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Psychiatric Complications of Pregnancy and the Postpartum

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Girls withdrawn. Veronica and Bart. What medications are safe for treating veronica's depression? ... Cohen LS etal. J.Clin Psych 1998:59(suppl 2) Some years later ... – PowerPoint PPT presentation

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Title: 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

4
Outline 1
  • Review DSM-IV diagnoses

5
Outline 2
  • Psychiatric illness during pregnancy
  • incidence equal to nonpregnant
  • review medication risks and safety

6
Outline 3
  • Psychiatric illness in the postpartum
  • increased incidence
  • clinical features of
  • bipolar/depression/panic/OCD/psychosis
  • prophylaxis and treatment

7
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.

8
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)

9
DSM-IV
  • Manic episode

10
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

11
DSM-IV
  • Major Depressive Episode

12
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)

13
DSM-IV
  • Hypomanic episode

14
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

15
DSM-IV
  • Panic Attack

16
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.

17
DSM-IV
  • Obsessions

18
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.

19
DSM-IV
  • Compulsions

20
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)

21
DSM-IV
  • Generalized Anxiety Disorder

22
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?

23
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

24
Veronica
  • It turns out that veronica has had two episodes
    of major depression. Will pregnancy increase her
    relapse risk?

25
Relapse risk during pregnancy same as nonpregnant
26
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?

27
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

28
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

29
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
30
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
31
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

32
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

33
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

34
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?

35
Neonatal Risks of Untreated Depression and Anxiety
  • During Pregnancy
  • N500
  • Lower birth weight
  • Preterm delivery
  • Steer RA epidemiology 451093-1099, l992

36
Neonatal risks of untreated depression/anxiety
  • Elevated maternal glucocorticoid levels adversely
    affect fetal brain development
  • Meaney MJ Developmental Neuroscience 1849-72,
    l996

37
Postpartum Psychiatric Morbidity
38
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

39
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?

40
Postpartum depression incidence is
  • 10 to 15 with no prior psych history

41
Postpartum relapse rates are increased
42
Veronica, otra vez
  • Veronica and her boyfriend get very little sleep
    and argue a lot. Does their marital conflict
    increase her risk of depression?

43
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

44
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

45
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

46
Psych Syndromes in the Postpartum Bipolar
  • Manic episodes are particularly difficult to
    control once well established
  • Mania is usually followed by a depression

47
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

48
Psych Syndromes in the PostpartumDepression
  • Frequent variability in the severity of symptoms
  • scary thought about the baby are common
  • Prominent somatic symptoms

49
Psych Syndromes in the PostpartumDepression
  • Feeling overwhelmed about parenting
  • Difficulty sleeping even when the baby sleeps
  • Marked guilt/disbelief in inability to bond

50
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

51
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

52
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

53
Psych syndromes in the postpartum psychosis
  • Postpartum Psychosis most likely a manic episode
    with psychotic features.
  • 1/1000
  • Hospitalize
  • role plays

54
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?

55
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

56
Veronica and Bart
  • What medications are safe for treating veronicas
    depression?

57
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

58
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

60
Breastfeeding and Benzodiazepines
  • Limited data support safety
  • No significant impact on neurobehavioral function
  • Cohen LS etal. J.Clin Psych 199859(suppl 2)

61
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.

62
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

63
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

64
Postpartum Depression Risk Stratification and
Prophylaxis
65
Postpartum Depression Risk Stratification and
Prophylaxis
66
Postpartum Depression Risk Stratification and
Prophylaxis
67
Postpartum Depression Risk Stratification and
Prophylaxis
68
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

69
Resources for Support for the Mother
  • http//www.ppmdsupport.com/
  • Quarterly newsletter
  • 206 283 9278

70
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

72
Did I mention that Im getting a new guitar amp...
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