start time: 2 minutes 38 seconds - new mexico state … using the edinburgh postnatal depression...

Start time: 2 minutes 38 seconds

Peripartum Depression:

the Pediatric’s Perspective Why does it matter?

Presented by: Janelle Aragon, MD

Yolanda Ortega, RN

Yates Family: mom drowned

her 5 children

Otty Sanchez: dismembered her 3 ½ week old

son

LaShanda Armstrong: drove into a lake

killing herself and 3 of her 4 children

Kristi-An Walker, 20, from Angleton, Texas, called an

ambulance to her home in June and told them her child

was unresponsive even after she performed CPR

Lyndsey Walker, 20, with fiancé Andrew, experienced rare

postpartum psychosis following the birth of her daughter

Elizabeth, now 15 months old

Objectives Review Risk Factors associated with Peripartum Mood Disorders

List and describe 3 adverse outcomes for children of parents with Peripartum Mood Disorders

Be able to screen, assess for and recognize Peripartum Mood Disorders using the Edinburgh Postnatal Depression Scale

Evaluate Case Examples of peripartum depression and decide if there should be concern

Be able to answer: Why is this important to families in New Mexico?

Questions

Common Misconceptions Parents with postpartum depression look depressed,

are sad and cry all the time.

Only mothers get postpartum depression.

It only happens to those already depressed or with

mental health issues.

It occurs within the first few weeks postpartum and only

lasts a few weeks.

Common Misconceptions It will go away on its own.

If the pregnancy and birth go well, parents are not at

risk for postpartum depression.

If a patient has been diagnosed with postpartum

depression in a prior pregnancy, he/she will have it

again.

Feeling depressed and anxious are to be expected of

new parents.

Common Misconceptions Breastfeeding prevents postpartum depression

Nursing moms can’t take antidepressants.

Sleep will cure postpartum depression.

Women with postpartum depression will hurt their

children.

What parents are told: Just snap out of it

Pray harder

Stay busy

Focus on the positive

You’re just being selfish

I told you that you were too young to have a baby.

Why parents don’t seek help: They might think:

I’m suppose to be happy

This is suppose to be a joyful time

I made a mistake

I am not a good mother

My baby just doesn’t like me. He just keeps crying

Everyone was right. I am too young, I am a bad mom.

They wonder:

What will people think of me?

The big one: They will take my baby away!

“With a period prevalence of 21.9% the year after birth,

depression is a frequent complication of childbearing.

However, recognition and treatment rates are even

lower in pregnant and postpartum women (14%) than

in the general population (26%).” JAMA Psychiatry.

Published March 13, 2013.

Case of a Pregnant mom: A 16 year old girl reports to her school counselor that “a

friend” is pregnant with her first baby in her third

trimester of pregnancy and has not revealed to her

parents that she is pregnant. She is afraid of being

thrown out and is contemplating taking pills so it will “all

go away.” She is asking help on what to tell her friend

Concerning or not concerning?

New Mexico and Postpartum

Depression

According to the New Mexico Pregnancy Risk Assessment and

Monitoring System (PRAMS) Surveillance Report for birth years 2009-

2010:

Risk Factors History of depression

Depressive symptoms during pregnancy

Family history of depression

Premenstrual or oral contraceptive-associated mood

changes

Stress around child care

Psychosocial impairment in the areas of work,

relationships, and leisure activities.

Risk Factors Unwanted pregnancy with contemplation of termination

Poor relationship with own mother

Not breastfeeding or difficulties with breastfeeding

Young parents

Unemployment

Stressful life events in previous 12 months

Congenitally malformed infant, premature infant

Sick Child (hospitalized child)

Women with postpartum blues are at increased risk of developing postpartum depression.

New Mexico Pregnancy Risk Assessment and

Monitoring System (PRAMS) Surveillance Report

for birth years 2009-2010:

Peripartum Mood disorders

Peripartum Mood Disorders

Blues

Depression

Obsessive-Compulsive Disorder

Psychosis

Peripartum Anxiety/Panic Disorder

Postpartum Blues Transient Condition

Mild and rapid mood swings (i.e. elationsadness), irritability, anxiety, decreased concentration, insomnia, tearfulness, crying spells

40-80% of postpartum women experience this within 2-3 days after delivery

Peaks around the 5th postpartum day and resolves within two weeks

May represent prodrome of depression and symptoms should be monitored

Case of a postpartum mom: First time 15 year old mom status post C-section post-

op day 2 is with her mother when she starts crying and

tells her mother she feels empty. Mother calls the RN

worried about depression.


