mood and anxiety disorders in nicu families

Mood And AnxietyMood And AnxietyDisorders in Disorders in

NICU FamiliesNICU Families

By By

Pec Indman EdD, MFTPec Indman EdD, MFT

The Field of Neonatology Has The Field of Neonatology Has Expanded beyond the Primary Expanded beyond the Primary Aim of Saving Infant’s Lives to Aim of Saving Infant’s Lives to

Minimizing Survivor’s Long-term Minimizing Survivor’s Long-term Complications, and thus Complications, and thus

Extending Clinicians’ Extending Clinicians’ Responsibilities beyond the BabyResponsibilities beyond the Baby

to the Broader Family. to the Broader Family.

Meyer EC, Brodsky D, Hansen AR, et al. An interdisciplinary, family-focused approach to relational learning in neonatal intensive care. J Perinatol 2011; 31: 212- 219.

© 2012 Pec Indman EdD, MFT

MYTHS ABOUT PERINATALMYTHS ABOUT PERINATALMOOD DISORDERSMOOD DISORDERS


HISTORICAL INFORMATIONHISTORICAL INFORMATION

• Psychiatric historyPsychiatric history• History of sexual abuse or traumaHistory of sexual abuse or trauma• Fertility problemsFertility problems• Perinatal lossPerinatal loss• Previous pregnancy, birth, or postpartum Previous pregnancy, birth, or postpartum

difficultiesdifficulties


DEPRESSION IN DEPRESSION IN PREGNANCYPREGNANCY

• About 15-21% of women experience depression About 15-21% of women experience depression in pregnancy up to 38% in low SES in pregnancy up to 38% in low SES (Alfonso DD, et al. Birth 1990;17:121-130)

• 50-75% relapse after discontinuing medication 50-75% relapse after discontinuing medication when pregnant when pregnant ((Cohen LS, et al. Psychother Psychosom. 2004 Jul-Aug;73(4):255-8)

• Over 40% resume medication during pregnancy Over 40% resume medication during pregnancy ((Cohen LS, et al.. Psychother Psychosom. 2004 Jul-Aug;73(4):255-8)

• Most are undetected and under treated Most are undetected and under treated (Marcus, S., Depression during Prengnancy:Rates, Risks, and Consequences. Can J Clin Pharmacol Winter 2009 Vol 16 (1)


DEPRESSION/ANXIETY IN DEPRESSION/ANXIETY IN PREGNANCYPREGNANCY

Depression in pregnancy associated with:Depression in pregnancy associated with:• Low birth weight (under 2500 grams)Low birth weight (under 2500 grams)• Preterm delivery (less than 37 weeks) up to Preterm delivery (less than 37 weeks) up to

2X risk 2X risk ((Li D, Liu L, Odouli R, Hum Repod. 2009 Jan;24(1):146-53. Epub 2008 Oct 23, Straub H, Adams M, Kim JJ, et al. Am J Obstet Gynecol 2012;207)

• Small-for-gestational age/IUGRSmall-for-gestational age/IUGR (Grote, N, et al. ARCH GEN PSYCHIATRY/VOL 67 (NO. 10), OCT 2010)

Severe anxiety in pregnancy associated with:Severe anxiety in pregnancy associated with:• Constriction in placental blood supplyConstriction in placental blood supply• Heightened startle response in newbornHeightened startle response in newborn• Newborns more inconsolable, poor sleepNewborns more inconsolable, poor sleep

(Bennett HA, Einarson, A. et al. Clin Drug Invest 2004;24 (3)


POSTPARTUM “BLUES”POSTPARTUM “BLUES”

• Occurs in 50-80% of postpartum womenOccurs in 50-80% of postpartum women• Onset usually in first week postpartumOnset usually in first week postpartum• Symptoms may persist from several days Symptoms may persist from several days

to a few weeksto a few weeks

NORMALNORMAL


BLUES OR BEYOND?BLUES OR BEYOND?

