Transcript Perinatal Mood Disorders: Why We Should Care

Perinatal Mood Disorders:
Why We Should Care
Debbie Ruxer RN, MS, CNM
Miami Valley Regional Postpartum
Depression Network
Objectives
At the end of this presentation the participant will be able
to:
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Discuss physiology and risk factors for perinatal mood
disorders
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List the different types of perinatal mood disorders
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Discuss the effects of maternal depression on the infant
and the family
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Discuss medication and other therapies for perinatal
mood disorders
CONFLICT OF INTEREST
 The planners and faculty have declared no conflict of interest.
COMMERCIAL SUPPORT/SPONSORSHIP
 Good Samaritan Hospital is the sponsor for this activity. The
information presented today will be presented fairly and without bias.
CRITERIA FOR SUCCESSFUL COMPLETION
 You must attend the entire event and submit a completed evaluation
form in order to receive credit for this presentation.
The moment a child is born, the mother is also born. She never
existed before. The woman existed, but the mother, never. A
mother is something absolutely new.” Rajneesh
Myths and Facts about Motherhood
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I will fall in love with my baby immediately.
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Being a mother will complete me.
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Having a child will strengthen our relationship.
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Having a child will keep him around.
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Mothering is natural.
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Breastfeeding is natural, and it will be easy.
Effects of PPD on Women
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PPD is the number one
complication of childbirth
Affects 1 in every 5 to 8
women
Depression the second
leading cause of disease
burden
High rate of co-morbidity
with anxiety disorders,
substance abuse and
eating disorders
• <20% of pregnant women with psychiatric
diagnosis were treated.
• >50% of pregnant women on
antidepressant medication
were symptomatic due to
suboptimal treatment.
• <25% of OB/GYN patients had their psychiatric
diagnosis recognized.
Depression for Two?
•Decreased prenatal care and self-care
•Increased self-medication and substance
abuse
•Increased risk of being victim of violence
•Increased risk of pre-eclampsia
•Increased rates of miscarriages, preterm
birth and low birth weight
•Uterine artery resistance
Physiology
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Stress
Changes in brain chemistry
Thyroid dysfunction
Physical discomfort
Risk factors that increase susceptibility
LACK OF SLEEP!!!!!!
Immune system response to stress
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Sympathetic response, catecholamine release
Cascading release of CRH, ACTH, cortisol
Release of proinflammatory cytokines (IL-1B, IL6, TNF-a, IFN-y)
Sustained levels of proinflammatory cytokines
blunts cortisol’s anti-inflammatory action, and
increases risk of depression.
Neurotransmitters
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Serotonin :
 Inhibits
stress response
 Regulates sleep
 Pain sensitivity
 Sexual functioning
 Appetite
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Diminished serotonin – result of stress?
Who is at risk?
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Risk Factors:
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History of depression or mental health
diagnosis
Lack of social support (family is far away)
Unexpected pregnancy
High Risk pregnancy
Infertility
Adoption
Who is at risk?
 Difficult
labor or unexpected outcome
NICU
 Birth Defect
 Preterm delivery
 Fetal demise or previous fetal demise
 Unplanned C-section
 Difficult or prolonged labor and/or delivery
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Spectrum of disorders
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Depression/Anxiety
Obsessive/Compulsive Disorder
Panic Attacks
Post-traumatic Stress
Bipolar
Postpartum Psychosis
Baby Blues
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Occurs in about 80% of mothers
Onset 1st week, lasts up to 3 weeks
Mood instability, weepiness, sadness, anxiety,
lack of concentration
Treatment supportive
Not considered part of the spectrum of perinatal
mood disorders
Depression and/or Anxiety
Incidence: 15-20% of new mothers
Symptoms:
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Excessive worry or anxiety
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Irritability, short temper
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Feeling overwhelmed by responsibilities,
difficulty making decisions
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Sad mood, feelings of guilt, fear, phobias
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Hopelessness
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Sleep disturbances (insomnia or
hypersomnolence), fatigue
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Somatic symptoms without apparent cause
Discomfort around baby
Lack of feelings towards baby
Loss of focus and concentration
Loss of interest and pleasure
Changes in appetite – significant wt gain or loss
Obsessive-Compulsive Disorder
Incidence: 3-5% of new mothers
Risk factors: Personal or family hx OCD
Symptoms:
 Intrusive,
repetitive and persistent thoughts or
mental pictures
 Thoughts often about harming the baby
 Tremendous sense of horror and shame
 Behaviors to reduce anxiety and protect baby
 Counting, checking, cleaning, other repetitive
behaviors
 These women can
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think and reason and
articulate clearly
At the mercy of
intrusive thoughts and
behaviors
 These women DO

NOT HARM their
babies!
