Postpartum Mood Disorders www.freelivedoctor.com
Primary Objectives <ul><li>Review the range of pregnancy related mood disorders </li></ul><ul><li>Discuss the risk factors...
Secondary Objectives <ul><li>Review the prevalence of mood disorders in women </li></ul><ul><li>Investigate the etiology o...
Major Depressive Disorder <ul><li>Leading cause of disability </li></ul><ul><li>Prevalence of 5-9% </li></ul><ul><li>Lifet...
Peripartum Depressive Disorders <ul><li>Antepartum Depression </li></ul><ul><li>Postpartum Blues </li></ul><ul><li>Postpar...
Antepartum Depression <ul><li>Symptoms often seen in non-depressed pregnant women </li></ul><ul><ul><li>Sleep and appetite...
Postpartum Blues <ul><li>Aka “baby blues” </li></ul><ul><li>Characteristics: </li></ul><ul><ul><li>Mild mood swings  </li>...
Postpartum Blues <ul><li>Occur within 2-3 days of delivery </li></ul><ul><li>Symptoms peak on 4 th  or 5 th  postpartum da...
Postpartum Depression <ul><li>Same DSM IV criteria as for non-pregnancy related depression </li></ul><ul><li>Symptoms usua...
Symptoms of PPD <ul><li>Change in somatic function </li></ul><ul><li>Significant anxiety </li></ul><ul><li>Intense irritab...
Symptoms of PPD <ul><li>Sense of being overwhelmed  </li></ul><ul><li>Unable to care for baby </li></ul><ul><li>Feelings o...
Postpartum  Psychosis <ul><li>Usually a manifestation of bipolar disorder </li></ul><ul><li>Typically presents within 2 we...
Signs and Symptoms of PPP <ul><li>Severe insomnia </li></ul><ul><li>Rapid mood swings </li></ul><ul><li>Anxiety </li></ul>...
Fetal Implications <ul><li>Increased rate of: </li></ul><ul><ul><li>Preterm birth </li></ul></ul><ul><ul><li>Low birth wei...
Familial Implications <ul><li>Postnatal depression in men </li></ul><ul><li>Interference with maternal-infant bonding, inc...
Familial Implications <ul><li>Negative interactive patterns with infant </li></ul><ul><li>Children exposed to maternal psy...
Prevalence <ul><li>Postpartum blues occur in 40 – 80% of women </li></ul><ul><li>PPD affects 10 – 30% of women  </li></ul>...
Antepartum Depression Prevalence <ul><li>10% of all pregnancies </li></ul><ul><li>Increased risk for women with history of...
Postpartum Depression Prevalence <ul><li>Up to 13% in the first year postpartum </li></ul><ul><li>50% higher risk of recur...
Prevalence in Active Duty <ul><li>Positive depression screen </li></ul><ul><ul><li>Antepartum </li></ul></ul><ul><ul><li>P...
Risk Factors for PPB <ul><li>History of depression or premenstrual mood changes </li></ul><ul><li>Depressive symptoms duri...
PPD Risk Factors <ul><li>Personal history of depression </li></ul><ul><li>Family psychiatric history </li></ul><ul><li>Mar...
PPD Risk Factors <ul><li>Lack of emotional & financial support from partner </li></ul><ul><li>Living without a partner </l...
PPD Risk Factors <ul><li>Having contemplated terminating current pregnancy </li></ul><ul><li>Poor relationship with own mo...
PPD Risk Factors <ul><li>Unemployment in the mother </li></ul><ul><li>Lifetime history of depression in partner </li></ul>...
PPD Risk Factors <ul><li>Child care related stressors </li></ul><ul><li>Sick leave during pregnancy </li></ul><ul><li>High...
Risk Factors for PPP <ul><li>History of bipolar disorder </li></ul><ul><li>History of psychosis prior to pregnancy </li></...
Co-morbidities <ul><li>Decreased weight gain during pregnancy </li></ul><ul><li>Increased rate of tobacco use </li></ul><u...
Etiology <ul><li>No clear etiology </li></ul><ul><li>Possibly due to combination of: </li></ul><ul><ul><li>Genetic suscept...
Etiology <ul><li>Investigators have examined the role of: </li></ul><ul><ul><li>Estrogen  </li></ul></ul><ul><ul><li>Proge...
Screening - Overview <ul><li>Important to identify proper timing of screening </li></ul><ul><li>Avenues include both infor...
Screening - Timing <ul><li>Antepartum visits  </li></ul><ul><li>During hospital stay  </li></ul><ul><li>Postpartum visits ...
Screening - Tools <ul><li>Beck’s Depression Inventory (PDI) </li></ul><ul><li>Postpartum Depression Screening Scale (PDSS)...
