MARISA ECHENIQUE, PSY.D. ASSISTANT PROFESSOR DEPARTMENT OF PSYCHIATRY UNIVERSITY OF MIAMI MILLER...

MARISA ECHENIQUE, PSY.D. ASSISTANT PROFESSOR

DEPARTMENT OF PSYCHIATRYUNIVERSITY OF MIAMI

MILLER SCHOOL OF MEDICINE

Maternal Mental Health and Post Partum

Continuing Education Disclosure

The activity planners and speakers do not have any financial relationships with commercial entities to disclose.

The speakers will not discuss any off-label use or investigational product during the program.

This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.

Session Objectives

Upon completion of this program, participants will be

able to: Define maternal mental illness Identify signs and symptoms of maternal mental illness Define post partum depression Identify signs and symptoms of post partum depression Identify effective treatment options in maternal mental

health Discuss strategies to decrease mental health stigma,

increase comfort level to discuss mental illness and increase the ability of healthcare providers to provide culturally sensitive care

Maternal Mental Health

The World Health Organization defines maternal mental health as:

‘‘a state of wellbeing in which a mother realizes her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to her community’’

Maternal Mental Illness

In the year 2000, 205,000 women aged 18 to 44 years were discharged with a diagnosis of depression

7% of all hospitalizations among young women were for depression

The peak period for onset of depression occurs during the childbearing years and its impact extends to the offspring of afflicted women as well as their families


Given that depression is a mood disorder that affects 1 in 4 women at some point during their lifetime, it should be no surprise that this illness can also touch women who are pregnant

But all too often, depression is not diagnosed properly during pregnancy because people think it is just another type of hormonal imbalance

Pregnancy is supposed to be one of the happiest times of a woman’s life, but for many women this is a time of confusion, fear, stress, and even depression

According to The American Congress of Obstetricians and Gynecologists (ACOG), between 14-23% of women will struggle with some symptoms of depression during pregnancy

Mental Illness in Pregnancy

Pregnancy and the postnatal period are critical times of psychological adjustment for women, and there is increasing evidence that a woman’s mental state during this time influences both obstetric outcomes and the future development of the infant, affect other children in the family, as well as the woman’s partner and their relationship

Severe mental illness, such as psychosis, bipolar disorder or severe depression, may be particularly detrimental, both during pregnancy and subsequently, given the dependence of an infant on its mother and the rapid adjustment to motherhood faced by first-time mothers


A woman with mental illness often does not have the strength or desire to adequately care for herself or her developing baby Ex: Babies born to mothers who are depressed

may be less active, show less attention and be more agitated than babies born to moms who are not depressed

Mental Illness that is not treated can have potential dangerous risks to the mother and baby Can lead to poor nutrition, drinking, smoking,

and suicidal behavior, premature birth, low birth weight, and developmental problems

Mental Illness and Fetal Demise

Although maternal mental health disorders in pregnancy have been linked to fetal morbidity, there have been few reports of actual fetal mortality

However, since many of the neonatal complications listed are also present in cases of fetal demise, it seems plausible that there is a true association between maternal mental health and fetal mortality

Mental Illness and Fetal Demise

Fetal loss is not uncommon in pregnancy, with spontaneous abortions (miscarriages) before 20 weeks' gestation occurring in up to 15% of all pregnancies and with stillbirths after 20 weeks affecting nearly 1% of all births . In addition, there may be additional losses early in the first

trimester that are never recognized as clinical pregnancyWhen a woman is pregnant, treating physicians must

weigh potential benefits from pharmacological treatment with potential risks to the fetus; being able to determine whether mental illness itself is associated with fetal death might help physicians better evaluate overall fetal risk


Types of Mental Illness/Psychiatric Issues Depression Disorder Anxiety Disorder Panic Disorder Psychosis PTSD Eating Disorders Cognition Substance Use

*While it is rare for women to experience first onset psychoses during pregnancy, relapse rates are high for women previously diagnosed with some form of psychosis

Risk Factors Maternal Mental Health

Previous history of depression Discontinuation of medication(s) by a woman who has a History of depression Previous history of postpartum depression Family history of depression Negative attitude toward the pregnancy Lack of social support Maternal stress associated with negativelife events A partner or family member who is unhappy about thepregnancy

