PERINATAL DEPRESSION

Improving Treatment Through Collaboration

P. Lynn Ouellette M.D.Director, MAPP Postpartum

Depression Project

OVERVIEW

• Depression during pregnancy: rates, significance,

• Postpartum Depression: rates, risk factors, significance, risks of untreated PPD

• Screening for PPD• Treatment of Perinatal Depression

MATERNAL DEPRESSION, ESPECIALLY PERINATAL

DEPRESSION, IS A PUBLIC HEALTH PROBLEM

DEPRESSION DURING PREGNANCY

DEPRESSION DURING PREGNANCY

• Between 10-20% of women will experience significant depression during pregnancy

• This will be a first episode for one third

• Most often this is unrecognized and untreated

SIGNIFICANCE

Untreated depression during pregnancy is associated with serious risks, short and long

term health and mental health consequences for mother and

her baby.

RISKS OF UNTREATED DEPRESSION DURING PREGNANCY

• Premature delivery• Low birth weight• More likely to be colicky, irritable babies• Poor compliance with prenatal care• Poor nutrition• Lower APGAR scores• Increased rate of stillborns (six times in one study)

• Increased admissions to neonatal ICU

RISKS OF UNTREATED DEPRESSION DURING PREGNANCY

• Higher rates of miscarriage • Higher risk of bleeding• More painful labor and higher use of analgesia• Increased alcohol and tobacco use• SUICIDE• POSTPARTUM DEPRESSION• Recurrent Major Depressions

LONGTERM CONSEQUENCES

• Prenatal anxiety, depression, and high stress lead to increased maternal cortisol transmitted to the fetus via the placenta

• Increasing research indicates that such fetal exposure to maternal adversity predisposes to: -cognitive and developmental delays -childhood behavioral and psychiatric illness

-adult onset psychiatric illness -medical illness in adulthood(Type II diabetes, HTN, metabolic syndrome,

etc)• Evidence shows that this can be mitigated by secure maternal attachment

and strong mothering • BUT, maternal adversity such as prenatal depression and anxiety predisposes

to postpartum psychiatric illness which further disrupts maternal infant attachment

POSTPARTUM DEPRESSION

THE MOST COMMON COMPLICATION OF

CHILDBIRTH IS DEPRESSION

PPD AS A PUBLIC HEALTH PROBLEM

• Over 4 million women give birth in America• One of every 8 new mothers experience

depression• Over half a million women will suffer postpartum

depression each year• Most common complication of childbearing• Causes serious and lasting effects on child health

and family functioning

1 Wisner K et al. N Engl J Med. 2002;347:194-199;2Wisner K et al. J Clin Psychiatry. 2001;62:82-86.

Epidemiology of Postpartum Episodes

Peak lifetime prevalence for psychiatric disorders and hospital admissions for women occurs in the first 3 months after childbirth)

Kendell RE et al. Br J Psychiatry. 1987;150:662-673.

0

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20

30

40

50

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Adm

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Pregnancy

–2 Years – 1 Year Childbirth +1 Year +2 Years

SPECTRUM OF POSTPARTUM MOOD DISORDERS

Postpartum Psychosis (0.1-0.2%)

Postpartum Depression (10-15%)

Postpartum Blues (50-85%)

None

POSTPARTUM BLUES• Very Common (80-85%) • Onset within 3-5 days after delivery• Symptoms include weepiness, sadness, fatigue,

irritability• Recommended “treatment” includes increased

partner (and community) support, walking, rest and possibly joining a new mother’s group

• Symptoms should resolve by 10 days, if not, consider PPD

POSTPARTUM PSYCHOSIS• Very Uncommon, but severe (0.1-0.2%)

• Includes agitation, paranoia, delusions, disorganized thinking and impulsivity

• Often appears “organic”

• Thoughts of harming the baby are frequently driven by delusions—Child must be saved from harm, child is malevolent, dangerous, has special powers, is Satan or God

• Rates of infanticide associated with untreated postpartum psychosis have been estimated to be as high as 4%.

A PSYCHIATRIC EMERGENCY REQUIRING IMMEDIATE INTERVENTION

POSTPARTUM DEPRESSION• Usually develops slowly over the first three months,

often beginning within the first 4 weeks, though some women have a more acute onset

• Signs and symptoms are those of Major Depression---

depressed mood, irritability, loss of interest and appetite, fatigue, insomnia.

