Post partum depression - Emergency Services LLC

POSTPARTUM MOOD DISORDERS Shazia Malik, M.D. CenterPointe Hospital 1 Disclosure The content of this presentation does not relate to any product of a commercial interest; therefore, there are no relevant financial relationships to disclose. 2 Disclaimer The Missouri State Medical Association cannot and does not provide legal advice. This presentation is informational in nature and may not be relied upon for legal advice. Medical practices should contact their legal counsel for assistance.

3 In Cyzius a woman gave birth to twin daughters with difficult labor and the lochial discharge was far from good. On the sixth day there was much wandering at night; no sleep. About the eleventh day she went out of her mind. -- Hippocrates, Of The Epidemics 4 HISTORY OF POSTPARTUM DISORDER 400 B.C. Hippocrates

1958 Louis Marce(French psychiatrist) Noted insanity in pregnant, puerperal and lactating women. 1961 R.S. Paffenbarger Recognized Postpartum Disorder Demonstrated admission to mental hospitals was increased during the first month postpartum. 1962 J.A. Hamilton

Argued puerperal psychosis was a distinct disorder. 5 EVOLUTION OF DIAGNOSTIC CRITERIA DSM II (1968) Psychosis related to childbirth was listed as psychosis caused by an organic disorder. DSM III & III R

Acknowledged Postpartum Affective Disorders Acknowledged Postpartum Psychosis as an Atypical Psychosis. DSM IV & IV TR In the past decade, increased research has led to many publications on this topic. 6 POSTPARTUM QUESTIONS Is childbirth a major stressor ? Are there neurophysiologic changes underlying postpartum mental changes?

Is the stress-diathesis model applicable? If so, can they happen to anyone or only to women who are vulnerable in some way? How can puerperal emotional disturbances be recognized and treated effectively? 7 OBJECTIVE OF DISCUSSION Provide an understanding of the

possible etiology phenomenology diagnosis prognosis and treatment of: Postpartum Blues (PPB) Postpartum Depression (PPD) Postpartum Psychosis (PPP) 8 SUMMARY OF DISCUSSION

Disorders Postpartum Blues Postpartum Depression Postpartum Psychosis Treatment Psychotherapy Pharmacotherapy

Social Interventions 9 REPRODUCTIVE JUNCTURES Reproductive junctures are times for affective monitoring in vulnerable women: Premenstrum Perimenopause/Menopause

Assisted Reproductive Technology Pregnancy Miscarriage Postpartum 10 HORMONAL INFLUENCES Progesterone Neurotransmitters Estrogens Beta-Endorphins

Thyroid Hormones Lack of Sleep 11 POSTPARTUM BLUES A Case Presentation A 28 year-old married white female gives birth to a full-term, healthy baby. For the first 3 days she is tired but happy. On the fourth day her mother, who is visiting and helping with the household chores, mentions that the house is a mess. The new mother bursts into tears saying, You should be helping me, not criticizing me The next day while watching a movie, she starts to cry over a romantic scene that would normally not bother her. Over the next few days she notices herself reacting strongly to minor issues, although overall she remains happy about her baby.

12 POSTPARTUM BLUES Incidence/Prevalence Common in every culture: 25% - 75 % of new mothers Acute onset: 3RD - 5TH day postpartum Short-lived: self-limited recovery complete in 2 weeks with no intervention. Diagnosis

No well established criteria for diagnosis DSM IV TR: offers no specific designation for this condition 13 POSTPARTUM BLUES Symptomology Primary symptom of depression: depressed or anhedonic mood is not typically present Predominant mood is joyful. Most characteristic symptom was tearfulness but not related to sadness.