Beck’s Depression Inventory <ul><li>Self administered survey </li></ul><ul><li>21 questions scored 0 – 3 </li></ul><ul><li...
Postpartum Depression Screening Scale <ul><li>94% sensitive and 96% specific in initial trials </li></ul><ul><li>35 item s...
Edinburgh Postnatal Depression Scale <ul><li>10 item questionnaire </li></ul><ul><li>Each response scored 0 – 3, with tota...
EPDS <ul><li>Score > 12 reported as 100% sensitive and 95% specific in detecting major depression </li></ul><ul><li>Studie...
www.freelivedoctor.com                                                                                                    ...
www.freelivedoctor.com                                                                                                    ...
Evaluation and Diagnosis <ul><li>Labs- CBC, TSH </li></ul><ul><li>Consider urine drug screen if history of drug use/abuse ...
Diagnosis <ul><li>DSM IV modifier </li></ul><ul><li>ICD coding </li></ul><ul><ul><li>Postpartum depression 648.4 </li></ul...
Treatment <ul><li>Factors to address: </li></ul><ul><ul><li>Biological  </li></ul></ul><ul><ul><li>Psychological  </li></u...
Treatment <ul><li>Psychosocial therapies </li></ul><ul><ul><li>First choice for those with mild to moderate symptoms of PP...
Psychosocial Therapies <ul><li>Group therapy </li></ul><ul><ul><li>Helps to increase support network </li></ul></ul><ul><l...
Psychosocial Therapies (cont) <ul><li>Supportive psychotherapy </li></ul><ul><ul><li>Groups that offer support and educati...
Interpersonal Therapy (IPT) <ul><li>Short-term, manual-driven psychotherapy </li></ul><ul><li>Addresses four major problem...
Pharmacologic Therapy <ul><li>No antidepressants are approved by the FDA for use during pregnancy </li></ul><ul><li>All ps...
Concerns for Psychotropic Use <ul><li>Risk of pregnancy loss or miscarriage </li></ul><ul><li>Risk of organ malformation o...
Neonatal Withdrawal – TCAs <ul><li>TCA withdrawal syndrome: </li></ul><ul><ul><li>Jitteriness  </li></ul></ul><ul><ul><li>...
Neonatal Withdrawal - SSRIs <ul><li>Transient symptoms of: </li></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>E...
Long Term Sequelae <ul><li>No significant difference in: </li></ul><ul><ul><li>IQ </li></ul></ul><ul><ul><li>Temperament <...
Pharmacologic Therapy <ul><li>Increase risk of suicide after initiation of medication </li></ul><ul><li>If significant anx...
Antidepressant Choice <ul><li>TCAs </li></ul><ul><ul><li>Desipramine and Nortryptiline are preferred </li></ul></ul><ul><u...
Additional Considerations <ul><li>Doses of both SSRIs and TCAs may need to be increased in pregnancy secondary to: </li></...
Other Therapies <ul><li>Hormonal Therapy </li></ul><ul><ul><li>Increased risk of PPD if Depo-provera given within 48 hrs o...
Other Therapies (cont) <ul><li>ECT </li></ul><ul><ul><li>Few adverse effects to mom or infant </li></ul></ul><ul><ul><li>G...
Length of Treatment <ul><li>Based on patient history and severity of symptoms </li></ul><ul><li>Continue 12 months after f...
Referrals <ul><li>Consider Psychiatric referral if: </li></ul><ul><ul><li>Poor response to therapy  </li></ul></ul><ul><ul...
Treatment of Postpartum Psychosis <ul><li>Medical emergency </li></ul><ul><li>Patient should be hospitalized until stable ...
Treatment of PPP (cont) <ul><li>Medications focused on controlling both psychosis and mood swings </li></ul><ul><li>Combin...
Prevention <ul><li>Monitor for signs in high risk women </li></ul><ul><li>Educate women and family members before childbir...
Conclusion <ul><li>Postpartum mood disorders are common </li></ul><ul><li>Military population has multiple risk factors fo...
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Postpartum mood disorders

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  • According to Agency for Healthcare Research and Quality, depression is the leading cause of disease related disability among women. Point prevalence of major depressive disorder in women is 5-9% with lifetime risk of 10-25%
  • Pregnancy related mood disorders bridge a range of conditions which vary in onset and severity. These include…. Postpartum depression occurs in as many as 1 in 8 US pregnancies. More common than gestational diabetes, preeclampsia or preterm delivery.
  • Transient condition
  • Transient condition
  • Fatigue, being overwhelmed common symptoms of depression and often seen in new mothers.
