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Post Partum Depression

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Title: Post Partum Depression


1
Post Partum Depression
  • Vani Ray, MD
  • Clinical Assistant Professor,
  • Dept. Of.Psychiatry,UW.Madison
  • Chief, Dept. Of Psychiatry , ASMC
  • Director, Consultation Liaison Services
  • Aurora Behavioral Health Services

2
Facts about Perinatal Depression
3
10-15 of women experience depression in the
perinatal period and up to 28 of women living in
poverty.
  • There were 70,934 births in Wisconsin in 2005.
  • That means that (10-15) over 7,000 to 10,000
    women were likely to suffer from prenatal and
    postpartum depression (PPD)

4
  • However, 40 of births were paid for by Medicaid,
    which is a surrogate measure for poverty.
  • 28 of over 27,000 women, over 7,600 women, were
    likely to suffer from prenatal and PPD.
  • What do these numbers mean for your practice?

5
Approximately 50 of women with postpartum
depression are untreated.
6
  • Depression affects how a woman is able to relate
    to others, including her baby.

7
Post Partum Depression
  • What is the post Partum Depression?
  • How is it different from Post partum blues?
  • what is the prevalence of Post partum Depression?
  • What are the risk factors for Post partum
    Depression?
  • Who should Screen Post partum Depression?
  • Who treats Post partum Depression?
  • What is the treatment of Post partum Depression?

8
Post Partum Depression
  • Tracey is a 27 year old mother brought into my
    office as an urgent care appointment. She just
    had a baby 4 weeks ago after much anticipation.
    Her husband is an only child and her in-laws
    filled the nursery with toys and clothes for the
    baby and are very excited.
  • She is unable to sleep and eat, extremely
    doubtful of her ability to do anything.
  • She is preoccupied with the fear that she will
    harm the baby and intense guilt of her inability
    to meet the expectations of the family.
  • She has been thinking that how easy it is kill
    herself than to be this worthless.

9
Post Partum Blues
  • The days and weeks immediately following the
    birth of baby can be an emotional
    roller-coaster. New mothers can experience
    elation, wonder, anxiety, and most have at least
    a touch of the blues.
  • Between 50 and 90 percent of all new mothers
    experience a bout of mild depression right after
    the birth of their babies.
  • It typically lasts 2-10 days some may progress to
    Major depression

10
Why Screen?
  • Screening is an easy, affordable method of
    identifying those women whose symptoms are
    interfering with function in their multiple roles.

11
Screening is effective in identifying depression.
  • You cant tell by looking that someone has
    depression.
  • How many times do you screen?
  • Do you have a system of referral?

12
Post Partum Depression
  • Depressed mood
  • Tearfulness
  • Sleep or appetite disturbances
  • Weight gain or loss
  • Hopelessness
  • Loss of interest pleasure
  • Feelings of being overwhelmed
  • Guilt
  • Anxiety or nervousness
  • Irritability
  • Low energy
  • Loss of concentration
  • Thoughts of harming self or infant

13
Mild Severe
  • Severe Symptoms
  • Thoughts of dying
  • Thoughts of suicide
  • Wanting to flee or get away
  • Being unable to feel love for the baby
  • Thoughts of harming the baby
  • Thoughts of not being able to protect the infant
  • Hopelessness

14
Psychological Factors that influence development
of PPD
  • Emotional stability Attitudes toward
    femininity. Relationship with mother and
    spouse. Cultural attitudes Preparation for
    parenthood Prior mental illness Presence or
    absence of prior children. Social
    support Socio-economic status
  • Life circumstances

15
Risk Factors for Development of Post Partum
Depression
  • During Pregnancy
  • A young and single mother
  • H/O Mental illness or substance abuse
  • Financial or relationship difficulties
  • Previous Pregnancy or postpartum depression
  • After Birth
  • Labor/Birth Complications
  • Low confidence as a parent
  • Problems with Babys Health
  • Lack of supports
  • Major Life change at the same time as birth of
    the baby

16
Role of emotional stress on obstetric outcome
  • Prematurity
  • Low birth weight
  • Increased child morbidity
  • Impaired emotional attachment
  • to fetus and difficulties in
  • mother-infant relationship
  • substance abuse

17
Psychological Changes in Pregnancy
  • Increased anxiety is focused on fetus rather than
    on the person herself.
  • Increased introspection and preoccupation with
    pregnancy with decreased emotional investment in
    the external world.
  • Heightened dependency needs.
  • In some, there is a shift toward primary process
    thinking and increase in primitive defenses.

18
Psycho-neuro-endocrine factors influencing
Depression
  • Gonodal hormones i.e. estrogen, progesterone and
    cortisol undergo rapid changes during pregnancy
    and increase significantly.
  • They regulate neurotransmitter, neuro endocrine,
    and neuro modulatory systems in the central
    nervous system. In turn they influence
    monoaminergic pathways that are implicated in
    pathogenesis .
  • Gonodal hormones also affect diurnal rhythm
    changes crucial in pathogenesis of affective
    disorders.

