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POSTPARTUM DEPRESSION BEYOND THE BLUES

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to suicidal ideation. to psychotic depression. DURATION OF SYMPTOMS. Untreated, symptoms can last: ... serious suicidal/homicidal ideation should be referred ... – PowerPoint PPT presentation

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Title: POSTPARTUM DEPRESSION BEYOND THE BLUES


1
POSTPARTUM DEPRESSION BEYOND THE BLUES
  • Debby Carapezza, R.N., M..S.N.
  • Nurse Consultant, Reproductive Health Program
  • Utah Department of Health

2
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

3
DEPRESSION IN WOMEN
  • Women are at increased risk of mood disorders
    during periods of hormonal fluctuation-
  • premenstrual
  • postpartum
  • perimenopausal

4
THE RANGE OF POST-DELIVERY 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

5
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

6
SYMPTOMS OF POSTPARTUM DEPRESSION
7
RANGE OF SYMPTOMS
  • Symptoms range-
  • from mild dysphoria
  • to suicidal ideation
  • to psychotic depression

8
DURATION OF SYMPTOMS
  • Untreated, symptoms can last
  • several months
  • into the second year postpartum

9
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

10
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

11
POSTPARTUM DEPRESSION IN UTAH
  • What can PRAMS data tell us?

12
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

13
  • 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.

14
Higher rates of depression were noted among women
who
15
THE IMPACT OF POSTPARTUM DEPRESSION
16
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

17
LONG TERM CONSEQUENCES OF PMD
  • Babies of mothers with PMD were perceived by
    their mothers as more difficult to care for and
    more bothersome.

18
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

19
RISK FACTORS FOR PMD
20
INTERVENTIONS
  • SCREENING FOR PMD

21
SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A
WOMAN MAY
  • Be unable to recognize she is depressed

22
SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A
WOMAN MAY
  • Believe her symptoms are normal for new moms

23
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 societys
    picture of bliss

24
SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A
WOMAN MAY
  • Feel she is going crazy and fears her baby will
    be taken from her

25
WHEN TO SCREEN FOR PMD
  • At preconception visit
  • During prenatal intake subsequent visits
  • During postpartum exams
  • During infants 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 mothers visits for routine episodic care

26
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

27
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

28
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

29
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

30
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

31
SAMPLE EPDS QUESTIONS (Cont.)
  • 6. Things have been getting on top of me
  • Yes, most of the time I havent been able to cope
    at all
  • Yes, sometimes I havent 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

32
TREATMENT
  • 1. Educate the woman and her support system
    regarding the diagnosis of postpartum
    depression.

33
TREATMENT OPTIONS
  • Pharmacological intervention
  • Counseling, individual and/or group
  • Support groups

34
PHARMACOLOGICAL INTERVENTION
  • Use of tricyclic antidepressants and selective
    serotonin reuptake inhibitors (SSRIs) may be
    indicated for both non-nursing 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

35
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

36
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 clients chart

37
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).

38
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

39
Counseling - Cont.
  • Any woman with symptoms of psychosis or with
    serious suicidal/homicidal ideation should be
    referred for emergency psychiatric evaluation

40
SUPPORT GROUPS
  • Numerous postpartum support groups are available.
    Contact
  • Local mental health agencies
  • Hospitals
  • Websites

41
WEBSITE INFO SUPPORT
  • Depression After Delivery - http//www.depressiona
    fterdelivery.com
  • Postpartum Support International
    -http//www.postpartum.net/
  • The Postpartum Stress Center -http//www.postpartu
    mstress.com/
  • Postpartum Education for Parents
    -http//www.sbpep.org
  • Office on Womens Health -http//www.4women.gov-pr
    egnancy-after the baby is born-PPD

42
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)

43
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
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