Transcript PERINATAL DEPRESSION

Picasso
PERINATAL MOOD
DISORDERS
Spectrum of Perinatal Mood
Disorders
• Antepartum depression
• Postpartum depression
• Postpartum psychosis
DEPRESSION DURING PREGNANCY
• Between 10-20% of women will
experience significant
depression during pregnancy
• This will be a first episode for
one third
Antenatal Risk Assessment
• Do you have a history of depression, bipolar disorder or
anxiety?
• Have you ever been treated with antidepressant medication
or other psychiatric medication?
• Did you recently stop your antidepressant or other
psychiatric medication?
• Do you have a family history of depression or bipolar
disorder?
• Are you currently struggling with or being treated for
depression or anxiety?
• Are you feeling a lack of support during your pregnancy or
worry that you will be without enough support after the
baby is born?
JAMA STUDY February 2006
• “Relapse of Major Depression During Pregnancy of Women Who
Maintain or Discontinue Antidepressant Treatment”
Lee Cohen et al. at MGH
• Women from 3 specialty centers who were not depressed for at
least 3 months prior to pregnancy and on antidepressant
treatment.
• 43% had a relapse in their major depression
• 26% of those who continued their medication had a relapse
(50% in first trimester)
• 68% of those who discontinued their medication had a relapse
(50 % In the 1st trimester, 90% by the end of the 2nd trimester)
JAMA STUDY February 2006
CONCLUSIONS:
• Pregnancy puts women with a history of depression at
higher risk of recurrence and is not protective.
• Women who are stable on antidepressants at the time of
pregnancy need to be aware that there is a much higher risk
of relapse associated with discontinuing their antidepressant
medication
• These issues should be part of the discussion with women
when weighing the risk/benefit ratio of using
antidepressants during pregnancy
PREGNANCY IS NOT A
TIME OF “PROTECTION”
FROM MOOD OR ANXIETY
DISORDERS
SIGNIFICANCE
Untreated depression during
pregnancy is associated with
serious risks for mother and
her baby.
OBSTETRICS AND GYNECOLOGY
April 2008
"Advising a pregnant or breastfeeding woman to
discontinue medication exchanges the fetal or
neonatal risks of medication exposure for the risk of
untreated mental illness."
Untreated or inadequately treated maternal mental
illness "may result in poor compliance with prenatal
care, inadequate nutrition, exposure to additional
medications or herbal medicines, increased alcohol
and tobacco use, deficits in mother-infant bonding,
and disruptions within the family environment.”
OBSTETRICS AND GYNECOLOGY
April 2008
Guidelines
• Level A evidence (from good and consistent scientific evidence):
– Lithium exposure in pregnancy may be associated with a small
increase in congenital cardiac malformations, with a risk ratio of 1.2 to
7.7.
– Valproate exposure in pregnancy is associated with an increased risk
for fetal abnormalities and should be avoided if possible, especially
during the first trimester
– Carbamazepine exposure during pregnancy is associated with fetal
carbamazepine syndrome and should be avoided if possible, especially
during the first trimester.
– Maternal benzodiazepine use shortly before delivery is associated with
floppy infant syndrome.
OBSTETRICS AND GYNECOLOGY
April 2008
• Level B evidence (from limited or inconsistent scientific evidence):
– Paroxetine use in pregnant women and women who are planning to
become pregnant should be avoided, if possible, and fetal
echocardiography should be considered when fetuses are exposed to
paroxetine in early pregnancy.
– Prenatal benzodiazepine exposure increased the risk for oral cleft
(absolute risk increased by 0.01%).
– Lamotrigine is a potential maintenance therapy option for pregnant
women with bipolar disorder and has a growing reproductive safety
profile relative to alternative mood stabilizers.
– Untreated or inadequately treated maternal
psychiatric illness may have various negative
consequences.
OBSTETRICS AND GYNECOLOGY
April 2008
• Level C evidence (primarily from consensus and expert opinion):
– Multidisciplinary care management involving the patient's
obstetrician, mental health clinician, primary health care
provider, and pediatrician is recommended whenever
possible.
– Use of a single medication at a higher dose is favored vs the use of
multiple medications to treat psychiatric illness during pregnancy.
– Close monitoring of lithium during pregnancy and postpartum is
recommended.
