depression in pregnancy and postpartum: screening ... · the postnatal period. • depression...
TRANSCRIPT
![Page 1: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/1.jpg)
Depression In Pregnancy and Postpartum: Screening, Diagnosis, Consequences of Untreated Illness,
Engagement, and Traveling the Road to Recovery
Dayna J. LePlatte, MD Department of Psychiatry & Depression Center Clinical Instructor, Department of Psychiatry
Child, Adolescent, and Adult Psychiatry
![Page 2: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/2.jpg)
Faculty Disclosures
Dr. LePlatte has disclosed no relevant financial relationships with any commercial interests
![Page 3: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/3.jpg)
Case: Mary • 29 year old single woman 2 weeks after the
birth of her third child • She had one prior severe depressive episode
that started while she was pregnant with her 2nd child. She also has a diagnosis of GAD
• No prior hospitalizations or suicide attempts, but she does have a history of SI
• Family History: bipolar in aunts and several cousins
• Prior medication trials: bupropion, fluoxetine, and clonazepam
![Page 4: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/4.jpg)
Case: Mary
• Today you note the following: – Mood, irritable, sad, anhedonic, stressed,
can’t relax, racing thoughts, hopelessness, overwhelmed, poor sleep, fleeting thoughts she would be better off dead
• She notes that she stopped the medication because, “I’m good. I don’t need it anymore.” She goes on to state, "I am scared the medications will harm by baby”.
![Page 5: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/5.jpg)
Key Point #1
When treating maternal illness in pregnancy or postpartum there is the mother and the
baby to consider.
![Page 6: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/6.jpg)
Risk-Benefit Ratio
Risk of Untreated
Illness
s
Risk of Untreated
Illness
![Page 7: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/7.jpg)
Outline
• Brief Review of Common Mood and Anxiety Disorders
• Consequences of Untreated/Under-treated Depression and Anxiety
• Screening and Treatment Options • Helping Families Recover • Issues Around Engagement in Treatment
![Page 8: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/8.jpg)
What are the Most Common Perinatal Mood and Anxiety
Disorders? What are Potential Consequences
if Left Untreated?
![Page 9: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/9.jpg)
Mood Disorders • Most often occur during developmental and hormonal
transitions: – Adolescence – Premenstrual – Peripartum – Perimenopause
• Hypotheses: – Increased sex-steroid sensitivity as a susceptibility factor? – Women with postpartum depression increased sensitivity to
estrogen signaling
Rawana JS, et al. J Youth Adolesc. 2014;43(4):597-611. Borrow AP, et al. Prog Neuropsychopharmacol Biol Psychiatry. 2014;54C:13-25. Mehta D, et al. Psychol Med. 2014;[Epub ahead of print].
![Page 10: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/10.jpg)
Postpartum Blues
• 50-85% of all new mothers
• Labile mood • Emotional
hypersensitivity • Tearful • Mild sleep disturbance • No major change in
functioning
• Generally responds to support and reassurance
• No treatment necessary, except if severe and >14 days
• Begins 2-4 days after birth
• Resolves 12-14 days later
Burt, Vivien. “Mood Disorders in Women: Focus on Postpartum Women’s Health in Primary Care. 2006:12-23.
![Page 11: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/11.jpg)
Postpartum Depression
• Begins a little later ~ a few weeks • 10-15% • Often not detected until much later • Symptoms: sleep disturbance, anhedonia,
hopelessness, worthlessness, energy changes, appetite changes, concentration difficulties, and SI/HI/SIB.
Burt, Vivien. “Mood Disorders in Women: Focus on Postpartum Women’s Health in Primary Care. 2006:12-23.
![Page 12: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/12.jpg)
Postpartum Psychosis • 0.1 -0.2% • 1-2 per 1,000 births • Rate is 100 times higher in women with BP or a previous
history of postpartum psychosis • Extremely disturbed mood • Highly agitated • Severely disturbed sleep • Delusions/hallucinations • Suicidal thoughts • Major loss of functioning • Rapid decline over 1-2 weeks • Psychiatric emergency
Burt, Vivien. “Mood Disorders in Women: Focus on Postpartum Women’s Health in Primary Care. 2006:12-23 Spinelli, Margaret. “ Postpartum Psychosis: Detection of Risk and Management. AmJ Psychiatry 166:4, April 2009
![Page 13: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/13.jpg)
Don’t Forget About The Fathers • More than 10% of
fathers suffer from psychiatric morbidity in the postnatal period.
• Depression amongst fathers is associated with: – having depressed
partners – having an unsupportive
relationship – being unemployed.
Ballard C, Davies R, Postnatal Depression In Fathers. International Review of Psychiatry. 1996. Vol 8. No1. Pages 65-71
![Page 14: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/14.jpg)
Perinatal Anxiety and OCD
• GAD: – Most common anxiety disorder in perinatal period – 8.5% to 10.5% of pregnant and postpartum women
meet criteria (5.2% general population) • OCD: <1% in pregnancy; 3-4% postpartum (<2% in
general population) • Panic Disorder: 1-2% (general population) • Key symptom: Scary thoughts – negative, unwanted,
repetitive, and/or intrusive thoughts/images
Rawana JS, et al. J Youth Adolesc. 2014;43(4):597-611. Borrow AP, et al. Prog Neuropsychopharmacol Biol Psychiatry. 2014;54C:13-25. Mehta D, et al. Psychol Med. 2014;[Epub ahead of print].
![Page 15: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/15.jpg)
Perinatal Anxiety and OCD
• Obsessive thoughts 91% • Intrusive memories of birth 15-37% • Excessive worry 15-37% • Rumination • Catastrophic misinterpretation of bodily
sensations
Ross LE, et al. J Clin Psychiatry. 2006;67(8):1285-1298. Hall PL, et al. J Midwifery Womens Health. 2006;51(5):321-330. Abramowitz JS, et al. Behav Res Ther. 2006;44(9):1361-1374. Creedy DK, et al. Birth. 2000;27(2):104-111. Wenzel A, et al. Arch Womens Ment Health. 2003;6(1):43-49.
