a 2016 review - unicef uk · a 2016 review kathleen kendall-tackett, phd, ibclc, ... dave et al....

What’s New in Postpartum Depression: A 2016 Review

Kathleen Kendall-Tackett, PhD, IBCLC, FAPA

Nothing to Disclose

Depression

Anxiety

OCD PTSD

PMADs (Postpartum Mood and Anxiety Disorders)

Perinatal Depression

Review of Current Studies

• Incidence • Adult Adversities • Depression and preterm

birth • Birth Interventions • Depression and

Breastfeeding Cessation • Breastfeeding protects

maternal mental health

40% to 60%

10% to 15% of New Mothers Privilege

Depression

Immigrant

Disaster Survivors

Ethnic Minority

Lower Income

Intimate Partner

Violence

Adult Adversities

True Incidence of Depression

31% had depression in the first 4 years Risk factors: young maternal age, stressful life events, adversity, IPV, and low income

1,507 Australian mothers, longitudinal study, 3 mos to 4 years

Woolhouse et al., 2015, Brit J Ob Gyn, 122, 312-321

• Depression is common in parents • High risk the first year • By age 12, 39% mothers and 21% of

fathers have been depressed

86,957 UK mothers and fathers, pregnancy to age 12

Dave et al. 2010 Arch Ped Adolescent, 164(11), 1038-1044

In the past 2 weeks, • 34% depressed

mood • 36% anhedonia

Declercq et al. 2008. New mothers speak out. New York: Childbirth Connection.

Listening to Mothers II, Nat’l representative US sample, N=1,573

CDC study found depression less likely to be diagnosed and treated: young women, African Americans, Hispanics, and other non-White women

Centers for Disease Control and Prevention, 2015. Mental health among women of reproductive age.

Korea • 49% (Lee & Hwang,

2015)

• 41% Pregnancy, 61% 4 weeks postpartum (Park et al., 2015)

Vietnam • 16%-20% (Murray

et al., 2015)

Lee & Hwang, 2015. Taiwanese J Ob Gyn, 54, 355-363; Murray et al., 2015, BMC Preg Childbirth, 234; Park et al., 2015. Asian Nurs Res, 9, 219-225

Han Chinese 18% (N=5391; Yang

et al., 2015)

India 23% (Patel et al., 2002)

Pakistan v Malawi 27% Pakistan, 3% Malawi (Zafar

et al., 2015)

Patel et al., 2002. Am J Psychi, 159, 43-47; Yang et al., 2015. J Affect Dis, 183, 339-346; Zafar et al., 2015. PLoS One, 10

Mothers in Turkey

• 14% (Danaci et al. 2002)

• 14% at 6 weeks (Kirpinar et al., 2010)

• 15% (Turkcapar et al., 2015)

Danaci et al., 2002. Soc Psychiatry Psychiatric Epidem, 37, 125-129; Kirpinar et al., 2010, J Clin Nurs, 19, 422-431; Turkcapar et al., 2015, BMC Preg Childbirth

8 studies of immigrant, asylum-seeking women, Canada Up to 42% (Collins et al., 2011)

24 studies, 13,749 women 20% of immigrants had PPD, twice that of native-born population (Falah-Hassani et al., 2015)

Collins et al., 2011. Arch Wom Mental Health, 14, 3-11; Falah-Hassani et al., J Psychiat Res, 70, 67-82

5,162 pregnant women, Montreal

• 15% reported IPV • More common in

poorest pregnant women

• Combo of immigrant status

and IPV increased risk of PPD by 7 times

• For native-born women,

IPV increased risk 4.78 times

Miszkurka et al., 2012, Arch Wom Ment Health, 15, 387-396

Review 67 articles

VAW during pregnancy increased risk of PMADs 3 times Antenatal depression increased the risk of IPV 3 to 5 times

Howard et al., 2013. PLoS Med, 10(5)

Latina women: 118 no IPV, 92 IPV Assessed during pregnancy, and 3, 7, and 13 months postpartum