OBSTETRICS AND GYNECOLOGY
April 2008
– Measuring serum drug levels in breast-fed neonates is not
recommended.
– Treatment with selective serotonin-reuptake inhibitors, selective
norepinephrine reuptake inhibitors, or both during pregnancy should
be individualized.
– A fetal echocardiogram examination should be considered when the
fetus is exposed to lithium during the first trimester of pregnancy.
RISKS OF UNTREATED DEPRESSION DURING
PREGNANCY
• Lack of adequate prenatal care
• Higher use of alcohol and drugs
• Obstetrical and neonatal complications
Higher rates of premature labor
Higher rates of miscarriage
Higher incidence of placental abruption
Increased bleeding during gestation
Increased risk of preeclampsia (five-fold in one
large study)
RISKS OF UNTREATED DEPRESSION DURING
PREGNANCY
More painful labor and higher use of analgesia
Small for gestational age infants
Lower APGAR scores
Low birth weight
Neonatal growth retardation
Increased rate of stillborns (six times in one study)
Increased admissions to neonatal ICU
RISKS OF UNTREATED DEPRESSION DURING
PREGNANCY
• More likely to have colicky, irritable babies
• Suicide
• Subsequent Postpartum Depression or
recurrent depression
TREATMENT OF DEPRESSION DURING
PREGNANCY
• Mild to moderate depression may
respond to supportive, cognitive or
interpersonal therapy or other nonpharmacolologic treatments
• More severe depression warrants
medication use
BIPOLAR DISORDER
75% of women with bipolar
disorder experience recurrent
illness if they discontinue treatment
during pregnancy
Postpartum Depression
Peak lifetime prevalence for
psychiatric disorders and
hospital admissions for women
occurs in the first 3 months after
childbirth (Kendall et al, 1981,
1987)
70
Epidemiology of
Postpartum Episodes
Admissions/Month
60
50
40
30
20
Pregnancy
10
0
–2 Years
– 1 Year
Childbirth
+1 Year
+2 Years
Kendell RE et al. Br J Psychiatry. 1987;150:6
THE MOST COMMON
COMPLICATION OF
CHILDBIRTH IS
DEPRESSION
BABY BLUES
• Baby Blues usually develop 3-5 days after
delivery
• Hallmark is emotional reactivity
• Occur in 70-80 % of all new mothers
• Normal reactions to the hormonal changes
and stress of having a baby
POSTPARTUM DEPRESSION
• Prevalence
– 15% of postpartum women (1 out of 7 new mothers)
• Higher-risk groups
– Young, low socioeconomic status,
poor social support
– Family history of mood disorders
– Past depression  25-40% risk of PPD
– Prior PPD  30-50% risk recurrence
Gaynes et al, 2005;
www.ahrq.gov/clinic/epcsums/peridepsum.htm
Wisner K et al. N Engl J Med. 2002;347:194-199
PRESENTATION OF PPD
• Usually develops slowly over the first three
months, most often beginning within the first 4
weeks, though some women have a more acute
onset
• More persistent and 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, but unable to sleep.
PRESENTATION OF PPD
• CLASSIC SYMPTOMS OF DEPRESSION WITH SOME
TYPICAL 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, obssessional
ruminations, usually focused on the baby,
often violent in nature, but they are
egodystonic and there is not a problem with
reality testing i.e. non-psychotic. One study
showed 50% of women with PPD had these.
Such obsessional thoughts do not increase
the risk of harm to the baby and are
important to distinguish from psychosis.
Duration of PPD
• Untreated depression often persists for months to
years after childbirth, with lingering effects on
physical and psychological functioning following
recovery from depressive episodes (England, Ballard
& George, 1994).
– 25%-50% women have episodes lasting 7 months
or longer (O’Hara, 1987).
– The most significant factor in the duration of PPD
is delay in receiving treatment (England, Ballard
& George, 1994).
RISK FACTORS
• Depression during pregnancy is the best predictor of post
partum depression
• Prenatal anxiety also a strong predictor of PPD
• History of depression, especially PPD
• Family history of depression
• History or family history of late luteal phase disorder
• Obstetrical complications at delivery
• Complicated pregnancy
• Neonatal loss or illness
• Difficult infant temperament
RISK FACTORS
•
•
•
•
•
•
•
•
•
Ambivalence about pregnancy
Marital conflict
Lack of social support
Number of children
Recent loss
History of sexual abuse
Low self esteem
Recent stressful life events
Breastfeeding difficulties
Risks of Untreated PPD
To mother:
• Diminished capacity to care for self and baby
• Substance abuse
• Increased healthcare costs
• Stressful impact on relationship between woman
and her partner.