PRESENTATION OF POSTPARTUM DEPRESSIONCommon characteristics:

• Women are often unable to sleep even when given the opportunity to do so

• Often anxiety is a major component

• Frequently (up to 50% of women) have intrusive, obsessional ruminations, or images, usually focused on the baby, often violent in nature, but they are egodystonic and there is not a problem with reality testing i.e. non-psychotic. One study showed 50% of women with PPD had these. Such obsessional thoughts do not increase the risk of harm to the baby and are important to distinguish from psychosis.

RISK FACTORS FOR PPD• Depression during pregnancy is the best

predictor of post partum depression• Prenatal anxiety• History of depression, especially PPD• Recently having stopped antidepressants prior

to pregnancy• Family history of depression• Pregnancy or obstetrical complications at

delivery

OTHER RISK FACTORS• Neonatal loss or illness• Difficult infant temperament• Lack of social support or marital

conflict• Recent loss or stressful life events• History of sexual abuse• Low self esteem• Breastfeeding difficulties

POSTPARTUM DEPRESSION

Maine Statistics:

• 41.4%, confidence interval 38.2–44.7%, reported no postpartum depression

• 50.8%, confidence interval 47.5–54.1%, reported low to moderate postpartum depression

• 7.7%, confidence interval 5.9–9.5%, reported severe depression

PRAMS Surveillance Data from 2000 of the Prevalence of Three Levels of Self-Reported Postpartum Depression in Seven PRAMS States

RISKS OF UNTREATED PPD To mother:• Stressful impact on relationship between woman and her

partner.• Suicidal thoughts more likely to be accompanied by homicidal

thoughts• Kindling phenomenon---development of a chronic low grade

depression with more susceptibility to repeated episodes of MDD

• Severe postpartum psychiatric disorder is associated with a high rate of death from natural and unnatural causes, particularly suicide

• Suicide risk in the first postnatal year is increased 70-fold

RISKS OF UNTREATED PPD

To child:• Poor weight gain• Sleep problems• Less breastfeeding-depressed mothers more likely

to discontinue breastfeeding• Impaired mother infant interactions leading to

poor attachment • Impaired maternal health and safety practices

RISKS OF UNTREATED PPD• Attuned infant-caregiver interactions promote

brain neurological “wiring”. • Future , hyperactivity, conduct disorders and

school behavior problems• Delays in language and social development• Increased risk of depression• Maternal depression is an “Adverse childhood

experience” ACE, often it is not the only adversity

MATERNAL POST PARTUM MOOD IS ONE OF THE

STRONGEST PREDICTORS OF NEUROCOGNITIVE

DEVELOPMENT IN CHILDREN MEASURED UP TO AGE SIX

Perinatal depression has a significant impact on the current and future health

of mother and child and stresses the functioning of the family.

TREATMENT OF DEPRESSION IN THE MOTHER IS AN EARLY INTERVENTION OR

PREVENTION FOR THE CHILD

NEED FOR PATIENT EDUCATION• Lack of knowledge about PPD, treatment options, and

community resources is common in postpartum women and their families, and frequently leads to delay in seeking treatment

• Delay in treatment for PPD results in a longer illness and increased risk of recurrent episodes

• Information about PPD should be provided to women in the prenatal period, soon after delivery, and further encounters with healthcare providers in the first postpartum year.

SCREENING FOR PERINATAL DEPRESSION

• Postpartum depression is often not recognized

• Despite the availability of validated screening tools, PPD remains under diagnosed

• Absence of screening often means untreated depression and poor outcomes for the mother, her newborn, and family

• Postpartum depression can be screened for with simple and validated screening tools

• It is also possible to screen for antenatal depression

VALIDATED SCREENING TOOLS• EPDS- Edinburgh postnatal Depression Screen• PHQ-9 Patient Health Questionnaire• PHQ-2• PPDS Postpartum Depression Scale• Beck Depression Inventory-II Center for

Epidemiological Studies-Depression Scale (CES-D)

PHQ-2 Over the past two weeks, how often have you been bothered by any

of the following problems? 1. Little interest or pleasure in doing things:

