peripartum depression laura j. miller, m.d. women’s mental health program university of illinois...

Peripartum Depression

Laura J. Miller, M.D.Laura J. Miller, M.D.

Women’s Mental Health ProgramWomen’s Mental Health Program

University of Illinois at ChicagoUniversity of Illinois at Chicago

Risks from untreated major depression during pregnancy

Decreased prenatal care Decreased nutrition Increased use of teratogenic addictive substances

– cigarettes– alcoholic beverages

(Halbreich 2004)

Effects on offspring of untreated depression during pregnancy

Low birth weight (Federenko & Wadhwa 2004)

Preterm birth (Dayan et al. 2002)

Pre-eclampsia (Kurki et al. 2000)

Neonatal irritability (Zuckerman et al. 1990)

Postpartum “blues”

Features: tearfulness, lability, reactivity Predominant mood: happiness Peaks 3-5 days after delivery Present in 50-80% of women Present in all cultures studied Unrelated to environmental stressors Unrelated to psychiatric history

(Miller & Rukstalis 1999)

“I started to experience a sick sensation in my stomach; itwas as it a vise were tightening around my chest. Insteadof the nervous anxiety that often accompanies panic, afeeling of devastation overcame me. I hardly moved.Sitting on my bed, I let out a deep, slow, guttural wail. Iwasn’t simply emotional or weepy, like I had been told Imight be. This was something quite different. This wassadness of a shockingly different magnitude. It felt as if itwould never go away.”

-from “Down Came the Rain: My Journey ThroughPostpartum Depression” (Brooke Shields)

Clinical features of postpartum depression

Mood predominantly depressed, despondent, anhedonic Sleep disturbance, fatigue, irritability Loss of appetite Poor concentration Feelings of inadequacy Ego-dystonic thoughts of harming the baby

(Miller 2002)

“I sat holding my newborn and could not avoid the imageof her flying through the air and hitting the wall in front ofme. I had no desire to hurt my baby and didn’t see myselfas the one throwing her, thank God, but the wall morphedinto a video game, and in it her little body smacked thesurface and slid down onto the floor. I was horrified, andalthough I knew deep in my soul that I would not harmher, the image all but destroyed me.”

From “Down Came the Rain: My Journey ThroughPostpartum Depression”, Brooke Shields, 2005

Characteristics of postpartum depression

Begins within 4 weeks of birth, but clinical presentation peaks 3-6 months after delivery

Present in 7 - 20% of new mothers in U.S. (Joseffson

et al. 2001) Much less prevalent in some cultures (Wile &

Arechiga 1999)

Related to psychiatric history (Steiner & Tam 1999)

Related to environmental stressors (Bernazzani et al. 2004)

Consequences of untreated postpartum depression

Disturbed mother-infant relationship (elevated cortisol found in both) Psychiatric morbidity in children later (depression, conduct disorder, lower IQ)

Family tension Vulnerability to future depression Suicide/homicide

(Lundy et al. 1999; Jacobsen 1999)

Peripartum depression: posited contributory factors

Hormonal flux interacting with stressors The magnitude of the postpartum drop in

hormones correlates with mood changes; absolute hormone levels don’t

The biological mother-infant attachment system may predispose to depression in the context of stress, low social support & limited resources

Peripartum depression: recognition and treatment in primary care settings

Ob/gyn survey (LaRocco-Cockburn et al. 2003):– Only 32% reported they’d been appropriately

trained to treat depression– 73% cited time constraints for screening

Pediatrician survey (Wiley et al. 2004):

– 49% not educated about PPD– Only 31% felt they’d recognize PPD– Only 7% were familiar with screening tools

Screening for Peripartum Depression with the Edinburgh Postnatal Depression Scale

[EDPS] 10 item scale; maximum score 30; cut-off 10 - 13 Self report : quick and easy to score Widely tested

– During pregnancy, sensitivity 100%; specificity 87%– Postpartum, sensitivity 78 - 100%; specificity 93 - 100%– Available in over 20 languages; cross-cultural validation

Defines population in need for further assessment Can be used to monitor treatment progress IDPA (Medicaid) reimburses for this screening

(Cox & Holden 2003)

Assessment of peripartum depression

Conducted by clinician for all women who score above the cut-off score on EPDS

Purposes - to ascertain whether the woman:– has major depression– is suicidal– is at risk of harming her baby– has bipolar disorder

Treating peripartum depression

Antidepressant medication Interpersonal psychotherapy Couples therapy Self help tools & networks ECT (rTMS) Hormone therapy Parenting coaching

Challenges in prescribing antidepressant medications peripartum

FDA categories have limited usefulness (based heavily on animal data)

Wide variation in amount of data for different antidepressants

Optimal dosing changes as pregnancy progresses

Wide variation in amount ingested by breast-feeding babies

Peripartum Depression Disease Management Model

Education (via workshops) Screening tool Assessment tool Treatment guidelines Self-care tools Referral networks Back-up consultation