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Breaking The Ice: Post-Partum Depression Marina Delazari Miller, MD Clinical Assistant Professor

Department of Obstetrics & Gynecology

University of Iowa Hospitals and Clinics

Objectives

�  Identify risk factors for post-partum depression

�  Understand screening strategies for post-partum depression

�  Understand how to establish the diagnosis of post-partum depression

�  Understand approaches to treatment of post-partum depression

Background

�  In 700 BC Hippocrates wrote about women suffering from emotional difficulties during their post-partum period

�  “Trotula of Salerno” – series of three books written in honor of 12th century female MD Trota makes mention of post-partum depression �  “If the womb is too moist,

the brain is filled with water, and the moisture running over the eyes, compels them to shed involuntary tears."

Background

�  18-19th century: �  Women did not talk about or report their

symptoms – fear of institutionalization and being labeled neurotic or insane, punished for behaving in ways that male society did not agree.

�  During this time, women were subjected to various peculiar treatments.

�  “Rest cure” in which patient was not allowed to read, write, feed herself, or talk to others.

�  1892 early feminist Charlotte Perkins Gilman published in The Yellow Wallpaper a short story recounting her post-partum depression after the birth of her daughter.

�  After 2 years she sought help from a famous neurosurgeon who prescribed complete confinement.

�  "Live as domestic a life as possible. Have your child with you all the time... Lie down an hour after each meal. Have but two hours' intellectual life a day. And never touch pen, brush or pencil as long as you live."

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Background

�  During the 1950s electroshock therapy was often the recommended treatment for a “neurotic" woman or they were occasional prescribed valium.

�  Louis Victor Marce - French psychiatrist wrote the first treatise entirely devoted to postpartum mental illness in 1958

�  1980s DSM-III first recognized post-partum depression as a condition.

Background

�  Recent celebrities have helped to establish that postpartum depression is no longer a "dirty little secret" for women to be ashamed of.

�  Marie Osmond “Behind The Smile”

�  Brooke Shields “Down Dame The Rain”

Background

�  Only 5% of pregnant women with psychiatric disorders receive treatment.

�  Suicide is the 5th leading cause of death among perinatal women in the US.

�  10-20% of women develop post-partum depressive disorder within 6 months of delivery.

�  If untreated, 25% will have persistence of depression at 1 year.

�  Up to 70% will have recurrence.

Background

�  Psychiatric disorder in pregnancy is associated with �  Scant prenatal care

�  Substance abuse

�  Poor obstetrical and neonatal outcomes �  Preterm birth, low birthweight, perinatal mortality

�  Higher risk of post-partum psychiatric illness

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Background

�  Pregnancy is a major life stressor and can precipitate or exacerbate depressive tendencies

�  Estrogen has been implicated in increased serotonin synthesis, decreased breakdown, and receptor modulation.

�  Women who experience postpartum depression have higher pre-delivery estrogen/progesterone.

Risk Factors �  The following have been shown to be risk factors for post-partum depression

�  Pre-existing:

�  Personal or family history of psychiatric illness

�  History of sexual, physical, or verbal abuse

�  Substance abuse

�  Personality disorders

�  Smoking/drinking

�  During pregnancy:

�  Young maternal age

�  Unintended pregnancy

�  Unmarried status, low social support

�  Hyperemesis gravidarum

�  Fetus with malformation

�  Preterm labor/delivery

�  Medical/obstetrical complications in pregnancy

�  Post-partum:

�  Difficulties with breastfeeding

�  Prolonged separation from the neonate

Screening

�  Perinatal depression often goes undiagnosed because changes in sleep, appetite, and libido may be attributed to normal pregnancy/post-partum changes.

�  Less than 20% of women report symptoms to their healthcare provider.

�  In patients with risk factors, consider scheduling post-partum visit sooner than 6 weeks.

Screening

�  Ask open-ended questions: �  How do you feel things are going?

�  How are things with the baby?

�  Are you feeling how you expected to feel?

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Screening

�  ACOG: �  Insufficient evidence for firm screening recommendations

�  Limited evidence that screening improves outcomes �  Can you diagnose and treat?

