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Mood Disorders in
Pregnancy and the
   Postpartum
 Stephanie Berg, MD
   The Women’s Emotional Health Center
         At Midlands Psychiatry

  Palmetto Health Behavioral Day Program


   September 19, 2012
Disclaimer
• I have nothing to disclose
• Some discussion of medications is off
  label as no medications are FDA in
  pregnancy
Objectives
•   Introduction
•   Depression in pregnancy
•   Baby blues
•   Postpartum depression
•   Postpartum psychosis
•   Postpartum obsessive-compulsive
    disorder
The Women’s Emotional
    Health Center
               at
Midlands Psychiatric Service, LLC
        125 Alpine Circle
    Columbia, South Carolina
             29223
        (803) 779 - 3548
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
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
Perinatal Psychiatric Disorders
• Pregnancy Depression
• Postpartum Blues
• Postpartum Depression
• Postpartum Psychosis
• Postpartum Obsessive-Compulsive
  Disorder
• Exacerbation of other illness
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.
Major Depressive Episode
• At least 2 weeks
  –   Sad
  –   Interest
  –   Guilt
  –   Energy
  –   Concentration
  –   Appetite
  –   Feeling restless or slowed
  –   Sleep
  –   Suicidality
Depression in Pregnancy

            • 10 – 20% of women
              during pregnancy
            • Up to 30% in low-
              income populations
Depression in pregnancy is very
            common
First trimester    7%


Second trimester   13 %


Third trimester    12 %
Depression in Pregnancy
             Risk Factors
•   Previous episode of depression
•   Family history of depression
•   Poor social support
•   “Unwanted” pregnancy
•   Young age - adolescents
Depression in Pregnancy
• Risks of untreated depression
  – Preeclampsia
  – Placenta abnormalities
  – Low birth weight
  – Preterm labor
  – Fetal distress
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
Postpartum Depression
  Previous Condition        Risk of PPD

Major depressive disorder   24 %


Depression in pregnancy     35 %


Previous PPD                50 %
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
Treatment in Pregnancy

• An individual decision
 that is made on a case
      by case basis
Antidepressant medications
• SSRIs
  –   Fluoxetine (Prozac)
  –   Sertraline (Zoloft)
  –   Paroxetine (Paxil)
  –   Fluvoxamine (Luvox)
  –   Citalopram (Celexa)
  –   Escitalopram (Lexapro)
• SNRIs
  – Venlafaxine (Effexor)
  – Duloxetine (Cymbalta)
  – Desvenlafaxine (Pristiq)
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)
Treatment in Pregnancy
• Sertraline (Zoloft) has the most safety data
  in pregnancy and with breastfeeding
• Avoid paroxetine (Paxil) if possible
  – Risk of heart malformations
Treatment in Pregnancy
• SSRI/SNRI risks
  – Miscarriage
  – Malformations
  – Earlier delivery?
  – Persistent Pulmonary Hypertension of the
    Newborn
  – Neonatal Adaptation Syndrome
Mood Disorders in Pregnancy and the Postpartum
Postpartum Psychiatric Disorders
 Disorder    Incidence     Time Course               Clinical
                                                    Features

                                                •Tearfulness
Postpartum   70 – 80 %     Within first week
                             → 14 days          •Anxiety
  Blues                                         •Insomnia
                                                •Mood Instability
                                                •Depression
Postpartum      10 %       Within first month
                                                •Guilt
                             (technically)
Depression                                      •Anxiety
                                                •Fear of harm to
                                                baby
                                                •Obsessions

                                                •Disorientation
Postpartum   0.1 – 0.2 %   Within first month
                                                •Confusion
Psychosis                                       •Delusions
                                                •Hallucinations
                                                •Rapid Mood Cycling
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.
Postpartum Blues
• A.K.A. Baby Blues
• Common
  – (70 – 80% of women)
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
Postpartum Blues
• Symptoms
  –   Mood swings
  –   Irritability
  –   Tearfulness
  –   Confusion
  –   Feeling tired
  –   Sensitivity
  –   Not depression or apathy
Postpartum Blues
• Treatment
  – Reassurance
  – Support
  – Education
  – Monitoring
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.
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
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
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
Postpartum Depression Risk
             Factors
• Risk is not reduced with subsequent
  children
  - may be increased
• Risk of recurrence:
  – 1 episode – 50%
  – 2 episodes
    – 75 – 80%
Postpartum Depression
  Previous Condition        Risk of PPD

Major depressive disorder   24 %


Depression in pregnancy     35 %


Previous PPD                50 %
Postpartum Depression
• Consequences
 – Inconsistent use of birth control
 – Parenting difficulties
 – Family and marriage difficulties
 – Developmental, behavioral, and
   emotional problems in children
 – Personal suffering
 – Suicide
Detection of Postpartum
           Depression
• Detection rates for depression in Ob-Gyn
  settings 15-30%
• Treatment rates – 75% are untreated
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
EPDS
Breastfeeding

• Most medications excreted into breast
  milk
• Drug levels in breast milk are less than
  what crosses the placenta
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
Half Lives of Antidepressants
Fluoxetine        2-3 days