0 – Not at all1—Several days2—More than half the days3—Nearly every day

2. Having little interest or pleasure in doing things: 0 – Not at all

1—Several days2—More than half the days3—Nearly every day

If positive should be followed by the PHQ-9

OBSTACLES TO SCREENING

• Lack of time • Lack of familiarity with screening tools• Lack of protocols for positive screen• Lack of easy assess to mental health

resources• Lack of reimbursement

GUIDELINES FOR PERINATAL DEPRESSION SCREENING

• Antenatal early risk assessment and screening during pregnancy. • ACOG recommends the PHQ-2 once per trimester• If at high risk (prior history, neonatal loss, obstetrical complications, etc):• Upon discharge from hospital. Need to assess support plan post discharge. Visiting

nurse follow-up visit a good time• At postpartum visit with OB/Midwife

• At early (2 week) follow up appointment if high risk• At routine 6-7 week visit

• Well-child visit is an ideal time to look for signs of PPD in the mother (See pediatric provider frequently first year) The American Academy of Pediatrics recommends "routine, brief, maternal depression screening conducted during well-child visits”

• Other possibilities are visiting nurse visits, lactation consultants

•

Obstacles to Treatment• Stigma• Shame• Fear of losing children• Fear of medication • Over half of women referred to

mental health services do not get there

Patient Perspectives• Goodman et al. looked at perceived barriers to

treatment in pregnant women who were not mentally ill

• They were given questionnaires regarding treatment that they would potentially participate if they wanted help for depression.

• 92% would likely participate in individual psychotherapy

• 35% would take medication for depression• 14% would participate in group therapy

Goodman, Birth 2009 mar 36 (1) 60-9

Patient PerspectivesWomen identified barriers as being:• lack of time 65%• Stigma 43%• childcare issues 33%• Most women preferred to get treatment in

their OB’s office, either from their OB provider or a mental health professional.

Goodman, Birth 2009 mar 36 (1) 60-9

APA/ACOG GuidelinesThe Management of Depression

During Pregnancy: A Report from the American Psychiatric Association and The American College of Obstetricians and Gynecologists.

Obstetrics & Gynecology (September 2009) and General Hospital Psychiatry (September/October 2009).

For women wishing to become pregnant:

• Women stable on antidepressants (mild or no symptoms for 6 months or longer) possibly consider tapering before pregnancy

• Discontinuation may not be appropriate for women with a history of severe, recurrent illness (or psychosis, bipolar disorder, or suicide attempts)

• Women with suicidal or acute psychotic symptoms should be referred for aggressive psychiatric treatment.

Pregnant women currently on medication:

• Those who wish to stay on medication, consult with psychiatrists and OB/GYN to discuss the risks

• Stable women may attempt discontinuation depending on their history. Women with a history of recurrent depression are at a high risk of relapse if medication is discontinued.

• Women with recurrent depression or who have symptoms despite their medication may benefit from psychotherapy to replace or augment medication

• Women with severe depression (with suicide attempts, functional incapacitation, or weight loss) should remain on medication. If a patient refuses medication, alternative treatment and monitoring should be in place, preferably before discontinuation.

ALL PREGNANT WOMEN:

Regardless of circumstances, a woman with suicidal or psychotic symptoms

should immediately see a psychiatrist for treatment.

TREATMENT OF DEPRESSION DURING PREGNANCY

TREATMENT OF DEPRESSION DURING PREGNANCY

• Pregnancy is not protective with respect to new onset or recurrent mood disorders

• Thoughtful consideration needs to be given to the risks of untreated psychiatric illness

• Thoughtful treatment decisions can be made regarding the use of psychotropics during pregnancy

• Weighing the relative risks of medication treatment should be done on an individualized case by case basis.

• Maintaining euthymic mood during pregnancy is crucial• NO DECISION IS PERFECT; NO TREATMENT IS RISK FREE.

PSYCHOTROPIC DRUG USE IN PREGNANCY

• FDA Category labeling is often misunderstood and interpreted to mean that the risk increases from A to B to C, etc That is NOT the case.

• No distinction is made between human and animal data

• Often is not updated

• New FDA labeling will be released in 2013 and will eliminate the categories. – Pregnancy and lactation subsections would have three components: a risk

summary, clinical considerations and a data section.

