Maternal Mental Health and Post Partum MARISA ECHENIQUE

Maternal Mental Health and Post Partum MARISA ECHENIQUE, PSY. D. ASSISTANT PROFESSOR DEPARTMENT OF PSYCHIATRY UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE

Continuing Education Disclosure � The activity planners and speakers do not have any financial relationships with commercial entities to disclose. � The speakers will not discuss any off-label use or investigational product during the program. This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.

Session Objectives � Upon completion of this program, participants will be able to: Define maternal mental illness Identify signs and symptoms of maternal mental illness Define post partum depression Identify signs and symptoms of post partum depression Identify effective treatment options in maternal mental health Discuss strategies to decrease mental health stigma, increase comfort level to discuss mental illness and increase the ability of healthcare providers to provide culturally sensitive care 

Maternal Mental Health �The World Health Organization defines maternal mental health as: � ‘‘a state of wellbeing in which a mother realizes her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to her community’’

Maternal Mental Illness � In the year 2000, 205, 000 women aged 18 to 44 years were discharged with a diagnosis of depression 7% of all hospitalizations among young women were for depression � The peak period for onset of depression occurs during the childbearing years and its impact extends to the offspring of afflicted women as well as their families

Maternal Mental Health � Given that depression is a mood disorder that affects 1 in 4 women at some point during their lifetime, it should be no surprise that this illness can also touch women who are pregnant But all too often, depression is not diagnosed properly during pregnancy because people think it is just another type of hormonal imbalance � Pregnancy is supposed to be one of the happiest times of a woman’s life, but for many women this is a time of confusion, fear, stress, and even depression According to The American Congress of Obstetricians and Gynecologists (ACOG), between 14 -23% of women will struggle with some symptoms of depression during pregnancy

Mental Illness in Pregnancy �Pregnancy and the postnatal period are critical times of psychological adjustment for women, and there is increasing evidence that a woman’s mental state during this time influences both obstetric outcomes and the future development of the infant, affect other children in the family, as well as the woman’s partner and their relationship �Severe mental illness, such as psychosis, bipolar disorder or severe depression, may be particularly detrimental, both during pregnancy and subsequently, given the dependence of an infant on its mother and the rapid adjustment to motherhood faced by first-time mothers

Maternal Mental Health � A woman with mental illness often does not have the strength or desire to adequately care for herself or her developing baby Ex: Babies born to mothers who are depressed may be less active, show less attention and be more agitated than babies born to moms who are not depressed � Mental Illness that is not treated can have potential dangerous risks to the mother and baby Can lead to poor nutrition, drinking, smoking, and suicidal behavior, premature birth, low birth weight, and developmental problems

Mental Illness and Fetal Demise �Although maternal mental health disorders in pregnancy have been linked to fetal morbidity, there have been few reports of actual fetal mortality � However, since many of the neonatal complications listed are also present in cases of fetal demise, it seems plausible that there is a true association between maternal mental health and fetal mortality

Mental Illness and Fetal Demise � Fetal loss is not uncommon in pregnancy, with spontaneous abortions (miscarriages) before 20 weeks' gestation occurring in up to 15% of all pregnancies and with stillbirths after 20 weeks affecting nearly 1% of all births. In addition, there may be additional losses early in the first trimester that are never recognized as clinical pregnancy �When a woman is pregnant, treating physicians must weigh potential benefits from pharmacological treatment with potential risks to the fetus; being able to determine whether mental illness itself is associated with fetal death might help physicians better evaluate overall fetal risk

Maternal Mental Health �Types of Mental Illness/Psychiatric Issues Depression Disorder Anxiety Disorder Panic Disorder Psychosis PTSD Eating Disorders Cognition Substance Use *While it is rare for women to experience first onset psychoses during pregnancy, relapse rates are high for women previously diagnosed with some form of psychosis

Risk Factors Maternal Mental Health q Previous history of depression q Discontinuation of medication(s) by a woman who has a q History of depression q Previous history of postpartum depression q Family history of depression q Negative attitude toward the pregnancy q Lack of social support q Maternal stress associated with negative life events q A partner or family member who is unhappy about the pregnancy

Risk Factors Maternal Mental Health q Having a hard time getting q Having twins or triplets q Losing a baby q Having a baby as a teen q Having premature labor and delivery q Having a baby who is different (birth defect or disability) q Pregnancy and birth complications q Having a baby or infant hospitalized q Having a healthy pregnancy and childbirth

Maternal Mental Health � What are possible triggers of depression during pregnancy Relationship problems q Family or personal history of depression q Previous miscarriages q Stressful life events q Health related complications q History of abuse or trauma q Poor social support q Financial difficulties q

Signs and Symptoms of Mental Illness

Signs and Symptoms of Mental Illness Depressed mood or a loss of interest or pleasure in daily activities for more than two weeks. Mood represents a change from the person's baseline. Impaired function: social, occupational, educational. Specific symptoms, at least 5 of these 9, present nearly every day: q Feeling sad or down q Confused thinking or reduced ability to concentrate q Excessive fears or worries, or extreme feelings of guilt q Extreme mood changes of highs and lows q Withdrawal from friends and activities q Significant tiredness, low energy or problems sleeping q Detachment from reality (delusions), paranoia or hallucinations q Inability to cope with daily problems or stress q Trouble understanding and relating to situations and to people q Alcohol or drug abuse q Major changes in eating habits q Sex drive changes q Excessive anger, hostility or violence q Suicidal thinking

Signs and Symptoms of Mental Illness SIGECAPS mnemonic for symptoms of Depression: q Sleep (insomnia or hypersomnia) q Interest (reduced, with loss of pleasure) q Guilt (often unrealistic) q Energy (mental and physical fatigue) q Concentration (distractibility, memory disturbance) q Appetite (decreased or increased) q Psychomotor (retardation or agitation) q Suicide (thoughts, plans, behaviours)

