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Perinatal Mood and Anxiety Disorders

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Title: Psychiatric Disorders and Medications During Pregnancy and the Postpartum Period Author: Cort A. Pedersen Last modified by: Myra Created Date – PowerPoint PPT presentation

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Title: Perinatal Mood and Anxiety Disorders


1
Perinatal Mood and Anxiety Disorders
  • Cort A. Pedersen, M.D.
  • UNC Department of Psychiatry

2
Prevalence of Perinatal Depressive and Anxiety
Disorders
  • Depression approximately 14 within the first
    2-3 months postpartum (similar rate during
    pregnancy). Half meet DSM-IV criteria, half RDC
    criteria.
  • Anxiety At least 14 in postpartum period
    combining panic disorder, OCD and generalized
    anxiety disorder.
  • By far, the most common serious medical
    complications of the perinatal period.

3
Obstacles to Recognition and Treatment of
Perinatal Mood/Anxiety Disorders
  • High expectations of joy happiness with new
    baby cognitive dissonance if dysphoric symptoms
    arise.
  • Attribution of dysphoria to stress, not assessing
    hallmark symptoms.
  • Self blame.
  • Lack of knowledge about mood and anxiety
    disorders. Critical role of antenatal education.

4
Common Dysphoric Emotional Experiences in New
Mothers
  • Mood lability-blues and euphoria.
  • Often unanticipated and sometimes overwhelming
    stress of newborn care loss of control of ones
    time, feeling trapped, Why did I do this?
  • Heightened anxiety due to hyper-vigilance about
    the babys welfare.
  • Delayed feelings of love for the baby.

5
Diagnosing Perinatal Depression Hallmark
Psychological Symptoms
  • Depressive mood, sadness, tearfulness.
  • Diminished interest or pleasure in most
    activities (especially in taking care of the
    baby).
  • Feelings of worthlessness or inappropriate guilt
    (especially about being an inadequate mother).
  • Recurrent thoughts of death or suicide.
  • Edinburgh Postnatal Depression Scale Cox et al.,
    1987, Br J Psychiatry 150 782-6.

6
Ambiguous Symptoms (often due to perinatal
physiological changes, demands of newborn, not
depression)
  • Changes in appetite or weight
  • Sleep disruption (however, persistent inability
    to sleep when the baby is asleep is a common
    symptom in postpartum depression).
  • Persistent fatigue.
  • Psychomotor retardation or agitation.
  • Diminished subjective perception of ability to
    think or concentrate.

7
Biological Risk Factors for Postpartum Depression
  • History of postpartum depression (up to 50
    risk).
  • History of depression not associated with
    pregnancy (up to 25 risk).
  • Depressive symptoms during pregnancy.
  • Family history of depression.
  • History of premenstrual dysphoric disorder.
  • Postpartum blues.

8
Do hormones play a role?
  • Progesterone and estrogen levels drop
    precipitously postpartum. Cortisol, thyroid and
    other large hormonal shifts also occur .
  • However, hormone levels and changes in levels do
    not correlate with mood symptoms.
  • But recent research indicates that women who get
    peripartum depression are more sensitive to
    hormone fluctuations (Bloch et al., 2000 Am J
    Psychiatry 157 924-930).

9
Psychosocial Risk Factors for Perinatal Depression
  • Lack of social support.
  • Poor relationship with the father of the baby.
  • Stressful life events.
  • Primiparity.
  • Adolescence.
  • Postpartum Depression Predictors Inventory-Beck,
    1998, JOGNN 27 39-46.

10
Postpartum Anxiety Disorders Clinical
Characteristics
  • Panic disorder
  • Intense fear of harm/harming baby.
  • Palpitations, hyperventilation, sweating,etc
  • Difficulty caring for, leaving baby.
  • OCD
  • Intrusive thoughts/images of grievous harm
    to baby.
  • Mother sometimes imagines herself inflicting
    harm.

11
Effects of Pregnancy on the Natural Course of
Anxiety Disorders
  • Panic disorder
  • Increased risk of recurrence or
    intensification postpartum.
  • Obsessive compulsive disorder
  • Many women with OCD (perhaps around 40) have
    initial onset of symptoms during pregnancy or the
    postpartum period.

12
Perinatal Depression and Anxiety Treatment and
Prophylaxis
  • Stress reduction.
  • Support groups.
  • Psychotherapy interpersonal, cognitive-behavioral
    , supportive. OHara et al., 2000, Arch Gen
    Psychiatry 57 1039-1045.
  • Medication usual txs are generally very
    effective. SSRIs best for prophylaxis.
  • Estrogen?
  • Light therapy

13
Pre Postpartum Prevalence of Psychiatric
Admissions among Women
14
Postpartum Psychosis Clinical Characteristics
  • Incidence 1-2/1000, first few postnatal weeks.
  • 90 are psychotic mood disorders.
  • Mood symptoms depression, mania, mixed, cycling.
    Suicidal impulses.
  • Psychotic symptoms hallucinations, delusions,
    thought disorder. Delusion-based
    homicidal/infanticidal impulses.
  • Symptoms of delirium often present disturbances
    of consciousness, attention, cognition,
    perception, fluctuation of symptoms.