Do NOT call
Children’s Services
based on this
Panic Disorder
Incidence: 10% of postpartum women
Risk Factors:
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Personal or family hx of anxiety or panic
disorder
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Thyroid dysfunction
Symptoms:
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Episodes of extreme anxiety
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SOB, chest pain
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Sensations of choking, smothering, dizziness
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Hot or cold flashes, trembling, tachycardia,
numbness or tingling
Restlessness, agitation, irritability
During attack, may fear she is going crazy,
losing her mind
Panic attack may wake her up from sleep
Excessive worry or fear (incl. fear of another
panic attack)
Posttraumatic Stress Disorder
Incidence: up to 6% of postpartum women
Risk factors: Past traumatic events
Symptoms:
 Recurrent nightmares
 Extreme anxiety
 Reliving past traumatic events (sexual, physical,
emotional, childbirth)
Bipolar Disorder
Incidence: no data
Risk factors: personal or family hx of bipolar
disorder
Symptoms:
 Mania – racing thoughts, high energy and little
sleep, compulsive activity
 Depression
 Rapid and severe mood swings
Postpartum Psychosis
Incidence: 0.1-0.2%
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Onset usually 2-3 days postpartum
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5% suicide and 4% infanticide rate
Risk factors:
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Personal or family hx psychosis, bipolar,
schizophrenia
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Previous hx postpartum psychosis or bipolar
episode
Symptoms:
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Visual or auditory
hallucinations
Delusional thinking
Delirium or mania
Very obviously
psychotic
Differentiate from
OCD
Experiences of women
Myself
 My daughter
 Lisa
 You?
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Effects of PPD on Children
Poor attachment
 Increase in accidents
 Less likely to see
pediatrician regularly
 Failure to thrive or
overfeeding
 Increased rates of
colic
 Increased use of ER
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Cognitive Effects
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Depressed mothers talk
less to their infants
Less expression of
positive emotions
Increased use of corporal
punishment
Decrease in cognitive
abilities present as early
as 2 months
Behavioral Effects
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Eating and sleeping
disorders
Increased crying
Less vocalizations and
smiling
Decreased vocalization at
18-24 months
Shorter attention spans
More anxious around
strangers
Less interactive play
Less self-knowledge
Effects of PPD on Relationships
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10% of fathers report
symptoms of PPD
Reality vs. expectations
Financial stress
Change in relationship
Partner suffering from
PPD
Relationships Continued
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PPD leads to relationship difficulties
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Higher divorce rate
 Both parents with PPD has an additive affect
on children
 Supportive partners are protective factor
against PPD
Relationships Continued
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Symptoms:
 Work
long hours
 Watch more TV/sports
 Increased use of
alcohol
 Withdrawn
 More irritable
Silent Suffering
We don’t talk about it - why?
 So much shame involved
 Feeling like a failure
 Motherhood isn’t so easy after all
 They might take away my baby if I say
anything
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But there is hope
There is much that providers, family,
friends and community can do to help
 Family and friends play a critical role in
helping women recover
 Family and friends: the first line of defense
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Screening
 Several tools available
 Edinburgh Postnatal Depression Scale:
validated, short and easy to use
 Who should screen?
