POSTPARTUM DEPRESSION BEYOND THE BLUES

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					POSTPARTUM
DEPRESSION
BEYOND THE BLUES


             Debby Carapezza, R.N., M..S.N.
      Nurse Consultant, Reproductive Health Program
               Utah Department of Health
INCIDENCE OF DEPRESSION

 Each year, 15% to 20% of adults in the
  United States experience a major depression

 The incidence among women is twice that
  of men and peaks between 18 to 44 years of
  age - the childbearing years
DEPRESSION IN WOMEN
 Women are at increased risk of mood
  disorders during periods of hormonal
  fluctuation-
     premenstrual
     postpartum
     perimenopausal
THE RANGE OF POST-
DELIVERY MOOD
DISORDERS
 50% to 80% of women experience transient
  “baby blues” within the first two weeks
  following delivery
 0.1% to 0.2% of women experience
  postpartum psychosis usually within the
  first 4 weeks following delivery
POSTPARTUM DEPRESSION
 6.8% to 16.5% of women experience
  postpartum depression (PPD) also known as
  postpartum major depression (PMD)

 Onset can be as early as 24 hours or as late
  as several months following delivery
SYMPTOMS OF
POSTPARTUM DEPRESSION
Hopelessness         Loss of pleasure in activities
Helplessness         Mood changes
Persistent sadness   Inability to adjust to role of
                     motherhood
Irritability         Inability to concentrate
Low self-esteem      Sleep /appetite disturbances
RANGE OF SYMPTOMS
 Symptoms range-
     from mild dysphoria
     to suicidal ideation
     to psychotic depression
DURATION OF SYMPTOMS
 Untreated, symptoms can last:

     several months

     into the second year postpartum
THE ETIOLOGY OF
POSTPARTUM DEPRESSION
 Various theories based in physiological
  changes have been postulated:
     hormonal excesses or deficiencies of estrogen,
      progesterone, prolactin, thyroxine, tryptophan,
      among others
ETIOLOGY OF POSTPARTUM
DEPRESSION
 Other theories cite numerous psychosocial
  factors associated with PMD:
     marital conflict
     child-care difficulties (feeding, sleeping, health
      problems)
     perception by mother of an infant with a
      difficult temperament
     history of family or personal depression
POSTPARTUM DEPRESSION
IN UTAH
     What can PRAMS* data tell us?

 *PRAMS is an ongoing, population-based risk factor surveillance
 system designed to identify & monitor selected maternal
 experiences that occur before & during pregnancy & experiences of
 the child‟s early infancy.
INDICDENCE OF
POSTPARTUM DEPRESSION
AMONG 2000 UTAH PRAMS
RESPONDENTS
 24.1% of PRAMS respondents indicated
  that in the months after delivery they were
  moderately to very depressed
 When the results of the survey are weighted
  to represent all 47,331 Utah women who
  had a live birth in 2000, this means an
  estimated 11,416 women reported being
  moderately or very depressed.
Higher rates of depression were
noted among women who:
Had less than a high school   Reported being abused before
education                     or during pregnancy
Were less than 19 years old   Had 0 to 1 person as a source
                              of social support
Resided in a household with   Were not married
an income <$15,000
Experienced an unintended     Reported 6 to 18 stresses
pregnancy                     during pregnancy (sick family
                              member, divorce, etc.)
THE IMPACT OF
POSTPARTUM DEPRESSION
LONG TERM
CONSEQUENCES OF PMD

 Negative impact on the infant „s social,
  emotional and cognitive development

     2 month old infants of mothers with PMD had
      decreased cognitive ability and expressed more
      negative emotions during testing
LONG TERM
CONSEQUENCES OF PMD
 Babies of mothers
  with PMD were
  perceived by their
  mothers as more
  difficult to care for
  and more bothersome.
POSTPARTUM DEPRESSION
& MATERNAL MORTALITY
IN UTAH

 In recent years, there have been two
  maternal deaths due to suicide by women
  within one year of giving birth.
 Neither woman had been screened for
  postpartum depression
RISK FACTORS FOR PMD
-Family history of mood         -Child-care difficulties:
disorder                        feeding, sleeping, health
-Client history of mood         -Marital conflict
disorder prior to pregnancy
-Anxiety/depression during      -Stressful life events
pregnancy
-Previous postpartum            -Poor social support
depression
-Baby blues following current
delivery
INTERVENTIONS
     SCREENING FOR PMD
SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:

 Be unable to recognize she is depressed
SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:


 Believe her symptoms are “normal” for new
  moms
SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:

 Fear being labeled a “bad mother” if she
  admits her maternal experience does not
  meet society‟s picture of bliss
SCREEN ALL POSTPARTUM
WOMEN FOR PMD BECAUSE
A WOMAN MAY:

 Feel she is going crazy and fears her baby
  will be taken from her
WHEN TO SCREEN FOR PMD
 At preconception visit
 During prenatal intake & subsequent visits
 During postpartum exams
 During infant‟s WCC & WIC visits
 When infant is seen for sick care or in ER
 At early intervention home visits
 At family planning visits during the first
  year postpartum
 At mother‟s visits for routine episodic care
SCREENING TOOLS
 There are several tools available:
     Edinburgh Postnatal Depression Scale (EPDS)
     The Mills Depression & Anxiety Checklist
     The Center for Epidemiological Studies
      Depression Scale (CES-D)
     Others, often on various websites for mental
      health
A WORD ABOUT SCREENING
TOOLS!
 Be familiar with the tool - its validity and
  limitations
 Have a referral network available for
  women screening positive
 Document the screening and any referrals
  made
 Follow-up with your client to assure that
  she received needed assistance
        EDINBURGH POSTNATAL
       DEPRESSION SCALE (EPDS)

