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Mood Disorders in Pregnancy and the Postpartum
This document discusses mood disorders during pregnancy and the postpartum period. It covers depression during pregnancy, postpartum blues, postpartum depression, postpartum psychosis, and postpartum obsessive-compulsive disorder. Depression is common during pregnancy, with risks including preterm birth and poor health behaviors. Postpartum blues typically occur within the first 2 weeks after delivery and involve mood swings and crying. Postpartum depression has a later onset and can involve intrusive thoughts, while postpartum psychosis involves confusion and delusions. Risks, symptoms, and treatment options are discussed for each condition.
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Mood Disorders in Pregnancy and the Postpartum
- 1. Mood Disorders in Pregnancyand 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 havenothing 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 BehavioralDay 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 BehavioralDay 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 pregnancyis 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 • Riskfactors – 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 • Twoweeks 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 • Lateronset 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.
- 39. Breastfeeding • Most medicationsexcreted 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 ofAntidepressants 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 inFathers • 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 • Believedto 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 • Riskfactors for infanticide – Psychosis – Suicidality – Depression – Life stress – Alcohol use – Limited social support – Personal history of abuse
- 51. Postpartum Psychosis • Relatedto 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
- 63.
- 64. Resources • www.womensmentalhealth.org • http://www.postpartumprogress.com/ • Midlands Postpartum Coalition • Postpartum Support International