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The Reproductive Health Implications of Depression: Postpartum Depression

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Title: The Reproductive Health Implications of Depression: Postpartum Depression


1
The Reproductive Health Implications of
Depression Postpartum Depression
  • Association of Reproductive Health Professionals
  • www.arhp.org

2
Expert Medical Advisory Committee
  • Norma Jo Waxman, MD
  • Ellen Haller, MD
  • Ann Hutton, PhD, APRN
  • Kathy Besinque, PharmD

3
Polling Question A
?
4
Learning Objectives
  • At the end of this session participants should
  • be able to
  • Recognize symptoms, risk factors and
    presentations of depression in women, including
    pre-menstrual and post partum mood disorders.
  • Screen women for depression throughout their
    reproductive years
  • Prescribe medications for depression in women and
    know when to refer

5
Postpartum Depression (PPD)
  • A sad story
  • 35 year old man, named, Moki, is a Japanese
    immigrant, and member of suicide survivors grief
    support group
  • His wife committed suicide two months prior to
    starting group
  • She was four months postpartum with third child
    two older children 5 and 8 years old

6
Question 1
?
  • D. 80 of women who are pregnant and have
    symptoms of depression remain untreated.

7
Significance of Postpartum Depression
  • During postpartum period up to 85 of women
    experience some type of mood disturbance, usually
    transient, baby blues.
  • Depression in postpartum period not distinct from
    major depressive disorders in general

8
Question 2
?
  • B. Symptom resolution within several days to 2
    weeks following birth.

9
Baby Blues
  • Occurs in 70-85 of women
  • Onset within the first few days (4-5 days) after
    delivery
  • Resolves by 2 weeks
  • Symptoms include mild depression, irritability,
    tearfulness, fatigue, anxiety
  • May have increased risk of post-partum major
    depression later on

Beck CT. Am J Nurs. 2006. Hirst KP, Moutier CY.
Am Fam Physician. 2010. Pearlstein T, et al. Am J
Obstet Gynecol. 2009.
10
Question 3
?
  • A. Up to 15 of women are estimated to be
    affected by postpartum depression.

11
Postpartum Depression
  • Similar symptoms but longer duration and more
    severe than baby blues
  • Affects 7 to 15 of women
  • 0.1 to 2 have postpartum psychosis

Beck CT. Am J Nurs. 2006. Hirst KP, Moutier CY.
Am Fam Physician. 2010. Pearlstein T, et al. Am J
Obstet Gynecol. 2009.
12
Postpartum Depression
  • Most frequent in first 4 months following birth
  • Significant impact on both mother and child
  • Under diagnosed, universal screening needed

Beck CT. Am J Nurs. 2006. Hirst KP, Moutier CY.
Am Fam Physician. 2010. Pearlstein T, et al. Am J
Obstet Gynecol. 2009.
13
Question 4
?
  • C. Older age at first birth is not a factor
    associated with increased risk of postpartum
    depression.

14
Risk Factors for Depression Pregnancy and
Postpartum
  • History of prior depressive episodes, family
    history of depression
  • History of childhood abuse, neglect
  • Single parent low SES
  • Absence of emotional, social support
  • Unplanned pregnancy
  • Domestic conflict, violence, abuse

15
Risk Factors for Depression Pregnancy and
Postpartum
  • Susceptibility to hormonal changes, PMS, PMDD
  • Recent loss, death, stressful life events
  • Any infant health problems (ex colic)

16
Postpartum Mood Disorders
Prevalence Onset Duration Treatment
Blues 50-80 1-5 days lt2 weeks Reassurance
Depression 10-15 2wk - 1 year 3-14 mo Medication or psychotherapy
Psychosis 0.1-0.2 2 days to 1 month Variable Medication, hospitalization
17
Polling Question B
?
18
Screening for Depression
  • Inquire about mood history before delivery
  • Alert patient to note mood changes on continuum
  • Severity guides treatment
  • Tools for screening