  • Usually a psychiatric emergency and will require hospitalization
  • Each of which has been shown to be a predictor of poorer fetal outcome.
  • Significant risk factors for development of postnatal depression in men include depression in partner during or shortly after pregnancy and personal h/o depression
  • Major depressive disorder in women  5 – 9% Lifetime risk is 10 – 25% Prevalence depends on assessment method, timing of assessment, and population characteristics. Prevalence of postpartum depression is close to that in nonpregnant women, but rate of onset of new episodes of depression is 3x higher than in nonpregnant controls. Postpartum psychosis occurs in 1.1-4 cases/1000 deliveries
  • AHRQ- major and minor depression 8.5 –11 % during pregnancy and 6.5 – 12.9% during 1 st postpartum year Prevalence of major depression is highest in 2 nd trimester, 2 months postpartum and 6 months postpartum
  • AHRQ- major and minor depression 8.5 –11 % during pregnancy and 6.5 – 12.9% during 1 st postpartum year Prevalence of major depression is highest in 2 nd trimester, 2 months postpartum and 6 months postpartum
  • Rate for + depression screen was almost 2x rate reported in nonmilitary populations, both antepartum and postpartum. OF those who screened +, 36% were considered emergent – score &gt;20 or + answer to suicide ideation question. In postpartum period, rate of suicide ideation was triple that observed in 1 study
  • Most women depressed during pregnancy will remain depressed postpartum Women who conceive less than 12 months after stillbirth are at higher risk of depression in 3 rd trimester of next pregnancy &amp; at 1 year postpartum compared to women who conceive after 12 months
  • Previous miscarriage- risk of PPD is higher among women with prior h/o depression than in those without h/o depression. Elevated risk is highest in 1 st six months after loss. Women who conceive less than 12 months after stillbirth are at higher risk of depression in 3 rd trimester of next pregnancy &amp; at 1 year postpartum compared to women who conceive after 12 months
  • Many of these occur in active duty population and dependents
  • Many of these occur in active duty population and dependents
  • Sick leave during pregnancy- related to hyperemesis, uterine irritability, psychiatric disorder
  • One study looked at association of postpartum blues and estrogen withdrawal. Women who developed PPB had a significantly higher level of free estriol at 38 wks and a greater fall of free estriol concentration on postpartum day #1.
  • One study looked at association of postpartum blues and estrogen withdrawal. Women who developed PPB had a significantly higher level of free estriol at 38 wks and a greater fall of free estriol concentration on postpartum day #1.
  • AHRQ all screeners (beck depression inventory, postpartum depression screening scale, EPDS) had high specificity for major depression alone. Means the risk of a screen being a false positive is low. EPDS and PDSS more sensitive Looking at major and minor depression together, the sensitivity is much lower
  • AHRQ all screeners (beck depression inventory, postpartum depression screening scale, EPDS) had high specificity for major depression alone. Means the risk of a screen being a false positive is low. EPDS and PDSS more sensitive Looking at major and minor depression together, the sensitivity is much lower
  • AHRQ all screeners (beck depression inventory, postpartum depression screening scale, EPDS) had high specificity for major depression alone. Means the risk of a screen being a false positive is low. EPDS and PDSS more sensitive Looking at major and minor depression together, the sensitivity is much lower
  • Developed in 1987
  • Compared to spontaneous detection, 35.4 % vs 6.3% AT 6 wk postpartum visit EPDS administration in first few days postpartum can predict maternal mood 4-8 wks later
  • Insert EPDS from UPTODATE here
  • DSM IV criteria- 5 or more symptoms for at least 2 wks- depressed mood, fatigue, loss of energy, loss of pleasure or interest, increased sense of worthlessness or guilt, significant weight loss/gain, decreased concentration, insomnia or hypersomnia, recurrent morbid thoughts or suicidal ideations, agitation or retardation, significant distress or impairment of function, not better accounted for by bereavement
  • DSM IV- uses postpartum onset modifier if occurs in first 4 wks postpartum ICD coding- if occurs in 1 st 6 wks postpartum, ICD code for postpartum depression
  • British study showed that multiple home visits thru 28 days postpartum in addition to a consult at 10-12 wks had lower EPDS scores than those receiving visits only thru 10-14 days postpartum
  • AHRQ reviewed 6 studies which showed significant benefit for depression outcomes with psychosocial thearpies Small study which compared women who received 6 sessions of CBT to women receiving fluoxetine showed same degree of improvement in functioning Interpersonal psychotherapy- good in tx of mood and anxiety disorders; effective in decreasing depressive symptoms and increasing social adjustment
  • Family and marital therapy more rapid recovery for postpartum women more appreciative of partner’s contributions to relationship when partner is supportive
  • Addresses four main problem domains with respect to human psychosocial functioning One small study of 13 women showed decrease in symptoms and induction of remission in all 13. In the 10 women followed post partum none developed post partum depression
  • Several studies have shown a non-statistically significant increase in the number of miscarriages in women taking SSRIs or SRNIs – it is not clear if this is secondary to the medications or the depression itself. Two meta-analyses of ssri and tca use during pregnancy failed to show an increase in fetal anomalies. However recently - Swedish Medical birth registry has shown a 1.5 to 2 fold increased risk for cardiovascular malformations (vsd and asd) associated with 1 st trimester exposure to paroxetine Risk of neonatal toxicity of withdrawal syndromes during the acute neonatal period One study showed women who took fluoxetine in the 3 rd trimester had significantly higher rates of preterm delivery and poor neonatal adaptation. In full term infants, the mean birth weight was significantly lower. Fluoxetine is most studied of SSRIs. Could be beneficial in that it has a long half life, so one does not need to taper the dose. Zoloft shows to have one of the lowest levels in breast milk Long term effects on cognitive development and behaviour are unknown.
