Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Mood Disorders in Pregnancy and the Postpartum

2,167 views

Published on

S.Berg presentation given at the 2012 South Carolina Home Visiting Summit

Published in: Education
  • Be the first to comment

Mood Disorders in Pregnancy and the Postpartum

  1. 1. Mood Disorders inPregnancy and the Postpartum Stephanie Berg, MD The Women’s Emotional Health Center At Midlands Psychiatry Palmetto Health Behavioral Day Program September 19, 2012
  2. 2. Disclaimer• I have nothing to disclose• Some discussion of medications is off label as no medications are FDA in pregnancy
  3. 3. Objectives• Introduction• Depression in pregnancy• Baby blues• Postpartum depression• Postpartum psychosis• Postpartum obsessive-compulsive disorder
  4. 4. The Women’s Emotional Health Center atMidlands Psychiatric Service, LLC 125 Alpine Circle Columbia, South Carolina 29223 (803) 779 - 3548
  5. 5. Palmetto Health Behavioral Day Program• Monday through Friday – Patients sleep at home• Partial Hospitalization Program – 9am to 2:45pm – 5 groups a day• Intensive Outpatient Program – 9am to 12:30pm – 4 groups a day
  6. 6. Palmetto Health Behavioral Day Programs• Integrative treatment – Group therapy • DBT, CBT, ACT • Nutrition • Yoga • Spirituality • Recreation therapy • Music therapy, art therapy – Individual therapy – Medication management
  7. 7. Perinatal Psychiatric Disorders• Pregnancy Depression• Postpartum Blues• Postpartum Depression• Postpartum Psychosis• Postpartum Obsessive-Compulsive Disorder• Exacerbation of other illness
  8. 8. Depression in Pregnancy Example• Ms. B has a history of depression. She stopped taking Prozac when she found out she was pregnant. At 7 weeks, she found her energy to be lower, she was crying more, and was unable to eat enough. She presented to her obstetrician unsure if she wanted to continue the pregnancy.
  9. 9. Major Depressive Episode• At least 2 weeks – Sad – Interest – Guilt – Energy – Concentration – Appetite – Feeling restless or slowed – Sleep – Suicidality
  10. 10. Depression in Pregnancy • 10 – 20% of women during pregnancy • Up to 30% in low- income populations
  11. 11. Depression in pregnancy is very commonFirst trimester 7%Second trimester 13 %Third trimester 12 %
  12. 12. Depression in Pregnancy Risk Factors• Previous episode of depression• Family history of depression• Poor social support• “Unwanted” pregnancy• Young age - adolescents
  13. 13. Depression in Pregnancy• Risks of untreated depression – Preeclampsia – Placenta abnormalities – Low birth weight – Preterm labor – Fetal distress
  14. 14. Depression in Pregnancy• Risks of untreated depression – Poor follow up with OB appointments – Poorer nutrition, less likely to take folate – More likely to smoke, use alcohol, or other substances – Greater likelihood to develop postpartum depression
  15. 15. Postpartum Depression Previous Condition Risk of PPDMajor depressive disorder 24 %Depression in pregnancy 35 %Previous PPD 50 %
  16. 16. Antenatal depression goes untreated• Less than 1/3 of women receive treatment for depression during pregnancy – Who does get treatment? • History of MDD • History of psychiatric treatment • Depression severity
  17. 17. Treatment in Pregnancy• An individual decision that is made on a case by case basis
  18. 18. Antidepressant medications• SSRIs – Fluoxetine (Prozac) – Sertraline (Zoloft) – Paroxetine (Paxil) – Fluvoxamine (Luvox) – Citalopram (Celexa) – Escitalopram (Lexapro)• SNRIs – Venlafaxine (Effexor) – Duloxetine (Cymbalta) – Desvenlafaxine (Pristiq)
  19. 19. Antidepressant medications• Other – Wellbutrin (Bupropion) • Norepinephrine and dopamine – Trazodone – Mirtazapine (Remeron)• Tricyclic Antidepressants – Amitriptyline (Elavil) – Nortriptyline (Pamelor) – Imipramine (Tofranil) – Clomipramine (Anafranil)• MAOIs – Phenylzine (Nardil) – Tranylcypromine (Parnate)
  20. 20. Treatment in Pregnancy• Sertraline (Zoloft) has the most safety data in pregnancy and with breastfeeding• Avoid paroxetine (Paxil) if possible – Risk of heart malformations
  21. 21. Treatment in Pregnancy• SSRI/SNRI risks – Miscarriage – Malformations – Earlier delivery? – Persistent Pulmonary Hypertension of the Newborn – Neonatal Adaptation Syndrome