15
Risk Factors for Postpartum Psychosis
  • History of bipolar or schizoaffective disorder
    risk increases with number of prior episodes and
    prominence of psychotic symptoms (perhaps up to a
    50 risk).
  • History of postpartum psychosis (50-75 risk).

16
Management and Treatment of Postpartum Psychosis
  • Management
  • Hospitalize immediately (psychiatric
    emergency!)
  • Constant, close observation
  • Supervise visits with baby
  • Treatment
  • Mood stabilizers (lithium, valproic acid)
  • Antipsychotics
  • Antidepressants (if primarily depressed)
  • Benzodiazepines (agitation)
  • ECT



17
Postpartum Psychosis Prophylaxis
  • Medication
  • Start mood stabilizers immediately postpartum
    or even late in pregnancy. Estrogen?
  • General
  • Social support/help network in place.
  • Patient/family education about symptoms.
  • Plan of action if symptoms develop.

18
Assessing the Safety of Psychotropic Medications
in Pregnancy/Lactation
  • Prospective, double blind studies drug trials are
    unethical. Therefore, we are dependent on
    information from case reports, retrospective
    chart reviews, animal toxicology studies.
  • Best summaries to date of this body of evidence
    Wisner et al., (2002) NEJM 347 194-199 Newport
    et al. (2004) The APA Textbook of
    Psychopharmacology, 3rd Edition

19
Assessing the Safety of Psychotropic Medications
in Pregnancy/Lactation-cont
  • A considerable body of evidence accumulated over
    the last 2 decades indicates that fetal/newborn
    exposure to most classes of psychotropic
    medication is relatively safe even during the
    first trimester.
  • Mounting evidence that stress during pregnancy,
    including the stress of untreated severe
    psychiatric illness, has adverse effects on fetal
    development.

20
Potential Risks of Treatment with Psychiatric
Medications
  • Malformations.
  • Behavioral teratogenicity.
  • Drug effects on the newborn- toxicity,
    withdrawal.
  • Blood volume changes Drug levels shift into the
    sub-therapeutic range during pregnancy or toxic
    range postpartum.

21
Potential Risks of Not Treating With Psychiatric
Medications
  • Depression, other untreated psychiatric disorders
    during pregnancy are associated with poor
    obstetric outcomes.
  • In utero stress retards fetal growth, may disrupt
    normal behavioral development.
  • Children of mentally ill mothers have more
    medical, psychological, and cognitive problems.
  • Increased risk of recurrence and treatment
    resistance of illness.

22
Antidepressants in Pregnancy and Lactation
  • SSRIs relatively safe even during 1st trimester
    except paroxetine (increases birth defect rates).
    Worrisome recent reports that exposure during
    late pregnancy more than doubles prevalence of
    pulmonary hypertension in newborns.
  • SSRIs (especially sertraline, citalopram,
    paroxetine) and TCAs (especially nortriptyline)
    relatively safe in breast-feeding. Fluoxetine
    accumulation, TCA-induced seizures. Venlafaxine
    accumulates in milk. Insufficient information
    about newer antidepressants, trazodone.
  • Bupropion FDA risk category B.
  • MAOIs associated with growth retardation,
    congenital malformations.

23
Mood Stabilizers in Pregnancy and Lactation
  • Lithium First trimester exposure-0.1 risk of
    Ebsteins anomaly (10-20 x RR). Safer 2nd and 3rd
    trimesters . Increases birth weight. Newborn
    hypotonicity, arrhythmias, hypothyroidism, DI.
    Contraindicated during nursing.
  • Anticonvulsants First trimester exposure-higher
    rates of miscarriage, birth defects (NTD,
    orofacial clefts), IUGR, neonate toxicity,
    cognitive impairment with VLP CBZ (VLP gt CBZ)
    but not with LTG (smaller database). Some
    evidence oxcarbazepine safer than VLP.
    Nursing-very low VLP, CBZ breast milk
    concentrations. LTG?

24
Anxiolytics During Pregnancy/Lactation
  • Diazepam, other benzos initial reports that 1st
    trimester exposure to diazepam, other benzos
    increase risk of oral clefts not substantiated.
  • Clonazepam lowest teratogenicity of all benzos
    in animal studies. No clear teratogenicity when
    used in pregnant epileptics. Lorazepam safe
    track record. Limited milk penetration.
    Low-medium doses considered reasonably safe.
  • Risks infant sedation, hypotonicity, postnatal
    withdrawal.
  • Alprazolam some evidence that exposure may
    increase oral cleft risk 12 times (0.06 to
    0.7).
  • Buspirone?