![Page 16: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/16.jpg)
Scary Thoughts of Harming the Baby
• >90 % of postpartum women have intrusive thoughts of accidental harm to their babies (illness, fall abduction, suffocation)
• 50% of postpartum mothers have intrusive thoughts about intentionally harming their baby
• OCD • Psycho
Fairbrother N, et al. Arch Womens Ment Health. 2008;11(3):221-229. Barr JA, et al. Can Fam Physician. 2008;54(12):1716-1717. Abramowitz JS, et al. J Anxiety Disord. 2003;17(4):461-478.
OCD Psychosis Intrusive thoughts cause distress (ego dystonic)
Not associated with distress (ego syntonic)
Fear of acting on intrusive thoughts, avoidance behaviors/rituals
Other associated symptoms of psychosis (confused, agitated, hallucinations, loss of reality)
Low likelihood to act; mom otherwise in touch with reality
Increased likelihood that mother may act on thoughts
![Page 17: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/17.jpg)
Trauma and PTSD • Obstetric/labor trauma
– 20% of women • Interpersonal trauma
– 28% have been sexually abused in childhood – 20% experience intimate partner violence – 4-8% are abused during pregnancy
• Peripartum PTSD – 12.3% - PTSD lifetime – 2-7% PTSD in pregnancy and postpartum – 1.5-3% new onset PTSD after birth trauma
PTSD = posttraumatic stress disorder. Menage J. Journal of Reproductive and Infant Psychology. 1993;11(4):221-228. Resnick HS, et al. J Consult Clin Psychol. 1993;61(6):984-991. Loveland Cook CA, et al. Obstet Gynecol. 2004;103(4):710-717. Ayers S, et al. Birth. 2001;28(2):111-118.
![Page 18: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/18.jpg)
Time To Relapse of Depression
26%
68%
N = 201. Cohen LS, et al. JAMA. 2006;295(5):499-507.
![Page 19: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/19.jpg)
Consequence of Untreated Depression and Anxiety
• Pregnancy: – Inadequate weight gain – Risk for preeclampsia – Pre-term birth – Low birth weight – Small for gestational age – Increased uterine artery resistance – Elevated maternal perinatal cortisol and neonatal
cortisol
Bonari L, et al. Can J Psychiatry. 2004;49(11):726-735. Grote NK, et al. Arch Gen Psychiatry. 2010;67(10):1012-1024. Bansil P, et al. J Womens Health. 2010;19(2):329-334. O’Donnell K, et al. Dev Neurosci. 2009;31(4):285-292. Cripe SM, et al. Paediatr Perinat Epidemiol. 2011;25(2):116-123. Jensen HM, et al. Psychopharmacology. 2013;228(2):199-205. Davalos DB, et al. Arch Womens Ment Health. 2012;15(1):1-14.
![Page 20: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/20.jpg)
Consequences of Untreated Depression and Anxiety
• Postpartum – Difficult infant temperament – Increased risk for later child behavior problems – Negative effects on child cognition – Impaired mother-infant interaction – Prenatal effects moderated by mother-infant
attachment
Davis EP, et al. J Am Acad Child Adolesc Psychiatry. 2007;46(6):737-746. O’Connor TG, et al. Br J Psychiatry. 2002;180:502-508. Van den Bergh BR, et al. Neurosci Biobehav Rev. 2005;29(2):237-258. Deave T, et al. BJOG. 2008;115(8):1043-1051. Bergman K, et al. Biol Psychiatry. 2010;67(11):1026-1032. Lovejoy MC, et al. Clin Psychol Rev. 2000;20(5):561-592.
![Page 21: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/21.jpg)
Key Point #2:
Screening is not enough “The potential effectiveness of screening for
Postpartum Depression appears to be related to the availability of systems to ensure adequate follow-up of women with positive results.”
Myers ER, et al. Efficacy and Safety of Screening for Postpartum Depression. Comparative Effectiveness Review 106. AHRQ Publication No. 13-EHC064-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm
![Page 22: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/22.jpg)
When to Screen?
• OB visit and at 6 weeks • Pediatrician well-baby visits up to 6 months • Continuously when engaged in a treatment relationship • Postpartum depression presents within the first weeks, but
peaks around 3-6 months • Screening took easily available ( EPDS, PHQ-2,PHQ-9) • Only 5 % of screen-positive women receive adequate
treatment. • Screening alone in OB does not yield higher rates of treatment
engagement, need for collaborative care models: – Barriers: low rates of referrals, off-site mental health, stigma,
undertreatment, low access to a variety of personalized treatment options, treatment delivery in a timely fashion
![Page 23: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/23.jpg)
Screening Measures • EPDS
– Sensitivity = 0.86; Specificity 0.78 – For positive screen >10 – Take 5-10 minutes, self administered, could be self-scored
• PHQ-2 – Sensitivity = 0.83; Specificity = 0.92 – For positive screen >3 – Takes Less than 1 minutes, self administered and can be asked
• PHQ-9 – Sensitivity = 0.88; Specificity = 0.88 – For positive screen >10 – Takes 5-10 minutes, self administered, could be self-scored
Muzik M, et al. Ment Health Fam Med. 2010;7(4):239-247.
