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Perinatal Mood Disorders: Identification, Screening and Overcoming Barriers


Perinatal Mood Disorders: Identification, Screening and Overcoming Barriers February 26, 2008 Jen Perfetti, M.A., L.P.C. Licensed Counselor/Private Practice – PowerPoint PPT presentation

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Title: Perinatal Mood Disorders: Identification, Screening and Overcoming Barriers

Perinatal Mood Disorders Identification,
Screening and Overcoming Barriers February 26,
Jen Perfetti, M.A., L.P.C. Licensed
Counselor/Private Practice
  • Recognize symptoms of postpartum depression and
  • Implementation of a brief screening tool
  • Finding resources treatment and referral options
  • Self-help options for women with mild to moderate
  • Mobilizing treatment resources for women with
    moderate to severe depression
  • Supporting couples in the transition to

Signs, Symptoms Risk Factors
Postpartum Blues
  • Prevalence 50-80 of new mothers
  • Onset Within hours or days of delivery
  • Duration 10-14 days
  • Symptoms emotional lability, anxiety, fatigue,
    insomnia, anger, sadness, irritability
  • Symptoms come and go
  • Considered normal

Postpartum Psychosis
  • Prevalence 1/1000 births (.1)
  • Onset Usually occurs in 1st week following
    birth, sudden onset
  • Symptoms Agitation, racing thoughts, rapid
    speech, severe insomnia, hallucinations,
    paranoia, irrational speech or behavior, threats
    of suicide and infanticide
  • A medical emergency requiring immediate care

Postpartum Depression (PPD)
  • Prevalence 8-15 of new mothers
  • Up to twice as high for women living in poverty
  • Can begin anytime in first year
  • Lasts at least two weeks
  • Anxiety may be central
  • 30-70 may experience the disturbance for one
    year or longer

DSM-IV criteria for Postpartum Depression
  • 5 or more of the following symptoms
  • Depressed mood, often accompanied by severe
  • Markedly diminished interest or pleasure in
  • Appetite disturbance
  • Sleep disturbance
  • Physical agitation or psychomotor slowing
  • Fatigue, decreased energy
  • Feelings of worthlessness or inappropriate guilt
  • Decreased concentration or inability to make
  • Recurrent thoughts of death or suicidal ideation
  • Symptoms present most of the day, nearly every
    day for at least 2 weeks

Moms Report...
  • Overwhelmed
  • Anxious, worried
  • Feeling constantly tired
  • Awake with thoughts running through head
  • Crying often
  • Not enjoying being a mother
  • Feeling disconnected from their baby
  • Feeling like a bad or inadequate mother
  • Anger or extreme irritability toward others

Risk Factors for PPD
  • Symptoms of depression or anxiety during
  • Past depression/mood disorders
  • Family history of depression
  • Perceived negative birth experiences
  • Quality of social support/marital satisfaction
  • Physical health problems in the mother or infant
  • Significant loss or life stress in the last year

Postpartum Depression Anxiety
  • Intense anxiety often prominent feature
  • Can be confusing for woman or providers if only
    looking for depressive symptoms
  • Anxiety, particularly panic and fears/obsessions
    about the care and safety of the baby, may be
    initially reported as more distressing by women
    than depressed mood
  • Matthey et al., 2003

Symptoms of Anxiety
  • Excessive worry
  • Difficulty controlling the worry
  • Restlessness or feeling keyed up
  • Fatigue
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance

Postpartum Onset Anxiety Disorders
  • Panic Disorder
  • Postpartum Obsessive/Compulsive Disorder
  • Posttraumatic Stress Disorder
  • (See Handout)

Impact of PPD on Parenting Infant
Impact of PPD on Parenting
  • Impaired ability to be involved in childs
    physical care and play and to meet childs normal
    needs for attention
  • Difficulty bonding with baby and resulting
    feelings of guilt and inadequacy
  • Anxiety about doing psychological or physical
    harm towards baby (Weissman et al., 1979)
  • Depressed moms show more matching of negative
    behavior states and less matching of positive
    behavior states (Field et al., 1990 Murray,
    Fiori-Cowley, Hooper Cooper, 1996)
  • Depressed mothers hold more negative views of
    their interactions with their infants, and show
    more anger in interactions with their infants
    than non-depressed mothers (Weinberg Tronick,