Post Partum Depression

Post Partum Depression � Postpartum depression can happen anytime within the first year after childbirth � The difference between postpartum depression and the baby blues is that postpartum depression often affects a woman's wellbeing and keeps her from functioning well for a longer period of time Postpartum depression needs to be treated by a doctor � Major depression creates suffering whether experienced in the postpartum period or at any other time in a woman’s life � What makes depression so poignant for postpartum women is that childbirth is culturally celebrated and there is an expectation that new parents, especially mothers, will be joyful, if not tired, during this time

Post Partum Depression � The demands on a new mother are substantial and include providing 24 -hour care for a newborn, often in the middle of the night, caring for older children, keeping up with normal household responsibilities, and often returning to work after a brief maternity leave � These burdens are often difficult to bear in normal circumstances and the difficulty of bearing them is exacerbated by the disability associated with depression symptoms (e. g. , sad mood, loss of interest, motor retardation, difficulty concentrating)

Post partum Depression

Post Partum Depression � Any of these symptoms during and after pregnancy that last longer than two weeks are signs of depression: Feeling restless or irritable Feeling sad, hopeless, and overwhelmed Crying a lot Having no energy or motivation Eating too little or too much Sleeping too little or too much Trouble focusing, remembering, or making decisions Feeling worthless and guilty Loss of interest or pleasure in activities Withdrawal from friends and family Having headaches, chest pains, heart palpitations (the heart beating fast and feeling like it is skipping beats), or hyperventilation (fast and shallow breathing) q After pregnancy, signs of depression may also include being afraid of hurting the baby or oneself and not having any interest in the baby q q q

Post Partum Psychosis It occurs in 1 or 2 out of every 1000 births and usually begins in the first 6 weeks postpartum Women who have bipolar disorder or another severe psychiatric problem such as in the schizophrenia spectrum have a higher risk for developing postpartum psychosis

Feeling ‘high’, ‘manic’ or ‘on top of the world’ Rapid changes in mood Severe confusion Being restless and agitated Racing thoughts Behavior that is out of character Being more talkative, active and sociable than usual Not wanting to sleep Losing your inhibitions Feeling paranoid, suspicious, fearful Feeling as if you’re in a dream world Delusions: these are odd thoughts or beliefs that are unlikely to be true. For example, you might believe you have won the lottery. You may think your baby is possessed by the devil. You might think people are out to get you. q Hallucinations: this means you see, hear, feel or smell things that aren’t really there. q q q

Mental Illness Detection

Treatment Options �Psychotherapy Stigma Access to care (insurance, resources) Environmental barriers (social support, transportation) �Psychopharmacology Fear of medication during pregnancy Risks vs benefits

Psychotropic Medications in Pregnancy �Women with histories of psychiatric illness who discontinue psychotropic medications during pregnancy are particularly vulnerable to major psych episodes Ko et al. 2012, prospectively followed a group of women with histories of major depression across pregnancy, of the 82 women who maintained antidepressant treatment throughout pregnancy, 21 (26%) relapsed compared with 44 (68%) of the 65 women who discontinued medication

Psychotropic Medications in Pregnancy �High rates of relapse have also been observed in women with bipolar disorder One study indicated that during the course of pregnancy, 70. 8% of the women experienced at least one mood episode The risk of recurrence was significantly higher in women who discontinued treatment with mood stabilizers (85. 5%) than those who maintained treatment (37. 0%). �Although data suggest that some medications may be used safely during pregnancy, knowledge regarding the risks of prenatal exposure to psychotropic medications is incomplete Thus, it is relatively common for patients to discontinue or to avoid pharmacologic treatment during pregnancy

U. S. FDA Category Designations for Pregnancy �FDA provided guidelines to drug companies for labeling medications with regard to their safety during pregnancy. Medications are assigned a pregnancy letter ranking: (A, B, C, D, X). For newer drugs, this designation usually occurs in the absence of systematic human pregnancy data �Most psychiatric medications are labeled as “C” or “D, ” without a clear demarcation in safety between these categories �The FDA is currently working on improving the current labeling system, and they are considering the provision of more information about the risks and benefits in a descriptive format and information about the risks of the untreated disorder for which the medication is used

Weighing the Risks �Not infrequently, women present with the first onset of psychiatric illness while pregnant Many pregnancies are unplanned and may occur unexpectedly while women are receiving treatment with medications for psychiatric disorders Many women may consider stopping medication abruptly after learning they are pregnant, but for many women this may carry substantial risks. �Decisions regarding the initiation or maintenance of treatment during pregnancy must reflect an understanding of the risks associated with fetal exposure to a particular medication but must also take into consideration the risks associated with untreated psychiatric illness in the mother Psychiatric illness in the mother is not a benign event and may cause significant morbidity for both the mother and her child; thus, discontinuing or withholding medication during pregnancy is not always the safest option

Weighing the Risks � Depression and anxiety during pregnancy have been associated with a variety of adverse pregnancy outcomes: Women who suffer from psychiatric illness during pregnancy are less likely to receive adequate prenatal care Are more likely to use alcohol, tobacco, and other substances known to adversely affect pregnancy outcomes Possible low birth weight and fetal growth retardation in children (born to depressed mothers) Preterm delivery Increased risk for having pre-eclapsia Operative delivery Infant admission to a special care nursery for a variety of conditions including respiratory distress, hypoglycemia, and prematurity * These data underscore the need to perform a thorough risk/benefit analysis of pregnant women with psychiatric illness, including evaluating the impact of untreated illness on the baby and the mother, as well as the risks of using medication during pregnancy *

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