• Standard language: “Use the medication in pregnancy when clearly needed”; when risk of treatment is outweighed by risk of underlying disorder

• Pregnancy registries are sparse across psychotropics

SSRI USE DURING PREGNANCY

• Recent findings and more data inform the pharmacologic treatment of depression during pregnancy

– Consistent conclusions that the absolute risk of SSRI exposure in pregnancy is small1-3

– Recent case-control studies reveal inconsistent data regarding teratogenic risk of individual SSRIs4-9

• Reproductive safety data on SSRIs exceeds what is known about most other medicines used in pregnancy

1 Louik C, et al. N Engl J Med 2007; 2 Einarson TR, Einarson A. Pharmacoepidemiol Drug Saf 2005; 3 Einarson A, et al. Am J Psychiatry 2008; 4 Alwan S, et al. N Engl J Med 2007; 5 Greene MF. N Engl J Med 2007; 6 Hallberg P, Sjoblom V. J Clin Psychopharmacol 2005; 7Wogelius P, et al. Epidemiology 2006; 8 www.gsk.ca/english/docs-pdf/PAXIL_PregnancyDHCPL_E-V4.pdf Dear Healthcare Professional (3/17/08); 9 www.fda.gov/medwatch/safety/2005/Paxil_dearhcp_letter.pdf Dear Healthcare Professional (3/17/08)

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Antidepressant Drug Treatment During Pregnancy

• SSRI’s most commonly used• More limited reproductive safety data available for

SNRI’s compared to SSRI’s, i.e.. venlafaxine, duloxetine • Data on bupropion includes growing number of

exposures supporting absence of increased risk for malformation o Buproprion registry over 500o Retrospective analysis of 1200 exposed infantso Prospective study of 105 infants

“POOR NEONATAL ADAPTATION” AND SSRI USE DURING PREGNANCY

• Consistent data: Late trimester exposure to SSRIs is associated with transient irritability, agitation, jitteriness, and tachypnea in 10-30% babies exposed in utero

• Studies do not control for maternal mental health condition, blinding of exposure in neonatal assessments

• Effectiveness of discontinuing or lowering the dose late in pregnancy aimed at reducing the risk of neonatal toxicity has not been prospectively studied

“Poor Neonatal Adaptation” and SSRI Use During Pregnancy

• No correlation between measures of umbilical cord blood levels of SSRIS and the risk if developing neonatal symptoms

• No difference in symptoms between two groups compared : infants born to mothers who had taken SSRIS but tapered 2 weeks prior to delivery vs. those who continued

• Lowering the dose of antidepressants does, however, increase the risk for maternal postpartum depression

Levinson-Castiel R, et al. Arch Pediatr Adolesc Med. 2006;160:173-176.Chambers CD, et al. N Engl J Med. 2006;354:579-587. Sit, D, et al. Pre-publication communicationWarburton et al, Acta Psychiatr Scand 2010; 121(6): 471-9.

Risk for PPHN Associated With Late Trimester Exposure to SSRI

Inconsistent Findings:• One report showed increased risk by 6-fold (Chambers 2006)(with this highest estimate of 6-fold increase 1% of exposed infants

would be affected)• Lower association seen with Källén and Olausson, 2008• NO association seen in three studies

Limitations:• Small number of SSRI exposures• Recall bias with respect to early versus late SSRI exposure• Recent data suggests lower risk than Chambers et al • PPHN correlated with cesarean section, race, body mass index, and

other factors not related to SSRI use**

Data supporting an association is weak

FDA revised its warning as a result

** Hernández-Díaz S, et al. Pediatrics. 2007;120:e272-e282. Kallen , August 2008 ; Pharmacoepidemiol Drug Safety Chambers CD, et al. N Engl J Med. 2006;354:579-587. Hernández-Díaz S, et al. Pediatrics. 2007;120:e272-e282

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TREATMENT OF PPD

TREATMENT OF PPDSelection of treatment:

• First requires good evaluation, review of prior history and assessment for suicidality/dangerousness

• Individual psychotherapy--CBT /IP Interpersonal and cognitive behavioral therapy very effective for mild to moderate PPD

• Support group• Community support programs• Medication• ECT• Hospitalization O'Hara MW, et al. Arch Gen Psych. 2000;57:1039-1045. Stuart S, et al. J Psychother Pract Res. 1995;4:18-29. Appleby L, et al. BMJ. 1997;314:932-936.