Risk Factors Maternal Mental Health

Having a hard time getting Having twins or triplets Losing a babyHaving a baby as a teenHaving premature labor and deliveryHaving a baby who is different (birth defect or

disability)Pregnancy and birth complicationsHaving a baby or infant hospitalizedHaving a healthy pregnancy and childbirth


What are possible triggers of depression during pregnancy

Relationship problems Family or personal history of depression Previous miscarriages Stressful life events Health related complications History of abuse or trauma Poor social support Financial difficulties

Signs and Symptoms of Mental Illness


Depressed mood or a loss of interest or pleasure in daily activities for more than two weeks. Mood represents a change from the person's baseline. Impaired function: social, occupational, educational.Specific symptoms, at least 5 of these 9, present nearly every day: Feeling sad or down Confused thinking or reduced ability to concentrate Excessive fears or worries, or extreme feelings of guilt Extreme mood changes of highs and lows Withdrawal from friends and activities Significant tiredness, low energy or problems sleeping Detachment from reality (delusions), paranoia or hallucinations Inability to cope with daily problems or stress Trouble understanding and relating to situations and to people Alcohol or drug abuse Major changes in eating habits Sex drive changes Excessive anger, hostility or violence Suicidal thinking


SIGECAPS mnemonic for symptoms of Depression:Sleep (insomnia or hypersomnia) Interest (reduced, with loss of pleasure) Guilt (often unrealistic) Energy (mental and physical fatigue) Concentration (distractibility, memory

disturbance) Appetite (decreased or increased) Psychomotor (retardation or agitation) Suicide (thoughts, plans, behaviours)

Post Partum Depression


Postpartum depression can happen anytime within the first year after childbirth

The difference between postpartum depression and the baby blues is that postpartum depression often affects a woman's well-being and keeps her from functioning well for a longer period of time Postpartum depression needs to be treated by a doctor

Major depression creates suffering whether experienced in the postpartum period or at any other time in a woman’s life

What makes depression so poignant for postpartum women is that childbirth is culturally celebrated and there is an expectation that new parents, especially mothers, will be joyful, if not tired, during this time


The demands on a new mother are substantial and include providing 24-hour care for a newborn, often in the middle of the night, caring for older children, keeping up with normal household responsibilities, and often returning to work after a brief maternity leave

These burdens are often difficult to bear in normal circumstances and the difficulty of bearing them is exacerbated by the disability associated with depression symptoms (e.g., sad mood, loss of interest, motor retardation, difficulty concentrating)

Post partum Depression


Any of these symptoms during and after pregnancy that last longer than two weeks are signs of depression:

Feeling restless or irritable Feeling sad, hopeless, and overwhelmed Crying a lot Having no energy or motivation Eating too little or too much Sleeping too little or too much Trouble focusing, remembering, or making decisions Feeling worthless and guilty Loss of interest or pleasure in activities Withdrawal from friends and family Having headaches, chest pains, heart palpitations (the heart beating fast and

feeling like it is skipping beats), or hyperventilation (fast and shallow breathing)

After pregnancy, signs of depression may also include being afraid of hurting the baby or oneself and not having any interest in the baby

Post Partum Psychosis

It occurs in 1 or 2 out of every 1000 births and usually begins in the first 6 weeks postpartum

Women who have bipolar disorder or another severe psychiatric problem such as in the schizophrenia spectrum have a higher risk for developing postpartum psychosis

Feeling ‘high’, ‘manic’ or ‘on top of the world’ Rapid changes in mood Severe confusion Being restless and agitated Racing thoughts Behavior that is out of character Being more talkative, active and sociable than usual Not wanting to sleep Losing your inhibitions Feeling paranoid, suspicious, fearful Feeling as if you’re in a dream world Delusions: these are odd thoughts or beliefs that are unlikely to be true. For

example, you might believe you have won the lottery. You may think your baby is possessed by the devil. You might think people are out to get you.

Hallucinations: this means you see, hear, feel or smell things that aren’t really there.