19
Mood disorders during pregnancy  
  • Diagnosis is difficult, as vegetative symptoms
    are normative for pregnancy
  • Pharmacological interventions pose challenge
    during pregnancy.
  • Psychotherapy is beneficial for mild to moderate
    depression
  • Post partum period is turbulent for patients with
    Bipolar disorder.
  • Treatment is individualized.based on risk vs.
    benefit analysis.

20
Depression Screening
  • Perinatal Visits
  • Labor
  • Post partum checkups
  • immediate and upto one year
  • wellbaby Clinics

21
Who Could Screen?
  • Clinicians service providers who work with
    pregnant postpartum women
  • Advance Practice NursesCNMs, and NPs
  • PhysiciansOB/GYN, Family Practice, Pediatrics
  • NICU staff
  • Public health, hospital, and parish nurses
  • Prenatal care coordinators
  • WIC dietitians
  • Lactation consultants home visitors (PH nurse,
    etc.)
  • Social workers
  • Doulas
  • Others?

22
How to introduce screening
  • One way to introduce screening to the woman is to
    say
  • It is routine for us in this office to check
    with all pregnant women (new moms) about how
    theyre feeling. We like to know a little about
    your emotional health.

23
Depression Screening Tools
  • Center for Epidemiological StudiesDepression
    (CES-D) Scale
  • Edinburgh Postnatal Depression Scale (EPDS)
  • Postpartum Depression Screening Scale (PDSS)
  • Depression Scale in Hmong

24
Edinburgh Post Natal Depression Scale (EPDS)
25
Edinburgh Post Natal Depression Scale (EPDS) -
Guidelines for raters
  • According to Warner, Appleby, Whitton, Faragher
    (1996), postpartum depression affects 10 of new
    mothers, with the range being from eight to 15.
    The Edinburgh Postnatal Depression Scale (EPDS)
    was developed in 1987 to act as a specific
    measurement tool to identify depression in new
    mothers. The scale has since been validated, and
    evidence from a number of research studies has
    confirmed the tool to be both reliable and
    sensitive in detecting depression. Response
    categories are scored 0,1,2, and 3 according to
    increased severity of the symptom. Questions
    3,5,6,7,8,9,10 are reverse scored (ie,
    3,2,1,0) Individual items are totalled to give an
    overall score. A score of 12 indicates the
    likelihood of depression, but not its severity.
    The EPDS Score is designed to assist, not replace
    clinical judgement. Warner, R., Appleby, L.,
    Whitton, A., Faraghen, B. (1996). Demographic
    and obstetric risk factors for postnatal
    psychiatric morbidity. British Journal of
    Psychiatry, 168, 607-611.

26
Two simple questions
  • During the past month, have you often been
    bothered by feeling down, depressed, or hopeless?
  • During the past month, have you often been
    bothered by little interest or pleasure in doing
    things?
  • US Preventive Services Task Force

27
When to Screen
  • The WAPC Pathways for Accessing Treatment
    Support Services for Women Experiencing Prenatal
    and Postpartum Depression recommends screening
    twice during pregnancy and twice postpartum, when
    possible. For example, at
  • First prenatal visit
  • The third trimester
  • The 6-week postpartum visit
  • And one other time during postpartum year
  • Such a frequency would identify most women who
    experience depression during that period.

28
Communicating with women about screening results
  • Based on what youve told me and your score, Im
    concerned that you have some symptoms of
    depression. Its hard to be going through this
    when you are pregnant or when you have a new
    baby. Remember, depression is partly due to an
    imbalance of chemicals in your body and things
    that cause stress in your life. There are things
    to do to feel better. Lets talk about some
    ideas that might work for you.

29
Consequences of Untreated Depression
  • Woman may not seek prenatal care or follow
    through on health care recommendations
  • May be less responsive to infant, resulting in
    delayed development
  • May cause stress in relationships
  • Increased risk for future episodes of depression
  • Increased risk of self injury/suicide
  • Difficulty or failure in job performance

30
Consequences of untreated depression for the
infant
  • Poor weight gain
  • Feeding problems
  • Sleep problems
  • Poor emotional attachment
  • Behavior problems/hyperactivity
  • Depression
  • Mother may be less attentive to hygiene/safety

31
Chronicity, rather than severity of depression
has more long-term effects on infants and
children.
32
Barriers to accessing care
  • Most dont seek treatment
  • Concerned with confidentiality
  • Fear that seeking treatment will affect job,
    relationships
  • Unsure of health coverage
  • Embarrassed or reluctant to talk
  • Myths Personal weakness, tough it out
  • Stigma

33
Postpartum Depression
  • It is important to treat women with symptoms of
    depression during pregnancy
  • The pharmacological treatment during pregnancy
    poses several dilemmas
  • Decision making when to treat them is complex
  • It involves careful consideration of risks versus
    benefits of treatment and education

34
Pharmacological Treatment of Depression
  • All psychotropic medications diffuse readily
    across the placenta.
  • Knowledge of the risks to the fetus of prenatal
    exposure to psychotropic medication is
    incomplete.
  • Little is known about potential of long-term
    behavior abnormalities in children exposed to
    psychotropic medications.
  • To date, the U.S. FDA approves NO psychotropic
    medication for use during pregnancy

35
Facts of Psychotropic drug use in pregnancy
  • Major Birth Defect incidence is 2to 4
  • Cause of 65 to 70 of these is unknown
  • Drug exposure as a cause is not established
  • 50 of pregnancies are unplanned.
  • To limit exposure to either illness or treatment
    which path poses least risk?
  • Category labeling of all the medications.
  • No decision is risk-free.