  • Seizures have only been seen with clomipramine
  • Have been seen with both fluoxetine and paroxetine Not clear if SSRIs with longer half lives have same withdraw symptoms
  • Two studies by nulman of children exposed to either tcas or ssris during pregnancy demonstrated no signficant differences in…..
  • Need to take into account risks of fetal exposure to medication, potential impact of untreated maternal depression during pregnancy on neonatal outcome and potential risks of neonatal syndromes associated with certain antidepressants.
  • One study showed there was no difference between nortryptiline and placebo
  • Small study with transdermal estradiol showed improvement in women with severe and persistent ppd
  • ECT typically requires 3-9 treatments to produce an effective response. Treatments are 3x/wk Rapid treatment needed = mother at risk for suicide or infanticide In past 50 years there has been only four cases of preterm labor and none of SROM associated with ECT
  • While a patient’s length of therapy is often based on their history of prior depression, recurrence rate, and severity of previous symptoms, it is often recommended that women continue medications for at least one year following full remission of symptoms. If a patient becomes pregnant while on antidepressants you should continue meds through pregnancy to reduce the risk of relapse. JAMA study in feb 1, 2006- of 201 women with h/o depression, 43% experienced relapse of major depression during pregnancy. Those who maintained meds during pregnancy only had 26% relapse vs 68% in those who stopped meds. 50% relapsed in 1 st trimester and 90% by end of 2 nd trimester Both duration of depressive illness and h/o more recurrent depressive were associated with significant increase in risk of depressive relapse during pregnancy Maintenance of euthymic mood during pregnancy is essential in reducing long term morbidity and mortality
  • JAMA study in feb 1, 2006- of 201 women with h/o depression, 43% experienced relapse of major depression during pregnancy. Those who maintained meds during pregnancy only had 26% relapse vs 68% in those who stopped meds. 50% relapsed in 1 st trimester and 90% by end of 2 nd trimester Both duration of depressive illness and h/o more recurrent depressive were associated with significant increase in risk of depressive relapse during pregnancy Maintenance of euthymic mood during pregnancy is essential in reducing long term morbidity and mortality
  • Combination therapy is often required, including mood stabilizers, antipsychotics, benzodiazopines, and antidepressants. Consideration should be given to discontinuing breastfeeding secondary to potential effects of medication combinations of the infant.