�  Consider screening if risk factors identified

�  Screening tools: �  Edinburgh Postnatal Depression Scale (EPDS)

�  Patient Health Questionnaire 9 (PHQ9)

Screening Tools

EPDS EPDS

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Diagnosis

�  Post-partum blues: �  Experienced by 50-70% of women within the first week

after delivery

�  A time-limited period of heightened emotional reactivity

�  Generally peaks on post-partum day 4-5 and normalizes by day 10

�  If lasting more than 2 weeks -> evaluate for depression

�  Patients feel predominantly happy, but may experience: labile mood, insomnia, weepiness, depression, anxiety, poor concentration, irritability.

Diagnosis

�  Post-partum depression �  Sad, anxious, or “empty” feelings

�  Hopelessness or pessimism �  Feelings of guilt, worthlessness, or helplessness

�  Irritability, restlessness

�  Loss of interest (anhedonia)

�  Fatigue/decreased energy

�  Difficulty concentrating �  Insomnia or excessive sleeping

�  Change in appetite

�  Suicidal ideation/attempt

�  Persistent aches/pains

Diagnosis

�  Occurs in 8-20% of pregnancies within 12 months after delivery �  Peaks between 2 and 4 months

�  SIG E CAPS �  Sleep, Interest, Guilt, Energy,

Cognition/Concentration, Appetite, Psychomotor, Suicide

�  At least 5 symptoms

�  Must include low mood/anhedonia

�  Last at least 2 weeks

Post-partum Psychosis

�  Post-partum psychosis: �  Usually with pre-existing bipolar disorder, but may occur

due to major depression

�  Incidence 1:1000 deliveries

�  More common in primiparas

�  Manifests within 2 weeks of delivery

�  50% recurrence risk; often develop chronic psychotic manic depression.

�  Requires hospitalization, pharmacological treatment, and long-term psychiatric care

�  More likely to commit infanticide

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Post-partum Psychosis

�  Symptoms: �  Physical or mental slowing

�  Agitation

�  Poor concentration

�  Delusions

�  Hallucinations

�  Disorganized behavior

�  Flat affect

Treatment

�  Post-partum blues: �  Supportive

�  Provide reassurance

�  Monitor for depression or other psychiatric disturbance

�  Post-partum depression: �  SSRI is first line

�  If improvement within 6 weeks, should be continued for at least 6 months

�  Psychotherapy

�  In high risk patients, consider starting SSRI immediately after delivery.

Treatment in Pregnancy

�  Paroxetine �  1:200 risk of ventricular septal defect

�  Should be avoided

�  SSRIs: �  2:1000 risk of pulmonary hypertension (marginal increase

above baseline)

�  30% of neonates will experience withdrawal symptoms

�  Use with caution, when risks outweigh benefits

Treatment While Breastfeeding

�  First line: �  SSRI: sertraline, paroxetine

�  TCA: nortriptyline

�  All have been studied and found at very low levels in breast milk and infant serum.

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Treatment in Pregnancy

�  No-No’s: �  Lithium

�  Cardiac malformations - Ebstein anomaly

�  Growth restriction, lithium toxicity

�  Valproic acid

�  Neural tube defects

�  Heart valve defects, cleft palate, hypospadias, polydactyly, growth restriction, withdrawal, hypofibrinogenemia

�  Carbamazepine �  Neural tube defects

�  Craniofacial defects, fingernail hypoplasia, developmental delay, growth restriction, microcephaly

Conclusions

�  Perinatal depression is common

�  It often goes unrecognized/untreated

�  Screening should take place at least once during the perinatal period using a standardized validated tool

�  Providers should be prepared to initiate treatment and refer patients as needed

�  Have a system in place to ensure follow up for diagnosis and treatment

References

�  Williams Obstetrics �  Obstetrics: Normal and Problem

Pregnancies �  Creasy and Resnik �  Committee on Obstetric Practice.

Committee Opinion no. 630: Screening for perinatal depression. Obstetrics and Gynecology. 2015 May; 125(5): 1269-71.

�  https://en.wikipedia.org/wiki/Trotula

�  https://en.wikipedia.org/wiki/Charlotte_Perkins_Gilman

�  https://en.wikipedia.org/wiki/The_Yellow_Wallpaper

�  http://www.healthguideinfo.com/postpartum-depression/p99788/

Thank you!