Maternal Depression 15th Annual CityMatCH Urban Maternal and Child Health Leadership Conference Sept

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Maternal Depression15th Annual CityMatCH Urban
Maternal and Child Health Leadership
ConferenceSeptember 12, 2005

• Diana Cheng, M.D.
• Medical Director, Womens Health
• Maryland Department of Health and Mental Hygiene

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Depression Rates by Gender United States
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Incidence of Depression

• Lifetime - 20 of women (10 of men) will
  experience depression
• Annual - 12 of women (6 men) will experience
  a depressive disorder during a one year period

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Genes vs. Environment
Kessler KS, Prescott CA. Arch Gen Psychiatry.
19995639-44
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Causes of Depression in Women

• Genetics
• Hormones
• Environment

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Depression Across the Female Lifespan
Pregnancy/Postpartum
Premenstrual
Peri-menopause
Birth
Death
Menopause
Menarche
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Depression During Pregnancy
Postpartum Depression
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In Cyzius a woman gave birth with difficult
labor to twin daughters,Sixth day Much wandering
at night no sleep. About the eleventh day she
went out of her mind and then was rational again.

• From Hippocrates Epidemics, fifth century B.C.

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Postpartum Psychosis

• Affects 0.1-0.2 of postpartum women
• Usually begins within first month after delivery
• Bipolar disorder, schizophrenia, unipolar
  depression
• Symptoms
• Agitation, confusion
• Hallucination
• Delusions and thought disorders
• Risk for infanticide 4

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Treatment for Psychosis

• A medical emergency (life-threatening!)
• Medication
• Hospitalization
• Electroconvulsive therapy (ECT)

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Baby Blues

• Affects 70 of postpartum women
• Begins 1-5 days after delivery
• Disappears by 14 days postpartum
• Mild symptoms
• Tearfulness, fatigue, insomnia, irritability,
  poor concentration, sadness, mood changes

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Postpartum Depression

• Affects 10-15 of postpartum women
• Begins 2 weeks 1 year postpartum
• Symptoms
• Strong feelings of depression, irritability,
  anger
• Emotional stress, helplessness
• Inability to do normal everyday tasks
• Appetite changes, sleeping too much/ too little
• Overly intense worries about baby
• Lack of interest or fear of harming baby (as high
  as 40)
• Thoughts of self-harm or suicide

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Psychiatric Hospitalizations for Women During
Perinatal Years
From Kendall RE et al. Br J Psychiatry, 1987
150662-673
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"I was sitting on the kitchen floor, heaving in
sobs, and all I could think was 'This can't
possibly be me.
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I thought I might try to escape or wouldnt be
able to stop myself from swallowing a bottle of
pills. I even thought Id welcome being
kidnapped. I wanted to disappear and retreat so
far. ..I didnt want to be living life with my
child
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Depression During Pregnancy

• Pregnancy is not protective against depression
• Affects 10-15 of pregnant women
• Begins any trimester
• Symptoms
• Strong feelings of depression, irritability,
  anger
• Emotional stress, helplessness
• Loss of interest in activities
• Inability to do normal everyday tasks
• Appetite changes, sleeping too much/ too little
• Thoughts of self-harm or suicide

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Criteria For Major Depression (including
depression during pregnancy and postpartum)

• Symptoms should be present
• most days
• most of the day
• for at least 2 weeks

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DSM-IV Criteria for Depression

• Symptoms present for at least 2 weeks, most of
  the day and nearly everyday
• 1) Depressed mood, and/or
• 2) Loss of interest or pleasure in most
  activities
• Plus 3 or more of the following symptoms

APA.DSM-N Diagnostic and Statistical Manual of
Mental Disorders, 4th ed.1994
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Diagnostic Criteria for Depression(Continued)

• At least 3 more symptoms, nearly everyday for 2
  weeks
• 1) Weight loss or weight gain/change in appetite
• 2) Insomnia or hypersomnia
• 3) Psychomotor agitation or retardation
• 4) Fatigue or loss of energy
• 5) Feelings of worthlessness or excessive guilt
• 6) Diminished concentration or indecisiveness
• 7) Thoughts of death or suicide

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Screening for Maternal DepressionEdinburgh
Postnatal Depression Scale

• Created for postpartum women
• Less emphasis on physical symptoms
• Can also be used during pregnancy
• Rates intensity of depressive symptoms
• 10 questions, each worth 0-3 points
• Score gt12 (out of 30) indicates likely depression
• Takes lt 5 minutes to complete
• Self-administered
• Validated screening tool

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Risk Factors for Maternal Depression

• Prior depression (30)
• Prior postpartum depression (50) or psychosis
  (70)
• Depression during pregnancy
• Prior PMDD (premenstrual dysphoric disorder)
• Family history of depression or bipolar disorder
• ?Younger age, single, high parity, multiple
  gestation
• Recent stressful events
• marital/partner discord, loss of loved one,
  family illness

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Maternal DepressionGetting Help
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Untreated Depression During Pregnancy