  • Risk of ppd is 25% in women with previous h/o depression and 50% if prior h/o ppd
  • It is important to screen patients during antepartum visits, while in the hospital and at postpartum and well baby visits
  • Postpartum mood disorders

    1. 1. Postpartum Mood Disorders www.freelivedoctor.com
    2. 2. Primary Objectives <ul><li>Review the range of pregnancy related mood disorders </li></ul><ul><li>Discuss the risk factors for developing a pregnancy related disorder </li></ul><ul><li>Identify screening strategies </li></ul><ul><li>Review treatment options during pregnancy and postpartum </li></ul>www.freelivedoctor.com
    3. 3. Secondary Objectives <ul><li>Review the prevalence of mood disorders in women </li></ul><ul><li>Investigate the etiology of pregnancy related mood disorders </li></ul><ul><li>Discuss the familial implications of these illnesses </li></ul><ul><li>Discuss prevention strategies </li></ul>www.freelivedoctor.com
    4. 4. Major Depressive Disorder <ul><li>Leading cause of disability </li></ul><ul><li>Prevalence of 5-9% </li></ul><ul><li>Lifetime risk of 10-25% </li></ul>www.freelivedoctor.com
    5. 5. Peripartum Depressive Disorders <ul><li>Antepartum Depression </li></ul><ul><li>Postpartum Blues </li></ul><ul><li>Postpartum Depression (PPD) </li></ul><ul><li>Postpartum Psychosis (PPP) </li></ul>www.freelivedoctor.com
    6. 6. Antepartum Depression <ul><li>Symptoms often seen in non-depressed pregnant women </li></ul><ul><ul><li>Sleep and appetite disturbance </li></ul></ul><ul><ul><li>Diminished libido </li></ul></ul><ul><ul><li>Low energy </li></ul></ul><ul><li>Pregnancy related conditions are associated with depressive symptoms </li></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>Gestational diabetes </li></ul></ul><ul><ul><li>Thyroid dysfunction </li></ul></ul>www.freelivedoctor.com
    7. 7. Postpartum Blues <ul><li>Aka “baby blues” </li></ul><ul><li>Characteristics: </li></ul><ul><ul><li>Mild mood swings </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Decreased concentration </li></ul></ul><ul><ul><li>Insomnia </li></ul></ul><ul><ul><li>Tearfulness </li></ul></ul><ul><ul><li>Crying spells </li></ul></ul>www.freelivedoctor.com
    8. 8. Postpartum Blues <ul><li>Occur within 2-3 days of delivery </li></ul><ul><li>Symptoms peak on 4 th or 5 th postpartum day </li></ul><ul><li>Symptoms resolve within 2 weeks </li></ul>www.freelivedoctor.com
    9. 9. Postpartum Depression <ul><li>Same DSM IV criteria as for non-pregnancy related depression </li></ul><ul><li>Symptoms usually begin in initial 12 months after delivery </li></ul><ul><li>Symptoms often seen as “normal” for new mothers caring for a newborn </li></ul>www.freelivedoctor.com
    10. 10. Symptoms of PPD <ul><li>Change in somatic function </li></ul><ul><li>Significant anxiety </li></ul><ul><li>Intense irritability and anger </li></ul><ul><li>Feelings of guilt </li></ul>www.freelivedoctor.com
    11. 11. Symptoms of PPD <ul><li>Sense of being overwhelmed </li></ul><ul><li>Unable to care for baby </li></ul><ul><li>Feelings of inadequacy </li></ul><ul><li>Not bonding with the baby </li></ul>www.freelivedoctor.com
    12. 12. Postpartum Psychosis <ul><li>Usually a manifestation of bipolar disorder </li></ul><ul><li>Typically presents within 2 weeks of delivery </li></ul><ul><li>May develop few months after birth as delusional depression </li></ul>www.freelivedoctor.com
    13. 13. Signs and Symptoms of PPP <ul><li>Severe insomnia </li></ul><ul><li>Rapid mood swings </li></ul><ul><li>Anxiety </li></ul><ul><li>Psychomotor restlessness </li></ul><ul><li>Delusions and hallucinations </li></ul>www.freelivedoctor.com
    14. 14. Fetal Implications <ul><li>Increased rate of: </li></ul><ul><ul><li>Preterm birth </li></ul></ul><ul><ul><li>Low birth weight </li></ul></ul><ul><ul><li>Small head circumference </li></ul></ul><ul><ul><li>Low APGAR scores </li></ul></ul>www.freelivedoctor.com
    15. 15. Familial Implications <ul><li>Postnatal depression in men </li></ul><ul><li>Interference with maternal-infant bonding, increases mom’s sense of shame and guilt </li></ul><ul><li>Influences infant development </li></ul>www.freelivedoctor.com
    16. 16. Familial Implications <ul><li>Negative interactive patterns with infant </li></ul><ul><li>Children exposed to maternal psychiatric illness have: </li></ul><ul><ul><li>Higher incidence of conduct disorders </li></ul></ul><ul><ul><li>Inappropriate aggression </li></ul></ul><ul><ul><li>Cognitive and attention deficits </li></ul></ul>www.freelivedoctor.com