Citalopram        34 hours
Escitalopram      30 hours

Sertraline        29 hours
Paroxetine        24 hours
Bupropion         12 hours

Duloxetine        12 hours
Venlafaxine       5 hours (metabolite = 11
                  hours)
Postpartum Depression Treatment
• Antidepressants
  – Low levels in breastmilk of
    • Paroxetine (Paxil)
    • Sertraline (Zoloft)
    • Citalopram (Celexa)
Postpartum Depression –
             Treatment
• Check thyroid function
• Increase support
• Psychotherapy
  – Interpersonal Psychotherapy
• Phototherapy
• ECT
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
Mood Disorders in Pregnancy and the Postpartum
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.
Postpartum Psychosis
• Believed to be related to bipolar disorder
  – 35% risk postpartum psychosis
  – 60 % risk of recurrent affective illness
• Psychiatric Emergency
  – HOSPITALIZE
Postpartum Psychosis
• Rare
  – 1 to 3 cases per 1000 births
• Abrupt onset
  – Usually by postpartum day number 3
Postpartum Psychosis
• Dangerous
  – 4 % risk of infanticide
  – 5 % risk of suicide
• HOSPITALIZE
Postpartum Psychosis
• Risk factors for infanticide
  – Psychosis
  – Suicidality
  – Depression
  – Life stress
  – Alcohol use
  – Limited social support
  – Personal history of abuse
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
Postpartum Psychosis
• Symptoms
  – Confusion
  – Bizarre behavior
  – Hallucinations
  – Mood lability
  – Restlessness
  – Agitation
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
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.
Postpartum Obsessive-Compulsive
             Disorder
 • Underappreciated
 • 21 % of women with OCD have perinatal
   onset
 • OCD worsens in pregnancy and the
   postpartum
 • 60-80% comorbidity with MDD



Brandes 2004
Postpartum Obsessive-Compulsive
            Disorder
• DSM IV-TR OCD Criteria
  – Obsessions or
  – Compulsions
  – Understands thoughts are excessive or
    unreasonable
  – Causes distress
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
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
Postpartum Obsessive-Compulsive
            Disorder
• Treatment
  – Reassurance
  – Cognitive behavioral therapy
  – Family therapy
  – SSRIs
    • No specific data
    • Require higher doses
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
Take Home Points
• SSRIs may be associated with
  malformations, PPHN, and a neonatal
  syndrome.
• SSRIs are “safe” in breastfeeding
  – Sertraline and paroxetine probably safest
Take Home Points
• Postpartum psychosis is a true psychiatric
  emergency
• Postpartum obsessive compulsive
  disorder is often overlooked and marked
  by intrusive thoughts
Questions?
Resources
•   www.womensmentalhealth.org
•   http://www.postpartumprogress.com/
•   Midlands Postpartum Coalition
•   Postpartum Support International

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Mood Disorders in Pregnancy and the Postpartum