25
Antipsychotics in Pregnancy/Lactation
  • Phenothiazines 1st trimester exposure may
    increase malformation rate from 2.0 to 2.4.
    Aliphatic gt piperazine, piperidine. Haloperidol
    relatively safe.
  • Infant toxicity EPS, bowel obstruction (rare).
  • Atypicals malformation, IUGR rates appear WNLs.
    Metabolic, neurodevelopmental effects, neonate
    toxicity, breast milk concentrations unknown.
  • EPS treatments Diphenhydramine is probably
    safest although birth defects rate somewhat
    higher with 1st trimester exposure increased
    malformation rate with benztropine,
    trihexyphenidyl, and especially amantadine.
    Propranolol is reasonably safe.

26
Psychotropics in Pregnancy/Lactation General
Considerations
  • Explain risks and benefits of medication and
    non-medication treatment approaches, respect the
    mothers wishes, document decision-making.
  • Dont use medication unless truly necessary,
    especially during the first trimester.
  • Dose medications to adequately treat disorders
    (i.e., dont under-medicate to decrease drug
    exposure).

27
Psychotropics in Pregnancy/Lactation General
Considerations-cont.
  • Adjust doses of some medications (mood
    stabilizers, antidepressants) to compensate for
    changes in blood volume as pregnancy advances and
    postpartum.
  • Consider tapering dose or stopping some
    medications pre-partum to diminish drug effects
    on the newborn, especially if there are obstetric
    complications.

28
Guidelines for Treatment of Major Depression
During Pregnancy/Lactation
  • SSRIs (fluoxetine, sertraline) or secondary amine
    tricyclic antidepressants (desipramine,
    nortriptyline) during pregnancy or lactation.
    Buproprion is probably reasonably safe.
  • Monitor TCA blood levels increase dose as
    necessary as pregnancy advances, cut back dose at
    parturition.

29
Guidelines for Treatment of Mania During
Pregnancy/Lactation
  • First trimester Haloperidol for psychosis,
    clonazepam for agitation if mood stabilizer is
    necessary, lithium may be first choice. ECT.
  • Second/Third trimester/Postpartum Lithium or
    anticonvulsants, haloperidol and/or clonazepam if
    truly needed. Continue treatment postpartum if no
    obstetric complications. Follow breast-fed
    infants closely.

30
Guidelines for Treatment of Mania During
Pregnancy/Lactation-cont
  • Monitor blood levels of mood stabilizers as
    pregnancy advances and increase doses to maintain
    effective concentrations.
  • At parturition, decrease doses of mood
    stabilizers by approximately one third to prevent
    levels from rising into the toxic range.

31
Guidelines for Treatment of Anxiety Disorders
During Pregnancy/Lactation
  • Panic Disorder SSRIs or secondary amine TCAs.
    Clonazepam if a benzodiazepine is necessary.
  • Obsessive-Compulsive Disorder SSRIs or
    clomipramine if SSRIs are ineffective (risk of
    hypotension during pregnancy, infant seizures).

32
Guidelines for Treatment of Psychosis During
Pregnancy/Lactation
  • Haloperidol would generally be the first choice
    although phenothiazines probably increase risk
    minimally.
  • First choice for controlling EPS is
    diphenhydramine. Try to avoid during first
    trimester.

33
Managing Pregnancy in Women Who Require Chronic
Psychotropic Medication
  • Emphasize the importance of birth control and
    planning pregnancies.
  • Stop meds during 1st trimester, if feasible.
  • Plan A If possible, taper and stop medication
    prior to attempts to conceive, e.g. at the
    beginning of a menstrual cycle.
  • Plan B Detect pregnancy as early as possible (2
    wks with OTC pregnancy tests), then taper/stop
    medication.

34
Managing Pregnancy in Women Who Require Chronic
Psychotropics-cont
  • If stability requires 1st trimester medication,
    consider switching to a less risky medication
    that could reasonably prevent relapse (e.g., from
    anticonvulsant to lithium or haloperidol).
  • If a mood stabilizer or lithium is necessary
    during the 1st trimester, discuss ultrasound
    examination of the fetus at 16-18 wks of
    pregnancy and how malformations might be handled
    (abortion?) before conception.

35
Managing Pregnancy in Women Who Require Chronic
Psychotropics-cont
  • To diminish the period off of or on less than
    optimal medication, resuming most psychotropics
    after the 1st trimester (lithium, some
    anticonvulsants?) is reasonably safe.
  • Risk of postpartum relapse in women with history
    of recurrent mood disorders is diminished by
    resuming medication immediately postpartum or
    even shortly prepartum.
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