Transcript Weighing the Risks - Healthy Mothers Healthy Babies Coalition of

Maternal Mental Health and Post Partum
MARISA ECHENIQUE, PSY.D.
ASSISTANT PROFESSOR
DEPARTMENT OF PSYCHIATRY
UNIVERSITY OF MIAMI
MILLER SCHOOL OF MEDICINE
Continuing Education
Disclosure
 The activity planners and speakers do not have any
financial relationships with commercial entities to
disclose.
 The speakers will not discuss any off-label use or
investigational product during the program.
This slide set has been peer-reviewed to ensure that there are no
conflicts of interest represented in the presentation.
Session Objectives
 Upon completion of this program, participants will be able to:
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Define maternal mental illness
Identify signs and symptoms of maternal mental illness
Define post partum depression
Identify signs and symptoms of post partum depression
Identify effective treatment options in maternal mental
health
Discuss strategies to decrease mental health stigma,
increase comfort level to discuss mental illness and
increase the ability of healthcare providers to provide
culturally sensitive care
Maternal Mental Health
 The World Health Organization defines maternal
mental health as:
 ‘‘a state of wellbeing in which a mother realizes
her own abilities, can cope with the normal
stresses of life, can work productively and
fruitfully and is able to make a contribution to her
community’’
Maternal Mental Illness
 In the year 2000, 205,000 women aged 18 to 44 years were
discharged with a diagnosis of depression
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7% of all hospitalizations among young women were for
depression
 The peak period for onset of depression occurs during the
childbearing years and its impact extends to the
offspring of afflicted women as well as their families
Maternal Mental Health
 Given that depression is a mood disorder that affects 1 in 4
women at some point during their lifetime, it should be no
surprise that this illness can also touch women who are pregnant
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But all too often, depression is not diagnosed properly during
pregnancy because people think it is just another type of
hormonal imbalance
 Pregnancy is supposed to be one of the happiest times of a
woman’s life, but for many women this is a time of confusion,
fear, stress, and even depression
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According to The American Congress of Obstetricians and
Gynecologists (ACOG), between 14-23% of women will
struggle with some symptoms of depression during pregnancy
Mental Illness in Pregnancy
 Pregnancy and the postnatal period are critical times of
psychological adjustment for women, and there is
increasing evidence that a woman’s mental state during
this time influences both obstetric outcomes and the
future development of the infant, affect other children in
the family, as well as the woman’s partner and their
relationship
 Severe mental illness, such as psychosis, bipolar disorder
or severe depression, may be particularly detrimental,
both during pregnancy and subsequently, given the
dependence of an infant on its mother and the rapid
adjustment to motherhood faced by first-time mothers
Maternal Mental Health
 A woman with mental illness often does not have the
strength or desire to adequately care for herself or her
developing baby
 Ex: Babies born to mothers who are depressed may be
less active, show less attention and be more agitated than
babies born to moms who are not depressed
 Mental Illness that is not treated can have potential
dangerous risks to the mother and baby
 Can lead to poor nutrition, drinking, smoking, and
suicidal behavior, premature birth, low birth weight, and
developmental problems
Mental Illness and Fetal Demise
 Although maternal mental health disorders in
pregnancy have been linked to fetal morbidity, there
have been few reports of actual fetal mortality
 However, since many of the neonatal complications
listed are also present in cases of fetal demise, it
seems plausible that there is a true association
between maternal mental health and fetal mortality
Mental Illness and Fetal Demise
 Fetal loss is not uncommon in pregnancy, with
spontaneous abortions (miscarriages) before 20 weeks'
gestation occurring in up to 15% of all pregnancies and
with stillbirths after 20 weeks affecting nearly 1% of all
births .
