jorgensen postpartum depression.pptx

7/27/2019 Jorgensen postpartum depression.pptx

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Postpartum MoodDisorders


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Primary Objectives

Review the range of pregnancy related

mood disorders

Discuss the risk factors for developing a

pregnancy related disorder

Identify screening strategies

Review treatment options during pregnancy

and postpartum


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Secondary Objectives

Review the prevalence of mood disorders

in women

Investigate the etiology of pregnancy

related mood disorders

Discuss the familial implications of these

illnesses

Discuss prevention strategies


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Major Depressive Disorder

Leading cause of disability

Prevalence of 5-9%

Lifetime risk of 10-25%


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Peripartum Depressive Disorders

Antepartum Depression

Postpartum Blues

Postpartum Depression (PPD)

Postpartum Psychosis (PPP)


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Symptoms often seen in non-depressedpregnant women Sleep and appetite disturbance

Diminished libido

Low energy

Pregnancy related conditions are associatedwith depressive symptoms Anemia

Gestational diabetes

Thyroid dysfunction


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Postpartum Blues

Aka baby blues

Characteristics:

Mild mood swings Irritability

Anxiety

Decreased concentration Insomnia

Tearfulness

Crying spells


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Postpartum Blues

Occur within 2-3 days of delivery

Symptoms peak on 4th or 5th postpartum day

Symptoms resolve within 2 weeks


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Postpartum Depression

Same DSM IV criteria as for non-pregnancyrelated depression

Symptoms usually begin in initial 12months after delivery

Symptoms often seen as normal for newmothers caring for a newborn


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Symptoms of PPD

Change in somatic function

Significant anxiety

Intense irritability and anger

Feelings of guilt


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Symptoms of PPD

Sense of being overwhelmed

Unable to care for baby

Feelings of inadequacy

Not bonding with the baby


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Postpartum Psychosis

Usually a manifestation of bipolar disorder

Typically presents within 2 weeks of

delivery

May develop few months after birth as

delusional depression


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Signs and Symptoms of PPP

Severe insomnia

Rapid mood swings

Anxiety

Psychomotor restlessness

Delusions and hallucinations


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Fetal Implications

Increased rate of:

Preterm birth

Low birth weight

Small head circumference

Low APGAR scores


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Familial Implications

Postnatal depression in men

Interference with maternal-infant bonding,

increases moms sense of shame and guilt

Influences infant development


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Familial Implications

Negative interactive patterns with infant

Children exposed to maternal psychiatric

illness have:

Higher incidence of conduct disorders

Inappropriate aggression

Cognitive and attention deficits


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Prevalence

Postpartum blues occur in 4080% of

women

PPD affects 1030% of women

Postpartum psychosis is rare


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Prevalence 10% of all pregnancies

Increased risk for women with history of

affective illnesses

Relapses most common in the first trimester

1/3 of all cases represent first episode of

depression


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Prevalence in Active Duty

Positive depression screen

Antepartum

Postpartum

Suicide ideation rate


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Risk Factors for PPB

History of depression or premenstrual moodchanges

Depressive symptoms during pregnancy

Family history of depression

Concern about child care

Psychosocial impairment


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PPD Risk Factors

Personal history of depression

Family psychiatric history

Marital conflict

Lack of perceived social support


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PPD Risk Factors

Lack of emotional & financial support from

partner

Living without a partner

Unplanned pregnancy

Previous miscarriage


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PPD Risk Factors

Having contemplated terminating

current pregnancy

Poor relationship with own mother

Not breastfeeding


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PPD Risk Factors

Unemployment in the mother

Lifetime history of depression in partner

Stressful life events in previous 12 months


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PPD Risk Factors

Child care related stressors

Sick leave during pregnancy

High number of prenatal visits

Congenitally malformed infant


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Risk Factors for PPP

History of bipolar disorder

History of psychosis prior to pregnancy

Family history of psychosis


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Co-morbidities

Decreased weight gain during pregnancy

Increased rate of tobacco use

Increased rate of alcohol and illicit drug use


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Etiology

No clear etiology

Possibly due to combination of:

Genetic susceptibility

Hormonal changes

Major life events


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Etiology

Investigators have examined the role of:

Estrogen

Progesterone Thyroid hormone

Testosterone

Cholesterol

Corticotropin-relasing hormone

Cortisol


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Screening - Overview

Important to identify proper timing of

screening

Avenues include both informal and formal

techniques

Various formal screening tools available


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Screening - Timing

Antepartum visits

During hospital stay

Postpartum visits

Well child visits


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Screening - Tools

Becks Depression Inventory (PDI)

Postpartum Depression Screening Scale

(PDSS)

Edinburgh Postnatal Depression Scale

(EPDS)