19
Two Question Screen for Depression
During the past month, have you been bothered by
little interest or pleasure in doing things?
During the past months, have you often been
feeling down, depressed, or hopeless?
Validated screening tool with 97 sensitivity,
67 specificity
Arroll B. BMJ 2003.
20
Edinburgh Postnatal Depression Scale
British Journal of Psychiatry 150782-786
21
Edinburgh Postnatal Depression Scale
  • A 10-item screening tool
  • Woman self-reports how she has been feeling
    during the previous week for a number of affect
    states
  • Maximum score is 30
  • Possible depression score 10
  • Includes item to assess risk of suicide

Cox JL et al. Br J Psychiatry. 1987. Hirst KP,
Moulter CY. Am Fam Physician. 2010.
22
Brief Patient Health Questionnaire (PHQ-9)
MacArthur Initiative on Depression and Primary
Care. 2009
23
PHQ-9
  • 9 Questions based on DSM-IV criteria for major
    depression
  • Scores between 10 and 27 moderate to severe
    depression
  • Used by CNMs to make referrals

24
Assessment of Suicide Risk
  • Screen every patient suspected of depression
  • Asking does not insult patient or initiate
    thought
  • Ask direct questions
  • "Have you had thoughts of hurting yourself?"
  • "Do you sometimes wish your life was over?"
  • "Have you had thoughts of ending your life?"

Hackley et al 2010. MacArthur Initiative on
Depression and Primary Care. 2009
25
Assessment of Suicide Risk
  • If yes, assess immediate risk
  • "Do you feel that way now?
  • "Do you have a plan?"
  • "Do you have the means to carry out your plan?
  • Contracting not to harm has not been shown to be
    a preventive strategy.
  • Call 911 or the police, to have patient
    transported for evaluation (5150) if high risk

Hackley et al 2010. MacArthur Initiative on
Depression and Primary Care. 2009
26
Common Symptoms of Postpartum Depression
Worry about the babys health, well-being and
safety
Intrusive thoughts about harming the baby
Feelings of inadequacy or detachment from infant
Beck CT. Am J Nurs. 2006. Hirst KP, Moutier CY.
Am Fam Physician. 2010. Pearlstein T, et al. Am J
Obstet Gynecol. 2009.
27
Postpartum Depression with Atypical Features
  • Common in young women with depression,
  • Two of the following symptoms
  • Hypersomnia
  • Either increased appetite or weight gain
  • Leaden paralysis
  • Interpersonal rejection sensitivity and
    irritability

28
Comorbidities
  • Anxiety Disorders
  • Eating Disorders
  • Substance related disorders
  • Personality Disorders
  • Avoidant
  • Borderline
  • Histrionic

