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Postpartum Depression

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Highest concentrations found in 'hind' milk 8 hours after maternal dose. ... Greatest in hind milk. No detectable concentrations of paroxetine found in infant sera ... – PowerPoint PPT presentation

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Title: Postpartum Depression


1
Postpartum Depression
Postpartum Depression
  • Lucy J. Puryear, M.D.
  • Private Practice Houston, Texas
  • Clinical Assistant Professor of Psychiatry
  • Baylor College of Medicine

Lucy J. Puryear, M.D. Private Practice Clinical
Assistant Professor of Psychiatry Baylor College
of Medicine
2
Depression in Women
  • Occurs twice as often in women as in men
  • Lifetime prevalence of 21.3 compared to 12.7 in
    men
  • Factors may include
  • psychosocial events
  • brain structure and function
  • hormonal factors

(Kessler et al, 1993)
3
Age at First Onset of Major Depression
U.S. ECA
Females Males
4.0
3.5
3.0
2.5
Rate Per 100
2.0
1.5
1.0
0.5
0.0
0-14
15-24
25-34
35-44
45-54
55-64
Age at First Onset (Years)
Weissman et al. JAMA. 1996276-293 (Epidemiologic
Catchment Area Study, N18,000)
4
Hypothalamic-Pituitary-Ovarian Axis
NE DA
5-HT
Hypothalamus
GNRH
(-)
Pituitary
(-)
(-)
LH FSH
Progesterone
Estrogen
5
Estrogen and Serotonin
  • Increases the rate of degradation of MAO1
  • Displaces tryptophan from plasma albumin binding
    sites2
  • Increase in the density of 5-HT2A binding sites
    in the CNS3
  • Increase in tritiated imipramine binding sites4
  • Increase in serotonin transport

1Luine, 1977 2Aylward, 1973 3Fink, 1996
4Sherwin, 1990
6
Psychiatric Hospitalizations for Women During
Postpartum Years
60
All Admissions Admissions Per Month
50
40
30
20
10
1 Year
-1 Year
-2 Years
Childbirth
2 Years
Psychosis Admissions Admissions Per Month
50
40
30
20
10
1 Year
-1 Year
2 Years
-2 Years
Childbirth
  • Kendell RE et al. Br J Psychiatry.
    1987150662-673

7
(No Transcript)
8
Baby Blues
  • Occurs in 80 of deliveries
  • Symptom onset day 3 postpartum
  • Remits by 2 weeks
  • Tearfulness, mood lability
  • Likely to be response to rapid change in hormone
    levels

9
Postpartum Depression
  • Occurs in every one out of ten women postpartum
  • Greater than 60 have symptom onset within 6
    weeks
  • DSM IV requires symptom onset within 4 weeks
  • May not present until several months after
    delivery when symptoms are severe

10
Risk factors
  • Previous episode of depression
  • Severe PMS
  • Depression during pregnancy, particularly third
    trimester
  • Prior episode of PPD 50-70 risk of recurrence
  • Family history of depression
  • Family history of bipolar disorder
  • Poor marital support

11
Postpartum Depression
  • Pregnant women have the same risk of depression
    as other non-pregnant women
  • During the first month postpartum, childbearing
    women have a 3x greater risk for depression
    compared to nonchildbearing women

Cox JL et al. Br J Psychiatry. 199316327-31
12
Key Signs and Symptoms
  • SLEEP DISTURBANCE may be hallmark of illness
  • Ruminations about infant
  • Mood swings
  • Loss of appetite
  • Anxiety out of proportion to event
  • GUILT

13
Are you able to sleep when the baby is sleeping?
Are you able to sleep when the baby is
sleeping?
14
Risk factors
  • Previous episode of depression
  • Severe PMS
  • Depression during pregnancy, particularly third
    trimester
  • Prior episode of PPD 50-70 risk of recurrence
  • Family history of depression
  • Family history of bipolar disorder
  • Poor marital support

15
Treatment
16
Acute Interventions
  • Mother MUST get uninterrupted sleep
  • Recruit ANYONE to help mother, in-laws,
    neighbors, sisters, church members
  • If breastfeeding allow someone else to feed
    infant at night with expressed breast milk or
    formula
  • Consider discontinuing breastfeeding

17
Non-Pharmacologic Interventions
  • Support groups
  • Interpersonal Psychotherapy dealing with loss
    and role change
  • Light therapy

18
Pharmacologic Treatment
19
Tricyclic Antidepressants
  • No adverse reports in infants
  • Respiratory distress in one infant exposed to
    doxepin (Sinequan)
  • Minimal levels of parent compound and metabolite
    found in infant serum
  • Nortriptyline has a therapeutic window

20
Sertraline and Breastfeeding
  • Sertraline and desmethysertraline present in
    breast milk, below the detection of most
    commercial laboratories
  • Highest concentrations found in hind milk 8
    hours after maternal dose.
  • Increasing dose increased breast milk
    concentration
  • No adverse effects on infant noted

(Stowe et al, 1997)
21
Paroxetine and Breastfeeding
  • Breast milk and mother and infant sera collected
    in 16 mother/infant pairs
  • Paroxetine doses of 10-50 mg/day
  • Present in all breast milk samples
  • Greatest in hind milk
  • No detectable concentrations of paroxetine found
    in infant sera