    17. 17. Prevalence <ul><li>Postpartum blues occur in 40 – 80% of women </li></ul><ul><li>PPD affects 10 – 30% of women </li></ul><ul><li>Postpartum psychosis is rare </li></ul>www.freelivedoctor.com
    18. 18. Antepartum Depression Prevalence <ul><li>10% of all pregnancies </li></ul><ul><li>Increased risk for women with history of affective illnesses </li></ul><ul><li>Relapses most common in the first trimester </li></ul><ul><li>1/3 of all cases represent first episode of depression </li></ul>www.freelivedoctor.com
    19. 19. Postpartum Depression Prevalence <ul><li>Up to 13% in the first year postpartum </li></ul><ul><li>50% higher risk of recurrent PPD in subsequent pregnancies </li></ul><ul><li>If history of depression prior to pregnancy, risk of PPD is 25 – 30% </li></ul>www.freelivedoctor.com
    20. 20. Prevalence in Active Duty <ul><li>Positive depression screen </li></ul><ul><ul><li>Antepartum </li></ul></ul><ul><ul><li>Postpartum </li></ul></ul><ul><li>Suicide ideation rate </li></ul>www.freelivedoctor.com
    21. 21. Risk Factors for PPB <ul><li>History of depression or premenstrual mood changes </li></ul><ul><li>Depressive symptoms during pregnancy </li></ul><ul><li>Family history of depression </li></ul><ul><li>Concern about child care </li></ul><ul><li>Psychosocial impairment </li></ul>www.freelivedoctor.com
    22. 22. PPD Risk Factors <ul><li>Personal history of depression </li></ul><ul><li>Family psychiatric history </li></ul><ul><li>Marital conflict </li></ul><ul><li>Lack of perceived social support </li></ul>www.freelivedoctor.com
    23. 23. PPD Risk Factors <ul><li>Lack of emotional & financial support from partner </li></ul><ul><li>Living without a partner </li></ul><ul><li>Unplanned pregnancy </li></ul><ul><li>Previous miscarriage </li></ul>www.freelivedoctor.com
    24. 24. PPD Risk Factors <ul><li>Having contemplated terminating current pregnancy </li></ul><ul><li>Poor relationship with own mother </li></ul><ul><li>Not breastfeeding </li></ul>www.freelivedoctor.com
    25. 25. PPD Risk Factors <ul><li>Unemployment in the mother </li></ul><ul><li>Lifetime history of depression in partner </li></ul><ul><li>Stressful life events in previous 12 months </li></ul>www.freelivedoctor.com
    26. 26. PPD Risk Factors <ul><li>Child care related stressors </li></ul><ul><li>Sick leave during pregnancy </li></ul><ul><li>High number of prenatal visits </li></ul><ul><li>Congenitally malformed infant </li></ul>www.freelivedoctor.com
    27. 27. Risk Factors for PPP <ul><li>History of bipolar disorder </li></ul><ul><li>History of psychosis prior to pregnancy </li></ul><ul><li>Family history of psychosis </li></ul>www.freelivedoctor.com
    28. 28. Co-morbidities <ul><li>Decreased weight gain during pregnancy </li></ul><ul><li>Increased rate of tobacco use </li></ul><ul><li>Increased rate of alcohol and illicit drug use </li></ul>www.freelivedoctor.com
    29. 29. Etiology <ul><li>No clear etiology </li></ul><ul><li>Possibly due to combination of: </li></ul><ul><ul><li>Genetic susceptibility </li></ul></ul><ul><ul><li>Hormonal changes </li></ul></ul><ul><ul><li>Major life events </li></ul></ul>www.freelivedoctor.com
    30. 30. Etiology <ul><li>Investigators have examined the role of: </li></ul><ul><ul><li>Estrogen </li></ul></ul><ul><ul><li>Progesterone </li></ul></ul><ul><ul><li>Thyroid hormone </li></ul></ul><ul><ul><li>Testosterone </li></ul></ul><ul><ul><li>Cholesterol </li></ul></ul><ul><ul><li>Corticotropin-relasing hormone </li></ul></ul><ul><ul><li>Cortisol </li></ul></ul>www.freelivedoctor.com
    31. 31. Screening - Overview <ul><li>Important to identify proper timing of screening </li></ul><ul><li>Avenues include both informal and formal techniques </li></ul><ul><li>Various formal screening tools available </li></ul>www.freelivedoctor.com
    32. 32. Screening - Timing <ul><li>Antepartum visits </li></ul><ul><li>During hospital stay </li></ul><ul><li>Postpartum visits </li></ul><ul><li>Well child visits </li></ul>www.freelivedoctor.com
    33. 33. Screening - Tools <ul><li>Beck’s Depression Inventory (PDI) </li></ul><ul><li>Postpartum Depression Screening Scale (PDSS) </li></ul><ul><li>Edinburgh Postnatal Depression Scale (EPDS) </li></ul>www.freelivedoctor.com
