Psychiatric Complications of Pregnancy and the Postpartum

1
Psychiatric Complications of Pregnancy and the
Postpartum

• Joseph Breuner, MD
• Swedish Family Medicine Residency
• July 11, 2006

2
Objectives

• Appreciate the postpartum period as a time of
  increased vulnerability to psychiatric illness
• Recognize and diagnose psychiatric illness during
  pregnancy and the postpartum

3
Objectives

• Understand risks to the fetus of psychiatric
  medications
• Prevent and treat psychiatric illness in
  pregnancy and the postpartum

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Outline 1

• Review DSM-IV diagnoses

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Outline 2

• Psychiatric illness during pregnancy
• incidence equal to nonpregnant
• review medication risks and safety

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Outline 3

• Psychiatric illness in the postpartum
• increased incidence
• clinical features of
• bipolar/depression/panic/OCD/psychosis
• prophylaxis and treatment

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But first, a review

• The following slides contain DSM-IV criteria for
  various episodes. Please SHOUT OUT what you think
  they are, first three correct answers for each
  slide get a prize.

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DSM-IV Definition of...

• For at least one week (or less, if
  hospitalized) the patient's mood is
• abnormally and persistently high, irritable or
  expansive.
• To a material degree during this time, the
  patient has persistently had 3 or
• more of these symptoms (4 if the only
  abnormality of mood is irritability)
• -Grandiosity or exaggerated self-esteem
• -Reduced need for sleep
• -Increased talkativeness
• -Flight of ideas or racing thoughts
• -Easy distractibility
• -Psychomotor agitation or increased
  goal-directed activity (social, sexual,
• work or school)
• -Poor judgment (as shown by spending sprees,
  sexual adventures, foolish
• investments)

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DSM-IV

• Manic episode

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DSM-IV definition of...

• In the same 2 weeks, the patient has had 5 or
  more of the following symptoms,
• which are a definite change from usual
  functioning. Either depressed mood or
• decreased interest or pleasure must be one of
  the five.
• -Mood. For most of nearly every day, the
  patient reports depressed mood or
• appears depressed to others.
• -Interests. For most of nearly every day,
  interest or pleasure is markedly
• decreased in nearly all activities (noted by
  the patient or by others).
• -Eating and weight. Although not dieting, there
  is a marked loss or gain of
• weight (such as five percent in one month) or
  appetite is markedly decreased
• or increased nearly every day.
• -Sleep. Nearly every day the patient sleeps
  excessively or not enough.
• -Motor activity. Nearly every day others can
  see that the patient's activity
• is agitated or retarded.
• -Fatigue. Nearly every day there is fatigue or
  loss of energy.
• -Self-worth. Nearly every day the patient feels
  worthless or inappropriately
• guilty. These feelings are not just about being
  sick they may be delusional.
• -Concentration. Noted by the patient or by
  others, nearly every day the
• patient is indecisive or has trouble thinking
  or concentrating.
• -Death. The patient has had repeated thoughts
  about death (other than the fear

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DSM-IV

• Major Depressive Episode

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DSM-IV definition of...

• For at least 4 days the patient has a distinct,
  sustained mood that is
• elevated, expansive or irritable. This is
  different from the patient's usual
• nondepressed mood.
• During this time, the patient has persistently
  had 3 or more of the following
• symptoms (4 if the only abnormality of mood is
  irritability). They have been
• present to an important degree.
• -Grandiosity or exaggerated self-esteem
• -Reduced need for sleep
• -Increased talkativeness
• -Flight of ideas or racing thoughts
• -Easy distractibility
• -Psychomotor agitation or increased
  goal-directed activity (social, sexual,
• work or school)
• -Poor judgment (as shown by spending sprees,
  sexual adventures, foolish
• investments)

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DSM-IV

• Hypomanic episode

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DSM-IV definition of...