• Maternal
• Longer persistence of symptoms
• Increased risk of postpartum depression
• Increased risk of recurrence
• Poor prenatal behaviors
• Infant
• Poor pregnancy outcomes
• Irritable, lethargic, poor sleep, need for
  neonatal care, lower apgars, future behavioral
  development

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Untreated Postpartum Depression

• Maternal
• Longer persistence of symptoms
• Increased risk of recurrence, postpartum and non
• Infant
• Decreased cognitive skills
• Delay in language development
• Poor attention span

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Postpartum DepressionGetting Help
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Treatment for Depression

• Support
• Counseling
• Other treatments
• Medication

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Helping Yourself

• Do not set difficult goals for yourself.
• Do not take on new responsibilities.
• Do what you can when you can.
• Try to be with other people.
• Force yourself to participate in activities.
• Try engaging in mild exercise.
• Eat healthy.
• Avoid tranquilizers and alcohol.
• Do not make major life decisions.
• Get help from a professional.

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Helping the Depressed Person

• Help her get treatment.
• Offer emotional support.
• Invite her for activities.
• Dont expect her to snap out of it.
• Reassure her that things will get better.

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Mood Regulation Neurotransmitters
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Antidepressants - SSRIs

• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Sertraline (Zoloft)
• Citalopram (Celexa)
• Fluvoxamine (Luvox)

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Safety of SSRIs during PregnancyRisk vs. Benefit

• Lack of large prospective randomized studies
• Limited data show no teratogenic effects
• Little data of long-term neurobehavioral effects
• Recent report of neonatal syndrome with SSRIs
• Conflicting reports, other findings
• Need for further studies
• Risk of untreated depression and relapse

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Safety of SSRIs during BreastfeedingRisk vs.
Benefit

• Psychotropic medications secreted in breast milk
• Limited data show no adverse effects on infants
• Little data of long-term effects on offspring
• Undetectable serum levels in infants
• All antidepressants same safety profile
• Need for further studies
• Risk of untreated depression and relapse

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Getting Help Reality vs. Myth

• Myth
• I am an unfit and uncaring mother.

• Reality
• I am a responsible mother and am looking out for
  the welfare of my family and myself.

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Maryland Depression Programs

• Committees
• Maternal Depression
• New Mother Information
• Educational Presentations
• Providers, Organizations, Businesses, Women
• Educational Materials
• Brochures, articles, website, interviews
• Public Awareness
• SaferMaternity.org
• Legislators
• Direct Services

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Data Sources

• Female population
• Depression
• HSCRC
• BRFSS
• Suicides
• Vital records

• Perinatal population
• Depression
• HSCRC
• PRAMS
• Suicides
• Vital Records
• Medical Examiner charts

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PRAMS Survey
In the months after your delivery, would you say
that you were Not depressed at all A little
depressed Moderately depressed Very
depressed Very depressed and had to get help
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Postpartum Depression 2003
Not depressed 78
Depressed 22
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Presentations

• Grand rounds
• Ob/gyn
• Pediatrics
• Family practice
• Medical conferences
• Local health depts
• Annual meetings
• WIC, MCOs, DV, WH

• Daycare providers
• Schools
• Health Fairs
• Womens groups
• Businesses

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Maternal Depression Team

• Maternal Mortality Review
• Maryland State Medical Society (MedChi)
• Provider awareness
• Education
• Screening
• Treatment
• Referral
• Multi-disciplinary

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Maryland Maternal Depression Team

• Maryland State Medical Society
• Maryland Department of Health and Mental Hygiene
• MCH
• Mental Health
• Medicaid
• Maryland Health Partners
• Hospitals
• University of Maryland
• Johns Hopkins
• Sinai Hospital
• Franklin Square Hospital

• Mental Health Assn of MD
• Family Mental Health Fdn
• ACOG
• Friends of the Family
• Baltimore City Health Dept
• Healthy Start
• Amerigroup Corp
• Healthcare Providers
• Obs, Peds, CNMs, Psychs, nurses, SW,

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Maternal Depression Team

• Survey of state practitioners
• Resource library
• Provider Referral list
• Patient and provider education
• Provider toolkit

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Maryland House Bill 844

• Introduced 2004 General Assembly
• Distribute information about postpartum
  depression to new mothers in the hospital
• Not passed

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Educational Materials for New Mothers

• Hospital discharge packets after delivery
• Maryland Hospital Association New Mother
  Information Workgroup
• Established July 2004
• Stakeholders to decide on content
• Maryland Department of Health and Mental Hygiene
  Committee
• Established September 2004

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Maryland Department of Health and Mental
Hygiene November 2004
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Depression in WomenFrom Data to Action
Awareness Education Advocacy Community
groups Access Screening, Treatment, Referral
DATA Depression Suicide
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Maternal Depression
Common disorder Frequently unrecognized Under-t
reated Effective treatments Medication/therapy R
isk vs. benefit of treatment Risk vs benefit of
untreated depression Need for Education and
Awareness