Peripartum Mood Disorders Blues

Depression


Psychosis


Peripartum Depression

Most recent onset of mood symptoms occurs during pregnancy or

in the 4 weeks following delivery

Duration: minimum of 2 weeks

Change in functioning

MUST have: depressed mood or

loss of interest/pleasure

Criteria for Peripartum Depression

Weight change

Insomnia: Inability to sleep when baby sleeps

Restless/slowed down

Low energy level/fatigue

Feelings of guilt: Feelings of inadequacy and of being a failure as

a mother

Can’t think or make a decision

Recurrent thoughts of death


50% begin prior to delivery

Significant anxiety and panic attacks

Crying

Poor libido

Lack of interest in the baby

Overwhelmed or unable to care for baby

Not bonding with baby


Thoughts

Intrusive

Suicidal

Scary: usually not revealed unless woman questioned directly

Obsessional thoughts about harming self or baby.

Recognized as illogical and intrusive not predictive of

suicide or infanticide.

Occasionally indicative of psychosis


Blues

Depression


Psychosis

Postpartum Anxiety/Panic Disorder

Obsessive-compulsive disorder

Underappreciated

21% women have perinatal onset

Worsens in pregnancy and postpartum

60-80% co-morbidity with Major Depressive Disorder

Criteria Obsessions OR compulsions, Understands thoughts are

excessive or unreasonable, Causes distress, Intrusive thoughts, Seen

with depression, Intrusive, Violent thoughts of harm to child, Avoidant

behaviors to avoid harm, Often contamination fears, Usually not

associated with compulsions

Case of a postpartum mom: A 17 year old first time mom is postpartum 6 weeks. Prior

to delivery was in the Career Enrichment Program to

obtain her LPN. She frequently has thoughts about her

child being ill, and she believes that her child has all the

ailments of every sick child she has studied.



Blues

Depression


Psychosis

Postpartum Anxiety/Panic Disorder

Psychosis

This is not postpartum depression!

Rare (1-3 cases/1000 births)

May be more common in first time pregnancy

Abrupt onset

Amongst identified women: 4% risk of infanticide

Amongst identified women: 5% risk of suicide

Increased risk of psychosis

Prior postpartum mood episodes

Prior history of depression

Prior history of bipolar disorder (bipolar 1)

Family history of bipolar disorder

Risk of recurrence with each subsequent delivery is

30%-50%


Blues

Depression


Psychosis


Summary of Postpartum Mood disorders

Case

A 34 year old married, employed, elementary math

teacher requested urgent evaluation in the 10th week of a

wanted pregnancy. From the fourth week of gestation,

she had suffered from intractable vomiting and severe

anxiety with bouts of tearfulness she found frightening.


Screening for Postpartum

Depression Screening is an on going process and should be

conducted by all providers who come in contact with

mothers and fathers and their young infants.

Research shows that most women feel comfortable

with the screening process.

If you don’t ask many parents will not tell. Using a

validated screening tool provides an opportunity to

explore the emotional adjustment new mothers and

fathers are experiencing.

Assessment Tools Beck Depression Inventory

Postpartum Depression Screening Scale

Center for Epidemiological Studies Depression Scale

PRIME-MD Patient Health Questionnaire

Edinburgh Postnatal Depression Scale

Edinburgh Postnatal Depression

Scale Can be used during pregnancy and postpartum

10 items, self-administered

Validated in 12 languages

Easy to score: Each response scored 0-3 with total of 30 possible

Score of 9-13 may indicate depression at-risk group

Score > 14 or greater is likely to be suffering from a depressive illness of varying severity and needs a careful assessment to confirm diagnosis

Does it work If a negative screen, <9, probability she did not have

depression was 99%.

If a positive screen, >14 probability of a major

depressive disorder was 57%

Providing some form of support to women who screen

positive appears to decrease depressive symptoms

Case of a postpartum mom: First time mom presents with her 5 day old baby for a

well baby check. Dad is concerned because mom

cries frequently. Mom assures the pediatrician that she

has always been a cry baby and is not depressed.


What about Dad? 5% of dads overall from 1st trimester to 1 year after

delivery

26% occur/diagnosed at 3-6 months postpartum

Biggest correlation related to presence of depression in

the partner

Associated with significant relationship discord

Kim P, Swain JE. Sad dads: paternal postpartum depression.

Psychiatry (Edgmont) 2007 Feb;4(2):35–47.

Case of a postpartum dad: 16 year old male with his first child, starts saying and doing

things out of character per family: Becomes stoic with close

friends and family, irritable with everyone, doesn’t allow anyone

but himself or mother-of-baby to care for the baby.