  • 1. Mood Disorders in Pregnancy and the Postpartum Stephanie Berg, MD The Women’s Emotional Health Center At Midlands Psychiatry Palmetto Health Behavioral Day Program September 19, 2012
  • 2. Disclaimer • I have nothing to disclose • Some discussion of medications is off label as no medications are FDA in pregnancy
  • 3. Objectives • Introduction • Depression in pregnancy • Baby blues • Postpartum depression • Postpartum psychosis • Postpartum obsessive-compulsive disorder
  • 4. The Women’s Emotional Health Center at Midlands Psychiatric Service, LLC 125 Alpine Circle Columbia, South Carolina 29223 (803) 779 - 3548
  • 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. 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. Perinatal Psychiatric Disorders • Pregnancy Depression • Postpartum Blues • Postpartum Depression • Postpartum Psychosis • Postpartum Obsessive-Compulsive Disorder • Exacerbation of other illness
  • 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. Major Depressive Episode • At least 2 weeks – Sad – Interest – Guilt – Energy – Concentration – Appetite – Feeling restless or slowed – Sleep – Suicidality
  • 10. Depression in Pregnancy • 10 – 20% of women during pregnancy • Up to 30% in low- income populations
  • 11. Depression in pregnancy is very common First trimester 7% Second trimester 13 % Third trimester 12 %
  • 12. Depression in Pregnancy Risk Factors • Previous episode of depression • Family history of depression • Poor social support • “Unwanted” pregnancy • Young age - adolescents
  • 13. Depression in Pregnancy • Risks of untreated depression – Preeclampsia – Placenta abnormalities – Low birth weight – Preterm labor – Fetal distress
  • 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. Postpartum Depression Previous Condition Risk of PPD Major depressive disorder 24 % Depression in pregnancy 35 % Previous PPD 50 %
  • 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. Treatment in Pregnancy • An individual decision that is made on a case by case basis
  • 18. Antidepressant medications • SSRIs – Fluoxetine (Prozac) – Sertraline (Zoloft) – Paroxetine (Paxil) – Fluvoxamine (Luvox) – Citalopram (Celexa) – Escitalopram (Lexapro) • SNRIs – Venlafaxine (Effexor) – Duloxetine (Cymbalta) – Desvenlafaxine (Pristiq)
  • 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. 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. Treatment in Pregnancy • SSRI/SNRI risks – Miscarriage – Malformations – Earlier delivery? – Persistent Pulmonary Hypertension of the Newborn – Neonatal Adaptation Syndrome
  • 23. Postpartum Psychiatric Disorders Disorder Incidence Time Course Clinical Features •Tearfulness Postpartum 70 – 80 % Within first week → 14 days •Anxiety Blues •Insomnia •Mood Instability •Depression Postpartum 10 % Within first month •Guilt (technically) Depression •Anxiety •Fear of harm to baby •Obsessions •Disorientation Postpartum 0.1 – 0.2 % Within first month •Confusion Psychosis •Delusions •Hallucinations •Rapid Mood Cycling
  • 24. 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.
  • 25. Postpartum Blues • A.K.A. Baby Blues • Common – (70 – 80% of women)
  • 26. 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
  • 27. Postpartum Blues • Symptoms – Mood swings – Irritability – Tearfulness – Confusion – Feeling tired – Sensitivity – Not depression or apathy
  • 28. Postpartum Blues • Treatment – Reassurance – Support – Education – Monitoring
  • 29. 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.
  • 30. 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
  • 31. 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
  • 32. 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
  • 33. Postpartum Depression Risk Factors • Risk is not reduced with subsequent children - may be increased • Risk of recurrence: – 1 episode – 50% – 2 episodes – 75 – 80%
  • 34. Postpartum Depression Previous Condition Risk of PPD Major depressive disorder 24 % Depression in pregnancy 35 % Previous PPD 50 %
  • 35. Postpartum Depression • Consequences – Inconsistent use of birth control – Parenting difficulties – Family and marriage difficulties – Developmental, behavioral, and emotional problems in children – Personal suffering – Suicide
  • 36. Detection of Postpartum Depression • Detection rates for depression in Ob-Gyn settings 15-30% • Treatment rates – 75% are untreated
  • 37. 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
  • 38. EPDS
  • 39. Breastfeeding • Most medications excreted into breast milk • Drug levels in breast milk are less than what crosses the placenta
  • 40. 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
  • 41. Half Lives of Antidepressants Fluoxetine 2-3 days Citalopram 34 hours Escitalopram 30 hours Sertraline 29 hours Paroxetine 24 hours Bupropion 12 hours Duloxetine 12 hours Venlafaxine 5 hours (metabolite = 11 hours)
  • 42. Postpartum Depression Treatment • Antidepressants – Low levels in breastmilk of • Paroxetine (Paxil) • Sertraline (Zoloft) • Citalopram (Celexa)
  • 43. Postpartum Depression – Treatment • Check thyroid function • Increase support • Psychotherapy – Interpersonal Psychotherapy • Phototherapy • ECT
  • 44. 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
  • 46. 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.
  • 47. Postpartum Psychosis • Believed to be related to bipolar disorder – 35% risk postpartum psychosis – 60 % risk of recurrent affective illness • Psychiatric Emergency – HOSPITALIZE
  • 48. Postpartum Psychosis • Rare – 1 to 3 cases per 1000 births • Abrupt onset – Usually by postpartum day number 3
  • 49. Postpartum Psychosis • Dangerous – 4 % risk of infanticide – 5 % risk of suicide • HOSPITALIZE
  • 50. Postpartum Psychosis • Risk factors for infanticide – Psychosis – Suicidality – Depression – Life stress – Alcohol use – Limited social support – Personal history of abuse
  • 51. 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
  • 52. Postpartum Psychosis • Symptoms – Confusion – Bizarre behavior – Hallucinations – Mood lability – Restlessness – Agitation
  • 53. 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
  • 54. 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.
  • 55. Postpartum Obsessive-Compulsive Disorder • Underappreciated • 21 % of women with OCD have perinatal onset • OCD worsens in pregnancy and the postpartum • 60-80% comorbidity with MDD Brandes 2004
  • 56. Postpartum Obsessive-Compulsive Disorder • DSM IV-TR OCD Criteria – Obsessions or – Compulsions – Understands thoughts are excessive or unreasonable – Causes distress
  • 57. 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
  • 58. 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
  • 59. Postpartum Obsessive-Compulsive Disorder • Treatment – Reassurance – Cognitive behavioral therapy – Family therapy – SSRIs • No specific data • Require higher doses
  • 60. 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
  • 61. Take Home Points • SSRIs may be associated with malformations, PPHN, and a neonatal syndrome. • SSRIs are “safe” in breastfeeding – Sertraline and paroxetine probably safest
  • 62. Take Home Points • Postpartum psychosis is a true psychiatric emergency • Postpartum obsessive compulsive disorder is often overlooked and marked by intrusive thoughts
  • 64. Resources • www.womensmentalhealth.org • http://www.postpartumprogress.com/ • Midlands Postpartum Coalition • Postpartum Support International

Editor's Notes

  1. A “public health crisis for low-income women”
  2. Euphoria and dysphoria 10 % meet criteria for hypomania 50-80% tearfulness not necessarily due to sadness 64% confusion