• Severity

• Timing

• Duration


POSTPARTUM DEPRESSION-NICUPOSTPARTUM DEPRESSION-NICU

• PPD rates 40% if premature infantPPD rates 40% if premature infant• Sustained (up to 52 wks) depression Sustained (up to 52 wks) depression

associated with: associated with: • earlier gestational ageearlier gestational age• lower birth weightlower birth weight• ongoing infant illness/disability ongoing infant illness/disability • perceived lack of social support. perceived lack of social support. • most studies failed to consider depression most studies failed to consider depression

in pregnancy as a confounding variablein pregnancy as a confounding variable(Vigod SN, Villegas L, Dennis CL, Ross LE. Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: a systematic review. BJOG. 2010 Apr;117(5):540-50)


SYMPTOMS OF POSTPARTUMSYMPTOMS OF POSTPARTUM DEPRESSION/ANXIETYDEPRESSION/ANXIETY::

• Sad mood, guilt, irritability, excessive worry, Sad mood, guilt, irritability, excessive worry, anxiety, or feelings of being overwhelmedanxiety, or feelings of being overwhelmed

• Sleep problems (often insomnia), fatigueSleep problems (often insomnia), fatigue• Symptoms or complaints in excess of, or Symptoms or complaints in excess of, or

without physical causewithout physical cause• Discomfort around baby, or lack of feelings Discomfort around baby, or lack of feelings

towards babytowards baby• Loss of focus and concentration (may miss Loss of focus and concentration (may miss

appointments)appointments)• Loss of interest or pleasure Loss of interest or pleasure • Appetite changes-poor appetite or weight gainAppetite changes-poor appetite or weight gain


NICU MOMS and PPDNICU MOMS and PPD

• A mom’s perception of of nursing A mom’s perception of of nursing support and depressive symptoms support and depressive symptoms were found to be directly related.were found to be directly related.

• As the perception of nursing support As the perception of nursing support decreased by one point, the risk of decreased by one point, the risk of depression increased by 6%depression increased by 6%(Kyle Mounts, Screening for Maternal Depression in the Neonatal ICU, Clin

Perinatol, 2009;36: 137-152)


NICU MOMS AT 1 yearNICU MOMS AT 1 year• 39%-63% depressed at 1 year pp39%-63% depressed at 1 year pp


RISK FACTORS FOR PPD RISK FACTORS FOR PPD • 50-80% risk if previous postpartum 50-80% risk if previous postpartum

depression depression • 50% risk if depression or anxiety during 50% risk if depression or anxiety during

pregnancy pregnancy • Personal and/or family history of depression Personal and/or family history of depression

or other psychiatric disorderor other psychiatric disorder• History of severe PMS or PMDDHistory of severe PMS or PMDD• Social isolation/poor support system/teensSocial isolation/poor support system/teens

(Suri R and Burt VK. The Assessment and treatment of Postpartum Psychiatric Disorders. Jrnl Prac Psych and Behav Hlth. March 1997)


TREATMENT FOR POSTPARTUMTREATMENT FOR POSTPARTUM DEPRESSION/ANXIETYDEPRESSION/ANXIETY

• Individual/couples therapy, groupIndividual/couples therapy, group• CBT or Interpersonal Therapy (IPT)CBT or Interpersonal Therapy (IPT)

• Antidepressant and/or antianxiety Antidepressant and/or antianxiety medication, Sleep meds medication, Sleep meds (Wisner KL, et al., N Engl J

Med. July 2002;347(3):194-199)

• Treat thyroiditis Treat thyroiditis • ECTECT

INADEQUATE TREATMENT CAN LEAD INADEQUATE TREATMENT CAN LEAD TO CHRONIC DEPRESSION OR TO CHRONIC DEPRESSION OR RELAPSERELAPSE


POSTPARTUM OBSESSIVE-POSTPARTUM OBSESSIVE-COMPULSIVE DISORDER COMPULSIVE DISORDER

(OCD)(OCD)

• 3% to 9% of new mothers may develop 3% to 9% of new mothers may develop obsessive symptomsobsessive symptoms

(Abramowitz JS, et al. Anxiety Disorders 2003. 17:461-478, Chaudron, LH and Neha

Nirodi. The obsessive–compulsive spectrum in the perinatal period: a prospective pilot study. Arch Womens Ment Health, March, 2010;1434-1816.)