![Page 24: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/24.jpg)
ACOG/APA GUIDELINES
• Mild or moderate depression but no personal or family history – START WITH THERAPY such as
– Self-help strategies (support groups, yoga, mindfulness) – Counseling (IPT, CBT)
• Moderate depression and personal or family history
of depression, or active severe depressive episode – Start THERAPY AND MEDICATIONS at once
• Treatment-resistant depression – Consider augmenting with mood stabilizer/antipsychotics or
ECT
ACOG = American College of Obstetricians and Gynecologists; APA = American Psychiatric Association; IPT = interpersonal psychotherapy; CBT = cognitive-behavioral therapy. Yonkers KA, et al. Gen Hosp Psychiatry. 2009;31(5):403-413.
![Page 25: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/25.jpg)
Treatment Options
![Page 26: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/26.jpg)
Psychotherapies
• Interpersonal psychotherapy (IPT) • Cognitive-behavioral therapy (CBT) • Behavioral activation (BA) • Dyadic relational/attachment interventions • Home based interventions
Grote NK, et al. Psychiatr Serv. 2009;60(3):313-321. Spinelli MG, et al. Am J Psychiatry. 2003;160(3):555-562. O’Hara MW, et al. Arch Gen Psychiatry. 2000;57(11):1039-1045. O’Mahen H, et al. Depress Anxiety. 2013;30(7):679-687. Dimidjian S, et al. Clin Obstet Gynecol. 2009;52(3):498-515
![Page 27: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/27.jpg)
Antidepressants vs. CBT Vs. Placebo for Moderated to Severe Depression
25%
50%
43% 46%
40%
0%
10%
20%
30%
40%
50%
60%
Placebo (n = 60) ADM (n = 120) CT (n = 60)
8 Weeks 16 Weeks
Res
pond
ers
(%)
![Page 28: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/28.jpg)
Complementary and Alternative Treatments
• Light therapy • Exercise • Mindfulness • Yoga • Omega 3 Fatty Acids • SAM-e
– 1600mg/day 70% in depression over 30 days in women with postpartum depression
• St. John’s wort (mild depression) • N-acetylcysteine • Vitamin D (treat if deficient) • Vitamin B12 (treat if deficient)
ADM = antidepressant medication; CT = cognitive therapy. DeRubeis RJ, et al. Arch Gen Psychiatry. 2005;62(4):409-416; Qureshi, NA, et al. Neuropsychiatric Disease and Treatment 2013; 9 639-658
![Page 29: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/29.jpg)
COMPLEMENTARY AND ALTERNATIVE MEDICINE
Not the primary treatment for mood disorders.
More research necessary.
![Page 30: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/30.jpg)
Severe depression, bipolar disorder, and treatment resistant depression require
antidepressants, mood stabilizers, and atypical antipsychotics
![Page 31: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/31.jpg)
Mary is No Getting Better
• Mary is now 2 months postpartum. • She has met with her therapist a couple of times but she is
getting more depressed and dysfunctional • She and her husband are now worried about postpartum
depression given her prior history • She agrees to start medicine now • She still desires to breastfeed? • Prior medication trials: sertraline, bupropion, clonazepam,
fluoxetine (remission), venlafaxine (remission)
How do you address the risk-benefit discussion?
![Page 32: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/32.jpg)
Key Point #3
• Use what worked in the past! • Encourage families to be open • Encourage families to reflect on family history
![Page 33: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/33.jpg)
Consult with Doctor
• We can use antidepressants and mood stabilizers during pregnancy and in post-partum.
• Always important to weight risks and benefits
![Page 34: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/34.jpg)
Breastfeeding
• All medications transferred to breast milk, but concentrations are far less than in utero exposure.
• Drug transfer to the breast milk and to baby is variable by medication but ranging from <1-20% – Least likely to transfer: paroxetine, sertraline,
TCAs • Avoid drugs with a long half-life; possibility of
accumulation in breast milk • Check baby for adverse effects: drowsiness, poor
feeding, monitor CBC, comp, TSH.
Fortinguerra F, et al. Pediatrics. 2009;124(4):e547-e556. Payne JL, et al. Clin Obstet Gynecol. 2009;52(3):469-482. Eberhard-Gran M, et al. CNS Drugs. 2006;20(3):187-198.
![Page 35: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/35.jpg)
ECT
• Safe application in pregnancy • No teratogenic effects • No intrauterine growth restriction • No neurodevelopmental toxicity • Some adverse effect on neonate: cyanotic, low
muscle tone • 2nd and 3rd trimester: Women should be
positioned slightly toward left side with support under the right hip to prevent vena cava compression syndrome
![Page 36: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/36.jpg)
Practical “Take Aways” • Always balance the risks of medication and reoccurrence of
illness – Aiming to minimize fetal/neonate exposure to both
maternal mental illness and medication • Avoid polypharmacy • Non-pharmacological interventions should be a key
component of the treatment plan. • Use lowest effective dose BUT dose adequately • Use medications with the lowest teratogenic risk • History of previous treatment response should help guide
decisions • Provide written materials to explain the risks • Document in your notes that you discussed and they voiced
understanding
![Page 37: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/37.jpg)
Road to Recovery and Treatment Engagement
“One small crack does not mean that you are broken, it means that you
were put to the test and you didn’t fall apart” – Linda Poindexter
![Page 38: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/38.jpg)
Road to Recovery
• Acceptance – Mental Illness is REAL – It cannot be ignored – Sooner you accept; the easier recovery will be – Remove judgement and negative emotion – Mental Illness does not define you
![Page 39: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/39.jpg)
Road to Recovery
• Overcoming Fear – Fear, embarrassment, guilt are often preventing
people from getting help – Educate, Educate, Educate! – Increase support
• Groups, therapist, other providers, family, friends
![Page 40: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/40.jpg)
Road to Recovery
• Being Patient – Every step is putting you closer to the goal of
recovery – Some frustration is Normal – Recognize the old you returning – Engage family members – Keep note of initial symptoms of relapse – Recovery is not always “perfect” – There is not always a right way
![Page 41: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/41.jpg)
Road to Recovery
• Encourage “positive thinking” • “Be kind to yourself” • Celebrate success! • Stay in the present • Empower them to be their own advocate • Review Distress Tolerance Skills • Use Motivational Interviewing
![Page 42: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/42.jpg)
What can you do
• Talk to them – Express concern and support – Opportunity to provide information, support, and
guidance – Improved recognition of early signs – Earlier treatment – Greater understanding and compassion
• Connect them to other supports – School counselor, primary care provider, spiritual
leader, etc
![Page 43: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/43.jpg)
What Can Family/Friends Do
• Offer to help with every day tasks • Including your friend or family member in your
plans: – Continue to invite him or her without being
overbearing – Continue to invite them even if they resists your
invitations • Educate other people so they understand the facts
about mental health and do not discriminate • Treat people with respect, compassion, and empathy www.mentalhealth.gov
![Page 44: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/44.jpg)
Other things that are helpful?
