Postpartum Depression Delivery by mikeholy


									    Postpartum Mood Disorders

         Stephanie Calkins, MD
Maine Dartmouth Family Practice Residency
             July 10, 2006
            Baby Blues
 Transient
 Heightened emotional reactivity
 50-85% women experience baby blues
 Peaks 3-5 days after delivery
 Lasts up to 10-14 days
              Baby Blues
 Considered normal experience of childbirth
 Symptoms can be distressing
 Usually don’t affect mother’s ability to
  function and care for child
    What Causes Baby Blues?
   Two leading hypothesis:
    – Abrupt hormone withdrawal
          Greater change more important than absolute values

    – Biological system underlying attachment
          Affects mother-infant attachment behavior
          Regulated primarily by oxytocin
          Under “normal” circumstances, these changes promote
          Under high stress, emotional reactivity increases risks
     Postpartum Depression

 13-15% of women after delivery
 Average duration 7 months
 ¼ still affected at child’s first birthday
 Overlooked and under diagnosed
      Postpartum Depression:
   Infant & child development:
    – Cognitive
    – Emotional
    – Social
 Marital difficulties
 Partner depression
      Early Parenting Practices
   4874 families in 24 pediatric practices, 2 and 4
    month interviews
   17.8% mothers reported depressive symptoms
   Similar safety practices
   Reduced odds of continuing breastfeeding
   Reduced odds showing books, playing with infant,
    following routines.
   Arch Ped Adol Med Mar 2006
Infant Assessment at 30 Months

 Less optimal mother-infant interactions
 Insecure infant attachment
 Problem behaviors and lower competencies
  for boys
 Quality of early interactions affected
  behaviors in girls
   Journal of American Academy of Child and Adolesc
    Psychiatry, Jan 2001
      Intellectual Effects
 London study 2001 demonstrated lower
  IQ’s in 11 year olds whose mothers were
  depressed at 3 months age
 Increased behavior concerns and ADHD
  (esp in boys)
 Shorter duration of breastfeeding in PPD
 Continued breastfeeding in PPD was
    PPD: Why do we miss it?
 Patient, society, and physicians dismiss or
  minimize patients experiences as “normal”
 Patient without a primary care physician
  don’t know who to turn to
 Women’s fear and shame about not being a
  “good mother”
 Patients don’t present with CC of
    DSM-IV: Major Depression,
       Postpartum Onset
 Noted in medical history since Hippo crates
     Recognized in DSM-IV in 1994
 Major depression that occurs within 4
  weeks of delivery
    – Definition used by researchers usually allows
      up to 6 months
   5 symptoms, every day, at least 2 weeks
    – AND functional impairment
       DSM-IV Major Depression
   Depressed mood
   Lack of pleasure or interest
   Appetite disturbance or weight loss*
   Sleep disturbance*
   Physical agitation or psychomotor slowing
   Fatigue, loss of energy*
   Feelings of worthlessness or excessive guilt
   Diminished concentration, or indecisiveness*
   Thoughts of death or suicidal ideation
          Causes of PPD
 Cause unclear
 Rapid decline in reproductive hormones
 Several factors increase risk
           Predictors of PPD
   Prior episodes depression, anxiety, OCD,
    bipolar d/o, eating d/o
    – Prior depression = 25% risk PPD
    – Prior PPD = 50% risk recurrent PPD
 Stressful life events
 FHx mood disorders
 Hx of PMDD
 Inadequate social support
    Unrelated Factors of PPD
 Education level
 Sex of infant
 Breastfeeding
 Mode of delivery
 Planned or unplanned pregnancy
Interview with Patient
          Screening for PPD

 Assess risk prenatally, prior to discharge, 2
  week well child check, 4-6 week
  postpartum check
 Ask about intentions to harm self or
 Assess thyroid function, anemia
    – Postpartum thyroid incidence 6%-8%
Edinburgh Postnatal Depression

 EPDS specifically designed for primary
 Measures emotional & cognitive symptoms
 Excludes somatic symptoms except sleep
 Score>12 is 100% sensitive, 95.5% specific
 Score >= 10: possible depression
 Department based screening feasible for
  physician practices if infrastructure in place
  to respond to positive screens.
 20 depts, 4000+ women screened.
        Screening for PPD
 Be familiar with diagnostic criteria
 Inquire in a semi-structured fashion
 Provide new mothers opportunities to talk
  about their feelings.
 Consider prophylaxis and prevention
           Treatment of PPD