  22. 22. Postpartum Psychiatric Disorders Disorder Incidence Time Course Clinical Features •TearfulnessPostpartum 70 – 80 % Within first week → 14 days •Anxiety Blues •Insomnia •Mood Instability •DepressionPostpartum 10 % Within first month •Guilt (technically)Depression •Anxiety •Fear of harm to baby •Obsessions •DisorientationPostpartum 0.1 – 0.2 % Within first month •ConfusionPsychosis •Delusions •Hallucinations •Rapid Mood Cycling
  23. 23. Postpartum Blues Case• Three days after she brought her baby home from the hospital after an uneventful pregnancy and delivery, Ms. S started worrying that she would drop her baby and found herself become teary while watching television. She was able to sleep when her baby slept and was eating normally. This resolved by the time her baby was two weeks old.
  24. 24. Postpartum Blues• A.K.A. Baby Blues• Common – (70 – 80% of women)
  25. 25. Postpartum Blues• Risk factors – Low mood during last trimester of pregnancy – History of bad premenstrual symptoms – Depression in the past – Preeclampsia – Stress – Not enough support – Not feeling comfortable with how baby is nursing
  26. 26. Postpartum Blues• Symptoms – Mood swings – Irritability – Tearfulness – Confusion – Feeling tired – Sensitivity – Not depression or apathy
  27. 27. Postpartum Blues• Treatment – Reassurance – Support – Education – Monitoring
  28. 28. Postpartum Depression• Two weeks after Ms. J’s son is born, she begins to feel sad and have lower motivation. Even though she is continually exhausted, she has trouble falling asleep when her baby sleeps. She has repetitive thoughts of her baby falling out the window but these thoughts scare her and she would never act on them.
  29. 29. Postpartum Depression• Later onset than Postpartum Blues• Places child at risk down the road – Lower self-esteem – More acting out – Nursing infants gain less weight – Duration of mother’s episode correlated with degree of impairment in child
  30. 30. Postpartum Depression• Symptoms – Depression, crying – Inability to sleep when the baby sleeps – Intrusive thoughts • Thoughts of hurting the baby • Thoughts of hurting self – Suicidal thoughts – Loss of appetite – Lack of interest in the baby – Anxiety and panic attacks
  31. 31. Postpartum Depression Risk Factors• Family history• Psychosocial Factors – Social/partner support• Related to hormonal related depressions – PMS – Seasonal – Perimenopausal• Multiples• Difficulty with breastfeeding – Watch with weaning
  32. 32. Postpartum Depression Risk Factors• Risk is not reduced with subsequent children - may be increased• Risk of recurrence: – 1 episode – 50% – 2 episodes – 75 – 80%
  33. 33. Postpartum Depression Previous Condition Risk of PPDMajor depressive disorder 24 %Depression in pregnancy 35 %Previous PPD 50 %
  34. 34. Postpartum Depression• Consequences – Inconsistent use of birth control – Parenting difficulties – Family and marriage difficulties – Developmental, behavioral, and emotional problems in children – Personal suffering – Suicide
  35. 35. Detection of Postpartum Depression• Detection rates for depression in Ob-Gyn settings 15-30%• Treatment rates – 75% are untreated
  36. 36. Detection of Postpartum Depression• Edinburgh Postnatal Depression Scale (EPDS) – Can be used during pregnancy and postpartum – 10-item, self-administered – Easy to score – Score of at least 10-13 indicates depression – Validated in at least 12 languages
  37. 37. EPDS
  38. 38. Breastfeeding• Most medications excreted into breast milk• Drug levels in breast milk are less than what crosses the placenta
  39. 39. Medications in breastfeeding• Avoid long half life or sustained release medications• Schedule medication dosing immediately after feeding or right before long rest period• Advise mother to monitor for oversedation, especially with cosleeping
  40. 40. Half Lives of AntidepressantsFluoxetine 2-3 daysCitalopram 34 hoursEscitalopram 30 hoursSertraline 29 hoursParoxetine 24 hoursBupropion 12 hoursDuloxetine 12 hoursVenlafaxine 5 hours (metabolite = 11 hours)
  41. 41. Postpartum Depression Treatment• Antidepressants – Low levels in breastmilk of • Paroxetine (Paxil) • Sertraline (Zoloft) • Citalopram (Celexa)
  42. 42. Postpartum Depression – Treatment• Check thyroid function• Increase support• Psychotherapy – Interpersonal Psychotherapy• Phototherapy• ECT