• Know how to connect people to help • Communicate in a straightforward manner • Speak at a level appropriate to a person’s age
and developmental level • Discuss the topic when and where the person
feels safe and comfortable • Watch for reactions during the discussion and
slow down or back up if the person becomes confused or looks upset.
![Page 45: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/45.jpg)
Similar to Other Health Problems
• Cold vs. Flu • Management of High Cholesterol • Management of Diabetes “Just like people need to take medicine and get
professional help for physical conditions, someone with a mental health problem may need to take a medicine and/or participate in therapy
to get better”
![Page 46: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/46.jpg)
Key Point #4
Building a Good Relationship is Key? (Think about Your Favorite Teacher or Favorite Boss)
![Page 47: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/47.jpg)
Risk Factors • Biopsychosocial Risk Factors
– Hopelessness – Impulsive and/or aggressive tendencies – History of trauma or abuse – Family history of suicide – Past behavior – Alcohol and other substance use disorders
• Environmental Risk Factors – Relational or social loss – Easy access to lethal means – Local clusters of suicide that have a contagious influence
• Sociocultural Risk Factors – Lack of social support and sense of isolation – Stigma associated with help-seeking behavior – Certain cultural and religions beliefs – Barriers to assessing substance abuse health care treatment
![Page 48: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/48.jpg)
TREATMENT ENGAGEMENT
We should no longer whisper about mental illness
![Page 49: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/49.jpg)
Key Point #5
Do not forget about yourself!
![Page 50: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/50.jpg)
Take Care of Yourself
• Eating right • Sleep well • Exercise • Take breaks when necessary • It is okay to ask for help • Do things you enjoy • Use coping techniques • Talk to someone • Do things you enjoy!
![Page 51: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/51.jpg)
Thank you
• Michigan Home Visiting Conference Organizers
• Dr. Muzik and Dr. Rosenblum • Mary Ludtke • Thank you to my patients! (Always teaching
me about how to be a better clinician and how to improve mental wellness).
![Page 52: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/52.jpg)
Questions?
![Page 53: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/53.jpg)
IF YOU ARE INTERESTING IN LEARNING MORE ABOUT
MEDICATION MANAGEMENT
![Page 54: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/54.jpg)
What Do You Have to Consider When Treating with Medications?
• Teratogenicity (congenital malformations)
• Toxicity for pregnancy/fetal outcomes – SA – PTB – LBW – SGA
• Neonatal syndrome
• Neurobehavioral/developmental effects
SA = spontaneous abortion; PTB = preterm birth; LBW = low birth weight; SGA = small for gestational age.
![Page 55: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/55.jpg)
Teratogenity Baseline Risk
• Baseline population risk for any malformation is 2-4% among healthy, unexposed women
• Thus, any medicine risk must be measured against this baseline risk
![Page 56: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/56.jpg)
FDA Pregnancy Categories
• Are not enough information and misleading
A Well controlled studies in human pregnancy show no increased risk (<1% of medications)
B Animal studies show no risk OR While animal data show risk well controlled human studies do not C Animal studies show risk and no well controlled human studies available
OR There are no animal or well controlled human studies (66% of
medications) D Human data show risk OR Benefits may outweigh known risk
X Animal or human data show fetal risk positive; the risk clearly outweighs the benefit
![Page 57: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/57.jpg)
Problems with Studies
• Confounding factors are not taken into account in studies – Maternal age – Other prescription and non-prescription drugs – Nutrition – ETOH/cigarettes – Genetic influences – Effects of mental illness or comorbid health conditions – Environmental toxins – Stress – Socioeconomic status – Method of delivery
![Page 58: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/58.jpg)
Teratogenicity
• TCA overall risk is low
• SSRIs overall risk is low
• Other antidepressants less data but assuring – Bupropion: cardiac malformation risk minimal (2/1000) – Venlafaxine, duloxetine, mirtazapine: no malformation risk
TCA = tricyclic antidepressant; SSRI = selective serotonin reuptake inhibitor. Altshuler LL, et al. Am J Psychiatry. 1996;153(5):592-606. Einarson A. Can J Clin Pharmacol. 2009;16(1):e58-e65. Alwan S, et al. N Engl J Med. 2007;356(26):2684-2692. Louik C, et al. N Engl J Med. 2007;356(26):2675-2683. Lennestal R, et al. J Clin Psychopharmacol. 2007;27(6):607-613. Grigoriadis S, et al. J Clin Psychiatry. 2013;74(4):e293-e308. Byatt N, et al. Acta Psychiatr Scand. 2013;127(2):94-114. Einarson A. Acta Psychiatr Scand. 2013;127(2):115-116. Myles N, et al. Aust N Z J Psychiatry. 2013;47(11):1002-1012. Alwan S, et al. Am J Obstet Gynecol. 2010;203(1):52.e1-52.e6. Einarson A, et al. Am J Psychiatry. 2001;158(10):1728-1730. Way CM. Pharmacotherapy. 2012;27(4):546-552. Djulus J, et al. J Clin Psychiatry. 2006;67(8):1280-1284.