29
Question 5
?
  • C. Individual or group psychotherapy can
    effectively manage mild to moderate depression.

30
Postpartum Depression Treatment
Include the patient in decision-making
Beck CT. Am J Nurs. 2006. Dennis CL, Hodnett E.
Cochrane Database Syst Rev. 2007. Hirst KP,
Moutier CY. Am Fam Physician. 2010. Pearlstein T,
et al. Am J Obstet Gynecol. 2009.
31
Selective Serotonin Reuptake Inhibitors (SSRIs)
Medication Dose Range Advantages Disadvantages
Citalopram Celexa 20-40 mg Few drug interactions Short half-life
Escitalopram Lexapro 10-30 mg Greater potency Indicated for anxiety No generic yet Short half-life
Fluoxetine Prozac 10-80 mg Long half-life Less frequent symptoms with discontinuation Reduces PTSD symptoms Can be over-stimulating Inhibitor of P450 2D6 and 3A4 Use with caution with elderly patients and those on other meds Higher rates of GI side effects
Paroxetine Paxil 10-50 mg Relieves anxiety Reduces PTSD symptoms Sedation, sweating, wt gain Anticholinergic effects Inhibitor of CYP2D6
Sertraline Zoloft 25-200 mg Indicated for anxiety disorders, PTSD Weak inhibitor of CYP2D6 Diarrhea
Lam RW. J Affect Disord. 2009. Papakostas GI. J
Clin Psychiatry. 2010. The MacArthur Initiative
on Depression and Primary Care. 2009.
32
Serotonin-Norepinephrine Reuptake Inhibitors
(SNRIs)
Medication Dose Range Advantages Disadvantages
Duloxetine Cymbalta 40-60 mg Also indicated for GAD, diabetic neuropathy, fibromyalgia Nausea and vomiting Sexual dysfunction
Venlafaxine Effexor and generic 75-375 mg Relieves anxiety disorders, neuropathic pain, and perimenopausal vasomotor symptoms Higher doses may increase risk of hypertension Drug interactions Sexual dysfunction less common Nausea and vomiting
Desvenlafaxime Pristiq 50-100 mg Relieves anxiety disorders, neuropathic pain, and vasomotor symptoms Can be started without titration at effective dose No generic
Lam RW. J Affect Disord. 2009. Papakostas GI. J
Clin Psychiatry. 2010. The MacArthur Initiative
on Depression and Primary Care. 2009.
33
Additional Classes of Antidepressants
Medication Dose Range Advantages Disadvantages
Mirtazapine (serotonin and norepinephrine antagonist) 15-45 mg Few drug interactions Low rate of sexual dysfunction May stimulate appetite Increased risk of sedation at doses 15 mg Weight gain due to appetite stimulation
Bupropion (norepinephrine/ dopamine reuptake inhibitor- NDRI) Wellbutrin, Zyban 200-450 mg Can be stimulating Low rate of sexual dysfunction May decrease appetite Higher doses can cause seizures Contraindicated for patients with seizures or eating disorders Can increase anxiety or insomnia
Nortriptyline (tricyclic - TCA) 25-100 mg Less likely to cause orthostatic hypotension than other tricyclics Helpful for pain, migraine and insomnia Anticholinergic, cardiac, and hypotensive effects Use cautiously for patients with cardiac conduction disorder
Lam RW. J Affect Disord. 2009. Papakostas GI. J
Clin Psychiatry. 2010. The MacArthur Initiative
on Depression and Primary Care. 2009.
34
Safety Of Drugs Lactation
  • All antidepressants found in breast milk
  • Limited data on newborn impact
  • No findings of effect on growth or development
  • Milk-to-plasma ratio of meds in breast milk
    varies, but usually lt 0.1, decreasing concern
    about harm
  • Sertraline, then Paroxetine, then Nortriptyline
    recommended for the least relative infant dose
    and the most studied
  • Avoid Fluoxetine (Prozac) due to long half life-
    and increased accumulation in the infant

Lanza di Scalea. 2009.
35
Safety of SSRIs
  • May delay developmental milestones
  • Cost-benefit of SSRIs during pregnancy and
    postpartum
  • GlaxoSmithKline paid 2.5 million to settle
    lawsuit relating to Paxil (paroxetine) that
    included birth defects.

36
SSRIs in Treatment
  • Use of standard dosages
  • Start with low dosage and check for response
  • Ex Zoloft (sertraline) 50 mg
  • Some women are rapid responders, others 2 to 4
    weeks, but full remission may take several
    months, and dose may need to be increased
  • May need additional meds for anxiety and sleep

37
SSRIs in Treatment
  • Remain on SSRI 6 to 12 months to avoid relapse
  • Monitoring and tracking with mood diary
  • Refer for evaluation to mental health provider
    for complex cases, comorbid conditions, or
    failure to achieve remission

38
Complementary and Alternative Medicine Therapy
for Depression
  • Commonly used and often not revealed
  • St. Johns Wort for mild-moderate depression
  • Studies conflicting
  • Drug-drug interactions including hormonal
    contraception, SSRIs and Coumadin
  • Most guidelines discourage use
  • Exercise and mindfulness based stress reduction
  • Light therapy for seasonal affective disorder
  • No benefit in RCTs
  • Accupuncture and Omega-3 fatty acids

Ravindran AV, et al. J Affect Disord. 2009.
Cochrane Review, 2009. Freeman, M P et al.
2010. Complementary and alternative medicine in
MDD APA Task Force Report. J Clin Psy 2010.
39
Psychotherapy
  • Psychotherapy is important part of treatment for
    women who have past history of depression,
    developmental abuse, marital conflict, lack of
    support, or comorbid mental health conditions
  • Cognitive Behavior Therapy (CBT), Interpersonal
    Therapy (IPT) and Psychodynamic Therapy are all
    effective and may be cost-effective in
    improving long term outcomes