SYMPTOMS OF SYMPTOMS OF POSTPARTUM OCDPOSTPARTUM OCD

• Intrusive, repetitive, and persistent thoughts or Intrusive, repetitive, and persistent thoughts or mental picture – different that PTSD flashbackmental picture – different that PTSD flashback

• Thoughts often are about hurting or killing the Thoughts often are about hurting or killing the babybaby

• Tremendous sense of horror and disgust about Tremendous sense of horror and disgust about these thoughts (ego alien)these thoughts (ego alien)

• Thoughts may be accompanied by behaviors Thoughts may be accompanied by behaviors to reduce the anxiety (such as hiding knives)to reduce the anxiety (such as hiding knives)

• Repetitive counting (diapers in the bag), Repetitive counting (diapers in the bag), checking (baby’s checking (baby’s breathing), cleaningbreathing), cleaning

(The obsessive–compulsive spectrum in the perinatal period: a prospective pilot study. Arch Womens Ment Health, March, 2010;1434-1816. Sichel D and Driscoll JW. Women’s Moods, 1999)


TREATMENT FOR OCDTREATMENT FOR OCD

• Psychotherapy and psychoeducationPsychotherapy and psychoeducation• Medication (SSRIs)Medication (SSRIs)


POSTPARTUM PANIC POSTPARTUM PANIC DISORDERDISORDER

• May occur in about 10% of postpartum May occur in about 10% of postpartum womenwomen


SYMPTOMS OF PANIC SYMPTOMS OF PANIC DISORDERDISORDER

• Episodes of extreme anxiety: excessive or Episodes of extreme anxiety: excessive or obsessive worry or fearsobsessive worry or fears

• Shortness of breath, chest pain, sensations of Shortness of breath, chest pain, sensations of choking or smothering, dizzinesschoking or smothering, dizziness

• Hot or cold flashes, trembling, palpitations, Hot or cold flashes, trembling, palpitations, numbness or tingling sensationsnumbness or tingling sensations

• Restlessness, agitation, or irritabilityRestlessness, agitation, or irritability• During attack may fear she is going crazy, During attack may fear she is going crazy,

dying, or losing controldying, or losing control• Attack may awaken her from sleepAttack may awaken her from sleep• Often no identifiable trigger for panicOften no identifiable trigger for panic

(Sichel D and Driscoll JW. Women’s Moods, 1999)


TREATMENT FOR PANIC TREATMENT FOR PANIC DISORDERDISORDER

• PsychotherapyPsychotherapy• SSRIsSSRIs• Antianxiety medicationAntianxiety medication


BIPOLAR DISORDERBIPOLAR DISORDER

• In women with BD rates range up to 82%In women with BD rates range up to 82%• Time of increased vulnerability for relapseTime of increased vulnerability for relapse• Most present with depressionMost present with depression• Closely associated with postpartum Closely associated with postpartum

psychosispsychosis

(Sharma, V. et al. Bipolar II Postpartum Depression: Detection, Diagnosis, and Treatment. Am J Psychiatry 2009; 166:1217–1221.)Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy and Postpartum. American Psychiatric Publishing, Inc., 2005)


SYMPTOMS OF BIPOLARSYMPTOMS OF BIPOLAR

• Mania or hypomaniaMania or hypomania• DepressionDepression• Rapid and severe mood swingsRapid and severe mood swings


TREATMENT OF BDTREATMENT OF BD

• Careful observation for symptomsCareful observation for symptoms• High RiskHigh Risk postpartum mania/psychosis postpartum mania/psychosis

(Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy

and Postpartum. American Psychiatric Publishing, Inc., 2005)


POSTTRAUMATIC STRESS POSTTRAUMATIC STRESS DISORDER (PTSD)DISORDER (PTSD)

• May occur in 1-6% May occur in 1-6% (Beck CT. Nursing Research. (Beck CT. Nursing Research.