Treatment Support and reassurance to mom/dad and family

Adequate time for sleep and rest

Allow someone else to care for infant at night

Minor tranquilizers for insomnia

Medications

Counseling, Support groups

Light Therapy, ECT

Why does this go unrecognized? Discomforts in peripartum period (fatigue, difficulty

sleeping, low libido) similar to symptoms of depression and expected

Societal expectations of new mom

Reluctance to complain of mood

Only 1/3 of women with Postpartum depression believed themselves to have this disorder

80% women had not reported symptoms to health professional

Adverse Outcomes Inconsistent use of birth control unplanned

pregnancies

Parenting difficulties

Family and marriage difficulties

Personal suffering

Risk of child abuse

Suicide: Suicide accounts for about 20% of postpartum deaths and is the second most common cause of mortality in post-partum women.

Case of a postpartum mom: Mother of a 9 week old boy calls her girlfriend and tells her that

something is wrong. She has slept 5 hours total in 5 days. She

states she sees herself doing things to her child: while she is

cooking she sees herself put the baby in the oven, while she is

bathing the baby she sees herself pouring hot water on the baby

or letting the water cover the baby.


Why should You get involved?

Adverse Outcomes for the Family

Family Unit

Self-Neglect unintentional neglect of others

“Not present” compromise parental-child relationship

interferes with attachment and bonding

Relationship discord

Adverse Outcomes for Parenting

Parenting Capacity

Poor supervision of health and safety of the child

Poor judgment

“Absent” parent Unintentional neglect shame/guilt

withdrawal

Adverse Outcomes for the Child Duration of parental depression correlates with degree

of impairment for the child

Associated with developmental/cognitive, behavioral,

emotional problems in children

Adverse Outcomes for Child Peripartum depression poses a serious risk to Child

Development

Neuronal migration, pruning and synapse formation

Poor interaction: less engaged visually, lower activity levels

delay in fine and gross motor skills Poor social interaction

delayed language acquisition and social skills

Poor cognitive development

Cognitive and attention deficits

Adverse Outcomes for Child Behavioral

Secure attachments early in life are essential in the development of healthy social skills and behavioral patterns.

Interference with parental-infant bonding increases parent’s sense of shame and guilt neglect attachment disorder

Higher incidence of conduct disorders

Highest rate of preschool expulsion rates in the US

Inappropriate aggression

Emotional dysregulation

Adverse Outcomes for Child Social

Feeding is a social skill affected by absent parent

failure to thrive and consequences of malnourishment

Mom not eating maternal nutrition affects breastfeeding

and breast milk production premature cessation of

breastfeeding

Nursing infants gain less weight

Who detects postpartum depression?

Obstetrics/Gynecology, Nurse Midwifery:

14-30%

Problem: Women often not seen after 2-6 week

postpartum check

More than 75 % of women are undiagnosed and

untreated

Pediatricians How often do we see children accompanied by their

parents?

EVERY DAY!

Well Child visits occur:

Newborn, 2 week, 2-4-6-9-12 month visits AT LEAST

Sick Visits

Hospitalizations

Results of September 2013 0-8 9-12 >13 # tested

Mom 25 7 2 34

Dad 11 2 1 14

Total Score per

range

36 9 3 48

12/48 or 25% received more in depth conversation with medical

staff

All families received an informational packet

5 families accepted psychiatric consultation or Certified Nurse

Midwife consultation

This is where you come in!! You see these young parents more than medical

professionals do

You know them at their baseline

You have access to information we do not: school absences, behavioral changes, performance in class, observation with friends/family

Important stakeholders must be involved before the screening takes place. These stakeholders may consist of school administrators, teachers, families, and mental health organizations

How can you help? Be aware of this issue

Educate staff and families about Peripartum Mood Disorders

Screen young parents who are either expecting or have delivered (whether or not a child remains in the picture)

Identify support systems for these parents, including other family members willing to care for baby

Identify services in your area that can provide mental health services

How do we talk to parents?

How can we help? Observations and informal screening

Listen to c/o sleep problems and Ask More

Listen for signs of poor coping and Ask More

Note comments about infant and interactions with infant

Failure to thrive infants may be infants of depressed parents

Depressed parents may have difficulty focusing on infant’s needs

How can we help? Ask specifically about suicidal ideation. If the response

is positive or equivocal, then

Ask about specifics of ideation, plan or intent.

Assess risk factors for suicide

Develop a safety plan for further evaluation and treatment

Ask about anxiety symptoms

Ask about alcohol or other substance use

Resources https://womensmentalhealth.org

http://www.postpartum.net

Perinatal Clinic University of New Mexico Hospital

Anilla del Fabbro, MD Phone 505-272-6130

https://womensmentalhealth.org/

http://www.postpartum.net/

Case of a postpartum mom: Mother of a 9 week old boy. She starts to have loud thoughts in

her own voice. These thoughts tell her she is worthless, everyone

would be better off without her, and that she is a bad wife and

mother. While resting in an upstairs bedroom her thoughts wonder

what would happen if she just fell out the window. While walking

with her mother, her thoughts wonder what would happen if she

jumped in front of the car.