• Suicidal thoughts more likely to be accompanied
by homicidal thoughts
• Kindling phenomenon---development of a
chronic low grade depression with more
susceptibility to repeated episodes of MDD
Risks of Untreated PPD
To child:
•
Poor attachment, bonding, and less nurturing maternal
interaction
•
Poor weight gain
•
Sleep problems
•
Less likely to be breastfed
•
Less likely to receive preventative healthcare and child safety
practices
•
Poor cognitive, language and and motor development
•
Behavioral problems—future conduct disorders,
hyperactivity, and school behavior problems
•
Future depression and anxiety disorders
•
Risk of future medical illnesses as well —maternal depression is
an “Adverse Childhood Experience”
MATERNAL POST PARTUM MOOD IS
ONE OF THE STRONGEST
PREDICTORS OF NEUROCOGNITIVE
DEVELOPMENT IN CHILDREN
MEASURED UP TO AGE SIX
Summary: Impact of PPD
Diminished maternal ability to function in
many roles particularly the core parenting role
with long lasting adverse effects on child’s
health, cognitive and emotional development
and ongoing risk to mother’s emotional,
physical, and social wellbeing.
Treatment for mother is prevention or early
intervention for child
POST PARTUM ANXIETY DISORDERS
Postpartum Onset Anxiety/Panic Disorder
10% of new mothers
Postpartum Obsessive/Compulsive Disorder
(PPOCD)
3-5% of new mothers
Postpartum Stress Disorder (PPTSD)
1-3% of new mothers may develop. Mothers who
have had a traumatic childbirth experience,
premature birth and loss of child are at most risk for
onset of PPTSD. Mothers who have experienced a
history of childhood sexual or physical abuse are
also at higher risk.
POST PARTUM PSYCHOSIS
• 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
• Rates of infanticide associated with untreated
postpartum psychosis have been estimated to
be as high as 4%.
Risk Spectrum for Postpartum
Psychosis
• Highest-prior history of psychosis,
particularly postpartum
• Moderate --Bipolar disorder
• At risk--Previous postpartum
depression
TREATMENT OF POSTPARTUM PSYCHOSIS
Postpartum psychosis warrants emergency level
care and usually requires inpatient
hospitalization
• Treat as affective psychosis—i.e. as Bipolar
disorder
• Medication treatment is necessary beginning
with an antipsychotic/mood stabilizer such as
Zyprexa
Suicide in the Postpartum Period
• Any indication of self-harm or suicidal ideation should be
taken seriously
• Further assessment and intervention are urgently
required when a woman scores positive on item #10 on
EPDS or question # 9 0n the PHQ-9
• Severe postpartum psychiatric disorder is associated with
a high rate of death from natural and unnatural causes,
particularly suicide
• Suicide risk in the first postnatal year is estimated to be
increased by 70-fold (Appleby et al 1998)
Age at Death for Infants Dying From Intentional or Suspicious
Causes, US, 1990-97
50%
44%
45%
40%
42%
35%
30%
25%
20%
15%
10%
5%
8%
2%
4%
0%
<1 day
2-6 days
7-28 days 1-3 months
4-11
months
Source: Centers for Disease Control and Prevention. WONDER, compressed mortality file, 2000.
DESPITE MULTIPLE CONTACTS WITH MEDICAL
PROFESSIONALS FOLLOWING THE BIRTH OF A CHILD,
POSTPARTUM DEPRESSION MOST OFTEN GOES
UNDIAGNOSED.
All women should be considered at
risk for PPD and should be screened
Need for Patient Education
• 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.
Screening for Postpartum Depression
• Postpartum depression is often not recognized
• Despite the availability of many screening tools,
PPD remains under
• Absence of screening often means untreated
depression and poor outcomes for the mother, her
newborn, and family
• Postpartum depression can be screened for with
simple and validated screening tools
Validated Screening Tools
EPDS- Edinburgh postnatal Depression Screen
PHQ-9 Patient Health Questionnaire
PHQ-2
PPDS Postpartum Depression Scale
Beck Depression Inventory-IICenter for
Epidemiological Studies-Depression Scale
(CES-D)
EPDS
Please UNDERLINE the answer that comes closest to how you have felt in the
last seven days, not just how you are feeling today.