                              Social Support

            Treatment of
   SSRI preferred initially
    – All effective in open trials
   One placebo-controlled trial (Appleby
    – Fluoxetine = psychotherapy
    – Fluoxetine > > placebo
   Continue 6 months past remission
 Cochrane & Antidepressants
 Fluoxetine or cognitive-behavioral
  counseling equally effective in short term
 Long term effects unknown, especially in
  breastfeeding women and infants
 More trials needed to determine long term
  effectiveness and safety
       Breastfeeding and Meds
 All SSRI’s and TCA’s secreted in breast milk
 Sertraline recommended first line
 Sertraline, paroxetine, fluvoxamine have no
  published reports of adverse effects
 Fluoxetine:
    – Highly active metabolite (norfluoxetine)
    – Very long half-lives of drug and metabolite
    – Colic, less weight gain, sleep disturbance
   No long term data on SSRI’s
   Current data is on full term infants
      Treatment of PPD: Other
           Psych. Meds
   Anxiolytics
    – Clonazepam, lorazepam
   Electroconvulsive therapy
        Treatment of PPD:
 Studies show psychotherapy effective
 Psychotherapy + fluoxetine not any better
  than fluoxetine alone
 Cognitive-behavioral therapy versus
  interpersonal therapy
 Couples intervention
    Treatment of PPD: Estrogen
 Ahokas, Kaukoranta, Wahlbeck, Aito 2001
 23 women with PPD, inpatient psych unit
 Baseline: all severely depressed + low serum
  estradiol concentration
    – 16/23 patients lower than threshold for gonadal failure
 1st week: depression decreased significantly +
  serum estradiol approached follicular phase level
 2nd week: clinical recovery depression in 19/23
    Treatment of PPD: Estrogen
 Gregoire, et al 1996
 Double-blind, placebo controlled
 61 women
 Transdermal estradiol
 In first month, estrogen group recovered
  rapidly and more significant than placebo
Treatment of PPD: Hormones
 Estradiol treatment better than placebo in
  one study; but all women also on
 Progestin increased risk of PPD
 Not indicated as monotherapy
     Postpartum Psychosis
 2:1,000 births
 Psychiatric emergency
 Usually within 3 weeks
 Usually manifestation of bipolar d/o
 70% women experience recurrence in PPP
            PPP Symptoms
 Severe disturbances
 Rapidly evolving manic episodes
 Dramatic presentation
 Initial signs are restlessness, irritability,
 Infanticide: 4% of untreated PPP
 Suicide: 5% of untreated PPP
         Postpartum Psychosis
   Confusion/disorientation           Hyperactivity
   Extreme disorganization            Not feeling need to
    of thought
   Bizarre behavior
                                       Rapid speech
   Unusual hallucinations
    – Visual, olfactory, or tactile    Loss of touch with
   Delusions (often centered           reality
    on the infant)
           PPP Treatment
 Psychiatric emergency! Inpatient treatment
 Mood stabilizers
 Antipsychotics
 Benzodiazepines
 Lithium prophylaxis
 Psychiatric consultation in patient with
  history of PPP
      PPD Cultural Differences
   Cultural difference:
    – Low prevalence in cultures with strong social support
      for new mothers
    – Specific to industrialized countries
   Rare in Nigeria, Nepal, China
    – Strong customs and social supports
   Equal in US, Japan, Australia, Italy, Netherlands,
    Greece, England
    – However, different factors contribute
    Asian Postpartum Practices
   China
    – “doing the month”
    – Avoid anything that might cause disease
    – No bathing, changing clothes, exposure to
      wind, illness
    – Eat only certain foods
    North America Postpartum
 Return from hospital is most vulnerable
 Social isolation, financial pressure, lack of
 Culture emphasizes independence,
  responsibility for oneself
    Latino Postpartum Practices
 Powerful examples of extended family
 La quarantine
    – Rest for 40 days
    – Female relatives do all household chores
    – Eat special foods; abstain from other foods
    – No bathing, wind exposure, walking barefoot
 African Postpartum Practices
 Takes entire village to raise a child
 Mothers occupy an important role
 Individuals who are not biological
 Sociocultural Aspects of PPD
 Affects how symptoms are expressed, and whether
  they will be socially acceptable
 Much of PPD is culture bound
 “an individual may seem to have adapted to a new
  culture, but at times of the most profound
  transitions, such as birth and death, one may yearn
  for the comfort of traditional practices and
  rituals.” (Wile, MSW, )
        Public Health Roles
 Inform the public
 Depression screening in public health
 Provide appropriate referrals
 Partnership with mental health, social
  service agencies
 Follow up care (home visits, support
 Common! 1:8 women
 Screening for PPD is imperative
 Proactive approach to treatment
   “Behind the Smile: My Journey Out of Postpartum
    Depression”, Marie Osmond
   “Down Came the Rain”, Brooke Shields
   Anne Lamott, “Operating Instructions: A Journal
    of My Son’s First Year”
   Depression After Delivery 1-800-944-4PPD
   National Women’s Health Information Center
   Postpartum Support International 1-805-967-7636

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