Other mood disorders, unit 8


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  • 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
  • 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
  • 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
  • Other mood disorders, unit 8

    1. 1. Postpartum Blues This condition is also known as “baby blues” Characteristics of PPD  Insomnia  Tearfulness  Crying spells  Irritability  Anxiety  Decreased concentration  Mood Swings
    2. 2. Postpartum Blues Onset of symptoms 2-3 day post delivery Peak around the 5th after delivery Resolve within 2 weeks
    3. 3. Postpartum Depression Onset of symptoms within first 12 month after delivery Often regarded as normal symptoms for a new mother or a mother caring for a baby. Same DSM criteria as for non-pregnancy related depression
    4. 4. Postpartum Psychosis AKA Puerperal Psychosis Characteristics:  Depression  Delusions  Thoughts of self harm (suicide)  Thoughts of harming the infant (infanticide)
    5. 5. Postpartum Psychosis Incidence:  1 to 2 per 1000 childbirths  50% to 60% of cases- first child  50% of cases- family history of mood disorders
    6. 6. Postpartum Psychosis Symptoms  Onset within days of delivery but normally 2 to 3 weeks  Severe insomnia  Rapid mood swings  Anxiety  Psychomotor restlessness  Delusions and hallucinations
    7. 7. Pharmacologic Therapy PPD No antidepressants are approved by the FDA for use during pregnancy All psychotropic drugs are transferred through the placenta and breast milk Consider prior history SSRIs and TCAs have low detection in breastfed infant serum
    8. 8. Concerns for PsychotropicUse Risk of pregnancy loss or miscarriage Risk of organ malformation or teratogenesis Risk of neonatal toxicity or withdrawal syndromes Risk of longterm neurobehavioral sequelae
    9. 9. Neonatal Withdrawal – TCAs TCA withdrawal syndrome:  Jitteriness  Irritability  Seizures Anticholinergic effect of TCAs include:  Functional bowel obstruction  urinary retention
    10. 10. Neonatal Withdrawal - SSRIs Transient symptoms of:  Irritability  Excessive crying  Increased muscle tone  Feeding problems  Sleep disruption  Respiratory distress
    11. 11. Pharmacologic Therapy Increase risk of suicide after initiation of medication If significant anxiety or insomnia present, consider adding benzodiazepine Close follow-up
    12. 12. Antidepressant Choice TCAs  Desipramine and Nortryptiline are preferred  Least anti-cholinergic affects  Minimize postural hypotension SSRIs  Fluoxetine is the best studied
    13. 13. Additional Considerations Doses of both SSRIs and TCAs may need to be increased in pregnancy secondary to:  Increased plasma volume  Increased hepatic metabolism  Increased renal clearance
    14. 14. Other Therapies Hormonal Therapy  Increased risk of PPD if Depo-provera given within 48 hrs of delivery  Transdermal estradiol may improve symptoms Treat severe anemia Treat poorly controlled hypothyroidism
    15. 15. Other Therapies (cont) ECT  Few adverse effects to mom or infant  Good when rapid treatment is needed  For severe depression with psychotic symptoms or acute mania
    16. 16. Length of Treatment Based on patient history and severity of symptoms Continue 12 months after full remission Continue meds through pregnancy to reduce risk of relapse
    17. 17. Treatment of PostpartumPsychosis Consider it a medical emergency Patient should be hospitalized until stable Mother is unable to care for herself or the infant during the psychosis phase
    18. 18. Treatment of PPP (cont) Medications focused on controlling both psychosis and mood swings Combination therapy often necessary Most will not be able to continue breastfeeding ECT may be highly effective
    19. 19. Prevention Monitor for signs in high risk women Educate women and family members before childbirth Counseling and increase social support prior to delivery Consider starting therapy during third trimester or immediately after delivery