• The patient suddenly develops a severe fear or
  discomfort that peaks within 10
• minutes.
• During this discrete episode, 4 or more of the
  following symptoms occur
• -Chest pain or other chest discomfort
• -Chills or hot flashes
• -Choking sensation
• -Derealization (feeling unreal) or
  depersonalization (feeling detached from
• self)
• -Dizzy, lightheaded, faint or unsteady
• -Fear of dying
• -Fears of loss of control or becoming insane
• -Heart pounds, races or skips beats
• -Nausea or other abdominal discomfort
• -Numbness or tingling
• -Sweating
• -Shortness of breath or smothering sensation
• -Trembling

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DSM-IV

• Panic Attack

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DSM-IV definition of...

• The patient must have all of
• 1 Recurring, persisting thoughts, impulses or
  images inappropriately intrude
• into awareness and cause marked distress or
  anxiety.
• 2 These ideas are not just excessive worries
  about ordinary problems.
• 3 The patient tries to ignore or suppress these
  ideas or to neutralize them by
• thoughts or behavior.
• 4 There is insight that these ideas are a
  product of the patient's own mind.

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DSM-IV

• Obsessions

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DSM-IV definition of...

• The patient must have all of
• 1 The patient feels the need to repeat physical
  behaviors (checking the stove
• to be sure it is off ,handwashing) or mental
  behaviors (counting things,
• silently repeating words).
• 2 These behaviors occur as a response to an
  obsession or in accordance with
• strictly applied rules.
• 3 The aim of these behaviors is to reduce or
  eliminate distress or to prevent
• something that is dreaded.
• 4 These behaviors are either not realistically
  related to the events they are
• supposed to counteract or they are clearly
  excessive for that purpose.

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DSM-IV

• Compulsions

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DSM-IV definition of...

• For more than half the days in at least 6 months,
  the patient experiences
• excessive anxiety and worry about several
  events or activities.
• The patient has trouble controlling these
  feelings.
• Associated with this anxiety and worry, the
  patient has 3 or more of the
• following symptoms, some of which are present
  for over half the days in the
• past 6 months
• -Feels restless, edgy, keyed up
• -Tires easily
• -Trouble concentrating
• -Irritability
• -Increased muscle tension
• -Trouble sleeping (initial insomnia or
  restless, unrefreshing sleep)

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DSM-IV

• Generalized Anxiety Disorder

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First Case

• Your patient veronica is the director of
  entertainment on a cruise ship. She wants to have
  a baby but her boyfriend is worried that
  pregnancy will make her crazy, or at least make
  her more likely to have a mental illness. Is
  psychiatric illness more common in pregnancy?

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Pregnancy and Psychiatric Morbidity

• In general population, pregnancy confers no risk
  or benefit of developing a psych diagnosis,
  except that 25 of new OCD cases start in
  pregnancy
• In patients with prior psych history, relapse
  risk is unaffected by pregnancy, except that
• panic disorder may improve

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Veronica

• It turns out that veronica has had two episodes
  of major depression. Will pregnancy increase her
  relapse risk?

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Relapse risk during pregnancy same as nonpregnant
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First Case, Again

• Three months later, Veronica is pregnant.She
  would like to know which classes of psych meds
  are dangerous for her baby, so that when she
  sails to Asia on her next cruise she can obtain
  treatment with confidence.
• Extra credit question in which trimester?

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Teratogenic Risk from Tricyclic Exposure

• 689 exposed cases
• 414 first-trimester exposed cases
• 13 malformations (3.14 incidence, within
  baseline incidence of 2-4)
• McElhatton PR Reprod Toxicol 10(4) 285-294, 1996

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Teratogenic Risk of SSRI exposure

• Paxil 0 of 63 first-trimester exposures
• SSRI monotherapy 2 of 92 exposures
• Prozac N1700 first-trimester exposures no
  increased incidence of malformations

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Neurodevelopmental Risk of SSRI exposure

• Long term risk
• 22 children exposed in-utero to SSRI compared to
• 14 children not exposed
• Studied for internalizing behaviors anxiety,
  depression, withdrawal at 4 yrs of age
• No difference
• Strong correlation with present maternal
  depression and anxiety

Am J Psych june 2006
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SSRI in utero neonatal abstinence or toxicity?

