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PPD-PartIII

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									                           STAR-D trial
                              Summary
• The acute remission rates were (only) modest for the first two treatment
  levels (37 % for step 1, and 31 % for step 2)
• Follow-up results indicate that remission at entry into follow-up was
  associated with a better prognosis than simple improvement without
  remission
• More treatment steps (regardless of remission status) was associated with
  higher rates of relapse + shorter average time to relapse
• Those with concurrent medical/psychiatric (substance abuse, ADHD, PTSD,
  OCD) morbidity and those with more prolonged/chronic depression – are
  less likely to achieve remission with acute treatment.
                           STAR-D trial
                             Summary
• Cognitive Therapy after unsuccessful treatment with medication
  was as effective as medication only
         cognitive therapy alone (Switch group) – spared side effects of
            medication
• Major Depressive Disorder treated in primary care and outpatient
  mental health care settings were similar in severity, recurrence
  rates, clinical features
                          Psychotherapy
Types:
•   Cognitive-Behavioral therapy
•   Interpersonal therapy
•   Problem-solving therapy
•   Psychodynamic therapy
•   Client-centered therapy
•   Marital/Family therapy
•   Eclectic therapy – selection of what’s valid or useful from all
    models and practices
                    Psychotherapy
Recommendations:
• For mild to moderate depression – similar efficacy to drug therapy
• Combined with drug therapy for:
          Severe depression
          Chronic (more than 2 years), recurrent, or treatment-resistant
           depression
                             Psychotherapy
Issues/barriers:
• Stigma associated with mental health care
• Must be a “fit” between therapist and client (variables: age, gender, experience,
  theoretical orientation, warmth and style of communication)
• Overcome patient’s possible perception of being rejected or “dumped”
• Limited third-party coverage for psychotherapy
        → copays/family deductibles
          → limited # visits per year (i.e. 20) – physician + therapist
• Access/availability (especially in rural areas)
          → 39 primary care shortage areas in Nebraska
          → 95 mental health shortage areas
          (Bureau of Health Professionals, Health Resources & Service Administration 3/08)
• May require strong motivation and active participation in therapy  limited
  application to patients with severe depression or intellectual limitations.
  Men and Depression

Paternal Peripartum Depression
               .,
Ramchandani P Stein A., Evans J., O’Connor, T.G. Paternal depression in the postnatal period and child
development: a prospective population study Lancet, 2005 Jun 25-Jul 1; 365 (9478): 2201-2205
Paulson J.F., Dauber S., Leiferman J.A. Individual and Combined Effects of Postpartum Depression
in Mothers and Fathers on Parenting Behavior Pediatrics, 2006 Aug; 118 (2): 659-668
        What is the prevalence of paternal
            peripartum depression?
Ramchandani P., Stein A., Evans J., O’Connor, T.G. Paternal
depression in the postnatal period and child development: a
prospective population study Lancet, 2005 Jun 25-Jul 1; 365
(9478): 2201-2205
    • Depressive symptoms were assessed in mothers (n=13,351) and
       fathers (n=12,884) 8 weeks after birth
    • A threshold of 12 on the Edinburgh Postnatal Depression Scale
       (EPDS) was used to classify 10 % of mothers and 4 % of
       fathers in this study as depressed
              E.P.D.S. Validation in Men
Matthey S., Barnett B., Kavanagh D., Howie P. Validation of
the Edinburgh Postnatal Depression Scale for men, and
comparison of item endorsement with their partners Journal
of Affective Disorders 64 (2001), 175-184
     • The only study which has validated the EPDS in men
     • Mean scores are significantly different for men and women
         – the optimum cut-off (best sensitivity and specificity) to screen for
         depression in men is 2 points lower than for women
     • In this study, a score of 12 on the EPDS had a sensitivity of
       only 42.9 % for depression in men
     •            (~ 57 % of cases would be missed)
       What is the prevalence of paternal
           peripartum depression?
Paulson J.F., Dauber S., Leiferman J.A. Individual and Combined
Effects of Postpartum Depression in Mothers and Fathers on
Parenting Behavior Pediatrics, 2006 Aug; 118 (2): 659-668
   • > 14,000 births sampled – parents interviewed at 9 months
   • Final sample size = 5089 two-parent families
   • Center for Epidemiologic Studies Depression (CES-D) Scale
   • 14 % of mothers and 10 % of fathers had moderate
   • or severe depressive symptoms
   • Neither parent depressed = 78.2 %, Mother only = 11.5 %,
   • Father only = 7.4 %, Both parents = 2.9 %
     Does paternal peripartum depression
             impact the family?
Ramchandani P., Stein A., Evans J., O’Connor, T.G. Paternal
depression in the postnatal period and child development: a
prospective population study Lancet, 2005 Jun 25-Jul 1; 365
(9478): 2201-2205
  • A depressed father at 8 weeks postpartum was found
    to double the risk of behavioral and emotional
    problems in children at 3.5 years of age
  (after controlling for maternal peripartum depression and later paternal depression)
         Does paternal peripartum depression
                 impact the family?
Paulson J.F., Dauber S., Leiferman J.A. Individual and Combined Effects
of Postpartum Depression in Mothers and Fathers on Parenting Behavior
Pediatrics, 2006 Aug; 118 (2): 659-668
                                Findings:
    Maternal and Paternal depression each negatively impacts:
1) positive parent-child enrichment activities (reading, playing, singing)
2) parenting behaviors emphasized in anticipatory guidance by pediatricians
   (back to sleep, breastfeeding, putting infants to bed drowsy and without a bottle)