Stowe et al. Am J Psychiatry, 2000
22
Weight Gain in Fluoxetine Breastfed Infants
  • Retrospective cohort study
  • 64 women took fluoxetine during pregnancy
  • 26 of these women breastfed on fluoxetine
  • 38 breastfed off of medication
  • Infants exposed during breastfeeding had a
    statistically significant deficit in weight (avg.
    392 g)
  • No abnormal behavior noted

(Chambers et al. Pediatrics 1999)
23
Third Trimester Prophylaxis
24
Neonatal SSRI Withdrawal?
  • Studies not well controlled for maternal
    depression
  • Unclear whether SSRI alone or combined
    pharmacotherapy
  • Recommendations do not take into account maternal
    need for psychiatric medication

25
Fluoxetine and Neurodevelopment
  • 80 children TCA exposure, 55 Fluoxetine, 84
    controls
  • Children age range of 16 to 86 months
  • No difference in IQ scores or language
    development
  • No differences noted between first trimester
    exposure only Vs. entire pregnancy

(NEJM, 1997)
26
Third Trimester Exposure to Paroxetine
  • Comparing 27 women with 1st and 2nd trimester
    exposure to paroxetine and 27 with
    non-teratogenic exposure to 55 women with 3rd
    trimester exposure
  • 12 with complications 9 respiratory distress, 2
    hypoglycemia, 1 jaundice
  • Compared to 3 in comparison group

Arch Pediatr Adolesc Med, Nov 2002
27
Symptoms of Neonatal Withdrawal?
  • Mild respiratory distress
  • Hypotonia
  • Tremulousness
  • Excessive crying
  • Diminished pain response
  • Hypertonia

28
Neonatal Complications
  • 17 infants with neonatal complications
  • Admission to special care nursery brief
  • n11
  • All but two infants went home with mother
  • TTN, infant jittery, infant pale, lethargy,
    meconium, grunting

(Cohen et al., Biol Psychiatry 2000)
29
Consider Effects of Untreated Maternal Depression
  • Negative and disengaged parenting behaviors
  • Children more likely to experience psychiatric
    illness
  • Greater risk of insecure infant attachment
  • Higher serum cortisol levels in child correlating
    with severity of maternal depression
  • EEG changes in frontal lobe correlating with
    behavioral problems
  • Untreated maternal depression during pregnancy
    higher cortisol levels at 6 mos. of age
  • Alterations in Hypothalamic-Pituitary-Adrenal Axis

Newport et al. Am J Psychiatry 2002
30
Impact of Maternal Depression
  • Cohort of 160 infants of depressed mothers and
    160 infants of healthy mothers
  • Infants and mothers assessed at 2, 6, and 12
    months
  • Infants of depressed mothers showed significant
    growth retardation at all time intervals
  • RR for 5 or more diarheal episodes 2.4 (1.7-3.3)

Rahman A, et al, Arch Gen Psych, 2004
31
Postpartum OCD 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, must
    directly ask
  • Afraid to be alone with the baby

32
Treatment
  • Antidepressants must be given at OCD dose
  • Fluoxetine 40 to 80 mg
  • Sertraline 150 to 200 mg
  • Paroxetine 40 to 60 mg
  • Cognitive-behavioral therapy
  • Support groups
  • Social support

33
Postpartum Psychosis A Psychiatric Emergency
34
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35
Postpartum Psychosis
  • Occurs in 0.1 of deliveries
  • 50 of women will later be diagnosed with bipolar
    disorder
  • Recurrence rate extremely high with more severe
    episodes common
  • Onset fairly rapid, within 3 days to one week

36
Postpartum Psychosis
  • Typical symptoms revolve around the infant.
  • Aggitation and anxiety, disorganized behavior.
  • Delusion about the infant.
  • Altruistic infanticide.

37
Prevention
  • Prophylactic antidepressants
  • Omega-3 fatty acids (fish oil)
  • Interpersonal psychotherapy
  • Close psychiatric follow-up during subsequent
    pregnancies

38
Practice Management
  • Identify women at risk
  • Psychiatric referral prior to delivery
  • Follow-up by phone two weeks after delivery
  • Postpartum depression brochure in take home
    packet with numbers to call
  • Consider Edinburgh scale at six week visit

39
Yates Children Memorial Fund of the Mental Health
Association of Houston
  • Focus on education, research, referrals, and fund
    raising
  • Hope to have postpartum depression handout in the
    hands of every woman delivering a baby in the
    greater Houston area

40
HOUSE BILL 341
  • September 1, 2003

41
House Bill 341
  • A hospital, birthing center, physician, nurse
    midwife, or midwife who
  • Provides gestational care or care at delivery
    must
  • Provide a resource list
  • Doccument in patients record
  • Retain doccumentation for three years

42
Summary
  • Postpartum illness is under recognized and under
    treated
  • Not treating causes harm to both mother and her
    baby
  • Every woman after delivery should be screened for
    symptoms of postpartum psychiatric disorders

43
(No Transcript)
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