Post Partum Depression Vani Ray MD Clinical Assistant

Post Partum Depression Vani Ray, MD Clinical Assistant Professor, Dept. Of. Psychiatry, UW. Madison Chief, Dept. Of Psychiatry , ASMC Director, Consultation & Liaison Services Aurora Behavioral Health Services

Facts about Perinatal Depression

10%-15% of women experience depression in the perinatal period and up to 28% of women living in poverty. • There were 70, 934 births in Wisconsin in 2005. • That means that (10 -15%) over 7, 000 to 10, 000 women were likely to suffer from prenatal and postpartum depression (PPD)

• However, 40% of births were paid for by Medicaid, which is a surrogate measure for poverty. • 28% of over 27, 000 women, over 7, 600 women, were likely to suffer from prenatal and PPD. • What do these numbers mean for your practice?

Approximately 50% of women with postpartum depression are untreated.

• Depression affects how a woman is able to relate to others, including her baby.

Post Partum Depression • • What is the post Partum Depression? How is it different from Post partum blues? what is the prevalence of Post partum Depression? What are the risk factors for Post partum Depression? Who should Screen Post partum Depression? Who treats Post partum Depression? What is the treatment of Post partum Depression?

Post Partum Depression • Tracey is a 27 year old mother brought into my office as an urgent care appointment. She just had a baby 4 weeks ago after much anticipation. Her husband is an only child and her in-laws filled the nursery with toys and clothes for the baby and are very excited. • She is unable to sleep and eat, extremely doubtful of her ability to do anything. • She is preoccupied with the fear that she will harm the baby and intense guilt of her inability to meet the expectations of the family. • She has been thinking that how easy it is kill herself than to be this worthless.

Post Partum Blues • The days and weeks immediately following the birth of baby can be an emotional roller-coaster. New mothers can experience elation, wonder, anxiety, and most have at least a touch of the blues. • Between 50 and 90 percent of all new mothers experience a bout of mild depression right after the birth of their babies. • It typically lasts 2 -10 days some may progress to Major depression

Why Screen? Screening is an easy, affordable method of identifying those women whose symptoms are interfering with function in their multiple roles.

Screening is effective in identifying depression. • You can’t tell by looking that someone has depression. • How many times do you screen? • Do you have a system of referral?

Post Partum Depression • Depressed mood • Tearfulness • Sleep or appetite disturbances • Weight gain or loss • Hopelessness • Loss of interest & pleasure • Feelings of being overwhelmed • Guilt • Anxiety or nervousness • Irritability • Low energy • Loss of concentration • Thoughts of harming self or infant

Mild Severe • Severe Symptoms: – Thoughts of dying – Thoughts of suicide – Wanting to flee or get away – Being unable to feel love for the baby – Thoughts of harming the baby – Thoughts of not being able to protect the infant – Hopelessness

Psychological Factors that influence development of PPD Emotional stability Attitudes toward femininity. Relationship with mother and spouse. Cultural attitudes Preparation for parenthood Prior mental illness Presence or absence of prior children. Social support Socio-economic status Life circumstances

Risk Factors for Development of Post Partum Depression During Pregnancy After Birth • A young and single mother • H/O Mental illness or substance abuse • Financial or relationship difficulties • Previous Pregnancy or postpartum depression • Labor/Birth Complications • Low confidence as a parent • Problems with Baby’s Health • Lack of supports • Major Life change at the same time as birth of the baby

Role of emotional stress on obstetric outcome • Prematurity • Low birth weight • Increased child morbidity • Impaired emotional attachment to fetus and difficulties in mother-infant relationship • substance abuse

Psychological Changes in Pregnancy • Increased anxiety is focused on fetus rather than on the person herself. • Increased introspection and preoccupation with pregnancy with decreased emotional investment in the external world. • Heightened dependency needs. • In some, there is a shift toward primary process thinking and increase in primitive defenses.

Psycho-neuro-endocrine factors influencing Depression • Gonodal hormones i. e. estrogen, progesterone and cortisol undergo rapid changes during pregnancy and increase significantly. • They regulate neurotransmitter, neuro endocrine, and neuro modulatory systems in the central nervous system. In turn they influence monoaminergic pathways that are implicated in pathogenesis. • Gonodal hormones also affect diurnal rhythm changes crucial in pathogenesis of affective disorders.

