Perinatal Mood Disorders:Why We Should Care
Debbie Ruxer RN, MS, CNMMiami Valley Regional Postpartum
Depression Network
ObjectivesAt the end of this presentation the participant will be able
to:
Discuss physiology and risk factors for perinatal mood disorders
List the different types of perinatal mood disorders
Discuss the effects of maternal depression on the infant and the family
Discuss medication and other therapies for perinatal mood disorders
CONFLICT OF INTEREST The planners and faculty have declared no conflict of interest.
COMMERCIAL SUPPORT/SPONSORSHIP Good Samaritan Hospital is the sponsor for this activity. The
information presented today will be presented fairly and without bias.
CRITERIA FOR SUCCESSFUL COMPLETION You must attend the entire event and submit a completed evaluation
form in order to receive credit for this presentation.
The moment a child is born, the mother is also born. She never existed before. The woman existed, but the mother, never. A
mother is something absolutely new.” Rajneesh
Myths and Facts about Motherhood I will fall in love with my baby immediately.
Being a mother will complete me.
Having a child will strengthen our relationship.
Having a child will keep him around.
Mothering is natural.
Breastfeeding is natural, and it will be easy.
Effects of PPD on Women
PPD is the number one complication of childbirth
Affects 1 in every 5 to 8 women
Depression the second leading cause of disease burden
High rate of co-morbidity with anxiety disorders, substance abuse and eating disorders
• <20% of pregnant women with psychiatric diagnosis were treated.
• >50% of pregnant women on antidepressant medication were symptomatic due to suboptimal treatment.
• <25% of OB/GYN patients had their psychiatric diagnosis recognized.
Depression for Two?•Decreased prenatal care and self-care
•Increased self-medication and substance abuse
•Increased risk of being victim of violence
•Increased risk of pre-eclampsia
•Increased rates of miscarriages, preterm birth and low birth weight
•Uterine artery resistance
Physiology
Stress Changes in brain chemistry Thyroid dysfunction Physical discomfort Risk factors that increase susceptibility LACK OF SLEEP!!!!!!
Immune system response to stress
Sympathetic response, catecholamine release Cascading release of CRH, ACTH, cortisol Release of proinflammatory cytokines (IL-1B, IL-
6, TNF-a, IFN-y) Sustained levels of proinflammatory cytokines
blunts cortisol’s anti-inflammatory action, and increases risk of depression.
Neurotransmitters
Serotonin : Inhibits stress responseRegulates sleepPain sensitivitySexual functioningAppetite
Diminished serotonin – result of stress?
Who is at risk? Risk Factors:
History of depression or mental health diagnosis
Lack of social support (family is far away) Unexpected pregnancy High Risk pregnancy Infertility Adoption
Who is at risk?
Difficult labor or unexpected outcome NICU Birth Defect Preterm delivery Fetal demise or previous fetal demise Unplanned C-section Difficult or prolonged labor and/or delivery
Spectrum of disorders
Depression/Anxiety Obsessive/Compulsive Disorder Panic Attacks Post-traumatic Stress Bipolar Postpartum Psychosis
Baby Blues
Occurs in about 80% of mothers Onset 1st week, lasts up to 3 weeks Mood instability, weepiness, sadness, anxiety,
lack of concentration Treatment supportive Not considered part of the spectrum of perinatal
mood disorders
Depression and/or Anxiety
Incidence: 15-20% of new mothersSymptoms: Excessive worry or anxiety Irritability, short temper Feeling overwhelmed by responsibilities,
difficulty making decisions Sad mood, feelings of guilt, fear, phobias Hopelessness Sleep disturbances (insomnia or
hypersomnolence), fatigue
Somatic symptoms without apparent cause Discomfort around baby Lack of feelings towards baby Loss of focus and concentration Loss of interest and pleasure Changes in appetite – significant wt gain or loss
Obsessive-Compulsive Disorder
Incidence: 3-5% of new mothersRisk factors: Personal or family hx OCDSymptoms:
Intrusive, repetitive and persistent thoughts or mental pictures
Thoughts often about harming the baby Tremendous sense of horror and shame Behaviors to reduce anxiety and protect baby Counting, checking, cleaning, other repetitive
behaviors
These women can think and reason and articulate clearly
At the mercy of intrusive thoughts and behaviors
These women DO NOT HARM their babies!
