Perinatal Mood Disorders:Why We Should Care

Debbie Ruxer RN, MS, CNMMiami Valley Regional Postpartum

Depression Network

ObjectivesAt the end of this presentation the participant will be able

to:

Discuss physiology and risk factors for perinatal mood disorders

List the different types of perinatal mood disorders

Discuss the effects of maternal depression on the infant and the family

Discuss medication and other therapies for perinatal mood disorders

CONFLICT OF INTEREST The planners and faculty have declared no conflict of interest.

COMMERCIAL SUPPORT/SPONSORSHIP Good Samaritan Hospital is the sponsor for this activity. The

information presented today will be presented fairly and without bias.

CRITERIA FOR SUCCESSFUL COMPLETION You must attend the entire event and submit a completed evaluation

form in order to receive credit for this presentation.

The moment a child is born, the mother is also born. She never existed before. The woman existed, but the mother, never. A

mother is something absolutely new.” Rajneesh

Myths and Facts about Motherhood I will fall in love with my baby immediately.

Being a mother will complete me.

Having a child will strengthen our relationship.

Having a child will keep him around.

Mothering is natural.

Breastfeeding is natural, and it will be easy.

Effects of PPD on Women

PPD is the number one complication of childbirth

Affects 1 in every 5 to 8 women

Depression the second leading cause of disease burden

High rate of co-morbidity with anxiety disorders, substance abuse and eating disorders

• <20% of pregnant women with psychiatric diagnosis were treated.

• >50% of pregnant women on antidepressant medication were symptomatic due to suboptimal treatment.

• <25% of OB/GYN patients had their psychiatric diagnosis recognized.

Depression for Two?•Decreased prenatal care and self-care

•Increased self-medication and substance abuse

•Increased risk of being victim of violence

•Increased risk of pre-eclampsia

•Increased rates of miscarriages, preterm birth and low birth weight

•Uterine artery resistance

Physiology

Stress Changes in brain chemistry Thyroid dysfunction Physical discomfort Risk factors that increase susceptibility LACK OF SLEEP!!!!!!

Immune system response to stress

Sympathetic response, catecholamine release Cascading release of CRH, ACTH, cortisol Release of proinflammatory cytokines (IL-1B, IL-

6, TNF-a, IFN-y) Sustained levels of proinflammatory cytokines

blunts cortisol’s anti-inflammatory action, and increases risk of depression.

Neurotransmitters

Serotonin : Inhibits stress responseRegulates sleepPain sensitivitySexual functioningAppetite

Diminished serotonin – result of stress?

Who is at risk? Risk Factors:

History of depression or mental health diagnosis

Lack of social support (family is far away) Unexpected pregnancy High Risk pregnancy Infertility Adoption

Who is at risk?

Difficult labor or unexpected outcome NICU Birth Defect Preterm delivery Fetal demise or previous fetal demise Unplanned C-section Difficult or prolonged labor and/or delivery

Spectrum of disorders

Depression/Anxiety Obsessive/Compulsive Disorder Panic Attacks Post-traumatic Stress Bipolar Postpartum Psychosis

Baby Blues

Occurs in about 80% of mothers Onset 1st week, lasts up to 3 weeks Mood instability, weepiness, sadness, anxiety,

lack of concentration Treatment supportive Not considered part of the spectrum of perinatal

mood disorders

Depression and/or Anxiety

Incidence: 15-20% of new mothersSymptoms: Excessive worry or anxiety Irritability, short temper Feeling overwhelmed by responsibilities,

difficulty making decisions Sad mood, feelings of guilt, fear, phobias Hopelessness Sleep disturbances (insomnia or

hypersomnolence), fatigue

Somatic symptoms without apparent cause Discomfort around baby Lack of feelings towards baby Loss of focus and concentration Loss of interest and pleasure Changes in appetite – significant wt gain or loss

Obsessive-Compulsive Disorder

Incidence: 3-5% of new mothersRisk factors: Personal or family hx OCDSymptoms:

Intrusive, repetitive and persistent thoughts or mental pictures

Thoughts often about harming the baby Tremendous sense of horror and shame Behaviors to reduce anxiety and protect baby Counting, checking, cleaning, other repetitive

behaviors

These women can think and reason and articulate clearly

At the mercy of intrusive thoughts and behaviors

These women DO NOT HARM their babies!