   Designed for home or outpatient use
   Consists of 10 questions
   Can be completed in approx. 5 minutes
   Reviews feelings the previous 7 days
   Scored 0-3 depending on symptom severity
   Depending on study, cut off is 13 - 9 points
SAMPLE EPDS QUESTIONS
 1. I have been able to laugh & see the
     funny side of things
     As much as I always could
     Not quite so much now
     Definitely not so much not
     Not at all
SAMPLE EPDS QUESITONS
(Cont.)
 *3. I have blamed myself unnecessarily
     when things went wrong
     Yes, most of the time
     Yes, some of the time
     Not very often
     No never
SAMPLE EPDS QUESTIONS
(Cont.)
 *6. Things have been getting on top of me
     Yes, most of the time I haven‟t been able to
      cope at all
     Yes, sometimes I haven‟t been coping as well
      as usual
     No, most of the time I have coped as well as
      ever
     No, I have been coping as well as ever
TREATMENT

 1. Educate the woman and her support
  system regarding the diagnosis of
     postpartum depression.
TREATMENT OPTIONS
 Pharmacological intervention

 Counseling, individual and/or group

 Support groups
PHARMACOLOGICAL
INTERVENTION
 Use of tricyclic antidepressants and
  selective serotonin reuptake inhibitors
  (SSRIs) may be indicated for both non-
  nursing and nursing mothers
 Have low incidence of infant toxicity and
  adverse effects during breastfeeding*
 Decisions regarding use while breastfeeding
  must be on a case by case basis
OTHER CONSIDERATIONS:
 Provider must be familiar with agents and
  the hepatic function of mother and infant
 Client must be informed of risks/benefits of
  treatment Vs. no treatment for herself and
  her infant
     unknown impact of long-term use of
      medications on neurodevelopment of infant
Other Considerations - Cont.
 If the woman chooses to breastfeed while
  on psychotropics, she should work
  collaboratively with a psychiatrist and her
  pediatrician
 If the infant experiences insomnia or other
  behavior changes, his serum should be
  assayed for the presence of medication
 Document all discussions regarding
  treatment in the client‟s chart
   TREATMENT OF DEPRESSION
      PATIENT ASSISTANCE
          PROGRAMS
 Pharmacological treatment of depression can be
  effective. Unfortunately, it can also be expensive.
  Costs of antidepressants vary depending on the
  drug, dose and pharmacy.
 Paxil® 20mg qd X 30 Days = $85.39
 Prozac® 20mg qd X 30 Days = $67.79 (generic)
 Zoloft® 50mg qd X 30 days = $75.00
 Elavil®, at approximately 75mg qd X 30 days =
  $11.39 (generic) or $37.89 (brand).
COUNSELING
 Know referral sources in your locale,
  especially those that:
     accept Medicaid
     utilize a sliding fee
     will develop a payment plan with the client
     offer free counseling
 Be familiar with indigent drug programs
  available through various pharmaceutical
  manufacturers
Counseling - Cont.
 Any woman with symptoms of psychosis or
  with serious suicidal/homicidal ideation
  should be referred for emergency
  psychiatric evaluation
SUPPORT GROUPS


 Numerous postpartum support groups are
  available. Contact:
 Local mental health agencies
 Hospitals
 Websites
WEBSITE INFO & SUPPORT
 Depression After Delivery -
  http://www.depressionafterdelivery.com
 Postpartum Support International -
  http://www.postpartum.net/
 The Postpartum Stress Center -
  http://www.postpartumstress.com/
 Postpartum Education for Parents -
  http://www.sbpep.org
 Office on Women‟s Health -
  http://www.4women.gov-pregnancy-after
  the baby is born-PPD
Websites and Other Resources
 Mental Health Association in Utah
     http://www.xmission.com/~mhaut/


 For information on medication while
  breastfeeding, call Pregnancy RiskLine:
     In Salt Lake City: 328-BABY (2229)
     Outside Salt Lake: 1-800-822-BABY (2229)
SUMMARY
 Postpartum depression:
      is relatively common
     may have long-term consequences for mother,
      infant & family
     is easily missed
     should be screened for
     can be treated successfully
References
   1. Beck AT, Ward, CH, Mendelson M, Mock J, Erbaugh J. An inventory for
    measuring depression. Archives of General Psychiatry. (June 1961). 4:6:561-
    571.
   2. Cox JL, Holden, JM, Sagovsky R. Edinburgh Postnatal Depression Scale
    (EPDS). British Journal of Psychiatry. (1987). 150:782-786.
   3. Epperson CN. Postpartum major depression: detection & treatment.
    American Family Physician. (April 15, 1999). 59:8:2247-2254.
   4. Mandl KD, Tronick EZ, Brennan TA, Alpert HR, Homer J. Infant health
    care use and maternal depression. Archives of Pediatric Adolescent Medicine.
    (1999). 153:(8):808-813.
   5. Stowe Z. Depression after childbirth: I it the “baby blues” or something
    more? Pfizer Inc. January 1998.
   6. Stowe ZN, Nemeroff CB. Women at risk for postpartum-onset major
    depression. American Journal of Obstetrics & Gynecology. (August 1995).
    173:2:639-645.
   7. Utah Department of Health. (2001). [Untitled]. Unpublished Maternal
    Mortality Review Program data.
References (cont.)
   8. Utah Department of Health. (2001). [Untitled]. Unpublished PRAMS data.
   9. Whiffen VE, Gotlib IH. Infants of postpartum depressed mothers:
    temperament and cognitive status. Journal of Abnormal Psychology. (1989).
    98:3:274-279.

				
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