                                      Conclusions:
    A depressed parent may negatively impact the well parent’s
     interaction with their child
    Negative effects on children are exacerbated when both
     parents are depressed
    A well parent may “compensate” for a depressed parent
      Does paternal peripartum depression
              impact the family?
Responsive care provided by the father can buffer a
child from being negatively influenced by maternal
peripartum depression during development
¹ Hossain Z., Field T., Gonzales J., et. al. Infants of depressed mothers interact
better with their nondepressed fathers. Infant Mental Health Journal 1994; 15:
348-357
² Tannenbaum L., Forehand R. Maternal depressive mood: the role of the father
in preventing adolescent problem behaviors. Behavior Research and Therapy
1994; 32: 321-325
³ Hart S., Field T., del Valle C., Pelaez-Nogureas M. Depressed mothers’
interaction with their one year old infants. Infant Behavior and Development
1998; 21: 519-525
  Murray L. The impact of postnatal depression on infant development. Journal
of Child Psychology and Psychiatry. 1992; 33: 543-561
  Mezulis A.H., Hyde J.S., Clark R. Father involvement moderated the effect of
maternal depression during a child’s infancy on child behavior problems in
kindergarten. Journal of Family Psychology 2004; Vol. 18, No. 4, 475-588
           Does paternal peripartum depression
                   impact the family?

Responsive care provided by the father can buffer a
child from being negatively influenced by maternal
peripartum depression during development
6 Conrad  M., Harrem C. Protective and resource factors in high- and low-risk
children: a comparison of children with unipolar, bipolar, medically ill, and
normal mothers. Development and Psychopathology 1993; 5: 593-607
7 Hops H., Biglan A., Sherman L. Home observations of family interactions of
depressed women. Journal of Consulting and Clinical Psychology. 1987 Jun;
55 (3):341-346
8 Albertsson-Karlgren U., Graff M., Nettelbaladt P. Mental disease
postpartum and parent-infant interaction – evaluation of videotaped
sessions. Child Abuse Review 2001; 10: 5-17
9 Edhborg M., Lundh W., Seimyr L., Widstrom A.M. The parent-child
relationship in the context of maternal depressive mood. Archives of
Women’s Mental Health 2003; 6: 211-216
          Does paternal peripartum depression
                  impact the family?