    34. 34. Beck’s Depression Inventory <ul><li>Self administered survey </li></ul><ul><li>21 questions scored 0 – 3 </li></ul><ul><li>Score of over 17 indicates that patient would benefit from professional assistance </li></ul><ul><li>56% of postpartum women with postpartum depression identified in one study </li></ul>www.freelivedoctor.com
    35. 35. Postpartum Depression Screening Scale <ul><li>94% sensitive and 96% specific in initial trials </li></ul><ul><li>35 item self-administered questionnaire </li></ul><ul><li>Uses 5 point scale </li></ul>www.freelivedoctor.com
    36. 36. Edinburgh Postnatal Depression Scale <ul><li>10 item questionnaire </li></ul><ul><li>Each response scored 0 – 3, with total score of 30 possible </li></ul><ul><li>Scores > 12 or 13 identify most women with postpartum depression </li></ul>www.freelivedoctor.com
    37. 37. EPDS <ul><li>Score > 12 reported as 100% sensitive and 95% specific in detecting major depression </li></ul><ul><li>Studies comparing EPDS vs PCM evaluation of patient show EPDS has a higher incidence of detecting and diagnosing postpartum depression </li></ul>www.freelivedoctor.com
    38. 38. www.freelivedoctor.com                                                                                                                                                       
    39. 39. www.freelivedoctor.com                                                                                                                                                       
    40. 40. Evaluation and Diagnosis <ul><li>Labs- CBC, TSH </li></ul><ul><li>Consider urine drug screen if history of drug use/abuse </li></ul><ul><li>DSM IV diagnosis criteria </li></ul>www.freelivedoctor.com
    41. 41. Diagnosis <ul><li>DSM IV modifier </li></ul><ul><li>ICD coding </li></ul><ul><ul><li>Postpartum depression 648.4 </li></ul></ul><ul><ul><li>Major depression 296 </li></ul></ul>www.freelivedoctor.com
    42. 42. Treatment <ul><li>Factors to address: </li></ul><ul><ul><li>Biological </li></ul></ul><ul><ul><li>Psychological </li></ul></ul><ul><ul><li>Social </li></ul></ul><ul><li>Demonstrated maximal clinical response with biopsychosocial approach </li></ul>www.freelivedoctor.com
    43. 43. Treatment <ul><li>Psychosocial therapies </li></ul><ul><ul><li>First choice for those with mild to moderate symptoms of PPD </li></ul></ul><ul><ul><li>Cognitive-behavioral therapy </li></ul></ul><ul><ul><li>Interpersonal psychotherapy- focuses on patient’s interpersonal relationship and changing roles </li></ul></ul>www.freelivedoctor.com
    44. 44. Psychosocial Therapies <ul><li>Group therapy </li></ul><ul><ul><li>Helps to increase support network </li></ul></ul><ul><li>Family and marital therapy </li></ul><ul><ul><li>More rapid recovery </li></ul></ul><ul><ul><li>More appreciative of partner’s contribution </li></ul></ul><ul><li>Peer-support groups </li></ul>www.freelivedoctor.com
    45. 45. Psychosocial Therapies (cont) <ul><li>Supportive psychotherapy </li></ul><ul><ul><li>Groups that offer support and education </li></ul></ul><ul><ul><li>Postpartum Support International </li></ul></ul><ul><ul><ul><li>www. postpartum.net </li></ul></ul></ul><ul><ul><li>Depression After Delivery </li></ul></ul><ul><ul><ul><li>www. depressionafterdelivery.com </li></ul></ul></ul>www.freelivedoctor.com
    46. 46. Interpersonal Therapy (IPT) <ul><li>Short-term, manual-driven psychotherapy </li></ul><ul><li>Addresses four major problem domains: </li></ul><ul><ul><li>Grief </li></ul></ul><ul><ul><li>Interpersonal disputes </li></ul></ul><ul><ul><li>Role transitions </li></ul></ul><ul><ul><li>Interpersonal deficits </li></ul></ul><ul><li>Shown to reduce symptoms in pregnant women </li></ul>www.freelivedoctor.com
    47. 47. Pharmacologic Therapy <ul><li>No antidepressants are approved by the FDA for use during pregnancy </li></ul><ul><li>All psychotropic drugs are transferred through the placenta and breast milk </li></ul><ul><li>Consider prior history </li></ul><ul><li>SSRIs and TCAs have low detection in breastfed infant serum </li></ul>www.freelivedoctor.com
    48. 48. Concerns for Psychotropic Use <ul><li>Risk of pregnancy loss or miscarriage </li></ul><ul><li>Risk of organ malformation or teratogenesis </li></ul><ul><li>Risk of neonatal toxicity or withdrawal syndromes </li></ul><ul><li>Risk of longterm neurobehavioral sequelae </li></ul>www.freelivedoctor.com