Do NOT call Children’s Services based on this
Panic DisorderIncidence: 10% of postpartum womenRisk Factors: Personal or family hx of anxiety or panic
disorder Thyroid dysfunction
Symptoms: Episodes of extreme anxiety SOB, chest pain Sensations of choking, smothering, dizziness
Hot or cold flashes, trembling, tachycardia, numbness or tingling
Restlessness, agitation, irritability During attack, may fear she is going crazy,
losing her mind Panic attack may wake her up from sleep Excessive worry or fear (incl. fear of another
panic attack)
Posttraumatic Stress Disorder
Incidence: up to 6% of postpartum womenRisk factors: Past traumatic events
Symptoms: Recurrent nightmares Extreme anxiety Reliving past traumatic events (sexual, physical,
emotional, childbirth)
Bipolar DisorderIncidence: no dataRisk factors: personal or family hx of bipolar
disorder
Symptoms: Mania – racing thoughts, high energy and little
sleep, compulsive activity Depression Rapid and severe mood swings
Postpartum Psychosis
Incidence: 0.1-0.2% Onset usually 2-3 days postpartum 5% suicide and 4% infanticide rateRisk factors: Personal or family hx psychosis, bipolar,
schizophrenia Previous hx postpartum psychosis or bipolar
episode
Symptoms: Visual or auditory
hallucinations Delusional thinking Delirium or mania Very obviously
psychotic Differentiate from
OCD
Experiences of women
Myself My daughter Lisa You?
Effects of PPD on Children
Poor attachment Increase in accidents Less likely to see pediatrician regularly Failure to thrive or overfeeding Increased rates of colic Increased use of ER
Cognitive Effects
Depressed mothers talk less to their infants
Less expression of positive emotions
Increased use of corporal punishment
Decrease in cognitive abilities present as early as 2 months
Behavioral Effects Eating and sleeping disorders Increased crying Less vocalizations and smiling Decreased vocalization at 18-
24 months Shorter attention spans More anxious around
strangers Less interactive play Less self-knowledge
Effects of PPD on Relationships
10% of fathers report symptoms of PPD
Reality vs. expectations Financial stress Change in relationship Partner suffering from
PPD
Relationships Continued
PPD leads to relationship difficulties Higher divorce rateBoth parents with PPD has an additive affect
on childrenSupportive partners are protective factor
against PPD
Relationships Continued
Symptoms: Work long hours Watch more TV/sports Increased use of
alcohol Withdrawn More irritable
Silent Suffering
We don’t talk about it - why? So much shame involved Feeling like a failure Motherhood isn’t so easy after all They might take away my baby if I say
anything
But there is hope
There is much that providers, family, friends and community can do to help
Family and friends play a critical role in helping women recover
Family and friends: the first line of defense
Screening Several tools available Edinburgh Postnatal Depression Scale:
validated, short and easy to use Who should screen?
OB/Gyn providers Pediatricians Family Practice providers WIC Lactation consultants Home health nurses
Edinburgh Postnatal Depression ScaleAnswer the following questions, checking the answer
that comes closest to how you have felt over the last 7 days (not just today).
1. I have been able to laugh and see the funny side of things
2. I have looked forward with enjoyment to things3. I have blamed myself unnecessarily when things
went wrong4. I have been anxious or worried for no good reason.
5. I have felt scared or panicky for no very good reason.
6. Things have been getting on top of me (can’t keep up with my responsibilities)
7. I have been so unhappy that I have had difficulty sleeping
8. I have felt sad or miserable9. I have been so unhappy that I have been crying10. The thought of harming myself has occurred to me
Always look at the answer to the last question!
Score greater than 13 = probable depression
Going the Extra Mile It’s all in the presentation:
Provide a safe, non-judgmental environment Ask open-ended questionsGive reassurance that she’s not “crazy” or
“bad” Give her hope: “This is not your fault, you will
get better, you are not alone.” Don’t assume anything
What can family/friends do to help?
You can: Make dinner Watch the baby so she can
take a break (or take a nap) Do the laundry Do the dishes
More ideas: Sit and listen Clean the house Take a walk with her Go shopping or do errands
for her Be on duty overnight so
she can sleep
Keep her company – it is worse to be alone
Take on some of her responsibilities
Reduce her feeling of being overwhelmed
Give her time to sleep!!!!