Having two depressed parents is associated with worse
social and emotional adjustment for children than having
only a depressed mother
¹ Goodman S.H., Brogan D., Lynch M.E., Fielding B. Social and emotional competence
in children of depressed mothers. Child Development 1993; 64: 516-531
² Burke L. The impact of maternal depression on familial relationships. International
Review of Psychiatry 2003; 15: 243-255
  Carro M.G., Grant K.E., Gotlieb I.H., Compass B.E. Postpartum depression and child
development: An investigation of mothers and fathers of sources of risk and resilience.
Development and Psychopathology 1993; 5: 567-579
  Paulson J.F., Dauber S., Leiferman J.A. Individual and combined effects
of postpartum depression in mothers and fathers on parenting behavior.
Pediatrics 2006; 118(2): 659-669
          Does paternal peripartum depression
                  impact the family?

Having two depressed parents is associated with worse
social and emotional adjustment for children than having
only a depressed mother
5 Marchand  J.F., Hock E. The relation of problem behavior in preschool to
depressive symptoms in mothers and fathers. The Journal of Genetic Psychology
1998; 159: 353-366
6 Weissman M., Prusoff B., Gammon G., Merikangas K., Leckman J., Kidd K.
Psychopathology in the children (ages 6-18) of depressed and normal parents.
Journal of the American Academy of Child Psychiatry 1984; 23: 78-84
             What factors contribute to paternal
                        depression?

• Lack of a good role model
    Inexperience with infant care distress

• Fathers may desire more involvement with child care than allowed
    Cultural beliefs supporting rigid gender parenting roles
    Efficiency or quality (things are done faster or better if mother does it)
    Sympathy or admiration (“he’s done enough”)
    Anger – a result of marital conflict  restricted contact
        What factors contribute to paternal
                   depression?

• Child = additional financial responsibility
     a dilemma between Dad the “breadwinner” and Dad the
     caring/nurturing/involved parent
    Lack of paternity work leave
                             The cost of child rearing
           According to the U.S. Department of Agriculture’s report “Expenditures on
           Children by Families” in 2007 a two-parent family is likely to spend the
           following to raise one child from birth to age 17*:

                        If your pre-tax income is:    You’re likely to spend:
*assumes an average
annual inflation rate
                           < $45,800                  $196,010
     of 3.1 %
                        $45,800 to $77,100            $269,040
                        > $77,100                     $393,230

     Does not include:
     • health and lifestyle costs of pregnancy and prenatal preparation
     • cost of college tuition
     • the cost of a break in one’s working career to be a stay-at-home parent
                        What factors contribute to paternal
                                   depression?

                  • Maternal depression
                           Fathers whose partners are depressed have a 2.5 times higher
                            risk of depression at 6 weeks postpartum¹
                               (vs. fathers whose partners are not depressed)
                           24-50 % of men whose partners experience postpartum
                            depression were also depressed (during first postpartum year)²

¹ Matthey S, et. al. Paternal and maternal depressed mood during the transition to parenthood. J Affect Dis 2000; 60 (2):75-85
² Goodman JH. Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family
health. J Adv Nurs 2004 Jan; 45(1): 26-35
    What factors contribute to paternal
               depression?
• Same factors as for mothers:
        Lack of sleep/fatigue
        Complications of pregnancy or loss (miscarriage, stillbirth, abortion)
        Recent negative life events (unemployment, financial problems)
        Poor social support (from family/friends/coworkers)
        Marital instability (including mother-in-law conflicts)
        Lifestyle changes – less time with friends, more time with in-laws,
         less freedom/spontaneity, need for larger home, having to work more
         (men tend to process these “sacrifices” as a loss)
    What factors contribute to paternal
               depression?

Men in step families or partners of single mothers
tend to have higher levels of depressive symptoms
          than men in traditional families
Men and Depression

								
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