• • • Mood disorders during pregnancy Diagnosis is difficult, as vegetative symptoms are normative for pregnancy Pharmacological interventions pose challenge during pregnancy. Psychotherapy is beneficial for mild to moderate depression Post partum period is turbulent for patients with Bipolar disorder. Treatment is individualized. based on risk vs. benefit analysis.

Depression Screening • Perinatal Visits • Labor • Post partum checkups – immediate and upto one year • wellbaby Clinics

Who Could Screen? • Clinicians & service providers who work with pregnant & postpartum women – – – – – Advance Practice Nurses–CNMs, and NPs Physicians–OB/GYN, Family Practice, Pediatrics NICU staff Public health, hospital, and parish nurses Prenatal care coordinators WIC dietitians Lactation consultants & home visitors (PH nurse, etc. ) Social workers Doulas Others?

How to introduce screening: One way to introduce screening to the woman is to say: “It is routine for us in this office to check with all pregnant women (new moms) about how they’re feeling. We like to know a little about your emotional health. ”

Depression Screening Tools Center for Epidemiological Studies–Depression (CES-D) Scale Edinburgh Postnatal Depression Scale (EPDS) Postpartum Depression Screening Scale (PDSS) Depression Scale in Hmong

Edinburgh Post Natal Depression Scale (EPDS)

Edinburgh Post Natal Depression Scale (EPDS) Guidelines for raters • According to Warner, Appleby, Whitton, & Faragher (1996), postpartum depression affects 10% of new mothers, with the range being from eight to 15%. The Edinburgh Postnatal Depression Scale (EPDS) was developed in 1987 to act as a specific measurement tool to identify depression in new mothers. The scale has since been validated, and evidence from a number of research studies has confirmed the tool to be both reliable and sensitive in detecting depression. Response categories are scored 0, 1, 2, and 3 according to increased severity of the symptom. Questions 3, 5, 6, 7, 8, 9, 10 are reverse scored (ie, 3, 2, 1, 0) Individual items are totalled to give an overall score. A score of 12+ indicates the likelihood of depression, but not its severity. The EPDS Score is designed to assist, not replace clinical judgement. Warner, R. , Appleby, L. , Whitton, A. , & Faraghen, B. (1996). Demographic and obstetric risk factors for postnatal psychiatric morbidity. British Journal of Psychiatry, 168, 607 -611.

Two simple questions: • During the past month, have you often been bothered by feeling down, depressed, or hopeless? • During the past month, have you often been bothered by little interest or pleasure in doing things? US Preventive Services Task Force

When to Screen The WAPC “Pathways for Accessing Treatment & Support Services for Women Experiencing Prenatal and Postpartum Depression” recommends screening twice during pregnancy and twice postpartum, when possible. For example, at: • • First prenatal visit The third trimester The 6 -week postpartum visit And one other time during postpartum year Such a frequency would identify most women who experience depression during that period.

Communicating with women about screening results… “Based on what you’ve told me and your score, I’m concerned that you have some symptoms of depression. It’s hard to be going through this when you are pregnant [or ‘when you have a new baby’]. Remember, depression is partly due to an imbalance of chemicals in your body and things that cause stress in your life. There are things to do to feel better. Let’s talk about some ideas that might work for you. ”

Consequences of Untreated Depression • Woman may not seek prenatal care or follow through on health care recommendations • May be less responsive to infant, resulting in delayed development • May cause stress in relationships • Increased risk for future episodes of depression • Increased risk of self injury/suicide • Difficulty or failure in job performance

Consequences of untreated depression for the infant • • Poor weight gain Feeding problems Sleep problems Poor emotional attachment Behavior problems/hyperactivity Depression Mother may be less attentive to hygiene/safety

Chronicity, rather than severity of depression has more long-term effects on infants and children.

Barriers to accessing care • Most don’t seek treatment • Concerned with confidentiality • Fear that seeking treatment will affect job, relationships • Unsure of health coverage • Embarrassed or reluctant to talk • Myths – Personal weakness, “tough it out” • Stigma

Postpartum Depression • It is important to treat women with symptoms of depression during pregnancy • The pharmacological treatment during pregnancy poses several dilemmas • Decision making when to treat them is complex • It involves careful consideration of risks versus benefits of treatment and education

Pharmacological Treatment of Depression · All psychotropic medications diffuse readily across the placenta. · Knowledge of the risks to the fetus of prenatal exposure to psychotropic medication is incomplete. · Little is known about potential of long-term behavior abnormalities in children exposed to psychotropic medications. · To date, the U. S. FDA approves NO psychotropic medication for use during pregnancy

Facts of Psychotropic drug use in pregnancy • • • Major Birth Defect incidence is 2%to 4% Cause of 65% to 70% of these is unknown Drug exposure as a cause is not established 50% of pregnancies are unplanned. To limit exposure to either illness or treatment which path poses least risk? • Category labeling of all the medications. • No decision is risk-free.