Phenomenologically, the central feature is increased emotional reactivity to stimuli. Associated with: Irritability hypersensitivity to light anxiety exaggerated empathy 14

POSTPARTUM BLUES Biological Factors Current data support: hormone withdrawal hypothesis A greater decrease in free estriol postpartum However, no consistent correlation has been found for any hormones. A precipitous decline in progesterone Larger decreases in plasma beta-endorphin levels

15 POSTPARTUM BLUES Predisposing Psychosocial/Obstetric/Gynecological Factors Not associated with major depressive disorder Not associated with current stressers/ obstetric complications Not associated with marital status

All social climates among all cultures History of severe premenstrual symptoms Younger age at menarche Menstrual irregularities Primipara Ambivalent attitudes towards pregnancy/fear of labor 16 POSTPARTUM BLUES Prognosis Recovery is complete in 2 weeks.

If symptoms persist beyond 2 weeks, evaluate for Postpartum Depression. 20% experience major a depressive episode in the first post-natal year. Treatment Education Reassurance Support Adequate sleep and rest breaks PRN short-acting benzodiazepines 17

POSTPARTUM DEPRESSION 18 POSTPARTUM DEPRESSION A Case Presentation A 26 year-old married female, G:2 LB: 2, has a 2 year-old boy who is hyperactive. She has a family history of depression in mother and sister and postpartum depression in the mother. However, she has had no previous episode of mood disorder. She did suffer postpartum blues after her first pregnancy and gives a history consistent with symptoms of premenstrual dysphoria. Her husband loses his job when she is 6 months pregnant. She delivers healthy twin baby girls. She complains of fatigue and mild insomnia, but does generally well when in the 3rd week, her husband notices her to be:

Withdrawn and displaying decreased appetite not taking care of self and baby feeling guilty and unfit in her role as a mother not wanting to get out of bed. 19 POSTPARTUM DEPRESSION Incidence: 10% --15%

26 % in adolescents Onset: 2 weeks to 6 months postpartum 16% in adult females in first year after pregnancy Incidents rise in 30 days postpartum Can occur up to one year postpartum Can be insidious and unrecognized Duration: 6 months to 1 year 20 POSTPARTUM DEPRESSION

Etiology Biological: no one emergent biological factor Low levels of estrogen and progesterone High levels of prolactin Thyroid dysfunction can be a minor association 21 POSTPARTUM DEPRESSION Psychosocial/Obstetric/Gynecological Factors Social/Cultural Factors

Stressful life events during pregnancy Family history of alcoholism First episode of bipolar illness can present in postpartum. Marital discord Lack of social support/single parent Family history of mood disorder: increasing from 8% - 16% Personal or family history of Postpartum Depression 22 POSTPARTUM DEPRESSION Psychosocial/Obstetric/Gynecological Factors

Prenatal Depression Depression or anxiety during index pregnancy Personal History of Bipolar Disorder History of depression not associated with pregnancy Unwanted or unplanned pregnancy Pregnancy loss in past 12 months Twin births Infant medical problems 23

POSTPARTUM DEPRESSION Diagnosis DSM IV TR uses postpartum onset specific to affective disorders. Screening for women while they are pregnant may identify those at risk for PPD. Edinburgh Post-Natal Depression Scale (see handout)

10-item self-report questionnaire Postpartum Depression Checklist used by health care professionals Does not include somatic symptoms Specifically validated for detection of depression postpartum Maximum score of 30, score of > 12-13 identifies woman with postpartum 24 POSTPARTUM DEPRESSION Differential Diagnosis Postpartum Blues

Mood Disorder secondary to general medical condition Duration greater than 2 weeks Hypothyroidism HIV Infection Systemic Lupus Erythematosus Substance-Induced Depressive Disorder

Illicit Drugs Prescription Drugs Alcohol Sympathomimetics 25 POSTPARTUM DEPRESSION Symptomatology Period of well-being followed by gradual onset of depression

Obsessive thoughts Exaggerated vegetative symptoms Significant anxiety and/or panic attacks Intense anger or irritability Unable to care for self or baby Feelings of failure as a mother Feelings of guilt: inadequacies, real or imagined, regarding the baby 26 POSTPARTUM DEPRESSION Prognosis If not properly treated, future depressive episodes both associated and unassociated with pregnancy, worsening of

future premenstrual symptoms and menopausal depressive symptoms. Depression in the spouse in the first-year postpartum Most serious complications of untreated Postpartum Depression Difficulty bonding with infants leading to behavior, cognitive, and social developmental delays in infants Progression to delusional depression Suicide Infanticide 27