Bi-Directional Effects in Depressed Mother-Infant
  • Infants imitate a variety of adult facial
    expressions as early as 2 days after birth.
  • Mothers depressed mood may induce a depressed
    state in the infant
  • Infants subsequent distress and unresponsiveness
    are likely to maintain and perhaps increase the
    severity of the mothers depression
  • (Field et al., 1982 Meltzoff Moore, 1977
    Meltzoff, 1990)

Consequences of PPD for Infant Child Behavior
  • Infants of depressed mothers show less interest,
    more anger and sadness and more fussiness than
    infants of non-depressed mothers (Weinberg
    Tronick, 1998)
  • Clinical observations of infants Sober, sad or
    flat affect, regulation difficulties, poor
    attention eye contact, fewer vocalizations, and
    limited exploration of the environment (Clark et
    al., 1994)

Maternal Behavior and Child Regulatory Capacities
at 3-5 Years of Age
  • Intrusive and over-stimulating care by mothers
    with their 6 month-old infants is associated with
    symptoms of attention deficit hyperactivity
    disorder (ADHD) in kindergarten.
  • Insensitive and unresponsive maternal care in
    infancy predicts hostile, aggressive and other
    externalizing behaviors during preschool
  • (Jacobvitz Sroufe, 1987 Lyons-Ruth, Alpern
    Repacholi, 1993 Shaw, et al., 1994)

Factors that May Mitigate Risk to Infants
  • Course/timing of depression Chronicity
  • Mothers degree of sensitivity in parent-child
  • Mothers personality, co-morbid psychopathology
    relationship history
  • Availability of fathers/other caregivers
  • Length of maternity leave
  • Characteristics of the child Temperament
  • (Clark, Hyde, Essex, Klein, 1997 Lyons-Ruth et
    al., 1986 NICHD Early Child Care Research
    Network, 1999 Weinberg Tronick, 1996)

Why Screening is Important
  • Up to 50 of women with postpartum depression are
    missed by primary care physicians when screening
    instruments are not used. (Gale Harlow, 2003
    Steiner, 2002 Cooper Murray, 1998)
  • Why are so many women missed?
  • - Stigma
  • - Minimize symptoms or attribute to average
    demands of being a new mom
  • - Anxiety may be the prominent symptom

Media Attention and Stigma
  • Well publicized tragedies can help raise
    awareness among physicians and health care
  • May lead to an increase in early identification
    and treatment


Media Attention and Stigma
  • Media often does not distinguish psychotic
    features labels all symptoms as postpartum
  • May increase stigma of women suffering from PPD
  • May decrease likelihood of asking for help - fear
    that others will think they would hurt their

Media Attention and Stigma
  • Helpful to have women who are admired in our
    culture disclose PPD
  • Decreases stigma

Home Visitor Opportunities for Screening
  • During pregnancy
  • 1st prenatal visit and/or 3rd trimester
  • 6 weeks 3 months postpartum
  • Most cases of PPD begin within first 3 months
    postpartum (OHara, 1997)
  • Any visit during first year

Methods of Screening for PPD
  • Informal / Unstructured Screening
  • Clinical impressions Is this mother acting
    depressed? How well is this mother functioning?
  • Effective in detecting only the most severe and
    chronic patients
  • (Olson, AL,2002)

Edinburgh Postnatal Depression Scale (EPDS)
(Cox, Holden, Sagovsky, 1987)
  • 10 items, score of 10 or higher indicates
    potential depression
  • Quick to administer and score
  • Free to reproduce Available in English and
  • WAPC (both English and
    Spanish versions)


Edinburgh Postnatal Depression Scale (EPDS) Taken
from the British Journal of Psychiatry June,
1987, Vol. 150 by J.L. Cox, J.M. Holden, R.
Sagovsky Circle the number or each statement,
which best describes how often you felt or
behaved this way in the past 7 days

Discussing Screening Results
  • Your score indicates that you may be depressed.
    How does that fit with what youve been
  • Your score isnt in the range for likely
    clinical depression, but it sounds like youre
    struggling right now. Lets talk about what
    kinds of support would feel helpful.