Do NOT call Children’s Services based on this

Panic DisorderIncidence: 10% of postpartum womenRisk Factors: Personal or family hx of anxiety or panic

disorder Thyroid dysfunction

Symptoms: Episodes of extreme anxiety SOB, chest pain Sensations of choking, smothering, dizziness

Hot or cold flashes, trembling, tachycardia, numbness or tingling

Restlessness, agitation, irritability During attack, may fear she is going crazy,

losing her mind Panic attack may wake her up from sleep Excessive worry or fear (incl. fear of another

panic attack)

Posttraumatic Stress Disorder

Incidence: up to 6% of postpartum womenRisk factors: Past traumatic events

Symptoms: Recurrent nightmares Extreme anxiety Reliving past traumatic events (sexual, physical,

emotional, childbirth)

Bipolar DisorderIncidence: no dataRisk factors: personal or family hx of bipolar

disorder

Symptoms: Mania – racing thoughts, high energy and little

sleep, compulsive activity Depression Rapid and severe mood swings

Postpartum Psychosis

Incidence: 0.1-0.2% Onset usually 2-3 days postpartum 5% suicide and 4% infanticide rateRisk factors: Personal or family hx psychosis, bipolar,

schizophrenia Previous hx postpartum psychosis or bipolar

episode

Symptoms: Visual or auditory

hallucinations Delusional thinking Delirium or mania Very obviously

psychotic Differentiate from

OCD

Experiences of women

Myself My daughter Lisa You?

Effects of PPD on Children

Poor attachment Increase in accidents Less likely to see pediatrician regularly Failure to thrive or overfeeding Increased rates of colic Increased use of ER

Cognitive Effects

Depressed mothers talk less to their infants

Less expression of positive emotions

Increased use of corporal punishment

Decrease in cognitive abilities present as early as 2 months

Behavioral Effects Eating and sleeping disorders Increased crying Less vocalizations and smiling Decreased vocalization at 18-

24 months Shorter attention spans More anxious around

strangers Less interactive play Less self-knowledge

Effects of PPD on Relationships

10% of fathers report symptoms of PPD

Reality vs. expectations Financial stress Change in relationship Partner suffering from

PPD

Relationships Continued

PPD leads to relationship difficulties Higher divorce rateBoth parents with PPD has an additive affect

on childrenSupportive partners are protective factor

against PPD

Relationships Continued

Symptoms: Work long hours Watch more TV/sports Increased use of

alcohol Withdrawn More irritable

Silent Suffering

We don’t talk about it - why? So much shame involved Feeling like a failure Motherhood isn’t so easy after all They might take away my baby if I say

anything

But there is hope

There is much that providers, family, friends and community can do to help

Family and friends play a critical role in helping women recover

Family and friends: the first line of defense

Screening Several tools available Edinburgh Postnatal Depression Scale:

validated, short and easy to use Who should screen?

OB/Gyn providers Pediatricians Family Practice providers WIC Lactation consultants Home health nurses

Edinburgh Postnatal Depression ScaleAnswer the following questions, checking the answer

that comes closest to how you have felt over the last 7 days (not just today).

1. I have been able to laugh and see the funny side of things

2. I have looked forward with enjoyment to things3. I have blamed myself unnecessarily when things

went wrong4. I have been anxious or worried for no good reason.

5. I have felt scared or panicky for no very good reason.

6. Things have been getting on top of me (can’t keep up with my responsibilities)

7. I have been so unhappy that I have had difficulty sleeping

8. I have felt sad or miserable9. I have been so unhappy that I have been crying10. The thought of harming myself has occurred to me

Always look at the answer to the last question!

Score greater than 13 = probable depression

Going the Extra Mile It’s all in the presentation:

Provide a safe, non-judgmental environment Ask open-ended questionsGive reassurance that she’s not “crazy” or

“bad” Give her hope: “This is not your fault, you will

get better, you are not alone.” Don’t assume anything

What can family/friends do to help?

You can: Make dinner Watch the baby so she can

take a break (or take a nap) Do the laundry Do the dishes

More ideas: Sit and listen Clean the house Take a walk with her Go shopping or do errands

for her Be on duty overnight so

she can sleep

Keep her company – it is worse to be alone

Take on some of her responsibilities

Reduce her feeling of being overwhelmed

Give her time to sleep!!!!