44% met criteria for depression

IPV better predictor of postpartum depression than depression in pregnancy

Valentine et al. 2011. Arch Women’s Ment Health, 14, 135-143

Review of 43 studies of child abuse and partner violence

Alvarez-Segura et al. 2014, Arch Women’s Ment Health, 17, 343-357

Lifetime depression

Depression during

pregnancy

Postpartum depression

Child abuse + partner violence=More severe depression

317 new mothers after Sichuan earthquake

• 20% PTSD symptoms, 10% full criteria

• 29% PPD at 8 months, not higher than general population

Qu et al., 2012. Arch Wom Ment Health, 15, 49-55

Pregnant women in NOLA with high v low exposure to Hurricane Katrina

• 14% v 1% had PTSD • 32% v 12%

depression

Xiong et al., 2010. Am J Disas Med, 5, 181-187

Depression, PTSD, and Preterm Birth

35%

23%

25%

17%

Major Causes of Newborn Deaths

Preterm birth Asphyxia Infection Other

Save the Children, 2013, State of the World’s Mothers

Dayan et al. 2006, Psychosom Med, 68, 938-946

4% for non-depressed

women

9.7% for depressed

women

681 French pregnant women, 20-28 weeks gestation

7.4% no PTSD

8% previous

PTSD

9.2% current

PTSD

16,334 deliveries at VA Hospital 2000-

2012

Shaw et al. 2014, Obstet Gynecol, 124(6), 1111-1119

Rate of Preterm Birth

PTSD and major

depression increased the risk of preterm

birth by 4 times

Yonkers et al. 2014, JAMA Psychiatry, 71(8), 897-904

2,654 women in U.S.

Lauderdale, 2006. Demography, 43,185-201

Pregnant women in CA

Following September 11, women with Arabic last names were twice as likely to have a low birthweight baby • Not true for the prior year

Inflammation underlying mechanism for depression

IL-1β

IL-6

TNF-α

Coussons-Read et al. 2005, Psychosom Med, 67, 625-631

IL-6 and TNF-α ripen the cervix

IL-6 and TNF-α high in stressed and

depressed mothers

Smuts et al. 2003, Obstet Gyn, 101, 469-479

291 low-income moms

DHA-enriched eggs increased gestation length by 6 days (+

2.3 days)

• No difference in

–PPD at 6 weeks or 6 months

–Child cognitive or language development at 18 months

• “more women in the DHA group were induced or had cesareans because they were post-dates”

Makrides et al. 2010, JAMA, 304, 1675-1683

2,399 pregnant women from Australia, 800 mg DHA, 100 EPA, or vegetable oil placebo from 21 weeks gestation to birth

Women with moderate-to-high stress and high social support had less than half the rate of preterm birth

Retrospective case-control study , 1,027 preterm births, 1,282 full-term births, mothers from LA

Ghosh et al, 2010, Arch Women’s

Ment Health, 13, 327-338

• ACEs associated with low social support

• High social support associated with low CRP

Runsten 2013 Nordic J Psychiatry: Apr 30

Study of 116 women in Finland with depression

Birth Interventions

Rowlands & Redshaw, 2012

More breastfeeding problems at 3 months following forceps-assisted and unplanned cesarean births

5,332 mothers in the UK

Rowlands & Redshaw 2012, BMC Preg Childbirth, 12, 128

Epidurals had small effect on early

breastfeeding but no effect on

neonatal outcomes

Gizzo et al. 2012, Breastfeeding Med, 7, 262-268

317 with epidurals 617 no epidurals

Cesareans (vs. vaginal) at <32 weeks associated with lower milk volume at Day 4 and less exclusive breastfeeding at NICU

discharge

Murase et al., 2014, J Hum Lact, 30(4), 425-435

Induction of labor Opioid pain medications

Emergency cesarean

Bai et al., 2013, J Midwif Wom Health,

58(1), 25-32

1,280 mothers and infants from Hong Kong

Any Exclusive

• Epidurals associated with partial breastfeeding and breastfeeding difficulties in the first week postpartum

• Women who had epidurals twice as likely to stop breastfeeding by 24 weeks

Prospective study of 1280 Australian women, 1 to 24 weeks postpartum

Torvaldsen et al., 2006, Int Breastfeed J, 1:24

Survey of Mothers’ Sleep and Fatigue

Survey 6,410 mothers of infants 0-12 months, 59 countries

Feeding Method by Delivery Type

83

71 69 70 69

15

26 24

27 28

2 3

7

2 4

0102030405060708090

Vaginal Asst.Vaginal

Unplanned Planned Emergency

Breastfeeding Mixed Formula-Feeding

Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96

Epidural by Feeding Method

42

65 68 58

35 32

0

10

20

30

40

50

60

70

80

Breastfeed Mixed Formula

Epidural No Epidural


Other Pain Medications by Feeding Method

24

35 40

76

65 60

0

10

20

30

40

50

60

70

80

Breastfeed Mixed Formula-Feed

Pain Meds No Pain Meds


Epidurals 214 mothers from China

15 depressed with epidural 37 depressed

without epidural

Ding et al., 2014, Anesthes Analges, 119, 383-392

No Epidural

Epidural

PPD

PPD

185 women in Finland

At one week postpartum No difference at 4 months

Hiltunen et al. 2004, Acta Obstet Gynecol Scand, 83, 257-261

25%-28% depression

30%-37% anxiety

Following elective

cesarean

Kuo et al., 2014, PLoS ONE, 9, e86653

Ease of Labor by PPD

0

0.2

0.4

0.6

0.8

1

1.2

Very easy Moderate Verydifficult


Perceived Labor Pain by PPD

0.75

0.8

0.85

0.9

0.95

1

1.05

Low pain Moderate pain High pain


Impact of Epidural on PPD

0.75

0.8

0.85

0.9

0.95

1

Yes No


• Significantly related to depressive symptoms – Epidurals – Postpartum hemorrhage – Postpartum surgery

