSIS
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Occurs in 1-2/1000
5% suicide and 4% infanticide rate
(Doucet, S. et al. Differentiation and Clinical Implications of Postpartum
Depression and Postpartum Psychosis. JOGNN, 2009. 38, 269-279. Sit,
D. et al. A Review of Postpartum Psychosis, Journal of Women’s Health.
2006:15(4)
© 2012 Pec Indman EdD, MFT
SYMPTOMS OF POSTPARTUM
PSYCHOSIS
Usually begins 48-72 hours postpartum
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Most develop symptoms within 2-4
weeks
Visual or auditory hallucinations
Early symptoms restlessness, agitation,
irritability
Confusion, paranoia, extreme moodswings
Delusional thinking (infant death, denial of birth,
need to kill baby)
(Sit, D. et al. A Review of Postpartum Psychosis, Journal of Women’s Health.
2006:15(4)., Suri R and Burt VK., Jrnl Prac Psych and Behav Hlth. March 1997)
© 2012 Pec Indman EdD, MFT
RISK FACTORS FOR
POSTPARTUM PSYCHOSIS
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Personal (20-50% risk) and/or family
history of psychosis or bipolar disorder
80% risk if previous postpartum psychotic
or bipolar episode
First baby
(Sit, D. et al., A Review of Postpartum Psyhosis, Journal of Women’s Health 2006,
(15)4. Suri R and Burt VK., Jrnl Prac Psych and Behav Hlth. March 1997)
© 2012 Pec Indman EdD, MFT
TREATMENT FOR
POSTPARTUM PSYCHOSIS
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IMMEDIATE HOSPITALIZATION
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Antipsychotics
Mood stabilizers (antidepressants as
needed)
Psychotherapy
ECT
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(Yonkers KA, et al.. Am J Psychiatry. 2004;161:608-620)
© 2012 Pec Indman EdD, MFT
WHY TREAT PARENTS?
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Potential for child abuse and neglect
Negative impact on marital/family
relationships
Increased risk chronic depression
and relapse
(Field T. et al., Infant Behavior & Development 2004;(27) 216-229,
Hart S. et al., Infant Behavior & Development 1998; 21(3):519-525,
Murray L and Cooper PJ.,. Psychological Medicine 1997;27(2):253-260)
© 2012 Pec Indman EdD, MFT
OUTCOMES OF UNTREATED
PARENTAL ILLNESS
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Increased incidence of childhood
psychiatric disturbances
Impaired cognitive and language
development in children
Negative influence on preterm children's
later cognitive function
(McManus BM and Poehlmann J. Infant Behav Dev. 2012 Jun;35(3):489-98
Muzik, M and S. Borovska, Mental Health in Family Medicine 2010;7:239–47)
© 2012 Pec Indman EdD, MFT
BREASTFEEDING AND
ANTIDEPRESSANTS
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AAP now recommends 1 year of
breastfeeding. Depression preceeds
weaning.
“Paxil and Zoloft usually produce
undetectable infant levels.” (Weissman AM. et al. Am J
Psychiatry 2004;161:1066-1078)
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Studies of exposed infants show no
differences in IQ or neurobehavioral
development (Yoshida K, et al. Br J Clin Pharmacol. 1997
Aug;44(2):210-1)
© 2012 Pec Indman EdD, MFT
BREASTFEEDING
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Depressed moms breastfed for shorter
durations
Experienced breastfeeding more
negatively than non-depressed (Individual and
Combined Effects of Postpartum Depression in Mothers and Fathers on Parenting
Behavior. Paulson, Dauber, and Leiferman. Pediatrics, 118(2), Aug 2006:659-668)
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Decreased levels of breastfeeding selfefficacy
Increased breastfeeding difficulties
(Dennis CL & McQueen K. The Relationship Between Infant-Feeding Outcomes
and Postpartum Depression. Pediatrics 2009;123:e736-e751)
© 2012 Pec Indman EdD, MFT
WHAT ABOUT
DADS/PARTNERS?
© 2012 Pec Indman EdD, MFT
NICU DADS
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Fathers of premature infants in a medical
NICU demonstrated elevated levels of
stress that persisted.
Paternal self-reported stress and
depressive symptomatology was
independent of infant illness.
30% of NICU dads screened positive for
depression (Mackley AB, et al. Forgotten parent: NICU paternal
emotional response. Adv Neonatal Care. 2010 Aug;10(4):200-3)
© 2012 Pec Indman EdD, MFT
ROLE OF NICU
MENTAL HEALTH PROVIDERS
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Providing emotional support and therapy
to families in the NICU
Overcome barriers to treatment
Integrated family care
NICU psychologists in OK, Miami,
Pittsburgh, Columbia/Pres in NY, Kansas
City
National Perinatal Association
(www.nationalperinatal.org)
© 2012 Pec Indman EdD, MFT
POSTPARTUM SCREENING
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Edinburgh Postnatal Depression
Scale (EPDS), 1987 by Cox, et. al.
• Score of > 10  refer for evaluation
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PHQ9 and PHQ2-not well studied for
perinatal use, frequently used in practice
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Postpartum Depression Screening
Scale (PDSS), 2002 by Cheryl Beck
D.N.Sc.
(Gjerdingen, D, and Yawn, B. Postpartum Depression Screening, J Am
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Board Fam Med 2007;20:280 –288. ACOG Committee Opinion, Screening for Depression
During and After Pregnancy, No.453, 2/2010)
© 2012 Pec Indman EdD, MFT
TREATMENT GUIDELINES
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Always r/o bipolar spectrum before
starting SSRI’s.
http://www.psycheducation.org/depression
/MDQ.htm
F/U and treat to remission!
Meds work best with therapy
Find therapists with expertise in perinatal
moods and loss (www.postpartum.net and
www.mededppd.org).
© 2012 Pec Indman EdD, MFT
PROFESSIONAL RESOURCES
• Resources for information about
perinatal psychopharmacology
• UIC Perinatal Mental Health Project
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(800)573-6121 (free for providers)
www.psych.uic.edu/research/perinatalm
entalhealth
• Other online resources
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www.mededppd.org
www.toxnet.nlm.nih.gov/
www.reprotox.org
www.motherisk.org
© 2012 Pec Indman EdD, MFT
RESOURCES
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Postpartum Support International
www.postpartum.net
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North American Society for
Psychosocial OB/GYN
www.naspog.org
www.mededppd.org
Regrouptherapy.com
(online web video
support)
© 2012 Pec Indman EdD, MFT
Other Resources
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https://www.marchofdimes.com/pdf/california/Bernard_
-_Medical_PTSD_in_the_NICU.pdf
http://jpepsy.oxfordjournals.org/content/30/8/667.full.pd
f
http://www.kan.or.kr/new/kor/sub3/filedata_anr/200703
/199.pdf
http://fn.bmj.com/content/90/2/F109.full
© 2012 Pec Indman EdD, MFT