July/Aug 2004; 53(4):216-224)July/Aug 2004; 53(4):216-224)

• Up to 38% report traumatic Up to 38% report traumatic birthbirth (Beck C & Watson S, Impact of Birth Trauma on Nursing, Nursing (Beck C & Watson S, Impact of Birth Trauma on Nursing, Nursing

Research 2008(57);4:228-236)Research 2008(57);4:228-236)


PTSD in NICU FamiliesPTSD in NICU Families• Up to 70%Up to 70%• Common to experience PTSD, PMADsCommon to experience PTSD, PMADs

(Lefkowitz DS, Chiara Baxt C, Evans JR.. J Clin Psychol Med Settings 2010; 17: 230–237) Lefkowitz DS, Chiara Baxt C, Evans JR.. J Clin Psychol Med Settings 2010; 17: 230–237)


SYMPTOMS OF PTSDSYMPTOMS OF PTSD

• Recurrent nightmaresRecurrent nightmares• Extreme anxietyExtreme anxiety• Reliving past traumatic eventsReliving past traumatic events

• • sexualsexual• • physicalphysical• • emotionalemotional• • childbirthchildbirth


TREATMENT FOR PTSDTREATMENT FOR PTSD

• PsychotherapyPsychotherapy• SSRIs and/or antianxiety medicationSSRIs and/or antianxiety medication• May require sleep medicationMay require sleep medication• Social supportSocial support


POSTPARTUM PSYCHOSISPOSTPARTUM PSYCHOSIS

• Occurs in 1-2/1000Occurs in 1-2/1000• 5% suicide and 4% infanticide rate5% suicide and 4% infanticide rate

(Doucet, S. et al. Differentiation and Clinical Implications of Postpartum Depression and Postpartum Psychosis. JOGNN, 2009. 38, 269-279. Sit, D. et al. A Review of Postpartum Psychosis, Journal of Women’s Health. 2006:15(4)


SYMPTOMS OF POSTPARTUM SYMPTOMS OF POSTPARTUM PSYCHOSISPSYCHOSIS

Usually begins 48-72 hours postpartumUsually begins 48-72 hours postpartum• Most develop symptoms within 2-4 Most develop symptoms within 2-4

weeksweeks• Visual or auditory hallucinationsVisual or auditory hallucinations• Early symptoms restlessness, agitation, Early symptoms restlessness, agitation,

irritabilityirritability• Confusion, paranoia, extreme moodswingsConfusion, paranoia, extreme moodswings• Delusional thinking (infant death, denial of birth, Delusional thinking (infant death, denial of birth,

need to kill baby)need to kill baby)(Sit, D. et al. A Review of Postpartum Psychosis, Journal of Women’s Health. 2006:15(4)., Suri R and Burt VK., Jrnl Prac Psych and Behav Hlth. March 1997)


RISK FACTORS FOR RISK FACTORS FOR POSTPARTUM PSYCHOSISPOSTPARTUM PSYCHOSIS

• Personal (20-50%Personal (20-50%risk) and/or family risk) and/or family history of psychosis or bipolar disorderhistory of psychosis or bipolar disorder

• 80% risk if previous postpartum psychotic 80% risk if previous postpartum psychotic or bipolar episodeor bipolar episode

• First babyFirst baby

(Sit, D. et al., A Review of Postpartum Psyhosis, Journal of Women’s Health 2006,(15)4. Suri R and Burt VK., Jrnl Prac Psych and Behav Hlth. March 1997)


TREATMENT FOR POSTPARTUM TREATMENT FOR POSTPARTUM PSYCHOSISPSYCHOSIS

• IMMEDIATE HOSPITALIZATIONIMMEDIATE HOSPITALIZATION• AntipsychoticsAntipsychotics• Mood stabilizers (antidepressants as Mood stabilizers (antidepressants as

needed)needed)• PsychotherapyPsychotherapy• ECTECT

(Yonkers KA, et al.. Am J Psychiatry. 2004;161:608-620)


WHY TREAT PARENTS?WHY TREAT PARENTS?