Case continued: This mother was taken

immediately to be evaluated

at Psychiatric Emergency

Services.

She was admitted to the

psychiatric hospital where

she remained inpatient for 1

week while being started on

medication.

Summary Peripartum depression is a major problem in New

Mexico, which can have severe consequences on the

well-being of our children

We, as caregivers of children and young parents, have

an opportunity to identify, educate and provide services

for our families

References

Jane Knitzer, Suzanne Theberge & Kay Johnson. “Reducing Maternal Depression & Its Impact on Young Children”, National Center for Children in Poverty, Columbia University School of Public Health Jan 2008, http://www.nccp.org/publications/pub_791.html

Centers for Disease Control and Prevention. Prevalence of self-reported postpartum depressive symptoms--17 states, 2004-2005. MMWR Morb Mortal Wkly Rep. 2008 Apr 11;57(14):361-6.

Relation between perceived stress, social support, and coping strategies and maternal well-being: a review of the literature.Razurel C, Kaiser B, Sellenet C, Epiney M.Women Health. 2013;53(1):74-99. doi:

Postnatal depression in mothers bringing infants to the emergency department.Stock A, Chin L, Babl FE, Bevan CA, Donath S, Jordan B.Arch Dis Child. 2013 Jan;98(1):36-40.

Reliability of the postpartum depression screening scale in the neonatal intensive care unit.McCabe K, Blucker R, Gillaspy JA Jr, Cherry A, Mignogna M, Roddenberry A, McCaffree MA, Gillaspy SR.Nurs Res. 2012 Nov-Dec;61(6):441-5.

Screening for postpartum depression at pediatric visits.Meadows-Oliver M.J Psychosoc Nurs Ment Health Serv. 2012 Sep;50(9):4-5.

Depression during pregnancy and postpartum.Toohey J.Clin Obstet Gynecol. 2012 Sep;55(3):788-97

.Postpartum depression: a review.Patel M, Bailey RK, Jabeen S, Ali S, Barker NC, Osiezagha K.J Health Care Poor Underserved. 2012 May;23(2):534-42.

http://www.nccp.org/publications/pub_791.html

http://www.ncbi.nlm.nih.gov/pubmed/23421340
















References

Re: Maternal depressive symptomatology: 16-month follow-up of infant and maternal health-related quality of life.Stevens DG.J Am Board Fam Med. 2012 May-Jun;25(3):398.

Screening for depression and help-seeking in postpartum women during well-baby pediatric visits: an integrated review.Liberto TL.J Pediatr Health Care. 2012 Mar;26(2):109-17. doi: 10.1016/j.pedhc.2010.06.012. Epub 2010 Aug 11

Maternal psychopathology and infant development at 18 months: the impact of maternal personality disorder and depression.Conroy S, Pariante CM, Marks MN, Davies HA, Farrelly S, Schacht R, Moran P.J Am Acad Child Adolesc Psychiatry. 2012 Jan;51(1):51-61

Postnatal depression and its effects on child development: a review of evidence from low- and middle-income countries.Parsons CE, Young KS, Rochat TJ, Kringelbach ML, Stein A.Br Med Bull

Postpartum depression prevalence and impact on infant health, weight, and sleep in low-income and ethnic minority women and infants.Gress-Smith JL, Luecken LJ, Lemery-Chalfant K, Howe R.Matern Child Health J. 2012 May;16(4):887-93.
































References

Impact of a health promotion intervention on maternal depressive symptoms at 15 months postpartum.Surkan PJ, Gottlieb BR, McCormick MC, Hunt A, Peterson KE.Matern Child Health J. 2012 Jan;16(1):139-48.

Gaynes BN, Gavin N, Meltzer-Brody S, et al: Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evidence Report/Technology Assessment, No. 119. AHRQ Publication No. 05-E006-2. Rockville, MD, Agency for Healthcare Research and Quality, 2005.

Miller RL, Pallant JF, Negri LM: Anxiety and stress in the postpartum: is there more to postnatal distress than depression? BMC Psychiatry 6(March 24):12, 2006

Munk-Olsen T, Laursen TM, Mendelson T, et al: Risks and predictors of readmission for a mental disorder during the postpartum period. Arch Gen Psychiatry 66(2):189–195, 2009

Terp IM, Mortensen PB: Post-partum psychoses: clinical diagnoses and relative risk of admission after parturition. Br J Psychiatry 172:521–526, 1998

Yonkers KA, Ramin SM, Rush AJ, et al: Onset and persistence of postpartum depression in an inner-city maternal health system. Am J Psychiatry 158:1856–1863, 2001

Diagnostic and Statistical Manual of Mental Disorders. 5th ed.2., Depressive Disorders 160-168, 2013

Cox JL, Holden JM, Sagovsky R.: Detection of postnatal depression. Development of the 10-item Edinburgh Post




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