Formal Treatment Options
Treatments for Women with Postpartum Depression
  • Psychotropic Medication
  • Individual Psychotherapy
  • Group Psychotherapy
  • Mother-Infant/Family Psychotherapy

Psychiatric Evaluation - First Step In All
Treatment Modalities
  • Preferably by mental health professional with
    experience in the evaluation of perinatal mood
  • Purpose
  • Diagnosis PPD? Anxiety? Other comorbid
    conditions that require attention?
  • Safety Assessment Harm to self and/or infant

Use of Medication During Breastfeeding
  • Risks and benefits to the mother and infant must
    be weighed carefully when considering medication
  • There is insufficient long-term data documenting
    the outcomes of infants exposed to
    antidepressants during pregnancy and through
  • No psychotropic medication has been proven to be
    safe for infants who are breastfeeding
  • The importance of capable parenting which is
    compromised by depression and the benefits of
    breast feeding should be weighed in the decision
    making process
  • American Academy of Pediatrics, 2002
  • Wisner, 2002

What You Can Do To Support Moms Babies A Home
Visitors Toolbox
Be Alert for Risk of Depression, Starting in
  • You are in a prime position to observe mom over
  • Start a dialogue about risk and symptoms early to
    engage her in looking with you at the issue
  • Assess mothers risk for developing PPD early in
    pregnancy (focus on previous history of
    mood/anxiety disorder, partner support, life
  • Begin prevention planning together if risk is
    elevated -- put supports in place early

Make the Connection Refer when PPD Suspected
  • Boundaries You are not responsible for managing
    or treating symptoms of PPD, but you can
    facilitate a connection to a mental health
  • Use your relationship with mom as a basis to
    explore problem solve around concerns related
    to seeking help
  • Stigma
  • Depression as sign of weakness
  • Cultural expectations (of mothers of therapy)
  • Fear (losing children, unfamiliarity with
    treatment process, etc)
  • Barriers (cost, transportation, childcare, etc)

Self-Help Options for Moms With Mild to Moderate
1 Promote Self Care
  • God could not be everywhere, therefore he
    created mothers
  • Hebrew proverb
  • Women often focus or feel they should focus far
    more on the care of others than themselves
  • Encourage and give permission to mothers to
    incorporate self-care into their daily routines
    as a means of preventing PPD anxiety, as well
    as coping with it

Realistic Expectations
  • Slow down pace
  • Assess expectations around house, food,
  • Allow time for bonding

Nurture Yourself
  • Take time for yourself
  • Treat your emotional needs with respect
  • Connect with others

  • Use prayer or reflection as a calming time
  • Spiritual community may be a good support

Take Breaks
  • Do something you like to do, not something you
    have to do
  • Schedule brief breaks like at a job refreshes

  • Sleep or rest during day when baby is sleeping
  • Develop a routine to relax before bed

  • Increases feelings of well-being
  • Helps you sleep better
  • Can reduce symptoms of depression
  • Can give you greater control over feelings of

  • Try to increase the number of healthy foods you
    consume each day
  • Watch out for junk food, alcohol, and caffeine
  • Omega 3 fatty acids/DHA

Omega-3 Fatty Acids/DHA
  • Placebo-controlled clinical trial showed
    significant reduction of depression (Stoll et
    al., 1999)
  • Cultures with greater seafood consumption have
    lower rates of depression
  • American women generally reduce or eliminate fish
    during pregnancy and breastfeeding due to concern
    about mercury
  • Recommended amount 2-4 caplets per day (gt650
    mg/day EPA DHA combined gt300 mg/day as DHA)
  • Fish oil is best source - make sure screened for

Activate Circle of Support
  • Moms Groups
  • Dads/Significant Others
  • Family Members
  • Friends
  • Neighbors
  • Co-Workers
  • Faith Communities
  • Assess support/conflict ratio

Connect Mom to Informal Supports for PPD
  • Phone Support in WI
  • Postpartum Adjustment, Support, and Education
    (Warm line) (920-924-8539)
  • Local Support Groups
  • Postpartum Support International (PSI) Wisconsin
    Chapter (
  • Web Based Support Information
  • Postpartum Depression Bulletin Board
  • Depression After Delivery (DAD)

2 Supportive Communication
  • Listening as a skillful, active intervention
  • Understanding must precede action
  • Dont assume mother has others in her life to
    provide this type of emotional support
  • Dont underestimate the healing power of
    supportive listening empathy for both mother
    and infant

