Postpartum Mood Disorders

Primary Objectives

Review the range of pregnancy related mood disorders Discuss the risk factors for developing a pregnancy related disorder Identify screening strategies Review treatment options during pregnancy and postpartum

Secondary Objectives

Review the prevalence of mood disorders in women Investigate the etiology of pregnancy related mood disorders Discuss the familial implications of these illnesses Discuss prevention strategies

Major Depressive Disorder

Leading

cause of disability of 5-9%

Prevalence
Lifetime

risk of 10-25%

Peripartum Depressive Disorders

Antepartum Depression
Postpartum Blues Postpartum Depression (PPD) Postpartum Psychosis (PPP)

Antepartum Depression

Symptoms often seen in non-depressed pregnant women

Sleep and appetite disturbance Diminished libido Low energy

Pregnancy related conditions are associated with depressive symptoms

Anemia Gestational diabetes Thyroid dysfunction

Postpartum Blues
Aka

baby blues

Characteristics: Mild mood swings Irritability Anxiety Decreased concentration Insomnia Tearfulness Crying spells

Postpartum Blues

Occur within 2-3 days of delivery

Symptoms peak on 4th or 5th postpartum day Symptoms resolve within 2 weeks

Postpartum Depression

Same DSM IV criteria as for non-pregnancy related depression Symptoms usually begin in initial 12 months after delivery Symptoms often seen as normal for new mothers caring for a newborn

Symptoms of PPD

Change in somatic function

Significant anxiety Intense irritability and anger Feelings of guilt

Symptoms of PPD

Sense of being overwhelmed

Unable to care for baby Feelings of inadequacy Not bonding with the baby

Postpartum Psychosis

Usually a manifestation of bipolar disorder

Typically presents within 2 weeks of delivery

May develop few months after birth as delusional depression

Signs and Symptoms of PPP

Severe insomnia Rapid mood swings

Anxiety
Psychomotor restlessness Delusions and hallucinations

Fetal Implications

Increased rate of:

Preterm birth Low birth weight

Small head circumference

Low APGAR scores

Familial Implications

Postnatal depression in men

Interference with maternal-infant bonding, increases moms sense of shame and guilt

Influences infant development

Familial Implications

Negative interactive patterns with infant

Children exposed to maternal psychiatric illness have:
Higher incidence of conduct disorders Inappropriate aggression Cognitive and attention deficits

Prevalence

Postpartum blues occur in 40 80% of women

PPD affects 10 30% of women

Postpartum psychosis is rare

Antepartum Depression Prevalence

10% of all pregnancies Increased risk for women with history of affective illnesses Relapses most common in the first trimester 1/3 of all cases represent first episode of depression

Postpartum Depression Prevalence

Up to 13% in the first year postpartum

50% higher risk of recurrent PPD in subsequent pregnancies

If history of depression prior to pregnancy, risk of PPD is 25 30%

Prevalence in Active Duty

Positive depression screen

Antepartum Postpartum

Suicide ideation rate

Risk Factors for PPB

History of depression or premenstrual mood changes Depressive symptoms during pregnancy Family history of depression

Concern about child care

Psychosocial impairment

PPD Risk Factors

Personal history of depression

Family psychiatric history Marital conflict Lack of perceived social support

PPD Risk Factors

Lack of emotional & financial support from partner

Living without a partner

Unplanned pregnancy
Previous miscarriage

PPD Risk Factors

Having contemplated terminating current pregnancy

Poor relationship with own mother

Not breastfeeding

PPD Risk Factors

Unemployment in the mother

Lifetime history of depression in partner Stressful life events in previous 12 months

PPD Risk Factors

Child care related stressors

Sick leave during pregnancy High number of prenatal visits Congenitally malformed infant

Risk Factors for PPP

History of bipolar disorder

History of psychosis prior to pregnancy Family history of psychosis

Co-morbidities

Decreased weight gain during pregnancy

Increased rate of tobacco use Increased rate of alcohol and illicit drug use

Etiology

No clear etiology
Possibly due to combination of:
Genetic susceptibility Hormonal changes Major life events

Etiology

Investigators have examined the role of:

Estrogen Progesterone Thyroid hormone Testosterone Cholesterol Corticotropin-relasing hormone Cortisol

Screening - Overview

Important to identify proper timing of screening

Avenues include both informal and formal techniques Various formal screening tools available

Screening - Timing

Antepartum visits
During hospital stay Postpartum visits Well child visits

Screening - Tools

Becks Depression Inventory (PDI)

Postpartum Depression Screening Scale (PDSS)

Edinburgh Postnatal Depression Scale (EPDS)