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In addition, there may be additional losses early in the first trimester
that are never recognized as clinical pregnancy
 When a woman is pregnant, treating physicians must
weigh potential benefits from pharmacological treatment
with potential risks to the fetus; being able to determine
whether mental illness itself is associated with fetal death
might help physicians better evaluate overall fetal risk
Maternal Mental Health
 Types of Mental Illness/Psychiatric Issues
 Depression Disorder
 Anxiety Disorder
 Panic Disorder
 Psychosis
 PTSD
 Eating Disorders
 Cognition
 Substance Use
*While it is rare for women to experience first onset psychoses during pregnancy, relapse
rates are high for women previously diagnosed with some form of psychosis
Risk Factors Maternal Mental Health
 Previous history of depression
 Discontinuation of medication(s) by a woman who has a
 History of depression
 Previous history of postpartum depression
 Family history of depression
 Negative attitude toward the pregnancy
 Lack of social support
 Maternal stress associated with negative
life events
 A partner or family member who is unhappy about the
pregnancy
Risk Factors Maternal Mental Health
 Having a hard time getting
 Having twins or triplets
 Losing a baby
 Having a baby as a teen
 Having premature labor and delivery
 Having a baby who is different (birth defect or disability)
 Pregnancy and birth complications
 Having a baby or infant hospitalized
 Having a healthy pregnancy and childbirth
Maternal Mental Health
 What are possible triggers of depression during pregnancy
Relationship problems
 Family or personal history of depression
 Previous miscarriages
 Stressful life events
 Health related complications
 History of abuse or trauma
 Poor social support
 Financial difficulties
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Signs and Symptoms of Mental Illness
Signs and Symptoms of Mental Illness
Depressed mood or a loss of interest or pleasure in daily activities for more than two
weeks.
 Mood represents a change from the person's baseline.
 Impaired function: social, occupational, educational.
Specific symptoms, at least 5 of these 9, present nearly every day:
 Feeling sad or down
 Confused thinking or reduced ability to concentrate
 Excessive fears or worries, or extreme feelings of guilt
 Extreme mood changes of highs and lows
 Withdrawal from friends and activities
 Significant tiredness, low energy or problems sleeping
 Detachment from reality (delusions), paranoia or hallucinations
 Inability to cope with daily problems or stress
 Trouble understanding and relating to situations and to people
 Alcohol or drug abuse
 Major changes in eating habits
 Sex drive changes
 Excessive anger, hostility or violence
 Suicidal thinking
Signs and Symptoms of Mental Illness
SIGECAPS mnemonic for symptoms of Depression:
 Sleep (insomnia or hypersomnia)
 Interest (reduced, with loss of pleasure)
 Guilt (often unrealistic)
 Energy (mental and physical fatigue)
 Concentration (distractibility, memory disturbance)
 Appetite (decreased or increased)
 Psychomotor (retardation or agitation)
 Suicide (thoughts, plans, behaviours)
Post Partum Depression
Post Partum Depression
 Postpartum depression can happen anytime within the first year after
childbirth
 The difference between postpartum depression and the baby blues is
that postpartum depression often affects a woman's wellbeing and keeps her from functioning well for a longer period
of time
 Postpartum depression needs to be treated by a doctor
 Major depression creates suffering whether experienced in the
postpartum period or at any other time in a woman’s life
 What makes depression so poignant for postpartum women is that
childbirth is culturally celebrated and there is an expectation that new
parents, especially mothers, will be joyful, if not tired, during this time
Post Partum Depression
 The demands on a new mother are substantial and include providing
24-hour care for a newborn, often in the middle of the night, caring for
older children, keeping up with normal household responsibilities, and
often returning to work after a brief maternity leave
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These burdens are often difficult to bear in normal circumstances and
the difficulty of bearing them is exacerbated by the disability associated
with depression symptoms (e.g., sad mood, loss of interest, motor
retardation, difficulty concentrating)
Post partum Depression
Post Partum Depression
 Any of these symptoms during and after pregnancy that last
longer than two weeks are signs of depression:
Feeling restless or irritable
Feeling sad, hopeless, and overwhelmed
Crying a lot
Having no energy or motivation
Eating too little or too much
Sleeping too little or too much
Trouble focusing, remembering, or making decisions
Feeling worthless and guilty
Loss of interest or pleasure in activities
Withdrawal from friends and family
Having headaches, chest pains, heart palpitations (the heart beating fast and feeling like
it is skipping beats), or hyperventilation (fast and shallow breathing)
 After pregnancy, signs of depression may also include being afraid of hurting the baby or
oneself and not having any interest in the baby
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Post Partum Psychosis
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It occurs in 1 or 2 out of every 1000 births and usually begins in the first 6 weeks
postpartum
Women who have bipolar disorder or another severe psychiatric problem such as in
the schizophrenia spectrum have a higher risk for developing postpartum psychosis
Feeling ‘high’, ‘manic’ or ‘on top of the world’
Rapid changes in mood
Severe confusion
Being restless and agitated
Racing thoughts
Behavior that is out of character
Being more talkative, active and sociable than usual
Not wanting to sleep
Losing your inhibitions
Feeling paranoid, suspicious, fearful
Feeling as if you’re in a dream world
Delusions: these are odd thoughts or beliefs that are unlikely to be true. For
example, you might believe you have won the lottery. You may think your
baby is possessed by the devil. You might think people are out to get you.