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OB/Gyn providers
Pediatricians
Family Practice providers
WIC
Lactation consultants
Home health nurses
Edinburgh Postnatal Depression
Scale
Answer the following questions, checking the answer
that comes closest to how you have felt over the last
7 days (not just today).
1.
2.
3.
4.
I have been able to laugh and see the funny side of
things
I have looked forward with enjoyment to things
I have blamed myself unnecessarily when things
went wrong
I have been anxious or worried for no good reason.
5.
6.
7.
8.
9.
10.
I have felt scared or panicky for no very good
reason.
Things have been getting on top of me (can’t keep
up with my responsibilities)
I have been so unhappy that I have had difficulty
sleeping
I have felt sad or miserable
I have been so unhappy that I have been crying
The thought of harming myself has occurred to me
Always look at the answer to the last
question!
Score greater than 13 = probable depression
Going the Extra Mile
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It’s all in the presentation:
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Provide a safe, non-judgmental environment
 Ask open-ended questions
 Give reassurance that she’s not “crazy” or
“bad”
 Give her hope: “This is not your fault, you will
get better, you are not alone.”
 Don’t assume anything
What can family/friends do to help?
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You can:
 Make dinner
 Watch the baby so she can
take a break (or take a nap)
 Do the laundry
 Do the dishes
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More ideas:
Sit and listen
 Clean the house
 Take a walk with her
 Go shopping or do
errands for her
 Be on duty overnight so
she can sleep
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Keep her company – it is
worse to be alone
Take on some of her
responsibilities
Reduce her feeling of being
overwhelmed
Give her time to sleep!!!!
Medical Management
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ACOG/APA guidelines (2009)
 Psychotherapy
 Pharmacotherapy
 Individualized
plan of care
 Consider continuing medications during
pregnancy to avoid risk of relapse (bipolar,
psychosis, severe depression)
Psychotherapy
Front line therapy
As effective as medication
Lower relapse rate
One-on-one therapy
initially, but group therapy
helpful later
Cognitive Behavioral Therapy
 Highly effective
 Based on premise that distorted thinking
causes depression
 CBT teaches patients to recognize distorted
thinking, and counter these thoughts
Interpersonal Psychotherapy
 As effective as Cognitive Behavioral Therapy
 Based on attachment theory and interpersonal theory
 Addresses 4 problem areas:
 Role transitions
 Interpersonal disputes
 Grief
 Interpersonal deficits
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Focus on improved relationships, role transitions
Medications
Individual decision
 Risk versus benefit
 Risks of medication:
Miscarriage
Neonatal withdrawal
NICU admission
Persistent pulmonary hypertension
Congenital anomalies
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Risks of no medication
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Mother:
 Preterm
birth
 Risk of suicide
 Untreated depression can become chronic
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Infant:
 Poor
attachment
 Failure to thrive
 Decreased cognitive abilities
Antidepressants
Selective serotonin reuptake inhibitors
 Norepinephrine/dopamine reuptake
inhibitors
 Serotonin/norepinephrine reuptake
inhibitors
Not recommended:
 Monoamine oxidase inhibitors
 Tricyclic antidepressants
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Avoid in 1st trimester if possible
Start low
Titrate to therapeutic effect
Sub-therapeutic doses do not decrease risk
to fetus
Single drug therapy
Start with one that has worked for her in the
past
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Already on antidepressants?
