Transcript POSTPARTUM DEPRESSION BEYOND THE BLUES

POSTPARTUM DEPRESSION
BEYOND THE BLUES
Debby Carapezza, R.N., M..S.N.
Nurse Consultant, Reproductive Health Program
Utah Department of Health
INCIDENCE OF DEPRESSION
 Each year, 15% to 20% of adults in the
United States experience a major depression
 The incidence among women is twice that
of men and peaks between 18 to 44 years of
age - the childbearing years
DEPRESSION IN WOMEN
 Women are at increased risk of mood
disorders during periods of hormonal
fluctuation


premenstrual
postpartum
perimenopausal
THE RANGE OF POSTDELIVERY MOOD
DISORDERS
 50% to 80% of women experience transient
“baby blues” within the first two weeks
following delivery
 0.1% to 0.2% of women experience
postpartum psychosis usually within the
first 4 weeks following delivery
POSTPARTUM DEPRESSION
 6.8% to 16.5% of women experience
postpartum depression (PPD) also known as
postpartum major depression (PMD)
 Onset can be as early as 24 hours or as late
as several months following delivery
SYMPTOMS OF
POSTPARTUM DEPRESSION
Hopelessness
Loss of pleasure in activities
Helplessness
Mood changes
Persistent sadness
Irritability
Inability to adjust to role of
motherhood
Inability to concentrate
Low self-esteem
Sleep /appetite disturbances
RANGE OF SYMPTOMS
 Symptoms range


from mild dysphoria
to suicidal ideation
to psychotic depression
DURATION OF SYMPTOMS
 Untreated, symptoms can last:

several months

into the second year postpartum
THE ETIOLOGY OF
POSTPARTUM DEPRESSION
 Various theories based in physiological
changes have been postulated:

hormonal excesses or deficiencies of estrogen,
progesterone, prolactin, thyroxine, tryptophan,
among others
ETIOLOGY OF POSTPARTUM
DEPRESSION
 Other theories cite numerous psychosocial
factors associated with PMD:




marital conflict
child-care difficulties (feeding, sleeping, health
problems)
perception by mother of an infant with a
difficult temperament
history of family or personal depression
POSTPARTUM DEPRESSION
IN UTAH
What can PRAMS data tell us?
INDICDENCE OF
POSTPARTUM DEPRESSION
AMONG 2000 UTAH PRAMS
RESPONDENTS
 24.1% of PRAMS respondents indicated
that in the months after delivery they were
moderately to very depressed
 When the results of the survey are weighted
to represent all 47,331 Utah women who
had a live birth in 2000, this means an
estimated 11,416 women reported being
moderately or very depressed.
Higher rates of depression were
noted among women who:
Had less than a high school
education
Reported being abused before
or during pregnancy
Were less than 19 years old
Had 0 to 1 person as a source
of social support
Resided in a household with
an income <$15,000
Were not married
Experienced an unintended
pregnancy
Reported 6 to 18 stresses
during pregnancy (sick family
member, divorce, etc.)
THE IMPACT OF
POSTPARTUM DEPRESSION
LONG TERM
CONSEQUENCES OF PMD
 Negative impact on the infant ‘s social,
emotional and cognitive development

2 month old infants of mothers with PMD had
decreased cognitive ability and expressed more
negative emotions during testing
LONG TERM
CONSEQUENCES OF PMD
 Babies of mothers
with PMD were
perceived by their
mothers as more
difficult to care for
and more bothersome.
POSTPARTUM DEPRESSION
& MATERNAL MORTALITY
IN UTAH
 In recent years, there have been two
maternal deaths due to suicide by women
within one year of giving birth.
 Neither woman had been screened for
postpartum depression
RISK FACTORS FOR PMD
-Family history of mood
disorder
-Client history of mood
disorder prior to pregnancy
-Anxiety/depression during
pregnancy
-Previous postpartum
depression
-Baby blues following current
delivery
-Child-care difficulties:
feeding, sleeping, health
-Marital conflict
-Stressful life events
-Poor social support
INTERVENTIONS
SCREENING FOR PMD
SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:
 Be unable to recognize she is depressed
SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:
 Believe her symptoms are “normal” for new
moms
SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:
 Fear being labeled a “bad mother” if she
admits her maternal experience does not
meet society’s picture of bliss
SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:
 Feel she is going crazy and fears her baby
will be taken from her
WHEN TO SCREEN FOR PMD







At preconception visit
During prenatal intake & subsequent visits
During postpartum exams
During infant’s WCC & WIC visits
When infant is seen for sick care or in ER
At early intervention home visits
At family planning visits during the first
year postpartum
 At mother’s visits for routine episodic care
SCREENING TOOLS
 There are several tools available:




Edinburgh Postnatal Depression Scale (EPDS)
The Mills Depression & Anxiety Checklist
The Center for Epidemiological Studies
Depression Scale (CES-D)
Others, often on various websites for mental
health
A WORD ABOUT SCREENING
TOOLS!
 Be familiar with the tool - its validity and
limitations
 Have a referral network available for
women screening positive
 Document the screening and any referrals
made
 Follow-up with your client to assure that
she received needed assistance
EDINBURGH POSTNATAL
DEPRESSION SCALE (EPDS)






Designed for home or outpatient use
Consists of 10 questions
Can be completed in approx. 5 minutes
Reviews feelings the previous 7 days
Scored 0-3 depending on symptom severity
Depending on study, cut off is 13 - 9 points
SAMPLE EPDS QUESTIONS
 1. I have been able to laugh & see the
funny side of things




As much as I always could
Not quite so much now
Definitely not so much not
Not at all
SAMPLE EPDS QUESITONS
(Cont.)
 *3. I have blamed myself unnecessarily
when things went wrong




Yes, most of the time
Yes, some of the time
Not very often
No never
SAMPLE EPDS QUESTIONS
(Cont.)
 *6. Things have been getting on top of me




Yes, most of the time I haven’t been able to
cope at all
Yes, sometimes I haven’t been coping as well
as usual
No, most of the time I have coped as well as
ever
No, I have been coping as well as ever
TREATMENT
 1. Educate the woman and her support
system regarding the diagnosis of
postpartum depression.
TREATMENT OPTIONS
 Pharmacological intervention
 Counseling, individual and/or group
 Support groups
PHARMACOLOGICAL
INTERVENTION
 Use of tricyclic antidepressants and
selective serotonin reuptake inhibitors
(SSRIs) may be indicated for both nonnursing and nursing mothers
 Have low incidence of infant toxicity and
adverse effects during breastfeeding*
 Decisions regarding use while breastfeeding
must be on a case by case basis
OTHER CONSIDERATIONS:
 Provider must be familiar with agents and
the hepatic function of mother and infant
 Client must be informed of risks/benefits of
treatment Vs. no treatment for herself and
her infant

unknown impact of long-term use of
medications on neurodevelopment of infant
Other Considerations - Cont.
 If the woman chooses to breastfeed while
on psychotropics, she should work
collaboratively with a psychiatrist and her
pediatrician
 If the infant experiences insomnia or other
behavior changes, his serum should be
assayed for the presence of medication
 Document all discussions regarding
treatment in the client’s chart
TREATMENT OF DEPRESSION
PATIENT ASSISTANCE
PROGRAMS
 Pharmacological treatment of depression can be
effective. Unfortunately, it can also be expensive.
Costs of antidepressants vary depending on the
drug, dose and pharmacy.
 Paxil® 20mg qd X 30 Days = $85.39
 Prozac® 20mg qd X 30 Days = $67.79 (generic)
 Zoloft® 50mg qd X 30 days = $75.00
 Elavil®, at approximately 75mg qd X 30 days =
$11.39 (generic) or $37.89 (brand).
COUNSELING
 Know referral sources in your locale,
especially those that:




accept Medicaid
utilize a sliding fee
will develop a payment plan with the client
offer free counseling
 Be familiar with indigent drug programs
available through various pharmaceutical
manufacturers
Counseling - Cont.
 Any woman with symptoms of psychosis or
with serious suicidal/homicidal ideation
should be referred for emergency
psychiatric evaluation
SUPPORT GROUPS
 Numerous postpartum support groups are
available. Contact:
 Local mental health agencies
 Hospitals
 Websites
WEBSITE INFO & SUPPORT
 Depression After Delivery http://www.depressionafterdelivery.com
 Postpartum Support International http://www.postpartum.net/
 The Postpartum Stress Center http://www.postpartumstress.com/
 Postpartum Education for Parents http://www.sbpep.org
 Office on Women’s Health http://www.4women.gov-pregnancy-after
the baby is born-PPD
Websites and Other Resources
 Mental Health Association in Utah

http://www.xmission.com/~mhaut/
 For information on medication while
breastfeeding, call Pregnancy RiskLine:


In Salt Lake City: 328-BABY (2229)
Outside Salt Lake: 1-800-822-BABY (2229)
SUMMARY
 Postpartum depression:





is relatively common
may have long-term consequences for mother,
infant & family
is easily missed
should be screened for
can be treated successfully