    49. 49. Neonatal Withdrawal – TCAs <ul><li>TCA withdrawal syndrome: </li></ul><ul><ul><li>Jitteriness </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><li>Anticholinergic effect of TCAs include: </li></ul><ul><ul><li>Functional bowel obstruction </li></ul></ul><ul><ul><li>urinary retention </li></ul></ul>www.freelivedoctor.com
    50. 50. Neonatal Withdrawal - SSRIs <ul><li>Transient symptoms of: </li></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Excessive crying </li></ul></ul><ul><ul><li>Increased muscle tone </li></ul></ul><ul><ul><li>Feeding problems </li></ul></ul><ul><ul><li>Sleep disruption </li></ul></ul><ul><ul><li>Respiratory distress </li></ul></ul>www.freelivedoctor.com
    51. 51. Long Term Sequelae <ul><li>No significant difference in: </li></ul><ul><ul><li>IQ </li></ul></ul><ul><ul><li>Temperament </li></ul></ul><ul><ul><li>Behavior </li></ul></ul><ul><ul><li>Reactivity </li></ul></ul><ul><ul><li>Mood </li></ul></ul><ul><ul><li>Distractibility </li></ul></ul><ul><ul><li>Activity level </li></ul></ul>www.freelivedoctor.com
    52. 52. Pharmacologic Therapy <ul><li>Increase risk of suicide after initiation of medication </li></ul><ul><li>If significant anxiety or insomnia present, consider adding benzodiazepine </li></ul><ul><li>Close follow-up </li></ul>www.freelivedoctor.com
    53. 53. Antidepressant Choice <ul><li>TCAs </li></ul><ul><ul><li>Desipramine and Nortryptiline are preferred </li></ul></ul><ul><ul><li>Least anti-cholinergic affects </li></ul></ul><ul><ul><li>Minimize postural hypotension </li></ul></ul><ul><li>SSRIs </li></ul><ul><ul><li>Fluoxetine is the best studied </li></ul></ul>www.freelivedoctor.com
    54. 54. Additional Considerations <ul><li>Doses of both SSRIs and TCAs may need to be increased in pregnancy secondary to: </li></ul><ul><ul><li>Increased plasma volume </li></ul></ul><ul><ul><li>Increased hepatic metabolism </li></ul></ul><ul><ul><li>Increased renal clearance </li></ul></ul>www.freelivedoctor.com
    55. 55. Other Therapies <ul><li>Hormonal Therapy </li></ul><ul><ul><li>Increased risk of PPD if Depo-provera given within 48 hrs of delivery </li></ul></ul><ul><ul><li>Transdermal estradiol may improve symptoms </li></ul></ul><ul><li>Treat severe anemia </li></ul><ul><li>Treat poorly controlled hypothyroidism </li></ul>www.freelivedoctor.com
    56. 56. Other Therapies (cont) <ul><li>ECT </li></ul><ul><ul><li>Few adverse effects to mom or infant </li></ul></ul><ul><ul><li>Good when rapid treatment is needed </li></ul></ul><ul><ul><li>For severe depression with psychotic symptoms or acute mania </li></ul></ul>www.freelivedoctor.com
    57. 57. Length of Treatment <ul><li>Based on patient history and severity of symptoms </li></ul><ul><li>Continue 12 months after full remission </li></ul><ul><li>Continue meds through pregnancy to reduce risk of relapse </li></ul>www.freelivedoctor.com
    58. 58. Referrals <ul><li>Consider Psychiatric referral if: </li></ul><ul><ul><li>Poor response to therapy </li></ul></ul><ul><ul><li>Relapse </li></ul></ul><ul><ul><li>Major functional impairment </li></ul></ul><ul><ul><li>Suicidal or homicidal ideation </li></ul></ul>www.freelivedoctor.com
    59. 59. Treatment of Postpartum Psychosis <ul><li>Medical emergency </li></ul><ul><li>Patient should be hospitalized until stable </li></ul><ul><li>While psychotic, mom cannot adequately care for self or infant </li></ul>www.freelivedoctor.com
    60. 60. Treatment of PPP (cont) <ul><li>Medications focused on controlling both psychosis and mood swings </li></ul><ul><li>Combination therapy often necessary </li></ul><ul><li>Most will not be able to continue breastfeeding </li></ul><ul><li>ECT may be highly effective </li></ul>www.freelivedoctor.com
    61. 61. Prevention <ul><li>Monitor for signs in high risk women </li></ul><ul><li>Educate women and family members before childbirth </li></ul><ul><li>Counseling and increase social support prior to delivery </li></ul><ul><li>Consider starting therapy during third trimester or immediately after delivery </li></ul>www.freelivedoctor.com
    62. 62. Conclusion <ul><li>Postpartum mood disorders are common </li></ul><ul><li>Military population has multiple risk factors for developing postpartum depression </li></ul><ul><li>Important to screen patients in a variety of settings. </li></ul><ul><li>Treatment of postpartum depression important for maternal and familial well being </li></ul>www.freelivedoctor.com
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