Becks Depression Inventory

Self administered survey 21 questions scored 0 3 Score of over 17 indicates that patient would benefit from professional assistance 56% of postpartum women with postpartum depression identified in one study

Postpartum Depression Screening Scale

94% sensitive and 96% specific in initial trials

35 item self-administered questionnaire

Uses 5 point scale

Edinburgh Postnatal Depression Scale

10 item questionnaire
Each response scored 0 3, with total score of 30 possible

Scores > 12 or 13 identify most women with postpartum depression

EPDS

Score > 12 reported as 100% sensitive and 95% specific in detecting major depression
Studies comparing EPDS vs PCM evaluation of patient show EPDS has a higher incidence of detecting and diagnosing postpartum depression

Evaluation and Diagnosis

Labs- CBC, TSH

Consider urine drug screen if history of drug use/abuse

DSM IV diagnosis criteria

Diagnosis

DSM IV modifier
ICD coding
Postpartum depression 648.4 Major depression 296

Treatment

Factors to address:
Biological Psychological

Social

Demonstrated maximal clinical response with biopsychosocial approach

Treatment

Psychosocial therapies
First choice for those with mild to moderate

symptoms of PPD
Cognitive-behavioral therapy Interpersonal psychotherapy- focuses on

patients interpersonal relationship and changing roles

Psychosocial Therapies

Group therapy
Helps to increase support network

Family and marital therapy

More rapid recovery More appreciative of partners contribution

Peer-support groups

Psychosocial Therapies (cont)

Supportive psychotherapy
Groups that offer support and education

Postpartum Support International www. postpartum.net Depression After Delivery www. depressionafterdelivery.com

Interpersonal Therapy (IPT)

Short-term, manual-driven psychotherapy Addresses four major problem domains:

Grief Interpersonal disputes Role transitions Interpersonal deficits

Shown to reduce symptoms in pregnant women

Pharmacologic Therapy

No antidepressants are approved by the FDA for use during pregnancy All psychotropic drugs are transferred through the placenta and breast milk Consider prior history SSRIs and TCAs have low detection in breastfed infant serum

Concerns for Psychotropic Use

Risk of pregnancy loss or miscarriage Risk of organ malformation or teratogenesis Risk of neonatal toxicity or withdrawal syndromes Risk of longterm neurobehavioral sequelae

Neonatal Withdrawal TCAs

TCA withdrawal syndrome:

Jitteriness Irritability Seizures

Anticholinergic effect of TCAs include:

Functional bowel obstruction urinary retention

Neonatal Withdrawal - SSRIs

Transient symptoms of:

Irritability Excessive crying

Increased muscle tone

Feeding problems Sleep disruption Respiratory distress

Long Term Sequelae

No significant difference in:

IQ Temperament Behavior Reactivity Mood Distractibility Activity level

Pharmacologic Therapy

Increase risk of suicide after initiation of medication

If significant anxiety or insomnia present, consider adding benzodiazepine Close follow-up

Antidepressant Choice

TCAs
Desipramine and Nortryptiline are preferred Least anti-cholinergic affects

Minimize postural hypotension

SSRIs
Fluoxetine is the best studied

Additional Considerations

Doses of both SSRIs and TCAs may need to be increased in pregnancy secondary to:
Increased plasma volume

Increased hepatic metabolism

Increased renal clearance

Other Therapies

Hormonal Therapy
Increased risk of PPD if Depo-provera given

within 48 hrs of delivery Transdermal estradiol may improve symptoms

Treat severe anemia Treat poorly controlled hypothyroidism

Other Therapies (cont)

ECT
Few adverse effects to mom or infant

Good when rapid treatment is needed

For severe depression with psychotic symptoms

or acute mania

Length of Treatment

Based on patient history and severity of symptoms

Continue 12 months after full remission

Continue meds through pregnancy to reduce risk of relapse

Referrals

Consider Psychiatric referral if:

Poor response to therapy Relapse

Major functional impairment

Suicidal or homicidal ideation

Treatment of Postpartum Psychosis

Medical emergency
Patient should be hospitalized until stable While psychotic, mom cannot adequately care for self or infant

Treatment of PPP (cont)

Medications focused on controlling both psychosis and mood swings Combination therapy often necessary Most will not be able to continue breastfeeding ECT may be highly effective

Prevention

Monitor for signs in high risk women

Educate women and family members before childbirth Counseling and increase social support prior to delivery Consider starting therapy during third trimester or immediately after delivery

Conclusion

Postpartum mood disorders are common Military population has multiple risk factors for developing postpartum depression Important to screen patients in a variety of settings. Treatment of postpartum depression important for maternal and familial well being