POSTPARTUM PSYCHOSIS 28 POST PARTUM PSYCHOSIS A case study A 24 year-old primiparous female who gives a history of her mother being hospitalized after each of the two younger siblings were born. One of the siblings has a diagnosis of Bipolar Disorder. The patient has never been diagnosed or treated. She has a healthy baby after a C-Section with uncomplicated recovery. She complains of irritability with a decreased need for sleep. Three days after the birth of the baby, she has a decreased appetite. She exhibits extreme mood labiality and insists that the baby is dead. Further evaluation reveals that she is hearing voices which are telling her that her baby is dead. She exhibits poor insight. 29 POSTPARTUM PSYCHOSIS

Incidence: Infrequent: 1-2 in 1000 births Previous episode of postpartum psychosis is 1 in 3. Consistent across cultures Onset: can occur within 2 weeks of delivery and up to 3 months postpartum Severe in intensity

Risk for hospital admission: First 30 days: 21.7% Within 90 days 12.7% Risk generally increased in two years post-delivery 30 POSTPARTUM PSYCHOSIS Etiology Primary etiology is between psychotic disorder in

childbirth Lack of causal relationships between postpartum psychosis and psychosocial stressers. Biological Factors Most of these associations are hypotheses. Estrogen increases dopamine receptor binding Sudden decrease in estrogen postpartum leads to dopamine receptor sensitivity triggering psychosis Sleep deprivation 31 POSTPARTUM PSYCHOSIS Psychosocial/ Obstetric/Gynecological Factors

Life events and stress did not differentiate women who developed Postpartum Psychosis from a control group. First episode is in 36% who have bipolar disorder Primiparous 77% on index cases with a mean maternal age of 26 years After C-Section 20% Personal history of Bipolar Affective Disorder (BAD) - 50% Severity of past psychotic episode Past history of schizophrenia 20% Previous history of postpartum psychosis Family history of mood disorder - 50% of first degree relatives

had affective illness Family history of postpartum psychosis 40% 32 POSTPARTUM PSYCHOSIS Diagnosis DSM IV TR: not a diagnosis Postpartum Onset is a specifier to Bipolar Affective Disorder and Postpartum Psychosis is a psychotic disorder not otherwise specified (NOS). Differential Diagnosis

Substance-Induced Psychotic Disorder Recreational Drug Sympathomimetics High-Dose Metronidazole 33 POSTPARTUM PSYCHOSIS Differential Diagnosis (cont.)

Schizophrenia/Schizo Affective Disorder Psychotic Disorder secondary to Thyroid Disorder Psychotic Disorder secondary to Systemic Lupus Erythematosus First six months postpartum Serum antinuclear antibodies (ANA) to screen Psychotic Disorder secondary to HIV Psychotic Disorder secondary to Neurologic Disorder Psychotic Disorder secondary to Metabolic Disorder 34 POSTPARTUM PSYCHOSIS

Symptomatology Asymptomatic period of 2-3 days followed by severe onset of 3 -14 days postpartum; 77% of cases in the first two weeks Prodromal symptoms sleep disturbance/restlessness Delirium-like picture of cognitive disorganization Subjective experience of confusion Extreme affect instability

Bizarre behavior: hallucinations, delusions Homicidal and suicidal ideations 70% of these patients are diagnosed Bipolar Affective Disorder (BAD) or Major Depressive Disorder (MDD) with psychotic features. 35 POSTPARTUM PSYCHOSIS PROGNOSIS Excellent if treated rapidly and appropriately Benign course: rare, 23% of mothers with no psychiatric history

Future Postpartum Psychosis episodes: risk, 25% Future affective episodes: 64% Suicide: 5% Risk Factors: Postpartum Psychosis admission Teenage pregnancy Stillbirth: 70-fold increase in first Postpartum year 36 POSTPARTUM PSYCHOSIS PROGNOSIS