• Even after controlling for – All other birth interventions – Primip v multip – Number of hours in labor – Income – Education – History of depression – History of sexual assault – Current anxiety – Current anger/irritability

Depression by Birth Type

0.750.8

0.850.9

0.951

1.051.1


Houston et al. 2015, Am J Obstet Gynecol, 212, e1-7

160 patients, 24-36 weeks gestation

Po

stp

artu

m D

ep

ress

ion

Preferred vaginal birth

Depression is a direct threat to breastfeeding

PPD

Low Support

Weaning

Mathews et al. 2014, J Hum Lact 30(4): 480-487

d

Anxiety at 3 months

reduced odds of exclusive

breastfeeding by 11% at 6

months

Adedinsewo et al. 2014, J Hum Lact, 30(1), 102-109

Complex pregnancy was associated with

>30% lower odds of exclusive

breastfeeding

2400 births in U.S. Supportive

hospital practices increased odds of any or exclusive breastfeeding by

2 to 4 times

Kozhimannil et al. 2014. PLoS One, 9(8), e104820

Intended to breastfeed and did

Intended to breastfeed and did not

ALSPAC sample, Avon UK, 14,541 pregnancies

Borra et al, 2014, Matern Child Health J, DOI 10.1007/s10995-014-1591-z

PPD

PPD

More depression if mothers

had not intended to breastfeed

but did Borra et al, 2014, Matern Child Health J, DOI

10.1007/s10995-014-1591-z

Breastfeeding protects maternal mood

We

ll-b

ein

g

Aff

iliat

ion

Bo

nd

ing

Oxytocin

De

pre

ssio

n &

an

xiet

y

Alie

nat

ion

Ho

stili

ty &

str

ife

Stress

Mothers’ Depression

0.5

1

1.5

Breastfeeding Mixed Formula

Kendall-Tackett et al., 2011, Clin Lact, 2(2), 22-26

N=6,410

Minutes to Fall Asleep

19.61 22.36

27.05

0

5

10

15

20

25

30

Breastfed Mixed Formula


N=6,410

6.61

6.41

6.3

6.2

6.3

6.4

6.5

6.6

6.7

Breastfeeding Mixed Formula

Hours Mothers Sleep


N=6,410

What About Sexual Assault Survivors?

0.853

1.11

0

0.2

0.4

0.6

0.8

1

1.2

Current Depression

No Sexual Assault Sexual Assault

Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22

N=6,410, 994 sexual assault survivors

Percentage who are Breastfeeding

78.6 78.9

70

80

No Sexual Assault Sexual Assault


N=6,410, 994 sexual assault survivors

6.63

6.52

6.44

6.16

6

6.1

6.2

6.3

6.4

6.5

6.6

6.7

No assault Sexual assault

Hours Mothers Sleep

Breastfeeding

Mixed/Formula


18.73

23.87

22.07

27.01

18

20

22

24

26

28

No assault Sexual assault

Minutes to Get to Sleep

Breastfeeding

Mixed-/Formula


0.8

1.07 1.03

1.25

0.7

0.8

0.9

1

1.1

1.2

1.3

No Assault Sexual Assault

Depression

Breastfeeding

Mixed/Formula


1.49 1.51

1.53

1.69

1.35

1.4

1.45

1.5

1.55

1.6

1.65

1.7

1.75

No Assault Sexual Assault

Angry or Irritable

Breastfeeding

Mixed/Formula


Conclusions

Depression in new mothers is substantially more common than 10% to 15%

The effects of depression are severe—and potentially lethal. They are too serious to ignore

Depression is a direct threat to breastfeeding

Birth interventions can have a negative impact on both breastfeeding

and depression

There are many treatments that can help

Many mental health professionals are still not on board with breastfeeding

Empowered clinicians Empowered mothers

Find Me on Social Media

Kathleen Kendall-Tackett Kathy Kendall-Tackett

@UptySciChick

Kathleen Kendall-Tackett

Email: [email protected]

www.PraeclarusPress.com www.UppityScienceChick.com

www.BreastfeedingMadeSimple.com www.KathleenKendall-Tackett.com

a 2016 review - unicef uk · a 2016 review kathleen kendall-tackett, phd, ibclc, ... dave et al....

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