1. I have been able to laugh and see the funny side of things.
As much as I always could
Not so much now
Definitely not so much now
Not at all
2. I have looked forward with enjoyment to things.
3. I have blamed myself unnecessarily when things went wrong.
4. I have been anxious or worried for no good reason.
5. I have felt scared or panicky for not very good reason.
EPDS
6.
7.
8.
9.
10.
Things have been overwhelming me.
I have been so unhappy 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.
Scoring:
0-3 points per question
Score > 10 warrants further assessment
EPDS SCREENING
H/O BIPOLAR DISORDER
EPDS 5-9
EPDS 10 OR MORE
ANSWERS YES TO
QUESTION # 10 OR RISK
OF SUICIDE OR HARM TO
INFANT
EPDS 10 OR
MORE
Patient at increased risk
Discuss signs and symptoms
Follow more closely
MENTAL HEALTH
REFERRAL
ER OR CRISIS TEAM
ASSESSMENT INTERVIEW
EVALUATION
PPD CONFIRMED MEDICATION INDICATED
AND RISKS BENEFITS DISCUSSED AND
DOCUMENTED
PPD NOT CONFIRMED or
medication not indicated
Clinical jugdement to determine
the following:
Rescreen at next visit
Follow clinically
Mental health provider referral
Support Group
PATIENT ACCEPTS
PATIENT DECLINES
USE GUIDELINES AND PATIENT HISTORY
TO CHOOSE MEDICATION
http://www.hfs.illinois.gov/assets/0820
07_mch.pdf
Refer to support group or counseling
Involve partner/family
Mental health referral
Support Group Referral
Consider the following
recommendations:
bright
light therapy, omega fatty
acid therapy, exercise
EVALUATE 4-6 WEEKS
OUTCOME NEGATIVE
MENTAL HEALTH
REFERRAL
OUTCOME POSITIVE
DOCUMENT EVIDENCE IN MEDICAL RECORD
CONTINUE MEDICATION 9-12 MOS AFTER
SYMPTOMS REMIT
EVALUATE EVERY 3 MONTHS
PHQ-9
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite—being
so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself in some way
PHQ-9
Patient uses the following rating for each question:
Not at all
Several days
More than half
Nearly every day
Score Depression Severity
1-4 Minimal depression
5-9 Mild depression
10-14 Moderate depression
15-19 Moderately severe depression
20-27 Severe depression
10. If you checked off any problems, how difficult have these problems made it for
you to do your work, take care of things at home, or get along with other people?
PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an
educational grant from Pfizer Inc. For research information, contact Dr Spitzer at [email protected]. Use of the PHQ-9 may only be made in
accordance with the Terms of Use available at http://www.pfizer.com. Copyright ©1999 Pfizer Inc. All rights reserved. PRIME MD TODAY is a
trademark of Pfizer Inc
PHQ-9 SCREENING
H/O BIPOLAR DISORDER
PHQ-9 <5
PHQ-9 5-10
PHQ-9 >10 OR
MENTAL HEALTH REFERRAL
NO INTERVENTION
RISK OF SUICIDE OR HARM
TO INFANT
ER OR CRISIS TEAM
EVALUATION
ASSESSMENT INTERVIEW
PPD NOT CONFIRMED or
medication not indicated
PPD CONFIRMED
MEDICATION
INDICATED AND RISKS BENEFITS DISCUSSED
Clinical jug dement to determine
the following:
Rescreen at next visit
Follow clinically
Mental health provider referral
Support Group
PATIENT ACCEPTS
PATIENT DECLINES
USE GUIDELINES AND PATIENT
HISTORY TO CHOOSE MEDICATION
http://www.hfs.illinois.gov/assets/082
007_mch.pdf
Refer to support group and counseling
Involve partner/family
Mental health referral
Support Group Referral
Involve partner/family
Consider the following
recommendations: bright
light therapy, omega fatty
acid therapy, exercise
EVALUATE 4-6 WEEKS
OUTCOME NEGATIVE
MENTAL HEALTH
REFERRAL
OUTCOME POSITIVE
DOCUMENT EVIDENCE IN MEDICAL RECORD
CONTINUE MEDICATION 9-12 MOS AFTER
SYMPTOMS REMIT
EVALUATE EVERY 3 MONTHS
PHQ-2
Over the past two weeks, how often have you been
bothered by any of the
following problems?