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Becks Depression Inventory

Self administered survey

21 questions scored 03

Score of over 17 indicates that patient

would benefit from professional assistance

56% of postpartum women with postpartum

depression identified in one study


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Postpartum Depression

Screening Scale 94% sensitive and 96% specific in initial

trials

35 item self-administered questionnaire

Uses 5 point scale


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Edinburgh Postnatal Depression

Scale 10 item questionnaire

Each response scored 03, with total score

of 30 possible

Scores > 12 or 13 identify most women

with postpartum depression


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EPDS

Score > 12 reported as 100% sensitive and

95% specific in detecting major depression

Studies comparing EPDS vs PCM

evaluation of patient show EPDS has a

higher incidence of detecting anddiagnosing postpartum depression


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Evaluation and Diagnosis

Labs- CBC, TSH

Consider urine drug screen if history of

drug use/abuse

DSM IV diagnosis criteria


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Diagnosis

DSM IV modifier

ICD coding

Postpartum depression 648.4

Major depression 296


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Treatment

Factors to address:

Biological

Psychological

Social

Demonstrated maximal clinical responsewith biopsychosocial approach


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Treatment

Psychosocial therapies

First choice for those with mild to moderate

symptoms of PPD

Cognitive-behavioral therapy

Interpersonal psychotherapy- focuses onpatients interpersonal relationship andchanging roles


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Psychosocial Therapies

Group therapy

Helps to increase support network

Family and marital therapy

More rapid recovery

More appreciative of partners contribution

Peer-support groups


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Psychosocial Therapies (cont)

Supportive psychotherapy

Groups that offer support and education

Postpartum Support International

www. postpartum.net

Depression After Delivery

www. depressionafterdelivery.com


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Interpersonal Therapy (IPT)

Short-term, manual-driven psychotherapy

Addresses four major problem domains:

Grief Interpersonal disputes

Role transitions

Interpersonal deficits

Shown to reduce symptoms in pregnantwomen


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Pharmacologic Therapy

No antidepressants are approved by theFDA for use during pregnancy

All psychotropic drugs are transferredthrough the placenta and breast milk

Consider prior history

SSRIs and TCAs have low detection inbreastfed infant serum


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Concerns for Psychotropic Use

Risk of pregnancy loss or miscarriage

Risk of organ malformation or teratogenesis

Risk of neonatal toxicity or withdrawal

syndromes

Risk of longterm neurobehavioral sequelae


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Neonatal Withdrawal TCAs

TCA withdrawal syndrome:

Jitteriness

Irritability Seizures

Anticholinergic effect of TCAs include: Functional bowel obstruction

urinary retention


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Neonatal Withdrawal - SSRIs

Transient symptoms of:

Irritability

Excessive crying

Increased muscle tone

Feeding problems

Sleep disruption Respiratory distress


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Long Term Sequelae

No significant difference in:

IQ

Temperament Behavior

Reactivity

Mood

Distractibility

Activity level


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Pharmacologic Therapy

Increase risk of suicide after initiation of

medication

If significant anxiety or insomnia present,

consider adding benzodiazepine

Close follow-up


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Antidepressant Choice

TCAs

Desipramine and Nortryptiline are preferred

Least anti-cholinergic affects

Minimize postural hypotension

SSRIs

Fluoxetine is the best studied


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Additional Considerations

Doses of both SSRIs and TCAs may need to

be increased in pregnancy secondary to:

Increased plasma volume Increased hepatic metabolism

Increased renal clearance


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Other Therapies

Hormonal Therapy

Increased risk of PPD if Depo-provera given

within 48 hrs of delivery Transdermal estradiol may improve symptoms

Treat severe anemia

Treat poorly controlled hypothyroidism


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Other Therapies (cont)

ECT

Few adverse effects to mom or infant

Good when rapid treatment is needed

For severe depression with psychotic symptomsor acute mania


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Length of Treatment

Based on patient history and severity of

symptoms

Continue 12 months after full remission

Continue meds through pregnancy to reduce

risk of relapse


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Referrals

Consider Psychiatric referral if:

Poor response to therapy

Relapse Major functional impairment

Suicidal or homicidal ideation


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Treatment of Postpartum

Psychosis Medical emergency

Patient should be hospitalized until stable

While psychotic, mom cannot adequately

care for self or infant


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Treatment of PPP (cont)

Medications focused on controlling bothpsychosis and mood swings

Combination therapy often necessary

Most will not be able to continue

breastfeeding

ECT may be highly effective


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Prevention

Monitor for signs in high risk women

Educate women and family members beforechildbirth

Counseling and increase social support prior to

delivery

Consider starting therapy during third trimester orimmediately after delivery


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Conclusion

Postpartum mood disorders are common

Military population has multiple risk factors

for developing postpartum depression Important to screen patients in a variety of

settings.

Treatment of postpartum depressionimportant for maternal and familial wellbeing

jorgensen postpartum depression.pptx

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