![Page 59: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/59.jpg)
The “Paxil” Story
• In 2005 GlaxoSmithKline analyzed own data on N = 815 exposed infants, and found that these infants had 1.5- to twofold increased risk for heart defects, specifically atrial and ventricular septal defects paroxetine became FDA Category D
• Since 2005 many contradicting studies. Some found… – Increased risk for unspecific malformations – Increased risk for specific cardiac malformations
– No risk for malformation (risk .7%) – Risk is dose-dependent(>25 mg/day) and only when exposed in first
trimester
US Food and Drug Administration. www.fda.gov/downloads/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/UCM164864.pdf. Accessed July 7, 2014. Cole JA, et al. Pharmacoepidemiol Drug Saf. 2007;16(10):1075-1085. Kallen BA, et al. Birth Defects Res A Clin Mol Teratol. 2007;79(4):301-308. Wurst KE, et al. Birth Defects Res A Clin Mol Teratol. 2010;88(3):159-170. Reis M, et al. Psychol Med. 2010;40(10):1723-1733. Bakker MK, et al. Birth Defects Res A Clin Mol Teratol. 2010;88(2):94-100. Einarson A, et al. Am J Psychiatry. 2008;165(6):749-752. Berard A, et al. Birth Defects Res B Dev Reprod Toxicol. 2007;80(1):18-27. Painuly N, et al. Psychiatric Bulletin. 2013;37:198-203.
![Page 60: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/60.jpg)
Most Recent Study on Paroxetine
• Large, population-based cohort study b/w 2000 to 2007 • Participants: 949,504 pregnant women who were enrolled in
Medicaid during the period from 3 months before the last menstrual period through 1 month after delivery and their live born infants
• How many exposed? 64,389 women (6.8%) used ADs during the first trimester
• Finding: RR for cardiac malformation was 1.06 (95% CI, .93-1.22) in the fully adjusted analysis restricted to women with depression
• Conclusion: no substantiated risk between AD (in particular sertraline and paroxetine) and cardiac risk
• Funded by the Agency for Healthcare Research and Quality and the National Institutes of Health
AD = antidepressant; RR = relative risk. Huybrechts KF, et al. N Engl J Med. 2014;370(25):2397-2407.
![Page 61: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/61.jpg)
Neonatal Syndromes
• NAS in 25-30% for SSRIs and more common TCAs
– With 2nd (?) or 3rd trimester exposure
– Jitteriness, irritability, difficulty with feeding, breathing, hypotonia, temperature instability, seizure
– Long-term effect (19 months): no developmental effect
– Does not typically require NICU admission, transient ~2 weeks
– One study showed no difference in NAS rates with stopping medication 2 weeks prior to delivery (retrospective registry study)
NAS = neonatal abstinence syndrome; NICU = neonatal intensive-care unit. Oberlander TF, et al. Arch Gen Psychiatry. 2006;63(8):898-906. Moses-Kolko EL, et al. JAMA. 2005;293(19):2372-2383. Way CM. Pharmacotherapy. 2007;27(4):546-552. Warburton W, et al. Acta Psychiatr Scand. 2010;121(6):471-479. Levinson-Castiel R, et al. Arch Pediatr Adolesc Med. 2006;160(2):173-176. Grigoriadis S, et al. J Clin Psychiatry. 2013;74(4):e309-e320. Pedersen LH, et al. Pediatrics. 2010;125(3):e600-e608.
![Page 62: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/62.jpg)
Neonatal Syndromes (continued)
• Persistent pulmonary hypertension – At birth the normative closure of ductus arteriosus and foramen ovale does
not happen and they stay open leading to a left-to-right shunting of blood causing
– Hypoxia in neonatal organism – If chronic: right ventricle failure
• Base rate: 2/1000 • Absolute risk with exposure to SSRIs 6 x higher but still rare • Other possible risk variables: C-section, BMI, race • Revised FDA communication in 2012 noting that earlier the risk was
overestimated BMI = body mass index. Chambers CD, et al. N Engl J Med. 1996;335(14):1010-1015. Chambers CD, et al. N Engl J Med. 2006;354(6):579-587. Kallen B, et al. Pharmacoepidemiol Drug Saf. 2008;17(8):801-806. Andrade SE, et al. Pharmacoepidemiol Drug Saf. 2009;18(3):246-252. Occhiogrosso M, et al. Am J Psychiatry. 2012;169(12):134-140. Wilson KL, et al. Am J Perinatol. 2011;28(1):19-24. Grigoriadis S, et al. BMJ. 2014;348:f6932. Hernandez-Diaz S, et al. Pediatrics. 2007;120(2):e272-e282. US Food and Drug Administration. www.fda.gov/Drugs/DrugSafety/ucm283375.htm. Accessed July 7, 2014.
![Page 63: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/63.jpg)
Spontaneous Abortion
• Antidepressant-related to increased risk for SA – N = 3567 12.4% on antidepressants vs 8.7% off – No difference between various classes of antidepressants – None of the studies took confounders into consideration such
as – Poor health habits, psychiatric illness, smoking, etc – This reduces the clinical utility of findings
• Bupropion appears to have higher risk for SA than SSRIs
Hemels ME, et al. Ann Pharmacother. 2005;39(5):803-809. Ross LE, et al. JAMA Psychiatry. 2013;70(4):436-443. Chun-Fai-Chan B, et al. Am J Obstet Gynecol. 2005;192(3):932-936. Einarson A, et al. J Obstet Gynaecol Can. 2009;31(5):452-456.