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
• 0 = Not at all
• 1 = Several days
• 2 = More than half the days
• 3 = Nearly every day
Perinatal Depression Screening
When to screen:
Antenatal early risk assessment and
screening during pregnancy. ACOG recommends
the PHQ-2 once per trimester
If at high risk (prior history, neonatal loss,
obstetrical complications, etc):
Upon discharge from hospital. Need to assess support
plan post discharge
At early (2 week) follow up appointment
Perinatal Depression Screening
Postpartum OB/midwife visit 6-7 weeks
Well child pediatrician visits for the first year
Other possible times:
Lactation consultant visit
Visiting home nurse
Perinatal Depression Screening
• In a national sample, 57% of pediatricians felt responsible
for recognizing maternal depression (Olson AL et al.
Pediatrics. 2002;110:1169-1176)
• Well-child visit is an ideal time to look for signs of PPD in the
mother (See pediatric provider frequently first year)
• “Pediatricians should ascertain the physical and mental
health of the parents in their practice and periodically
review the importance of parents’ attention to their own
mental health needs.”
– AAP: Report of the Task Force on the Family
Perinatal Depression Screening
• Recognition is key: risk factors, warning signs,
symptoms, early identification
• Be alert for plans or intent to harm self (suicide), infant,
others
• Indications for emergency intervention: psychosis, risk of
suicide or harm to the infant
• Refer to mental health professional if concomitant substance
abuse, bipolar symptoms or history of bipolar disorder,
history of psychiatric hospitalization
Training for Office Staff
• Familiarize office staff with screening tools
• Train staff to ask the appropriate questions
when woman call
• Have accessible and up to date contact for
local emergency mental health care
• Have up to date information for other
mental health resources: outpatient mental
health providers, support groups, support
associations such as PSI
Perinatal Depression Screening
Selection of treatment:
first requires good evaluation, review of prior history,
patient education and assessment for
sociality/dangerousness







Individual psychotherapy--CBT /IPT
Medication with discussion of risks and benefits
Bright light therapy
Support group
Support programs
Hospitalization
ECT
Obstacles to Screening
• Lack of familiarity (health care provider and
patient
• Lack of training
• Lack of protocols
• Patient’s reluctance to disclose feelings
• Lack of easy assess to mental health resources
• Lack of time
• Lack of reimbursement
What Do Women Need To Talk About?
• Negative childbirth experiences—especially
with trauma
• Concerns about their infants—their
temperaments, health issues
• Interactions with their babies and caring for
them
• How this time differs from their expectations
• Feelings of isolation
What Do Women Need To Talk About?
• Loss—of prior employment role, closeness
with spouse or older child
• Feelings of frustration , inadequacy in
mothering
• Breastfeeding difficulties
• Loss of care and attention received during
pregnancy
• Ambivalence about returning to work and
sense of loss when that is a necessity
Maine LD 792
An Act to Promote Postpartum Mental
Health Education
Modeled after other state initiatives—
i.e. New Jersey
http://www.maine.gov/dhhs/data_reports.shtml#healthrelated
http://www.maine.gov/dhhs/publications.shtml#legislative
MAPP PPD PROJECT
A statewide project funded by a grant from
the American Psychiatric Association for the
purpose of collaborating with other medical
specialties and other members of the mental
health community to promote understanding
of postpartum depression as a psychiatric
illness with serious consequences to mothers
and infants, decrease stigma, and increase
recognition and treatment of PPD
PPD Resources
www.postpartum.net Postpartum Support International
Crisis hotline for postpartum depression and psychosis:
1-800-PPD-MOMS
www.mededppd.org NIMH supported website
Excellent resource, regularly updated
9 educational modules aimed at different provider categories offering CME’s
www.womensmentalhealth.org MGH Center for Women’s mental Health
1-800-PPD-MOMS Crisis hotline for postpartum depression and psychosis:
1-800-573-6121 Illinois Perinatal Mental health Consult Service—telephone consultation by
perinatal mental health experts for any health care provider with prescriptive authority