3 Support Mother/Infant Relationship
  • Suggest using part of visit to just be with
    baby in one-to-one special time
  • Developmentally appropriate play
  • Soothing activities (massage, cuddling/lullaby)
  • Singing/music
  • Making daily tasks playful
  • Face to face interaction
  • Smiling, even when you dont feel like it
  • When fussy, wonder with mom about what baby is
  • Support/reinforce her positive efforts toward
    reading babys cues providing support
  • (Clark, 2006)

3 Support Mother/Infant Relationship
  • Speak for baby to highlight cues reactions to
    moms efforts
  • Amplify babys initiatives toward mom
  • Model gentle handling responsivity toward baby
  • Non-judgmental developmental guidance
  • Dispel myths about spoiling young babies
  • (Clark, 2006)

Activating Resources for Moms with Moderate to
Severe Depression
Talk Openly About Safety
  • Reassure that you are asking because you want her
    to feel safe secure
  • Matter-of-fact approach
  • Openers
  • Some women who are feeling depressed or
    overwhelmed have thoughts of hurting themselves.
    Do you ever have these kinds of thoughts?
  • How about your baby? Do you worry about his
    safety or that you might hurt him?
  • Tell me more about these thoughts.
  • Normalize that it is difficult to talk about
  • Provide emergency resource information, even if
    not needed now

Safety Assessment - Harm to Infant
  • Nature of thoughts
  • Typical anxious thoughts fear of something
    terrible happening to babyfear of anger when
    tired or overwhelmed
  • Ego-dystonic
  • Ruminations
  • Atypical psychotic thought processes (e.g.,
    command hallucinations, religiosity)
  • History (impulsivity, violence, previous
  • Triggers coping strategies?
  • Who knows? Who can we talk with about helping you
    feel safer?

Safety Planning
  • Contract for safety
  • Involving another person in the home
  • Removal of means
  • Identification of triggers
  • Supervision of mom and/or baby
  • Plan for support/respite
  • Identification of coping strategies
  • Emergency Options 911, ER
  • Talkline 1-800-SUICIDE (National)
  • (Local)

Make the Connection Refer when PPD Suspected
  • Remind Her
  • To be the best mom she can, she needs to take
    care of herself
  • She isnt crazy, weak or to blame. PPD is real,
    affects hundreds of thousands of women and is
    usually a combination of biological factors and
  • Getting outside input or another perspective may
    help her find the best way to take care of
    herself during this difficult time
  • Recognize that in addition to fear about
    treatment, it is difficult to follow through when
    depressed due to symptoms such as fatigue
  • Call to make referral from moms home with her
  • Or get her permission to have provider contact
    her directly
  • Offer to take her to first appointment

Make the Connection Refer When PPD Suspected
  • Urgent/immediate danger ER
  • Active talk of hurting herself or baby
  • Psychosis, bizarre thinking patterns,
    hallucinations, delusions
  • NO sleep at all for several days
  • Emergent Acute/Urgent Care Services
  • Contact family doctor, local mental health crisis
    line, mental health center or hospital for
  • 1-800-SUICIDE- The National Hopeline Network
    Transfers you to a suicide helpline in your
  • 1-800-PPD-MOMS (1-800-773-6667) Crisis line run
    out of Maryland Provides short assessment with
    referral to either a peer counselor or connects
    woman to local crisis center.
  • Standard Outpatient evaluation for psychotherapy
    and/or medication

Make the Connection Refer When PPD Suspected
  • Locating Outpatient Treatment Resources..
  • Around the state
  • WI Maternal-Child Health Hotline
  • 1-800-722-2295
  • Around Dane County
  • UW PPD Treatment Program
  • 608-263-5000

Couples The Transition to Parenthood
Couples and Co-Parenting
  • 33 of all births are to unmarried women (AMP,
  • 85-90 of those babies are born to committed
    couples (McLanahan et al., 2002)
  • 25 of American households consist of a married
    man and woman and their children (Alternatives to
    Marriage Project, 2007)
  • 25 of married parents divorce within 5 years of
    their first childs birth (Cowan, 1992)
  • Over 50 of unwed parents end their relationships
    within 5 years of their childs birth (Cowan,

Relationship Satisfaction
  • Up to 67 of couples experience a significant
    decline in relationship satisfaction following
    birth of first child (Shapiro, Gottman Carrere,
  • Mothers usually experience the decline 4-6 mos.
    postpartum Fathers experience it at the end of
    the first year, continuing through the second

Becoming a Parent
  • Parenting changes family relationships and
    personal goals, roles, and vulnerability
  • Parenting typically connects a couple for life
  • Parenting requires a couple to establish mutual
  • Parenting is not an instinctive skill