Medical Management
ACOG/APA guidelines (2009)PsychotherapyPharmacotherapy Individualized plan of care Consider continuing medications during
pregnancy to avoid risk of relapse (bipolar, psychosis, severe depression)
Psychotherapy
Front line therapy
As effective as medication
Lower relapse rate
One-on-one therapy initially, but group therapy helpful later
Cognitive Behavioral Therapy
Highly effective Based on premise that distorted thinking
causes depression CBT teaches patients to recognize distorted
thinking, and counter these thoughts
Interpersonal Psychotherapy
As effective as Cognitive Behavioral Therapy Based on attachment theory and interpersonal theory Addresses 4 problem areas:
Role transitions Interpersonal disputes Grief Interpersonal deficits
Focus on improved relationships, role transitions
Medications Individual decision Risk versus benefit Risks of medication:
MiscarriageNeonatal withdrawalNICU admissionPersistent pulmonary hypertensionCongenital anomalies
Risks of no medication Mother:
Preterm birthRisk of suicideUntreated depression can become chronic
Infant:Poor attachmentFailure to thriveDecreased cognitive abilities
Antidepressants
Selective serotonin reuptake inhibitors Norepinephrine/dopamine reuptake
inhibitors Serotonin/norepinephrine reuptake
inhibitorsNot recommended: Monoamine oxidase inhibitors Tricyclic antidepressants
Avoid in 1st trimester if possible Start low Titrate to therapeutic effect Sub-therapeutic doses do not decrease risk
to fetus Single drug therapy Start with one that has worked for her in the
past
Already on antidepressants?
Risk of relapse high if meds stoppedRisk vs benefit Individualized treatment planAvoid changing medications if therapy
effective
SertralineLower maternal serum levelsAlmost undetectable in breast milk0.2% risk of cardiac septal defectsMild neonatal withdrawal
Paroxetine Higher risk of congenital anomalies Low levels in breast milk
Fluoxetine Mild neonatal withdrawalHigher levels in breastmilk
Citalopram No known association with congenital
anomaliesMild neonatal withdrawalOccasional neonatal somnolence
Other medications
Sleep aids as needed Anxiolytics (severe anxiety) Mood stabilizers (Bipolar) Antipsychotics (PP Psychosis)
Additional Therapies
Skin to skin time with baby
Omega-3 fatty acids
Bright light therapy Exercise Vitamin D
Skin-to-skin
Promotes infant well-being
Elicits maternal bonding hormones and behaviors
Omega-3 Fatty Acids
DHA and EPA improve mood EPA decreases inflammatory eicosanoids by
competing for same metabolic pathways Also inhibits production of proinflammatory cytokines Rates of postpartum depression tend to be lower in
countries with high dietary intake of fish Fish oil supplements: use USP-verified supplements
for minimal risk of contaminants 1000-3000 mg/day Flax seed ineffective (HLA)
Vitamin D
Association between Vitamin D deficiency and mood disorders, including postpartum mood disorders
Deficiency defined as circulating 25(OH)D levels less than 20ng/mL
Recent recommendations for intake of 800-2000 IU daily
Bright Light Therapy
As effective as medication Insurance reimbursement a possibility Several theories on mechanism:
Effect on circadian rhythms Anti-inflammatory component
Timing important: morning bright light more effective, works with body’s circadian rhythm
Exercise
Role in reducing depressive symptoms well-documented
Decreases stress, improves self-efficacy
Endorphin release Lowers levels of pro-inflammatory
cytokines Improves sleep Overall health benefits
St. John’s Wort Research demonstrates efficacy in treating
mild to moderate depression Fewer side effects than traditional
medications: 2.4% incidence of GI upset, allergic
reactions, rash, fatigue, restlessness Can trigger manic episodes in susceptible
patients
RISKS: Accelerates metabolism of anticonvulsants,
cyclosporins, OCP, other meds Interacts with SSRIs: serotonin syndrome
(potentially fatal)
Generally safe with breastfeeding Level of infant exposure comparable to other
SSRIs Rare cases of colic or lethargy in exposed
infants
Dose: 300mg, tid Look for USP labeling
What can I do as a health provider?
Promote: Non-separation of mothers
and babies Skin-to-skin for all babies Breastfeeding
Educate! New mothers Their families
Intervene Women depressed during hospitalization
What’s the good news? With proper support and treatment, she WILL
get better!
Miami Valley Postpartum Depression Network We’re here to help: Support Referral list 937-401-6844 1-866-848-3163 www.postpartum.net Facebook group: Postpartum Depression Many
Shades of Blue
in December 2001 Possibilities
The end of all education should surely be service to others. We cannot seek achievement for ourselves and forget about progress and prosperity for our community. Our ambitions must be broad enough to include the aspirations and needs of others, for their sake and for our own. ---Cesar Chavez
References cont.
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