![Page 64: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/64.jpg)
Preterm birth, low birth weight
• Antidepressant-related to near-term PTB (defined as birth >35 weeks but <37 weeks)
– Gestational age dependent on duration of exposure to antidepressant; longer exposure related to shorter gestation
• Antidepressant-related to increased risk for SGA
• Antidepressant exposure related to LBW; effect is minimal (~75 g less) and disappears when control group are untreated depressed mothers Wisner KL, et al. Am J Psychiatry. 2009;166(5):557-566. Suri R, et al. Am J Psychiatry. 2007;164(8):1206-1213.
Lund N, et al. Arch Pediatr Adolesc Med. 2009;163(10):949-954. Oberlander TF, et al. Br J Psychiatry. 2008;192(5):338-343. Oberlander TF, et al. Arch Gen Psychiatry. 2006;63(8):898-906. Kallen B. Arch Pediatr Adolesc Med. 2004;158(4):312-316.
![Page 65: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/65.jpg)
Neurobehavioral Toxicity
• TCA or fluoxetine exposure—no global IQ, language, or behavioral problems at 15 months and 7 years of age (N = 219; N = 122)
• No effects on motor performance and attention/learning tasks in 6-month-old babies who were SSRI exposed; but, babies exposed to antipsychotics did worse on neurological motor tasks
• Minor motor developmental delay in toddlers exposed to SSRIs
Nulman I, et al. N Engl J Med. 1997;336(4):258-262. Nulman I, et al. Am J Psychiatry. 2002;159(11):1889-1895. Nulman I, et al. Am J Psychiatry. 2012;169(11):1165-1174. Johnson KC, et al. Arch Gen Psychiatry. 2012;69(8):787-794. Casper RC, et al. J Pediatr. 2008;142(4):402-408. Gentile S, et al. J Affect Disord. 2011;128(1-2):1-9.
![Page 66: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/66.jpg)
Neurobehavioral Toxicity (continued)
• Two large population-based case-control studies hint at association between SSRI use and ASD in offspring – However, while significant SSRI explain only .6% of cases with
ASD
• A study of nearly 1000 mother-child dyads suggested that boys are significantly more at risk for ASD than girls if their mothers took an SSRI during pregnancy, especially during the first trimester
• Recent review concludes that exposure during the first trimester may increase the risk of ASD, however confounders were not assessed
ASD = autism spectrum disorder. Croen LA, et al. Arch Gen Psychiatry. 2011;68(11):1104-1112. Rai D, et al. BMJ. 2013;346:f2059. Harrington RA, et al. Pediatrics. 2014;[Epub ahead of print]. Andrade C. J Clin Psychiatry. 2013;74(9):940-941.
![Page 67: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/67.jpg)
Case: Mary
• Mary and her husband agree that she will start an antidepressant
• Which one?
• Past trials: sertraline, fluoxetine, bupropion XL, venlafaxine
![Page 68: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/68.jpg)
KEY POINT #3
Use what has worked in the past (Single exception: valproate in pregnancy)
![Page 69: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/69.jpg)
Case: Mary
• Previously euthymic on fluoxetine 40 mg
• Plan: restart fluoxetine 10 mg x 5 days, then 20 mg and titrate to 40 mg
“START LOW, GO SLOW, KEEP GOING”
“I am so anxious that I am crawling out of my skin!”
“Every time I increase the dose, I get more anxious and my sleep is
even worse for a few days.”
![Page 70: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/70.jpg)
Are anxiety meds safe?
• No evidence of congenital malformation – Initial concern cleft lip/palate, disproven
• Lorazepam and clonazepam preferred
– Less likely to accumulate in fetus/neonate – Alprazolam rapid on/off = unknown fetal effects
• 550 infants with normal development to 4 yo
Iqbal MM, et al. Psychiatr Serv. 2002;53(1):39-49. McElhatton PR. Reprod Toxicol. 1994;8(6):461-475. REPROTOX. http://reprotox.org/Default.aspx. April 2013.
![Page 71: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/71.jpg)
Sleep and Perinatal Depression
• 70% of pregnant women report poor sleep
• Women with poor sleep have higher EPDS score ≥10 (39% vs 20% HC; P < .01)
• Women with sleep <6 hours/night compared to 7-9 hours/night have more depressive symptoms (60% vs 31%, P = .03)
• 45% of pregnant and 55% of postpartum women with depressive symptoms also report clinical insomnia
• Sleep disturbances in the 2nd trimester predict significant depressive symptoms in the 3rd trimester
• Sleep disturbances during pregnancy predict significant depressive symptoms postpartum
OlBrien LM, et al. Am J Obstet Gynecol. 2012;207(6):487.e1-487.e9 . Swanson LM, et al. J Womens Health. 2011;20(4):553-558. Kamysheva E, et al. J Affect Disord. 2010;123(1-3):317-320. Dorheim SK, et al. Sleep. 2009;32(7):847-855. Okun ML, et al. Depress Anxiety. 2011;28(8):676-685.
![Page 72: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/72.jpg)
Treatment in Pregnancy • Stress reduction
– Massage, relaxation, and meditation techniques
• Sleep hygiene – Warm bath 1 hr before bed
raises core temp and stimulates sleep response
• CBT-I or medications – Diphenhydramine – Zolpidem – Trazodone – Tranquillizer
Treatment while Breastfeeding • Stress reduction
– Massage, relaxation, and meditation techniques
• Sleep hygiene – Warm bath 1 hr before bed raises core
temp and stimulates sleep response – Help w/ infant care and feeding – Minimize use of alcohol (paradoxical
effects)
• If ≥ 4 days CBT-I or medications
Khazaie H, et al. Psychiatry Res. 2013;210(3):901-905. Wikner BN, et al. J Clin Psychopharmacol. 2011;31(3):356-359.