40
Joan
  • 34 yo, 3 weeks postpartum
  • Moody, irritable, exhausted
  • Seems disconnected from her baby
  • Tearful and difficult to focus during the
  • visit
  • Having a hard time caring for the baby and gave
    up nursing, feels very guilty
  • No local family support, partner works all the
    time
  • Prior history of depression
  • Emergency C-section

41
Joan
  • Treatment
  • Sertraline 50 mg increased to 100 mg
  • Individual psychotherapy
  • Encourage mothers club involvement
  • Follow Up
  • Sertraline reduced irritability, stabilized mood
  • Therapy promoted insight
  • Meeting other new moms gave her support and
    outside of the house activities

42
Question 6
?
  • D. All of the above care consequences of
    depression during pregnancy which can affect the
    infant.

43
Treat Prophylactically for Additional Pregnancies
  • Increased likelihood of PPD after first episode
    of depression
  • Case example
  • first pregnancy, possible baby blues
  • second pregnancy, psychotic depression,
    hallucinated
  • third pregnancy covered with Zoloft prior to
    delivery

44
Hormones and CNS
  • Effect of estrogen and progesterone on affective
    states are probably not linear or dose-dependent
  • Estrogen and progesterone modulate each others
    effects on CNS and that complicates understanding
    of their individual effects

45
Hormones and the Gender Difference
  • Gender difference emerges at puberty
  • Some women more vulnerable, sensitive to estrogen
    precipitous change from birth to 48 hours
  • Women more likely than men to become depressed in
    response to stressful events
  • Sleep deprivation with motherhood may play a role
  • Need for further studies of treatment with
    transdermal estradiol in treatment of PPD

46
Neuroimaging Studies of Women with PPD
  • Dorsomedial prefrontal cortex less active in
    women with PPD than healthy new mothers
  • DMPFC involved in voluntary and automatic control
    and reappraisal of emotional responses in social
    cognition (interpret emotional responses of
    others)
  • Diminished HPA Axis drive DMPC connectivity with
    amygdala

Am J Psych, Sept. 2010
47
SHAPED BY LIFE IN THE WOMB
48
Comment on Perinatal Depression
  • Babies with mothers with untreated depression
    (Perinatal) show neurobehavioral changes, born at
    earlier gestational age, and have elevated stress
    hormones
  • Epigenetic changes and neurobiological models of
    emotion-behavior regulation are implicated
    attention regulation capacities that call on
    brain stem and limbic system networks

49
Improved Outcome with Integrated Care
  • Integrating primary care with mental health
    services has shown to improve overall medical
    care and reduces costs
  • Collaborate with Certified Nurse Midwives and
    others who refer patients with depression and
    other mental health diagnoses
  • Screen using the Patient Health Questionnaire
    (PHQ-9)

50
Provider Resources
  • MacArthur Initiative on Depression in Primary
    Care
  • http//www.depression-primarycare.org/
  • American Psychiatric Association
  • http//www.healthyminds.org/
  • Cox, J.L., Holden, J.M., and Sagovsky, R. 1987.
    Detection of postnatal depression Development of
    the 10-item Edinburgh Postnatal Depression Scale.

51
Provider and Patient Resources
  • National Institute of Mental Health
  • http//www.nimh.nih.gov/health/publications/women-
    and-depression-discovering-hope/index.shtml
  • WomensHealth.gov
  • http//www.womenshealth.gov/faq/depression-pregnan
    cy.cfm
  • Mayo Clinic
  • http//www.mayoclinic.com/health/depression/MH0003
    5

52
Provider and Patient Resources
  • Healthy Place
  • http//www.healthyplace.com/depression/women/depre
    ssion-in-women/menu-id-68/.
  • Massachusetts General Hospital Center for Womens
    Mental Health
  • http//www.womensmentalhealth.org/.
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