36
Facts of Psychotropic drug use in pregnancy
  • In humans , fetal brain develops through out the
    gestation and is susceptible to med toxicity even
    after first trimester is complete
  • This is the area of concern about use of CNS
    active drugs during the gestation
  • Behavioral teratogenicity is poorly understood
    aspect of teratology.

37
Facts of Psychotropic drug use in pregnancy
  • Category Description
  • A adequate, well-controlled studies in
    pregnant women have not shown an
    increased risk of fetal abnormalities. B Animal
    studies have revealed no evidence of harm to the
    fetus, however, there are no adequate and
    well-controlled studies in pregnant
    women. or Animal studies have shown an adverse
    effect, but adequate and well- controlled
    studies in pregnant women have failed to
    demonstrate a risk to the fetus. C Animal
    studies have shown an adverse effect and there
    are no adequate and well- controlled studies in
    pregnant women. or No animal studies have
    been conducted and there are no adequate and
    well- controlled studies in pregnant women.
    D Studies, adequate well-controlled or
    observational, in pregnant women have
    demonstrated a risk to the fetus. However,
    the benefits of therapy may outweigh the
    potential risk. X Studies, adequate
    well-controlled or observational, in animals or
    pregnant women have demonstrated positive
    evidence of fetal abnormalities. The use of the
    product is contraindicated in women who are or
    may become pregnant

38
FDA Warning
  • Neonates exposed to SSRIs and SNRIs during the
    late 3rd trimester have demonstrated increased
    complications
  • Prolonged hospitalization
  • Jitteriness, tremor, apnea
  • these symptoms are consistent with either
    toxicity or withdrawal
  • Caution - Neonatal work up

39
Antidepressants
  • Altschuler et al., 1996 TCA (N 437) No
    abnormalities
  • Chambers et al., 1996 TCA SSRI No
    abnormalities
  • Kulin et al., 1998
  • Nulman et al,. 1997
  • Einerson et al., 2001 Effexor No
    abnormalities
  • Ericson et al., 1999 TCASSRI (N 969) No
    abnormalities Sura Alwin et al, N.Engl J
    Med 2007 356 2684-92

40
Antidepressants
  • Nefazadone
  • Mirtazepine
  • Bupropion

41
Antidepressants
  • Tricyclics
  • Most studied are Nortriptylene and Desipramine.
  • SSRIS
  • Most studied. Safe to use.
  • MAOIS
  • Incomplete safety data, not indicated in
    pregnancy.
  • SNRIS
  • Venlafaxine
  • Duloxetine

42
Potential risks to the fetus with prenatal
exposure of psychotropic Medications
  • Teratogenicity (Organ malformations)
  • Neonatal toxicity (Perinatal syndromes)
  • Neonatal withdrawal syndromes.
  • Behavioral Teratology (Postnatal behavioral
    sequelae)

43
Psychological Treatment of Depression
  • Interpersonal Psychotherapy
  • Cognitive Behavioral Psycho therapy
  • Couples therapy
  • Family therapy
  • Post Partum Therapy groups
  • Post Partum Support groups

44
Non Pharmacological Interventions of Depression
  • Exercise
  • Nutritious and Balanced Meals
  • Taking some time for yourself
  • Mobilizing support networks

45
Mental Health Resources for Young Mothers
  • Aurora Behavioral Health Services
  • Aurora Sinai Medical Center
  • Aorora womens Pavillion
  • 414-773-4312
  • www.auroraheallhcare.org/ABHS
  • Perinatal Foundation, Inc.
  • McConnell Hall, 1010 Mound St.
  • Madison, WI 53715
  • aeconway_at_wisc.edu
  • (608) 267-6200 - phone
  • (608) 267-6089 - fax
  • www.perinatalweb.org

46
Depression is treatable and may not resolve
without treatment.
Women do recover.
47
Early identification treatment by primary care
clinicians or mental health specialists are
essential.
  • Those caring for women children from pregnancy
    through the first year of life should be alert to
    the symptoms of perinatal mood disorders.

48
A note about providers who have frequent contact
with women in the postpartum period
  • Women usually have one postpartum obstetrical or
    midwifery visit.
  • Women usually have frequent interactions with
    primary care providers such as pediatricians,
    family physicians, and nurse practitioners in the
    infants first year of life.

49
When to screen?
  • When does your facility screen?
  • Do you collaborate with others to ensure women of
    your community are being screened?
  • What are the best practices of the region?

50
Then what?
  • Anyone who screens women should have a follow-up
    action plan in place.

51
  • Motherhood is not magical for women suffering
    with postpartum depression
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