• Potential for child abuse and neglectPotential for child abuse and neglect• Negative impact on marital/family Negative impact on marital/family

relationshipsrelationships• Increased risk chronic depression Increased risk chronic depression

and relapseand relapse(Field T. et al., Infant Behavior & Development 2004;(27) 216-229,

Hart S. et al., Infant Behavior & Development 1998; 21(3):519-525,

Murray L and Cooper PJ.,. Psychological Medicine 1997;27(2):253-260)


OUTCOMES OF UNTREATED OUTCOMES OF UNTREATED PARENTAL ILLNESSPARENTAL ILLNESS

• Increased incidence of childhood Increased incidence of childhood psychiatric disturbancespsychiatric disturbances

• Impaired cognitive and language Impaired cognitive and language development in children development in children

• Negative influence on preterm children's Negative influence on preterm children's later cognitive functionlater cognitive function(McManus BM and Poehlmann J(McManus BM and Poehlmann J.. Infant Behav Dev. 2012 Jun;35(3):489-98 Infant Behav Dev. 2012 Jun;35(3):489-98

Muzik, M and S. Borovska, Muzik, M and S. Borovska, Mental Health in Family Medicine 2010;7:239–47)


BREASTFEEDING AND BREASTFEEDING AND ANTIDEPRESSANTSANTIDEPRESSANTS

• AAP now recommends 1 year of AAP now recommends 1 year of breastfeeding. Depression preceeds breastfeeding. Depression preceeds weaning.weaning.

• ““Paxil and Zoloft usually produce Paxil and Zoloft usually produce undetectable infant levels.” undetectable infant levels.” ((Weissman AM. et al. Am J

Psychiatry 2004;161:1066-1078)

• Studies of exposed infants show no Studies of exposed infants show no differences in IQ or neurobehavioral differences in IQ or neurobehavioral developmentdevelopment (Yoshida K, et al. Br J Clin Pharmacol. 1997

Aug;44(2):210-1)


BREASTFEEDINGBREASTFEEDING• Depressed moms breastfed for shorter Depressed moms breastfed for shorter

durationsdurations• Experienced breastfeeding more Experienced breastfeeding more

negatively than non-depressed negatively than non-depressed (Individual and

Combined Effects of Postpartum Depression in Mothers and Fathers on Parenting Behavior. Paulson, Dauber, and Leiferman. Pediatrics, 118(2), Aug 2006:659-668) )

• Decreased levels of breastfeeding self-Decreased levels of breastfeeding self-efficacy efficacy

• Increased breastfeeding difficultiesIncreased breastfeeding difficulties(Dennis CL & McQueen K. The Relationship Between Infant--Feeding Outcomes and Postpartum Depression. Pediatrics 2009;123:e736-e751)


WHAT ABOUT WHAT ABOUT DADS/PARTNERS?DADS/PARTNERS?


NICU DADSNICU DADS

• Fathers of premature infants in a medical Fathers of premature infants in a medical NICU demonstrated elevated levels of NICU demonstrated elevated levels of stress that persisted. stress that persisted.

• Paternal self-reported stress and Paternal self-reported stress and depressive symptomatology was depressive symptomatology was independent of infant illness. independent of infant illness.