PPD: PHARMACOLOGIC STRATEGIES

• Data to support use of serotonergic agents (sertraline, fluoxetine, venlafaxine, fluvoxamine) and TCAs (nortriptyline)

• Other antidepressants can also be effective

• Adequate dosage need to be given

• Adequate duration of treatment (>6 months)

• TREAT ANXIETY: Adjunctive anxiolytic agents (lorazepam, clonazepam) are often needed

WHICH ANTIDEPRESSANT IS THE BEST ?

The one that is most likely to be effective• Continue antidepressant used during pregnancy

• Use agent to which patient has responded to in the past

• All SSRIs are secreted into breast milk, but no serious adverse effects have been reported in association with this. There have been some anecdotal reports of mild adverse effects possibly associated with exposure to the drugs through breast milk

• Caution may be needed with exposure in premature infants with hepatic immaturity

USE OF SSRI’S DURING LACTATION

• Exposure for the infant is lowest for sertraline (Zoloft) and fluvoxamine (Luvox), somewhat higher for paroxetine (Paxil), highest with citalopram (Celexa) and fluoxetine (Prozac)

• SSRI’s are present in the infant’s blood stream at very low levels, not detectable by usual methods. ACOG does not recommend checking infant serum levels.

With the current knowledge there is no strong evidence to recommend one drug over another or rationale to switch

from one SSRI to another to promote safety during breastfeeding

USE OF BZN’S/HYPNOTICS DURING LACTATION

• When measured, exposure through breast milk is extremely low

• Some anecdotal reports of sedation, poor feeding, respiratory distress; pooled data show low incidence of adverse effects

• New study at Motherisk-- 126 infants adverse effects of 1.6 % only associated with other sedating drug exposure

• Diazepam more likely to accumulate in breast feeding baby

• Less likely to accumulate—lorazepam (Ativan) clonazepam (Klonopin)

Birnbaum et al; Pediatrics, 1999, July 104 (1)e11Kelly L, Poon S, Madadi P, Koren G. Neonatal Benzodiazepines Exposure during Breastfeeding. [3] J Pediatr. 2012([Epub ahead of print]).

IMPROVING TREATMENT THROUGH COLLABORATION

IMPROVING TREATMENT THROUGH COLLABORATION

• Recognition that most treatment is not done in a psychiatrists office

• Make resources available through easy access to information and informal psychiatric consultation , i.e. MAPP’s Consultation Project

• Ideal would full integration of care

IDEAL OUTCOME• Screen all pregnant and postpartum women for depression using

a standard tool• Providers would work as a team including those who are

specifically knowledgeable about psychiatric illness during pregnancy, particularly for women with recurrent, severe or complex disease

• Non-pharmacologic treatment options such as psychotherapy, support groups, and other community resources would be identified and included whenever possible

• Risks of psychotropic medications would be weighed against the risks of untreated psychiatric disease, recognizing that untreated psychiatric illness can have significant adverse effects

• Recognition that pharmacotherapy for some women with moderate or severe disease may be the most appropriate treatment to treat the disorder and prevent relapse

MCH WOMEN’S HEALTH AND BEHAVIORAL HEALTH INTEGRATION

Phases:1. Facilitated perinatal support group

(complete)2. Co-located psychiatric consultation services

(starting in the fall)3. Co-located psychotherapy and case

management (future)

MAPP PPD PROJECTContact me at: plopsymd@myfairpoint.net

Subject line: MAPP PPD ProjectFor more information on the MAPP PPD Project or

to request a perinatal psychiatric consultant for your practice

Visit the MAPP website: www.mainepsych.org and click on Postpartum Depression Project

To access resources from MAPP PPD Project—power points on many related topics, downloadable patient education brochures,

screening tools, web links, etc

RESOURCESwww.womensmentalhealth.org / MGH Center for Women’s Mental Health and Reproductive Psychiatry

www.postpartum.net / Postpartum Support International Crisis hotline for postpartum depression and psychosis … 1-800-PPD-MOMS

www.motherisk.org Canadian website focusing on use of psychotropics in perinatal period

www.otispregnancy.org Organization of Teratology Information Specialists

www.mededppd.org / NIMH supported websiteExcellent resource, regularly updated 9 educational modules aimed at different provider categories offering CME’s…

For Smartphone users: LactMed@NIH APP – information on drugs during lactation

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the only thing that ever has.”

-Margaret Mead