• Transient neonatal sx d 0-7
• Include
• Tremor
• hypertonicity
• irritability
• poor feeding
• Abstinence or hyperserotonergic state?
• Sx correspond to paxil serum levels

Ther Drug Mon, Feb 2006
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Teratogenicity of Lithium

• Lithium and Ebsteins anomaly
• base rate is 1/20,000
• lithium in first trimester is 1/1000
• screen with 16-20 week ultrasound
• consider genetic counselling

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Teratogenicity of Depakote and Tegretol

• Carbamazepine first-trimester risk for spina
  bifida is 0.5-1
• Valproic acid risk for neural tube defects is
  3-5
• Lithium is probably safer first trimester
• Depakote/Tegretol are better during breastfeeding

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Teratogenic Risks of Benzodiazepines

• Oral cleft rates
• general population 6/10,000
• first trimester BZD exposure 7/1,000
• altshuler ll Am J Psychiatry 153592-606, l996

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Why take Paxil?

• Veronica is now three months pregnant and
  clinically depressed. She cant sleep, cant tap
  dance, hates her life. Shes reluctant to take
  medication because it may hurt the baby and,
  though she may feel better, it wont help the
  baby.
• Is she right?

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Neonatal Risks of Untreated Depression and Anxiety

• During Pregnancy
• N500
• Lower birth weight
• Preterm delivery
• Steer RA epidemiology 451093-1099, l992

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Neonatal risks of untreated depression/anxiety

• Elevated maternal glucocorticoid levels adversely
  affect fetal brain development
• Meaney MJ Developmental Neuroscience 1849-72,
  l996

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Postpartum Psychiatric Morbidity
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Neurophysiology of post partum period

• Because of normal vigilance in new parents, the
  nervous system is naked or unprotected
• Locus ceruleus threshold is lowered
• Innocuous stimuli may be perceived as threatening

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First Case, revisited

• Veronica now has a lovely boy named Bart. Her
  boyfriends upset because the baby gets all the
  attention.
• If she has no history of depression, whats her
  risk of post partum depression? How about if she
  does?

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Postpartum depression incidence is

• 10 to 15 with no prior psych history

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Postpartum relapse rates are increased
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Veronica, otra vez

• Veronica and her boyfriend get very little sleep
  and argue a lot. Does their marital conflict
  increase her risk of depression?

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Risk factors for postpartum psychiatric illness

• Personal history of psychiatric illness
• First degree relative with psychiatric illness
• Marital conflict
• Poor emotional and physical support to the mother

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Risk factors for postpartum psychiatric illness

• Excessive sleep disruption
• Medical complications during pregnancy
• Child-care stress feeding problems, difficult
  infant, infant illness
• Stressful life events moves, job loss, financial
  stress
• Adolescent mother

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Psych Syndromes in the Postpartum Bipolar

• 50 of first manic episodes in women who have
  ever had a baby occur in the first six months
  postpartum
• Manic episodes usually emerge in the first 3
  postpartum weeks

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Psych Syndromes in the Postpartum Bipolar

• Manic episodes are particularly difficult to
  control once well established
• Mania is usually followed by a depression

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Psych Syndromes in the PostpartumDepression
Diagnoses

• Baby Blues begin within three days postpartum,
  resolve by 2 weeks untreated. Prevalence 30-70
• Postpartum Depression Can begin up to 6 mo
  postpartum, but typical is within 6 weeks. Meets
  DSM-IV criteria. 10-20 incidence is fourfold
  increase over nonpregnant population

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Psych Syndromes in the PostpartumDepression

• Frequent variability in the severity of symptoms
• scary thought about the baby are common
• Prominent somatic symptoms

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Psych Syndromes in the PostpartumDepression

• Feeling overwhelmed about parenting
• Difficulty sleeping even when the baby sleeps
• Marked guilt/disbelief in inability to bond

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Screening Questions for Postpartum Depression

• Can you sleep when the baby is sleeping
• Do you feel overwhelmed
• Are you comfortable in your relationship with the
  baby (over or under protective)
• Do your symptoms come and go rapidly
• Are you having headache/backache/abdominal pain
• A validated screening instrument for postpartum
  depression is the Edinburgh Postnatal Depression
  Scale