Infanticide: 2% - 4% Of those who commit infanticide, 62% commit suicide. 1-3 in 50,000 births Risk Factors: Maternal age of 15 years at first pregnancy Low education A 17-19 year-old mother with her second or subsequent child No prenatal care

Andrea Yates 37 POSTPARTUM PSYCHOSIS Medical Emergency - protection of mother and infant General Principles: Early identification

Involvement of family and other support Rapid evaluation Hospitalization Coordinated care of mother and infant 38 POSTPARTUM OBSESSIVE-COMPULSIVE DISORDER AND ANXIETY Extremely common and often comorbid with depression Intrusive thoughts or images of harming baby or something harmful happening

Terribly distressing and incapacitating Will not volunteer this information; we must directly ask the mother Mother is afraid to be alone with baby 39 POSTPARTUM OBSESSIVE-COMPULSIVE DISORDER AND ANXIETY Antidepressants must be given at ObsessiveCompulsive Disorder (OCD) dose Fluoxetine: 40-80 mg Sertraline: 150-200 mg Paroxetine: 40-60 mg

Cognitive-Behavioral Therapy (CBT) Support Groups Social Support 40 FACTORS CONTRIBUTING TO MATERNAL INFANT BONDING High-risk Maternal Attitudes Lack of interest in newborn Hostile expressions toward infant Disappointed about gender of infant Unrealistic expectation about development of infant from birth Young age of mother Mothers experience with rejection/ neglect in her own childhood

41 FACTORS CONTRIBUTING TO MATERNAL INFANT BONDING High-risk Environmental Factors Stressful life events Relationship of mother to spouse/partner Number of children under mothers care Economic resources High-risk Infant Attributes The behavioral disposition of the infant Medical complications relating to the infant 42 IMPACT OF MATERNAL MENTAL ILLNESS ON OFFSPRING Acute Effects Mother-infant bond (critical in first year of life) Secure base for child to explore Negative parenting attitudes in Postpartum Depression, if

continued beyond the first week of infants life Difficulty in mother infant bonding and engagement which if persists leads to Infant reciprocating negatively resulting in decreasing eye gaze during feeding less content and less playful more drowsy and fussy less playful and more squirming. 43 IMPACT OF MATERNAL MENTAL ILLNESS ON OFFSPRING Long-term Effects Behavioral functioning: Infants and toddlers More sleep disturbance Eating problems Temper tantrums persisting up to 3 years Electroencephalogram (EEG) changes in frontal lobe correlating with behavior problems. Cognitive functioning: less optimal cognitive development in

infants Delay in development of object permanence 44 IMPACT OF MATERNAL MENTAL ILLNESS ON OFFSPRING Long-term Effects (cont.) Social/ Interpersonal functioning: SECURE ATTACHMENT Sensitive responsive parent INSECURE AMBIVALENT { Neglectful and rejecting parents INSECURE AVOIDANT { Depressed mothers INSECURE DISORGANIZED Fearful experience with caregiver, Postpartum Psychosis, untreated Postpartum depression PRESCHOOL YEARS Lethargy, sadness, panic, school phobia Biological: High Serum Cortisol Alteration in hypothalamic adrenal axis

45 TREATMENT Primary Prevention/Secondary/Tertiary Prevention MEDICAL Ante- & post-natal care Pharmacotherapy ECT PSYCHOLOGICAL Interpersonal Therapy (IPT) Couples Therapy Group Therapy Mother-Infant Psychotherapy

SOCIAL Education Support Groups 46 PRIMARY PREVENTION Professional and Community Education Identification of Women-at-Risk, antenatal and during pregnancy; Use depression rating scales Postnatal Screening Treatment Options IPT starting with pregnancy and immediately after postpartum Pharmocotherapy Postpartum Psychosis with history of Bipolar Disorder; Lithium prophylaxis immediately postpartum Postpartum Depression; antidepressants immediately upon postpartum