  43. 43. Postpartum Depression in Fathers• More common than you would think – 10.4 % overall from 1st trimester to 1 year after delivery – 25.6% at 3-6 months• Biggest correlation is with depression in the partner – But also associated with marriage problems
  44. 44. Postpartum Psychosis• Ms. S was hospitalized 3 weeks after her baby was born. She was feeling that her neighbors were poisoning her water and planning to steal her 2 older children from their school. She heard the neighbors talking through the walls of her house. She was feeling that there was no choice but to kill herself and her children and made plans to drive them into a tree.
  45. 45. Postpartum Psychosis• Believed to be related to bipolar disorder – 35% risk postpartum psychosis – 60 % risk of recurrent affective illness• Psychiatric Emergency – HOSPITALIZE
  46. 46. Postpartum Psychosis• Rare – 1 to 3 cases per 1000 births• Abrupt onset – Usually by postpartum day number 3
  47. 47. Postpartum Psychosis• Dangerous – 4 % risk of infanticide – 5 % risk of suicide• HOSPITALIZE
  48. 48. Postpartum Psychosis• Risk factors for infanticide – Psychosis – Suicidality – Depression – Life stress – Alcohol use – Limited social support – Personal history of abuse
  49. 49. Postpartum Psychosis• Related to bipolar disorder – 75 % with bipolar disorder – 12 % with schizophrenia• Mothers with bipolar disorder have a 100- fold increase in rate of psychiatric hospitalization after delivery
  50. 50. Postpartum Psychosis• Symptoms – Confusion – Bizarre behavior – Hallucinations – Mood lability – Restlessness – Agitation
  51. 51. Postpartum Psychosis - Treatment• Treatment – Hospitalize – Mood stabilizers – Antipsychotic medications – Electroconvulsive Therapy• Consider prophylactic mood stabilizer treatment starting at birth with next pregnancy – Women with Bipolar Disorder should probably continue treatment through pregnancy
  52. 52. Postpartum Obsessive-Compulsive Disorder• After delivering her next child, Ms. J begins to have concerns that she might throw her newborn daughter out the window. She avoids picking up her daughter and keeps all the windows locked at all times. She does not want to hurt her daughter and is having difficulty sleeping because of these thoughts.
  53. 53. Postpartum Obsessive-Compulsive Disorder • Underappreciated • 21 % of women with OCD have perinatal onset • OCD worsens in pregnancy and the postpartum • 60-80% comorbidity with MDDBrandes 2004
  54. 54. Postpartum Obsessive-Compulsive Disorder• DSM IV-TR OCD Criteria – Obsessions or – Compulsions – Understands thoughts are excessive or unreasonable – Causes distress
  55. 55. Postpartum Obsessive-Compulsive Disorder• Intrusive thoughts – May be seen with depression – Intrusive, ego-dystonic thoughts – Often violent thoughts of harm to child • Avoidant behaviors to avoid harm – Often contamination fears – Usually not associated with compulsions
  56. 56. Postpartum Obsessive-Compulsive Disorder• Peak onset 2 weeks• Screening question – “It’s not uncommon for new mothers to experience intrusive, unwanted thoughts that they might harm their baby. Have any such thoughts occurred to you?”• Rule out psychosis or extreme anxiety
  57. 57. Postpartum Obsessive-Compulsive Disorder• Treatment – Reassurance – Cognitive behavioral therapy – Family therapy – SSRIs • No specific data • Require higher doses
  58. 58. Take Home Points• Depression in pregnancy is common• Untreated depression in pregnancy carries risks for both the mother and the child• No antidepressants are FDA approved in pregnancy – But sertraline is generally agreed to be “safest”• Must weigh risks and benefits with the mother (and partner) on an individual basis
  59. 59. Take Home Points• SSRIs may be associated with malformations, PPHN, and a neonatal syndrome.• SSRIs are “safe” in breastfeeding – Sertraline and paroxetine probably safest
  60. 60. Take Home Points• Postpartum psychosis is a true psychiatric emergency• Postpartum obsessive compulsive disorder is often overlooked and marked by intrusive thoughts
  61. 61. Questions?
  62. 62. Resources• www.womensmentalhealth.org• http://www.postpartumprogress.com/• Midlands Postpartum Coalition• Postpartum Support International

×