Medical Management

ACOG/APA guidelines (2009)PsychotherapyPharmacotherapy Individualized plan of care Consider continuing medications during

pregnancy to avoid risk of relapse (bipolar, psychosis, severe depression)

Psychotherapy

Front line therapy

As effective as medication

Lower relapse rate

One-on-one therapy initially, but group therapy helpful later

Cognitive Behavioral Therapy

Highly effective Based on premise that distorted thinking

causes depression CBT teaches patients to recognize distorted

thinking, and counter these thoughts

Interpersonal Psychotherapy

As effective as Cognitive Behavioral Therapy Based on attachment theory and interpersonal theory Addresses 4 problem areas:

Role transitions Interpersonal disputes Grief Interpersonal deficits

Focus on improved relationships, role transitions

Medications Individual decision Risk versus benefit Risks of medication:

MiscarriageNeonatal withdrawalNICU admissionPersistent pulmonary hypertensionCongenital anomalies

Risks of no medication Mother:

Preterm birthRisk of suicideUntreated depression can become chronic

Infant:Poor attachmentFailure to thriveDecreased cognitive abilities

Antidepressants

Selective serotonin reuptake inhibitors Norepinephrine/dopamine reuptake

inhibitors Serotonin/norepinephrine reuptake

inhibitorsNot recommended: Monoamine oxidase inhibitors Tricyclic antidepressants

Avoid in 1st trimester if possible Start low Titrate to therapeutic effect Sub-therapeutic doses do not decrease risk

to fetus Single drug therapy Start with one that has worked for her in the

past

Already on antidepressants?

Risk of relapse high if meds stoppedRisk vs benefit Individualized treatment planAvoid changing medications if therapy

effective

SertralineLower maternal serum levelsAlmost undetectable in breast milk0.2% risk of cardiac septal defectsMild neonatal withdrawal

Paroxetine Higher risk of congenital anomalies Low levels in breast milk

Fluoxetine Mild neonatal withdrawalHigher levels in breastmilk

Citalopram No known association with congenital

anomaliesMild neonatal withdrawalOccasional neonatal somnolence

Other medications

Sleep aids as needed Anxiolytics (severe anxiety) Mood stabilizers (Bipolar) Antipsychotics (PP Psychosis)

Additional Therapies

Skin to skin time with baby

Omega-3 fatty acids

Bright light therapy Exercise Vitamin D

Skin-to-skin

Promotes infant well-being

Elicits maternal bonding hormones and behaviors

Omega-3 Fatty Acids

DHA and EPA improve mood EPA decreases inflammatory eicosanoids by

competing for same metabolic pathways Also inhibits production of proinflammatory cytokines Rates of postpartum depression tend to be lower in

countries with high dietary intake of fish Fish oil supplements: use USP-verified supplements

for minimal risk of contaminants 1000-3000 mg/day Flax seed ineffective (HLA)

Vitamin D

Association between Vitamin D deficiency and mood disorders, including postpartum mood disorders

Deficiency defined as circulating 25(OH)D levels less than 20ng/mL

Recent recommendations for intake of 800-2000 IU daily

Bright Light Therapy

As effective as medication Insurance reimbursement a possibility Several theories on mechanism:

Effect on circadian rhythms Anti-inflammatory component

Timing important: morning bright light more effective, works with body’s circadian rhythm

Exercise

Role in reducing depressive symptoms well-documented

Decreases stress, improves self-efficacy

Endorphin release Lowers levels of pro-inflammatory

cytokines Improves sleep Overall health benefits

St. John’s Wort Research demonstrates efficacy in treating

mild to moderate depression Fewer side effects than traditional

medications: 2.4% incidence of GI upset, allergic

reactions, rash, fatigue, restlessness Can trigger manic episodes in susceptible

patients

RISKS: Accelerates metabolism of anticonvulsants,

cyclosporins, OCP, other meds Interacts with SSRIs: serotonin syndrome

(potentially fatal)

Generally safe with breastfeeding Level of infant exposure comparable to other

SSRIs Rare cases of colic or lethargy in exposed

infants

Dose: 300mg, tid Look for USP labeling

What can I do as a health provider?

Promote: Non-separation of mothers

and babies Skin-to-skin for all babies Breastfeeding

Educate! New mothers Their families

Intervene Women depressed during hospitalization

What’s the good news? With proper support and treatment, she WILL

get better!

Miami Valley Postpartum Depression Network We’re here to help: Support Referral list 937-401-6844 1-866-848-3163 www.postpartum.net Facebook group: Postpartum Depression Many

Shades of Blue

in December 2001 Possibilities

The end of all education should surely be service to others. We cannot seek achievement for ourselves and forget about progress and prosperity for our community. Our ambitions must be broad enough to include the aspirations and needs of others, for their sake and for our own. ---Cesar Chavez

References cont.

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References

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References cont.

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References cont.

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References cont.

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References cont.

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