Prenatal and Postpartum Depression

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					Prenatal & Postpartum Depression
Bev Young, MD, FRCP(C)
Head, Perinatal Mental Health Program, Mt. Sinai Hospital, Toronto, Ontario

Speakers’ Bureau:
GSK, Wyeth, Lundbeck, Astra Zeneca

Advisory Boards:
GSK, Wyeth, Janssen Ortho

Pregnancy & Postpartum Depression

Screening for PPD
• Up to 50% of PPD cases go undetected.
• Guilt, shame, and fear of negative consequences may prevent women from disclosing their emotional distress during what is supposed to be a happy time.

Depression During Pregnancy
• Prevalence similar to nonpregnant women • Symptoms different from usual pregnancy: –anxiety, irritability, insomnia –anhedonia –guilt, worthlessness –suicidality • Confounded by medical illness

Depression During Pregnancy
• Risk Factors:
– personal / family history of depression – marital discord – adverse life events – unwanted pregnancy

• Treatment:
– Psychotherapy- IPT, CBT – pharmacologic – ECT

Medication in Pregnancy
• First Trimester Exposure
– Organogenesis

• Third Trimester Exposure
– Neonatal Adaptation Syndrome

• Longterm Effects
– Behavioural Teratogenicity

Antidepressants in Pregnancy: Health Canada Advisory
• “When treating depression in pregnant women, physicians and patients should carefully consider the potential risks and benefits …for both the mother and the unborn baby” • “It is very important that patients do NOT stop taking these medications without first consulting with their doctor”

First Trimester Exposure
-Paroxetine and cardiac anomalies: -increased risk (2% vs. 1%) -cardiac malformations were not described • Motherisk study (2005):
– outcomes of almost 3000 infants exposed to antidepressants in utero – no increased risk in any major malformations including cardiac defects

Long term effects
• Fluoxetine and tricyclics – First trimester use only – Exposed throughout pregnancy • 4 year follow-up by neurologist, psychologist, pediatrician • No differences between exposed and nonexposed babies
Nulman I et al N Engl J Med 1997 Nulman I et al Am J Psychiatry 2002

Third Trimester Exposure: neonatal adaptation syndrome
• 30% of newborns exhibited symptoms, most were self- limiting • 60 neonates exposed in utero: 10 showed mild symptoms 8 showed severe symptoms: tremor, high pitched cry, hypertonicity, GI problems, respiratory difficulties and occasional seizures
Costei et al Arch Pediatr Adolesc Med. 2002 Levinson-Castiel et al: Arch Ped Adolesc Med 2006 Sanz et al : Lancet 2005

Untreated depression: physiological effects
• Adverse effects have been linked to increased risk for spontaneous abortion, bleeding during gestation, growth retardation, pre-eclampsia, premature labour and delivery • Untreated depression in pregnancy is the biggest predictor of postpartum depression
Bonari et al Can J Psychiatry 2004

Untreated Depression: psychological effects
• Women suffering from depression are less likely to get appropriate prenatal care, more likely to smoke and use alcohol • Women who are depressed are less likely to bond well with their baby
Buist. Aust Fam Physician 2000

Postpartum Mood Disorders
• Definition:
– Begin after delivery – DSM IV: “postpartum onset” modifier – symptoms onset within 4 wks pp – Range in severity: • Postpartum Blues • Postpartum Depression • Postpartum Psychosis

Postpartum Blues
• Prevalence: 50 - 85% • Mild and transient • Symptoms: low mood, crying, mood lability, irritability, anxiety, insomnia, memory & concentration problems • Course: begins 3-4 days after delivery peaks at day 5-6 back to normal in 2-3 weeks

Postpartum Psychosis
• Incidence: 1-2/1000 births • Onset: mean is 2-3 wks pp, usually within 8 wks of delivery • Symptoms: – Early - insomnia, mood lability, restless – Later - marked mem & conc impairment, incoherence, suspiciousness, irrational/obsessive concerns, delusions and hallucinations

Postpartum Psychosis
• Suicidal, homicidal ideation – High rates of maternal and infant morbidity and mortality - 4% infanticide • ? A variant of Bipolar Disorder: – 86% of PPP go on to develop Bipolar Disoder – Bipolar women have a hundredfold higher risk of developing PPP

Postpartum Psychosis
• Treatment: mood stabilizer, antipsychotic, benzodiazepine, ECT • Prevention: – Lithium prophylaxis 24 hrs. pp – Avoid antidepressants – Minimize sleep deprivation

Postpartum Depression
• Prevalence: 10-22% of women 26% of adolescent mothers • 60% have their first episode of depression in pp period • Onset: within 6 weeks after delivery 85% reported having PP Blues • Duration: a few wks to many months • Risk of future PPD: 50-65%

Postpartum Depression
• Symptoms: depressed mood, anxiety, fatigue, changes in sleep and appetite, anhedonia, guilt, suicidalilty • Risk factors: pers/fam hx of depression hx of PDD stressful life events marital discord few social supports preg/delivery complications

Postpartum Anxiety Disorders
• Panic Disorder • OCD • PTSD

Postpartum Depression
• Etiology: – Psychodynamic theories - reactivation of mother-daughter conflicts – Psychosocial theories - role adaptation – Neuroendocrine theories • hormonal withdrawal • ?pp autoimmune thyroiditis

Postpartum Depression
• Treatment: – Interpersonal psychotherapy – Psychosocial interventions – SNRI/SSRI’s, TCA’s – Estrogen – ECT • Prophylaxis: start antidepressant pp week 1

Medications in Breastfeeding
• • • • • Many benefits of breastfeeding All medications are excreted in breast milk Look at benefits vs. risks All antidepressants considered safe Guilt of not breastfeeding

Untreated Postpartum Depression
• PPD may be associated with: – increased rates of depression in husband – insecure attachment of infant to mother – negative infant cognitive and social adjustment

Take-home Messages
• If you ask it, they will respond
– Screen for depressive symptoms routinely

• Pregnancy is not protective for depression
– Treat like past depressive episodes

• Postpartum Blues: common, normal • Postpartum Depression: anxiety/ irritability/ guilt, treat ASAP • Postpartum Psychosis: psychiatric emergency, think bipolar disorder

Take-home Messages
• Perinatal depression / anxiety is very treatable
– Consider prophylactic meds if high risk – Rule-out medical problem- check TSH

• Medications in pregnancy and breastfeeding: weigh the risks and benefits of each case • Treatment decisions should be collaborated among patient, partner, obstetrician, family doctor, midwife, pediatrician and psychiatrist • Look for available community supports

For more information…
• MGH Women’s Mental Health Pgm

• B.C. Reproductive Mental Health Pgm

• Motherisk416-813-6780

• Postpartum Support International

• Perinatal Bereavement Services of Ontario

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