Facts of Psychotropic drug use in pregnancy • In humans , fetal brain develops through out the gestation and is susceptible to med toxicity even after first trimester is complete • This is the area of concern about use of CNS active drugs during the gestation • Behavioral teratogenicity is poorly understood aspect of teratology.

Facts of Psychotropic drug use in pregnancy Category Description A adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities. B C D X Animal studies have revealed no evidence of harm to the fetus, however, there are no adequate and well-controlled studies in pregnant women. or Animal studies have shown an adverse effect, but adequate and wellcontrolled studies in pregnant women have failed to demonstrate a risk to the fetus. Animal studies have shown an adverse effect and there are no adequate and wellcontrolled studies in pregnant women. or No animal studies have been conducted and there are no adequate and wellcontrolled studies in pregnant women. Studies, adequate well-controlled or observational, in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy may outweigh the potential risk. Studies, adequate well-controlled or observational, in animals or pregnant women have demonstrated positive evidence of fetal abnormalities. The use of the product is contraindicated in women who are or may become pregnant

FDA Warning • Neonates exposed to SSRIs and SNRIs during the late 3 rd trimester have demonstrated increased complications – Prolonged hospitalization – Jitteriness, tremor, apnea these symptoms are consistent with either toxicity or withdrawal Caution - Neonatal work up

Antidepressants • • Altschuler et al. , 1996 TCA (N 437) No abnormalities Chambers et al. , 1996 TCA &SSRI No abnormalities Kulin et al. , 1998 Nulman et al, . 1997 • Einerson et al. , 2001 Effexor No abnormalities • Ericson et al. , 1999 TCA&SSRI (N 969) No abnormalities Sura Alwin et al, N. Engl J Med 2007 356: 2684 -92

Antidepressants • Nefazadone • Mirtazepine • Bupropion

Antidepressants • Tricyclics Most studied are Nortriptylene and Desipramine. SSRIS Most studied. Safe to use. • MAOIS Incomplete safety data, not indicated in pregnancy. • SNRIS Venlafaxine Duloxetine

Potential risks to the fetus with prenatal exposure of psychotropic Medications • Teratogenicity (Organ malformations) • Neonatal toxicity (Perinatal syndromes) • Neonatal withdrawal syndromes. • Behavioral Teratology (Postnatal behavioral sequelae)

Psychological Treatment of Depression Interpersonal Psychotherapy Cognitive Behavioral Psycho therapy Couples therapy Family therapy Post Partum Therapy groups Post Partum Support groups

Non Pharmacological Interventions of Depression Exercise Nutritious and Balanced Meals Taking some time for yourself Mobilizing support networks

Mental Health Resources for Young Mothers Aurora Behavioral Health Services Aurora Sinai Medical Center Aorora women’s Pavillion 414 -773 -4312 www. auroraheallhcare. org/ABHS Perinatal Foundation, Inc. Mc. Connell Hall, 1010 Mound St. Madison, WI 53715 aeconway@wisc. edu (608) 267 -6200 - phone (608) 267 -6089 - fax www. perinatalweb. org

Depression is treatable and may not resolve without treatment. Women do recover.

Early identification & treatment by primary care clinicians or mental health specialists are essential. – Those caring for women & children from pregnancy through the first year of life should be alert to the symptoms of perinatal mood disorders.

A note about providers who have frequent contact with women in the postpartum period: • Women usually have one postpartum obstetrical or midwifery visit. • Women usually have frequent interactions with primary care providers such as pediatricians, family physicians, and nurse practitioners in the infant’s first year of life.

When to screen? • When does your facility screen? • Do you collaborate with others to ensure women of your community are being screened? • What are the “best practices” of the region?

Then what? • Anyone who screens women should have a follow-up action plan in place.

Motherhood is not magical for women suffering with postpartum depression