mood disorders in pregnancy and the postpartum

Mood Disorders in Pregnancy and the

Postpartum

Stephanie Berg, MDThe 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 CircleColumbia, 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

Postpartum Psychiatric DisordersDisorder Incidence Time Course Clinical

Features

Postpartum Blues

70 – 80 % Within first week → 14 days

•Tearfulness•Anxiety•Insomnia•Mood Instability

Postpartum Depression

10 % Within first month

(technically)

•Depression•Guilt•Anxiety•Fear of harm to baby•Obsessions

Postpartum Psychosis

0.1 – 0.2 % Within first month •Disorientation•Confusion•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 AntidepressantsFluoxetine 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

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