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Spectrum … › Postpartum blues › Adjustment disorder with depressed mood › Major Depression › Minor Depression › Dysthymic Disorder (2y) › Anxiety Disorders › Postpartum Psychosis › Bipolar Disorder

Paternal depression Interference with bonding and child

development Marital stress Suicide and infanticide Poor fetal growth (although studying this

is difficult to separate confounding factors)

Possible increased risk of psych disorder for offspring (confounded by genetics)

Characterized by rapid mood swings, anxiety, dec concentration, tearfulness, crying spells, insomnia, irritability

Symptoms peak on 5th pp day and resolve within 2 weeks (if persist beyond 2 weeks=depression)

40-80% of women experience these symptoms

Risk Factors: depressive sx during pregnancy, fam hx depression, PMDD, stress around child care, psychosocial impairment in work, relationships

Minor Depression: Have several symptoms of major depression (2-4) for at least 2 weeks but don’t meet criteria for major depression.

Dysthymic Disorder: depressed mood for at least 2 years.

Adjustment Disorder with Depressed Mood: occurs in response to a stressor. Symptoms do not meet criteria for major depression or dysthymic disorder. Also affects functioning.

Bipolar Disorder: screen for mania

Complicated diagnosis- similar symptoms to postpartum period

Perceived societal expectation of the new mother

Lifetime risk 10-25% Point prevalence 5-9% Risk Factors: marital conflict, stressful life

events, lack of perceived support from community/partner, unplanned pregnancy, no partner, prev SAB, prev psych hx, child care stressors, hyperemesis, congenital malformations in infant, GDMA

DSM-IV includes this as Major Depressive Disorder, not PPD, but rather with ‘postpartum onset specifier’

Differences from normal postpartum: › Unable to sleep when the baby is sleeping › Inability to enjoy taste of food › Profound lack of energy to the point that she

can’t get out of bed › Profound anxiety, anger, guilt, overwhelmed,

inadequacy, feeling as though failure of mother, not bonding to baby, which increases shame and guilt

5 or more of the following symptoms, present most of the day, nearly every day, for a minimum of 2 consecutive weeks (one of which is depressed mood) › Depressed Mood › Loss of interest in most or all activities › Insomnia/hypersomnia › Change in apetite or weight › Psychomotor retardation or agitation › Low energy › Poor concentration › Thoughts of worthlessness or guilt › Recurrent thoughts of death or suicide

Provide an environment of support for our patients, where they feel comfortable discussing these symptoms with us

Increase detection of postpartum depression and psychosis

Ensure that diagnosed patients get help Create a network of counseling referrals Educate patients regarding the mood

changes that can occur in pregnancy, birth and in the postpartum period

Education of staff, physicians, nurses Peripartum Depression Pamphlet Counselor referral network /correlate

with insurance Depression information sheet: coping

skills, counseling referrals, hotline Electronic Medical Record forms:

depression screening, nurse followup, incorporating EPDS into antepartum

Edinburgh Postnatal Depression Scale: 10 item self reported screening questionnaire

Aids in diagnosis of PPD much more than clinical exam alone (35% vs 6%)

Most pediatricians in community use EPDS for moms

Data is best for EPDS (Vs. Beck Depression Inventory, PPD Screening Scale, Center for Epidemiological Studies Depression Scale, PRIME MD scale)

Score equal to 13 or greater (positive screen) HAVING major depressive disorder 57%

Neg screen- 99% did NOT have PPD If mom has positive score, increased risk

for father having positive score.

Given at 28 weeks with EPDS and at all hospital discharges

EPDS given at 24-28w visit EPDS given at 6 w postpartum visit If EPDS over 12…

› Automatically screened for depression › Given depression information sheet › Discussed hotline › Rare referrals to psychiatrist or previous

treating physician › Discussed life stressors, social situation

1756 patients were screened with EPDS at 28 w prenatal visit and/or 6 w pp visit

Note: most studies of preg/pp have sample sizes of 300s…

90% of 28w prenatal visits were screened and recorded (949/1053 patients)

90% of 6w pp visits were screened and recorded. (827/924 patients)

Confounding factors: isolated midwife consults were screened at midwife’s office.