Clinical Pearl: Insomnia x 4 Nights = Red Flag
![Page 73: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/73.jpg)
Sleep Medications
• Benzodiazepines – Teratogenity: 1st trimester—possible cleft lip malformation (old
data) but this has not been replicated in later studies – 3rd trimester—floppy baby syndrome, withdrawal symptoms and
restlessness in neonates, PTB, LBW
• Trazodone – No malformations
• Zolpidem
– Possibly some increased risk for PTB, SGA, LBW—but clinically low significance; low risk for malformation
Wikner BN, et al. Pharmacoepidemiol Drug Saf. 2007;16(11):1203-1210. Wikner BN, et al. J Clin Psychopharmacol. 2011;31(3):356-359. Einarson A, et al. Can J Psychiatry. 2009;54(4):242-246. Juric S, et al. Arch Womens Ment Health. 2009;12(6):441-446. Wang LH, et al. Clin Pharmacol Ther. 2010;88(3):369-374.
![Page 74: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/74.jpg)
Valproic Acid
• Teratogenicity: 10%, particularly if exposure in 1st trimester – Risk is dose dependent (>1000 mg/day) – Midface hypoplasia and other facial anomalies – Cardiac anomalies – Folate supplementation up to 5 mg daily may reduce risk
• Intrauterine growth restriction • Mental retardation—independent of which trimester exposure • Neonatal toxicity
– Irritable, jittery, hypotone, feeding difficulties, liver toxicity – Hypoglycemia
• Single dosing causes higher peaks • Mostly exposure in unplanned pregnancy end of 1st trimester Wyszynski DF, et al. Neurology. 2005;64(6):961-965. Morrow J, et al. J Neurol Neurosurg Psychiatry. 2006;77(2):193-198. Meador KJ, et al. N Engl J Med. 2009;360(16):1597-1605.
![Page 75: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/75.jpg)
Lamotrigine
• Teratogenicity – 3 out of 4 registries report no more than baseline population risk for
malformations (2-4%) – 1 out of the 4 registries suggested increase in RR for midline facial
clefts with 1st trimester exposure; but absolute risk is very low (4:1000)
• Neonatal toxicity – Transient liver toxicity – Watch skin rash
• Increased excretion in pregnancy need to increase dose in later gestation
Cunnington M, et al. Neurology. 2005;64(6):955-960. Meador KJ, et al. Neurology. 2006;67(3):407-412. Clark CT, et al. Am J Psychiatry. 2013;170(11):1240-1247.
![Page 76: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/76.jpg)
Lithium
• Teratogenicity – Risk for cardiac malformation—Ebstein’s anomaly (tricuspidal
displacement/right ventricle hypoplasia) – Initial risk was overstated in the 1970s – Population risk is: 1 : 20,000 (.00005%) – Lithium-exposed risk is: 1-2 : 1,000 (.001-.002%) – Therefore, while the RR is increased by 20- to 40-fold, the absolute
risk for Ebstein’s anomaly is still extremely low when on lithium • Risk for neonatal toxicity
– Floppy baby, cyanose, hypotone, hypothyroidism, nephrogenic diabetes insipidus
– Clearance is increased in late pregnancy—dose increase! Gentile S. Expert Opin Drug Saf. 2012;11(3):425-437.
![Page 77: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/77.jpg)
Carbamazepine
• Teratogenicity: 2.6% same as general population – Neural tube exposure 1st trimester, dose related-spina bifida: risk 2.6x higher than
the general population rate of 1:1000 births—so absolute risk rate still small – Craniofacial and other facial anomalies not confirmed higher risk – Oxcarbazepine safe – Screening: maternal α-fetoprotein (blood) and 2D or 3D ultrasound weeks 16-20 – Vitamin K prophylaxis: start week 36 to prevent hemorrhagic disease in the
newborn (carbamazepine induces cytochrome P450 enzyme which degrades Vitamin K)
• Intrauterine growth restriction • Neonatal toxicity
– Transient liver toxicity – Neonatal bleeding, administer Vitamin K 1 mg to baby
• Mostly exposure in unplanned pregnancies or epilepsy patients The North American Antiepileptic Drug Pregnancy Registry. Winter 2009. www2.massgeneral.org/aed/newsletter/Winter2009newsletter.pdf. Accessed July 7, 2014. Morrow J, et al. J Neurol Neurosurg Psychiatry. 2006;77(2):193-198. Harden CL, et al. Neurology. 2009;73(2):133-141. Jentink J, et al. BMJ. 2010;341:c6581.
![Page 78: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/78.jpg)
First-Generation Antipsychotics
• Exposure to phenothiazines during pregnancy (N = 1309) – No differences were found in rates of congenital malformations,
perinatal mortality rate, birth weight as compared to the population
• Pregnancy exposure to haloperidol (N = 215) – No increase risk for major malformations
• Increased incidence of PTB and neonatal adaptation but not
malformation compared to unexposed
Slone D, et al. Am J Obstet Gynecol. 1977;128(5):486-488. Diav-Citrin O, et al. J Clin Psychiatry. 2005;66(3):317-322. Habermann F, et al. J Clin Psychopharmacol. 2013;33(4):453-462; Gentile S. Schizophr Bull. 2010; 36(3): 518–544.
![Page 79: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/79.jpg)
Second-Generation Antipsychotics
• Limited data on exposed children! • Manufacturers’ registries: olanzapine = 242, clozapine = 523,
quetiapine = 446, risperidone = 250 • Case reports: clozapine= 74, olanzapine = 69, quetiapine = 3
risperidone = 12 • Prospective comparative study
– 151 women were followed exposed to following drugs – Olanzapine = 60, risperidone = 49, quetiapine = 36, clozapine = 6
– The researchers found no teratogenic effects • 570 women in Swedish database were exposed to SGA: slight
increased risk for major malformations (OR 1.5) • Increased incidence of PTB and neonatal adaptation but not
malformation compared to unexposed SGA = second-generation antipsychotic. McKenna K, et al. J Clin Psychiatry. 2005;66(4):444-449. Reis M, et al. J Clin Psychopharmacol. 2008;28(3):279-288. Habermann F, et al. J Clin Psychopharmacol. 2013;33(4):453-462.