 Risk
of relapse high if meds stopped
 Risk vs benefit
 Individualized treatment plan
 Avoid changing medications if therapy
effective
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Sertraline
 Lower
maternal serum levels
 Almost undetectable in breast milk
 0.2% risk of cardiac septal defects
 Mild neonatal withdrawal
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Paroxetine
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Higher risk of congenital anomalies
 Low levels in breast milk
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Fluoxetine
 Mild
neonatal withdrawal
 Higher levels in breastmilk
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Citalopram
 No
known association with congenital
anomalies
 Mild neonatal withdrawal
 Occasional neonatal somnolence
Other medications
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Sleep aids as needed
Anxiolytics (severe anxiety)
Mood stabilizers (Bipolar)
Antipsychotics (PP Psychosis)
Additional Therapies
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Skin to skin time
with baby
Omega-3 fatty
acids
Bright light therapy
Exercise
Vitamin D
Skin-to-skin
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Promotes infant wellbeing
Elicits maternal bonding
hormones and
behaviors
Omega-3 Fatty Acids
 DHA and EPA improve mood
 EPA decreases inflammatory eicosanoids by
competing for same metabolic pathways
 Also inhibits production of proinflammatory cytokines
 Rates of postpartum depression tend to be lower in
countries with high dietary intake of fish
 Fish oil supplements: use USP-verified supplements
for minimal risk of contaminants
 1000-3000 mg/day
 Flax seed ineffective (HLA)
Vitamin D
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Association between Vitamin D deficiency and mood
disorders, including postpartum mood disorders
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Deficiency defined as circulating 25(OH)D levels less
than 20ng/mL
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Recent recommendations for intake of 800-2000 IU daily
Bright Light Therapy
 As effective as medication
 Insurance reimbursement a possibility
 Several theories on mechanism:
 Effect on circadian rhythms
 Anti-inflammatory component
 Timing important: morning bright light
more effective, works with body’s circadia
rhythm
Exercise
 Role in reducing depressive
symptoms well-documented
 Decreases stress, improves selfefficacy
 Endorphin release
 Lowers levels of pro-inflammatory
cytokines
 Improves sleep
 Overall health benefits
St. John’s Wort
 Research demonstrates efficacy in treating
mild to moderate depression
 Fewer side effects than traditional
medications:
 2.4% incidence of GI upset, allergic
reactions, rash, fatigue, restlessness
 Can trigger manic episodes in susceptible
patients
RISKS:
 Accelerates metabolism of anticonvulsants,
cyclosporins, OCP, other meds
 Interacts with SSRIs: serotonin syndrome
(potentially fatal)
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Generally safe with breastfeeding
Level of infant exposure comparable to other
SSRIs
Rare cases of colic or lethargy in exposed
infants
Dose: 300mg, tid
Look for USP labeling
What can I do as a health provider?
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Promote:
 Non-separation
of mothers
and babies
 Skin-to-skin for all babies
 Breastfeeding
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Educate!
 New
mothers
 Their families
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Intervene
 Women
depressed during hospitalization
What’s the good news?
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With proper support and treatment, she WILL
get better!
Miami Valley Postpartum
Depression Network
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We’re here to help:
Support
Referral list
937-401-6844
1-866-848-3163
www.postpartum.net
Facebook group: Postpartum Depression Many
Shades of Blue
The end of all education should surely be service to others.
We cannot seek achievement for ourselves and forget
about progress and prosperity for our community. Our
ambitions must be broad enough to include the
aspirations and needs of others, for their sake and for our
own.
---Cesar Chavez
in December 2001 Possibilities
References cont.
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Anderson,P (2007). Sleep Deprivation Leads to
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Barclay, L.(2009). Poor Sleep Independently Linked to
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References cont.
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Bennett, H A, et al (2004). Depression During
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References cont.
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References cont.
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References cont.
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Guo,W, et al (2008). Postpartum Depression: Racial
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References cont.
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McQueen, K, et al (2008). Evidence-Based
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References cont.
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Simpson, KR, and Creehan, PA (2008). Perinatal
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References cont.
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Ward, RK, Zamorski MA (2002). Benefits and Risks of
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Gonzalez, C (2010). Vitamin D Supplementation : An Update.
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www.goodsamdayton.org