Bringing Baby Home Workshop
  • In randomized clinical trial, workshop succeeded
  • Helping couples maintain marital satisfaction
  • Reducing hostility and increasing affection
    during conflict
  • Promoting positive parent-baby interactions
  • Promoting quality father involvement and father
  • Reducing postpartum mood difficulties for both
    parents (Shapiro Gottman, 2005)

Tools to Support Couples in Becoming Parents
Normalize the Transition to Parenthood
  • Profound shift in identity, values, and goals
  • Relationships change
  • Conflict increases
  • Sex declines
  • Conversation and communication declines
  • Bringing Baby Home, 2007

Normalize the Transition to Parenthood
  • Fathers tend to withdraw
  • Society of women
  • Increased provider role, more time at work
  • Unhappy relationship
  • Negative impact on relationship with baby
  • Physical and psychological changes
  • Sleep deprivation
  • Decrease in sex drive for women
  • Mom may be less emotionally available to partner
  • Bringing Baby Home, 2007

Staying in Touch with Each Other and Baby
  • Increase awareness of partners world
  • Day to day events, thoughts, feelings
  • Importance of affection and appreciation
  • Understand babys communication
  • Using face and voice to engage baby
  • Realizing children are on a different time scale
  • Be fully engaged and present
  • Recognize overstimulation
  • Bringing Baby Home, 2007

Help Partners Coordinate Play
  • Support, dont compete
  • Allow your partner to have their own ways of
    being with the baby
  • Choose activities you can do together with baby
  • Sit at equal distance from baby
  • Equal attention and involvement in game
  • Bringing Baby Home, 2007

The Importance of Touch
  • We are a low-touch culture
  • Jourard, 1966 - 1 hour conversation in coffee
    shops - Puerto Rico - 180x Paris - 110x Florida
    - 2x
  • Field, 1999 - teenagers in McDonalds - teens in
    Paris touched 60x more than US teens
  • Children raised in low-touch homes are usually
    more insecure, clingy and distressed
  • Responding to babys needs helps them to become
    secure, self-confident, and comfortable in their
  • 66 of all babies in the world sleep with their
    parents In 2/3 of 136 societies mother and baby
    sleep together until baby is weaned (Heller,
  • 15 min. of massage per day has been shown to
    reduce symptoms of depression (Field, 2002)
  • Bringing Baby Home, 2007

Effects of a Distressed Relationship on Children
  • Parents have more difficulty coordinating with
    each other
  • Parent-child interactions are more negative
  • Infants withdraw more from their fathers
  • Child is more at-risk for developing mental
    health or behavioral problems
  • Children do less well at school
  • Children are less physically healthy and sick
    more often
  • Gottman study of 3-4 yr. old children and
    parental conflict - Urine sample (cortisol) vs.
    marital satisfaction questionnaire
  • Bringing Baby Home, 2007

How To Avoid Fighting in Front of Children
  • Set a problem solving time with partner
  • Dont discuss issues that might upset you in
    front of the kids
  • Dont discuss problems during mealtimes
  • If argument does happen, resolve with physical
    hug and kiss in front of child
  • Bringing Baby Home, 2007

The Importance of Fathers
  • Play - Moms play more visual games and are
    largely verbal/Dads are more physical, tactile,
    encourage exploration and adventure
  • Dads emotional involvement and style of play
  • Better self-control abilities
  • Peer social acceptance in school
  • Social competence/emotional IQ
  • Higher verbal test scores
  • Better academic performance
  • Increased empathy as adults
  • Bringing Baby Home, 2007

The Importance of Fathers
  • Stanford study of 300 families when kids were 5
    yrs. Old
  • Followed up 26 yrs. later - best predictor of
    adult empathy was dads involvement in child
  • Followed up again at 41 yrs. of age - increased
    warmth from dads predicted better social
    relationships mid-life (marital, kids, community)
  • Women are happier with their relationships and
    their own parenting when dads are involved
  • Bringing Baby Home, 2007

Take Home Messages
  • You may be the most frequent and regular contact
    with both mom and baby
  • Depression can impact all aspects of moms life,
    her relationship with her baby, and her babys
  • You are key to screening and early identification
  • You can help mobilize resources for treatment and
    increase self-care
  • Your intervention can support the whole