![Page 80: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/80.jpg)
Second-Generation Antipsychotics (continued)
• Neurobehavioral development – Single study from Hong Kong
– Exposed = schizophrenia, 50% clozapine
– Control = no mental illness
– Exposed with significant delays at 2 to 4 months but caught up on all measures by 1 yo
• Aripiprazole: 3 case reports
• Ziprasidone: 3 case reports
• Overall: increased risk for EPS in neonate with antipsychotics
• 2011 FDA drug safety communication (EPS)
EPS = extrapyramidal symptoms. Peng M, et al. Psychopharmacology. 2013;228(4):577-584. REPROTOX. http://reprotox.org/Default.aspx. April 2013. Galbally M, et al. Therapeutic Advances in Drug Safety. 2014;5(2):100-109.
![Page 81: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/81.jpg)
Case: Mary
• Mary had an uneventful vaginal delivery at 39 weeks
• She experienced some worsening mood and disrupted sleep in the first week postpartum
• She wants to breastfeed and mild ejection is slow; this has been stressful. She is also concerned
“I want to breastfeed my baby”
“Is it safe for my baby to be on clonazepam and fluoxetine?”
![Page 82: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/82.jpg)
Medications and Breastfeeding
• All medications transferred to breast milk, but concentrations are far less than in utero exposure
• <10% of maternal serum plasma is considered compatible with breastfeeding – Fluoxetine: 5-9% of maternal dose
– Other SSRIs: range from 1-20%
– Carbamazepine: <1%
– Lorazepam, clonazepam: <1%
• Avoid drugs with a long half-life: possibility of accumulation in breast milk
• Check baby for adverse effects: drowsiness, poor feeding, monitor CBC, comp, TSH , CAVE: premies Chad L, et al. Can Fam Physician. 2013;59(6):633-634. Fortinguerra F, et al. Pediatrics. 2009;124(4):e547-e556.
![Page 83: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/83.jpg)
Breastfeeding
• Antidepressants – Breastfeeding OK, drug transfer to breast milk and to baby variable
by medication but ranging from <1-20%
– Least likely to transfer: paroxetine, sertraline, TCAs
– Rule: continue the medicine used in pregnancy or start agent that was effective in prior medication trials
Fortinguerra F, et al. Pediatrics. 2009;124(4):e547-e556. Payne JL, et al. Clin Obstet Gynecol. 2009;52(3):469-482. Eberhard-Gran M, et al. CNS Drugs. 2006;20(3):187-198.
![Page 84: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/84.jpg)
Breastfeeding (continued)
• Benzodiazepines – Breastfeeding OK as minimal excreted in breast milk (clonazepam,
lorazepam OK)
Fortinguerra F, et al. Pediatrics. 2009;124(4):e547-e556. Payne JL, et al. Clin Obstet Gynecol. 2009;52(3):469-482.
![Page 85: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/85.jpg)
Breastfeeding (continued)
• Lithium – Breastfeeding not recommended as baby vulnerable for dehydration
and lithium toxicity
– If mother insists, need to perform blood draws in first weeks to check how much lithium transferred via mild; transfer is variable up to 30%
Fortinguerra F, et al. Pediatrics. 2009;124(4):e547-e556. Payne JL, et al. Clin Obstet Gynecol. 2009;52(3):469-482. Viguera AC, et al. Am J Psychiatry. 2007;164(2):342-345. Eberhard-Gran M, et al. CNS Drugs. 2006;20(3):187-198.
![Page 86: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/86.jpg)
Breastfeeding (continued)
• Valproic acid – Breastfeeding OK, infant serum level 6% of mom, no adverse effects
• Carbamazepine
– Breastfeeding OK, infant serum 6-65% of mom, no adverse effects
• Lamotrigine – Breastfeeding OK, 30% mom dose, no adverse effects
Davanzo R, et al. Ital J Pediatr. 2013;39:50. Eberhard-Gran M, et al. CNS Drugs. 2006;20(3):187-198.
![Page 87: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/87.jpg)
ECT
• Safe application in pregnancy
• No teratogenic effects, no intrauterine growth restriction, no neurodevelopmental toxicity
• Some adverse effect on neonate: cyanotic, floppy, hypotone
• 2nd and 3rd trimester: women should be positioned slightly toward their left side with support under the right hip when receiving ECT to prevent a vena cava compression syndrome
ECT = electroconvulsive therapy. Rabheru K. Can J Psychiatry. 2001;46(8):710-719.
![Page 88: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/88.jpg)
Summary
1. Treatment of perinatal mood disorders aims to minimize fetal/neonatal exposure to both maternal mental illness and medication
2. Nonpharmacologic interventions should be a key component of the treatment plan
3. Use what has worked in the past (Single exception: valproate in pregnancy)
![Page 89: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/89.jpg)
Resources
• Pregnancy – www.reprotox.org – www.motherisk.org
• Lactation – http://toxnet.nlm.nih.gov – www.medsmilk.com
![Page 90: Depression In Pregnancy and Postpartum: Screening ... · the postnatal period. • Depression amongst fathers is associated with: – having depressed partners – having an unsupportive](https://reader036.vdocuments.mx/reader036/viewer/2022081600/6047f30e9b984b0c9e7cd9ba/html5/thumbnails/90.jpg)
THANK YOU
Questions?