Mental Illness Detection

Treatment Options

Psychotherapy Stigma Access to care (insurance, resources) Environmental barriers (social support,

transportation)

Psychopharmacology Fear of medication during pregnancy Risks vs benefits

Psychotropic Medications in Pregnancy

Women with histories of psychiatric illness who discontinue psychotropic medications during pregnancy are particularly vulnerable to major psych episodes Ko et al. 2012, prospectively followed a group of

women with histories of major depression across pregnancy, of the 82 women who maintained antidepressant treatment throughout pregnancy, 21 (26%) relapsed compared with 44 (68%) of the 65 women who discontinued medication

Psychotropic Medications in Pregnancy

High rates of relapse have also been observed in women with bipolar disorder One study indicated that during the course of pregnancy,

70.8% of the women experienced at least one mood episode The risk of recurrence was significantly higher in women

who discontinued treatment with mood stabilizers (85.5%) than those who maintained treatment (37.0%).

Although data suggest that some medications may be used safely during pregnancy, knowledge regarding the risks of prenatal exposure to psychotropic medications is incomplete Thus, it is relatively common for patients to discontinue or to

avoid pharmacologic treatment during pregnancy

U.S. FDA Category Designations for Pregnancy

FDA provided guidelines to drug companies for labeling medications with regard to their safety during pregnancy. Medications are assigned a pregnancy letter ranking: (A, B, C, D, X). For newer drugs, this designation usually occurs in the

absence of systematic human pregnancy dataMost psychiatric medications are labeled as “C” or

“D,” without a clear demarcation in safety between the these categories

The FDA is currently working on improving the current labeling system, and they are considering the provision of more information about the risks and benefits in a descriptive format and information about the risks of the untreated disorder for which the medication is used

Weighing the Risks

Not infrequently, women present with the first onset of psychiatric illness while pregnant Many pregnancies are unplanned and may occur unexpectedly while

women are receiving treatment with medications for psychiatric disorders

Many women may consider stopping medication abruptly after learning they are pregnant, but for many women this may carry substantial risks.

Decisions regarding the initiation or maintenance of treatment during pregnancy must reflect an understanding of the risks associated with fetal exposure to a particular medication but must also take into consideration the risks associated with untreated psychiatric illness in the mother Psychiatric illness in the mother is not a benign event and may cause

significant morbidity for both the mother and her child; thus, discontinuing or withholding medication during pregnancy is not always the safest option

Weighing the Risks

Depression and anxiety during pregnancy have been associated with a variety of adverse pregnancy outcomes:

Women who suffer from psychiatric illness during pregnancy are less likely to receive adequate prenatal care

Are more likely to use alcohol, tobacco, and other substances known to adversely affect pregnancy outcomes

Possible low birth weight and fetal growth retardation in children (born to depressed mothers)

Preterm delivery Increased risk for having pre-eclapsia Operative delivery Infant admission to a special care nursery for a variety of conditions including

respiratory distress, hypoglycemia, and prematurity

* These data underscore the need to perform a thorough risk/benefit analysis of pregnant women with psychiatric illness, including evaluating the impact of untreated illness on the baby and the mother, as well as the risks of using medication during pregnancy *

References

Rahman, A., Surkan, P. J., Cayetano, C. E., Rwagatare, P., & Dickson, K. E. (2013). Grand challenges: integrating maternal mental health into maternal and child health programmes.

Carter, D., & Kostaras, X. (2005). Psychiatric disorders in pregnancy. British Columbia Medical Journal, 47(2), 96.

Gold, K. J., Dalton, V. K., Schwenk, T. L., & Hayward, R. A. (2007). What causes pregnancy loss? Preexisting mental illness as an independent risk factor. General hospital psychiatry, 29(3), 207-213.

Illangasekare, S. L., Burke, J. G., Chander, G., & Gielen, A. C. (2014). Depression and social support among women living with the substance abuse, violence, and hiv/aids syndemic: a qualitative exploration. Women's health issues, 24(5), 551-557

Dickerson, F. B., Brown, C. H., Kreyenbuhl, J., Goldberg, R. W., Fang, L. J., & Dixon, L. B. (2014). Sexual and reproductive behaviors among persons with mental illness. Psychiatric Services.

O'Hara, M. W. (2009). Postpartum depression: what we know. Journal of clinical psychology, 65(12), 1258-1269.

Robertson, E., Grace, S., Wallington, T., & Stewart, D. E. (2004). Antenatal risk factors for postpartum depression: a synthesis of recent literature. General hospital psychiatry, 26(4), 289-295.

MARISA ECHENIQUE, PSY.D. ASSISTANT PROFESSOR DEPARTMENT OF PSYCHIATRY UNIVERSITY OF MIAMI MILLER...

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