 Hallucinations: this means you see, hear, feel or smell things that aren’t
really there.
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Mental Illness Detection
Treatment Options
 Psychotherapy
 Stigma
 Access to care (insurance, resources)
 Environmental barriers (social support, transportation)
 Psychopharmacology
 Fear of medication during pregnancy
 Risks vs benefits
Psychotropic Medications in Pregnancy
 Women with histories of psychiatric illness who
discontinue psychotropic medications during
pregnancy are particularly vulnerable to major psych
episodes
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Ko et al. 2012, prospectively followed a group of women with
histories of major depression across pregnancy, of the 82
women who maintained antidepressant treatment throughout
pregnancy, 21 (26%) relapsed compared with 44 (68%) of the
65 women who discontinued medication
Psychotropic Medications in Pregnancy
 High rates of relapse have also been observed in women
with bipolar disorder
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One study indicated that during the course of pregnancy, 70.8% of
the women experienced at least one mood episode
The risk of recurrence was significantly higher in women who
discontinued treatment with mood stabilizers (85.5%) than those
who maintained treatment (37.0%).
 Although data suggest that some medications may be
used safely during pregnancy, knowledge regarding the
risks of prenatal exposure to psychotropic medications is
incomplete
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Thus, it is relatively common for patients to discontinue or to avoid
pharmacologic treatment during pregnancy
U.S. FDA Category Designations for
Pregnancy
 FDA provided guidelines to drug companies for labeling
medications with regard to their safety during pregnancy.
Medications are assigned a pregnancy letter ranking: (A,
B, C, D, X).
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For newer drugs, this designation usually occurs in the absence of
systematic human pregnancy data
 Most psychiatric medications are labeled as “C” or “D,”
without a clear demarcation in safety between the these
categories
 The FDA is currently working on improving the current
labeling system, and they are considering the provision
of more information about the risks and benefits in a
descriptive format and information about the risks of the
untreated disorder for which the medication is used
Weighing the Risks
 Not infrequently, women present with the first onset of
psychiatric illness while pregnant
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Many pregnancies are unplanned and may occur unexpectedly while
women are receiving treatment with medications for psychiatric
disorders
Many women may consider stopping medication abruptly after
learning they are pregnant, but for many women this may carry
substantial risks.
 Decisions regarding the initiation or maintenance of
treatment during pregnancy must reflect an
understanding of the risks associated with fetal exposure
to a particular medication but must also take into
consideration the risks associated with untreated
psychiatric illness in the mother
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Psychiatric illness in the mother is not a benign event and may cause
significant morbidity for both the mother and her child; thus,
discontinuing or withholding medication during pregnancy is not
always the safest option
Weighing the Risks
 Depression and anxiety during pregnancy have been associated with a variety of
adverse pregnancy outcomes:
 Women who suffer from psychiatric illness during pregnancy are less likely to
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receive adequate prenatal care
Are more likely to use alcohol, tobacco, and other substances known to adversely
affect pregnancy outcomes
Possible low birth weight and fetal growth retardation in children (born to
depressed mothers)
Preterm delivery
Increased risk for having pre-eclapsia
Operative delivery
Infant admission to a special care nursery for a variety of conditions including
respiratory distress, hypoglycemia, and prematurity
* These data underscore the need to perform a thorough risk/benefit analysis of
pregnant women with psychiatric illness, including evaluating the impact of untreated
illness on the baby and the mother, as well as the risks of using medication during
pregnancy *
References
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Rahman, A., Surkan, P. J., Cayetano, C. E., Rwagatare, P., & Dickson, K. E. (2013). Grand
challenges: integrating maternal mental health into maternal and child health
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Carter, D., & Kostaras, X. (2005). Psychiatric disorders in pregnancy. British Columbia
Medical Journal, 47(2), 96.
Gold, K. J., Dalton, V. K., Schwenk, T. L., & Hayward, R. A. (2007). What causes
pregnancy loss? Preexisting mental illness as an independent risk factor. General
hospital psychiatry, 29(3), 207-213.
Illangasekare, S. L., Burke, J. G., Chander, G., & Gielen, A. C. (2014). Depression and
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Dickerson, F. B., Brown, C. H., Kreyenbuhl, J., Goldberg, R. W., Fang, L. J., & Dixon, L.
B. (2014). Sexual and reproductive behaviors among persons with mental illness.
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psychology, 65(12), 1258-1269.
Robertson, E., Grace, S., Wallington, T., & Stewart, D. E. (2004). Antenatal risk factors
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