28wk with EPDS 949 Patients

90% 28wk without EPDS

104 Patients

10%

PPV with EPDS 827 Patients

90% PPV without EPDS

97 Patients

10%

28wk with EPDS 0-12 859 Patients

91% 28wk with EPDS >12

90 Patients

9%

PPV w/ EPDS 0-12 755 Patients

91% PPV with EPDS >12

72 Patients

9%

EPDS > 12 with adjustment disorder

39 Patients

24%

EPDS > 12 with depression 74 Patients

46%

EPDS > 12 were ok, no diagnosis

49 Patients

30%

Depression diagnosis - receiving Meds

59 Patients

80%

Depression diagnosis - not receiving Meds

15 Patients

20%

Depression diagnosis - treated by provider

67 Patients

91%

Depression diagnosis - referred to PCP/Psych

7 Patients

9%

EDPS > 12 given suicide helpline info

158 Patients

98%

EDPS > 12 not given suicide helpline info

4 Patients

2%

EDPS > 12 given depression info sheet

158 Patients

98%

EDPS > 12 not given depression info sheet

4 Patients

2%

Depression disorder with follow up visit

86 Patients

95%

Depression disorder without follow up visit

5 Patients

5%

Depression disorder accepted meds

and/or counseling 71 Patients

73%

Depression disorder declined meds

and/or counseling 20 Patients

27%

Follow up Patients Felt Better 77 Patients

85%

Follow up Patients did not feel better

14 Patients

15%

EDPS > 12 with follow up

86 Patients

95%

EDPS > 12 unreachable for

follow up 5 Patients

5%

10 patients were started on meds or increased dosage of meds on the follow up call.

Several patients noted how grateful they were that someone called them.

5-9% point prevalence cited in literature for peripartum depression

Prior to EPDS screening, it was estimated that 1.8% of peripartum patients were diagnosed with depression. With universal EPDS screening, detection of depression increased to 4.2% depression and 2.2% adjustment disorder with depressed mood. › 1.8% was estimated by a year’s worth of

visits, EMR diagnosis codes

Education was vastly improved. Doctors didn’t just refer patients away for

treatment, on average 25 mins spent with a depressed patient.

Follow up contact improved care and ensured that people got treatment.

27% of people diagnosed with depression declined to go to counseling or start meds. › Intermittent improvement in symptoms › Concern of teratogenicity to fetus or through

breastfeeding

NUMEROUS examples of great care from doctors and nurses from Women’s Care.

Language barrier- materials translated Cultural differences- Asian population

especially If the patient had a severe pregnancy

complication requiring hospitalization (ie. Previa), follow up not documented.

Some follow up not done yet due to 2-4 week delay.

Educational insight into completing EPDS

Support Reassurance Ensure adequate time for sleep and rest Avoid alcohol (exacerbates mood

swings) Exercise- excellent for all mood disorders

“Scary Thoughts” › Women with obsessional thoughts of

harming oneself or the baby › Usually perceived by mother as illogical and

intrusive › Should alert clinician to screen (psych) for pp

psychosis › Occasional thought are not associated with

suicide or infanticide WHEN perceived by mom as illogical.

Interpersonal psychotherapy Cognitive behavioral psychotherapy Group Therapy (www.postpartum.net) Family and Marital Therapy Well Mama Looking Glass Counselor recommendations on the PP

Dep Info sheet

What med has the most data? › Sertraline has been most studied and

appears safest (Zoloft 50 mg qd starting) › Fluoxetine has the longest half life, and rate

of transfer through bf is highest. › Paroxetine has some ?concern over

teratogenicity. (OR 2.2 in some studies, not all, inc CV defects

› All above have increased risk of persistent pulmonary hypertension of newborn. (6-12 affected neonates/1000exposed fetuses.)

Response expected within 2-6 weeks of starting therapy

If suboptimal response, consult psychiatrist

For first episode of depression, treat for 12 months after remission to reduce chance of relapse

Taper meds when discontinuing