Social Support Groups 47 THE NINE STEPS TO WELLNESS Education Sleep (a minimum of 5 hrs) Nutrition Exercise and make time for yourself Sharing with non-judgmental listeners Emotional support Practical Support (help with chores) Referrals to professionals Hospitalization if necessary 48 PSYCHOTHERAPY Interpersonal Psychotherapy (IPT): Best documented psychosocial intervention for mild to moderate Postpartum Depression. Time-limited 12-20 sessions The focus is on role transitions, interpersonal disputes, and

if necessary grief/ interpersonal deficits. 49 PSYCHOTHERAPY Couples Therapy Birth of baby developmental stage Marital disharmony Lack of partner support Group Therapy Formalized group therapy found to be superior to social support groups in alleviating signs/symptoms of depression. Mother-Infant Psychotherapy Learn by watching in group therapy Social Support Groups Not an alternative for therapy or medication! 50 PHARMACOTHERAPY

5% to 17% of all nursing women take pospartum medications 12% to 20% of all nursing women smoke. No fixed guidelines Case-by-case approach evaluating risk/benefits AAP medicines grouped in 4 categories: Contra-indicated Effect unknown may be of concern Give with caution Compatible Timing a dose can reduce infant exposure Just after nursing and/or prior to infants longest sleep period. 51 ANTIDEPRESSANTS Some prefer Tricyclic Antidepressant (TCA) first line;

others prefer short-acting Selective Serotonin Reuptake Inhibitors (SSRIs) Nortryptiline/desipramine when full dose is used Seen in very small doses in milk and serum levels are undetectable Monitoring of breast milk and infant serum concentration is not recommended unless side effects are seen in infants. Adverse effects are colic, gastrointestinal, and sleep disturbance. 52 MOOD STABILIZERS Lithium Detectable Lithium levels can be seen in nursing babies. Acute effects include: Hypotonia, cyanosis, lethargy, hypothermia Long-term effects include: Hypothyroidism and Diabetes Insipidus

Valproate Present in low concentration in breast milk. Infant serum level is about 10% of maternal levels. Safe if maternal serum levels are within normal limits. 53 MOOD STABILIZERS Carbamazapine levels in infants is 40% of maternal serum levels. Effectively cleared by newborns, serum levels in infants are insignificant. Lamotrigine Glucuronidation is immature in infants, it should used with care. Serum concentration in nursing infants is 30% of maternal concentration. However, no adverse effects have been documented regarding infants when used during nursing.

54 ANTIPSYCHOTICS Olanzapine: 16 infants No toxicity reported No plasma concentrations noted in 6 infants during nursing Median infant daily dose was 1% -1.6% of maternal dose. Risperidone: Limited case reports Infant dose ranging from 2.3% - 4.7% of maternal dose No evidence of complications in nursing infants Quetiapine: Limited data Nursing infant dose is 0.09% of maternal dose. Low-potency antipsychotics can cause sedation and anticholinergic effects. High-potency antipsychotics are considered safe but no long-term data is available. 55

ELECTROCONVULSIVE THERAPY (ECT) Indications Refractory depression Psychotic depression Melancholic depression High suicide Risk Risks: Not known other than some post-ECT confusion 56 OPTIONS FOR BREASTFEEDING WOMEN Use non-pharmacologic treatment. Wean and initiate pharmacologic treatment. Continue to breastfeed and initiate pharmacologic treatment.

57 TREATMENT SUMMARY Use a medication appropriate for the diagnosis. Use a medication to which the patient has had a prior response. Use a medicine to which the infant has had a prior exposure. Use a medication for which there is a published data. 58 TREATMENT SUMMARY Monotherapy Infant serum monitoring is not recommended for antidepressants. Infant serum monitoring is recommended for mood stabilizers.

If adverse effects are suspected, suspend breastfeeding. 59 TREATMENT SUMMARY Diagnose early and effectively. Treat aggressively with a multimodal technique. HAPPY MOTHER! HAPPY CHILD! HAPPY FAMILY! 60

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