• 30% of NICU dads screened positive for 30% of NICU dads screened positive for depression depression (Mackley AB, et al. Forgotten parent: NICU paternal

emotional response. Adv Neonatal Care. 2010 Aug;10(4):200-3)


ROLE OF NICUROLE OF NICU MENTAL HEALTH PROVIDERS MENTAL HEALTH PROVIDERS

• Providing emotional support and therapy Providing emotional support and therapy to families in the NICUto families in the NICU

• Overcome barriers to treatmentOvercome barriers to treatment• Integrated family careIntegrated family care• NICU psychologists in OK, Miami, NICU psychologists in OK, Miami,

Pittsburgh, Columbia/Pres in NY, Kansas Pittsburgh, Columbia/Pres in NY, Kansas CityCity

• National Perinatal Association National Perinatal Association (www.nationalperinatal.org)(www.nationalperinatal.org)


POSTPARTUMPOSTPARTUM SCREENINGSCREENING• Edinburgh Postnatal Depression Edinburgh Postnatal Depression

Scale (EPDS), 1987 by Cox, et. al.Scale (EPDS), 1987 by Cox, et. al.• Score of Score of >> 10 10 refer for evaluation refer for evaluation

• PHQ9 and PHQ2-not well studied for PHQ9 and PHQ2-not well studied for perinatal use, frequently used in practiceperinatal use, frequently used in practice

• Postpartum Depression Screening Postpartum Depression Screening Scale (PDSS), 2002 by Cheryl Beck Scale (PDSS), 2002 by Cheryl Beck D.N.Sc. D.N.Sc. (Gjerdingen, D, and Yawn, B. Postpartum Depression Screening, J Am

• Board Fam Med 2007;20:280 –288. ACOG Committee Opinion, Screening for Depression During and After Pregnancy, No.453, 2/2010)


TREATMENT GUIDELINESTREATMENT GUIDELINES• Always r/o bipolar spectrum before Always r/o bipolar spectrum before

starting SSRI’s. starting SSRI’s. http://www.psycheducation.org/depressionhttp://www.psycheducation.org/depression/MDQ.htm/MDQ.htm

• F/U and treat to remission! F/U and treat to remission! • Meds work best Meds work best withwith therapy therapy• Find therapists with expertise in perinatal Find therapists with expertise in perinatal

moods and loss (www.postpartum.net and moods and loss (www.postpartum.net and www.mededppd.org).www.mededppd.org).


PROFESSIONAL RESOURCESPROFESSIONAL RESOURCES• Resources for information about Resources for information about

perinatal psychopharmacologyperinatal psychopharmacology• UIC Perinatal Mental Health Project UIC Perinatal Mental Health Project

• (800)573-6121 (free for providers)(800)573-6121 (free for providers)• www.psych.uic.edu/research/www.psych.uic.edu/research/

perinatalmentalhealthperinatalmentalhealth• Other online resources Other online resources

• www.mededppd.orgwww.mededppd.org• www.toxnet.nlm.nih.gov/www.toxnet.nlm.nih.gov/• www.reprotox.org www.reprotox.org • www.motherisk.orgwww.motherisk.org


RESOURCESRESOURCES• Postpartum Support InternationalPostpartum Support International

www.postpartum.netwww.postpartum.net• North American Society for North American Society for

Psychosocial OB/GYNPsychosocial OB/GYN

www.naspog.orgwww.naspog.org• www.mededppd.orgwww.mededppd.org• Regrouptherapy.com Regrouptherapy.com (online web video

support)


Other ResourcesOther Resources

• https://www.marchofdimes.com/pdf/california/https://www.marchofdimes.com/pdf/california/Bernard_-_Medical_PTSD_in_the_NICU.pdfBernard_-_Medical_PTSD_in_the_NICU.pdf

• http://jpepsy.oxfordjournals.org/content/http://jpepsy.oxfordjournals.org/content/30/8/667.full.pdf30/8/667.full.pdf

• http://www.kan.or.kr/new/kor/sub3/filedata_anr/http://www.kan.or.kr/new/kor/sub3/filedata_anr/200703/199.pdf200703/199.pdf

• http://fn.bmj.com/content/90/2/F109.fullhttp://fn.bmj.com/content/90/2/F109.full

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