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Psych Syndromes in the PostpartumPanic

• Panic Attacks and Generalized Anxiety are
  frequently comorbid with depression
• Panic is markedly heightened during periods of
  solo care of the baby
• Fear of diminished level of functioning is
  accompanied by profoundly lowered self-esteem

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Psych Syndromes in the PostpartumObsessive
Compulsive Disorder

• Features of OCD are nearly always present as
  frightening thoughts related to the safety of the
  baby. These thoughts are intrusive and
  ego-dystonic, but are typically concealed for
  fear of negative societal reaction. Marked
  anxiety is comorbid
• As a result, an apparent under or over concern
  about the baby frequently develops

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Psych syndromes in the postpartum psychosis

• Postpartum Psychosis most likely a manic episode
  with psychotic features.
• 1/1000
• Hospitalize
• role plays

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First case, still

• Veronica is now quite depressed. She read on the
  web that her baby will do more poorly in school
  if her postpartum depression goes untreated. Is
  this true?

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Long term effects on children of mothers with
untreated postpartum depression

• Compared controls, treated moms and untreated
  moms
• Blinded observers rated 5 and 9 year olds
• Boys disruptive
• Girls withdrawn

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Veronica and Bart

• What medications are safe for treating veronicas
  depression?

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Breastfeeding and Tricyclics

• Infant dose is approximately 0.5 of the maternal
  dose
• infant serum assays are nearly always negative
  with assay sensitivities below 1 ng/ml
• an exception is doxepin, with a case report of 3
  ng/ml

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SSRIs and Breastfeeding

• Prozac has been detected in an infants serum
  (340 ng/ml fluoxetine, 208 ng/ml norfluoxetine)
  and colic was attributed to it
• Zoloft was detected in 3 of 12 nursing infants,
  but serum levels did not exceed 1 ng/ml
• Paxil was not detected

59
Breastfeeding and Mood Stabilizers

• Depakote and Tegritol are generally considered
  safe
• no need to check levels in baby
• Lithium has been associated in case report with
  electrolyte abnormalities and floppy baby

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Breastfeeding and Benzodiazepines

• Limited data support safety
• No significant impact on neurobehavioral function
• Cohen LS etal. J.Clin Psych 199859(suppl 2)

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Some years later

• Bart is now 7.He has collected key chains from
  every time zone. Veronica is about to have their
  second baby. She wonders what could be done to
  prevent post partum depression this time around.

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Prophylaxis of Postpartum Depression

• Indicated in moms with prior hx of PPD or two or
  more episodes of MDD
• Depression recurrence in moms with prior hx PPD
  reduced by meds from 70 to 7

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Prophylaxis of Postpartum Depression

• 3 components
• 3.5 hour block of sleep x 2 each night
• 1 hour rest break every afternoon mobilizes
  support
• Antidepressant meds--paxil or zoloft in starting
  doses
• Continue until 6 months postpartum, then taper

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Postpartum Depression Risk Stratification and
Prophylaxis
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Postpartum Depression Risk Stratification and
Prophylaxis
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Postpartum Depression Risk Stratification and
Prophylaxis
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Postpartum Depression Risk Stratification and
Prophylaxis
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Resources for Support for the Mother

• Postpartum Support International of Washington
• free support groups, facilitated by recovered
  mothers, to provide emotional support and
  referral to services
• 24 hour hotline for call backs from recovered
  mothers, to provide emotional support and
  referral to services

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Resources for Support for the Mother

• http//www.ppmdsupport.com/
• Quarterly newsletter
• 206 283 9278

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Objectives

• Appreciate the postpartum period as a time of
  increased vulnerability to psychiatric illness
• Recognize and diagnose psychiatric illness during
  pregnancy and the postpartum
• Understand risks to the fetus of psychiatric
  medications
• Prevent and treat psychiatric illness in
  pregnancy and the postpartum

71
Acknowledgement

• Thanks to Rex Gentry, MD, a local psychiatrist
  with an interest in this area

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Did I mention that Im getting a new guitar amp...