Perinatal Mood Disorders. Chris Raines MSN APRN-BC Assistant Clinical Professor Perinatal Psychiatry Program UNC Center for Women s Mood Disorders

Transcription

1 Perinatal Mood Disorders Chris Raines MSN APRN-BC Assistant Clinical Professor Perinatal Psychiatry Program UNC Center for Women s Mood Disorders

2 Perinatal Mood Disorders What do you need to know? What does Perinatal Mood Disorder mean? What are the mechanisms and risk factors associated with PMD What are the special problems related to treating women with perinatal mood and anxiety symptoms Assessments, Evaluation tools, and Treatments

3 What does Perinatal Mood Disorder Mean? PMD is an umbrella term encompassing all of the following during pregnancy and 12 months postpartum Postpartum Blues (Not considered a disorder) Depression During Pregnancy Postpartum Depression Anxiety Disorders OCD, Panic Disorder, PTSD Postpartum Psychosis Bipolar Disorder

4 Perinatal Mood Disorders Prevalence 40 weeks of pregnancy 18.4% (7-9% in the general population) 1 st trimester 7.4%-11% 2 nd Trimester 8.9%-12.8% 3 rd Trimester 8.5%-12.0% ~ Robinson, G.E. (2012) Postpartum 10-15% Up to 50-80% increased risk with prior history

5 Perinatal Mood Disorder COMMON MORBID MISSED 10-20% prevalence 4 million women give birth annually in U.S.; ½ million with PPD Most common, unrecognized complication of perinatal period Compare to prevalence rate of gestational diabetes at 2-5% Devastating consequences for patient and family low maternal weight gain, preterm birth Impaired bonding between mother and infant Increased risk of suicide and infanticide No practice guidelines or routine screening Symptoms often different from classic DSM-IV depression Gavin et al, Ob & Gyn 2005; Gaynes et al. AHRQ Systematic Review 2005

6 Perinatal Mood Disorders What do you need to know? Don t all women get emotional during pregnancy and after they deliver. Most women do get emotional and anxious during pregnancy and in the postpartum period but that is not PMD What is different about PMD Usually presents as anxiety and/or insomnia Feels different from depression moms have had before I have every thing I ever wanted, good partner, new baby, home what do I have to be depressed about Meets criteria for Major Depression

7 Major Depression Must be present during the same 2 week period Represents a change from previous functioning At least one of the symptoms is either 1) depressed mood 2) loss of interest or pleasure

8 Major Depression Five (or more) of nine symptoms: Depressed Mood Loss of interest or pleasure in almost all activities Significant weight loss or gain Insomnia or hypersomnia Restlessness or feeling slowed down Fatigue Worthlessness or inappropriate guilt Inability to concentrate Suicidal ideation

9 Perinatal Mood Disorders Causes "Giving birth is like taking your lower lip and forcing it over your head. --Carol Burnett Rapid hormonal changes Physical and emotional stress of birthing Physical discomforts Emotional letdown after pregnancy and/or birth Awareness and anxiety about increased responsibility Fatigue and sleep deprivation Disappointments including the birth, spousal support, nursing, and the baby

10 Perinatal Mood Disorders Etiology Caused primarily by hormonal changes Changes in levels of estrogen and progesterone Life stressors, such as moving, illness, poor partner support, financial problems, and social isolation can negatively affect the woman s mental state Strong emotional, social, and physical support can greatly facilitate her recovery

11 Perinatal Mood Disorders Risk Factors Depression or anxiety during pregnancy Personal or family history of depression/anxiety Abrupt weaning Social isolation or poor support Child-care related stressors Stressful life events Mood changes while taking birth control pill or fertility medication, such as Clomid Thyroid dysfunction 50 to 80% risk if previous episode of PPD

12 Perinatal Mood Disorders Preterm Birth Risk Factors Risk factors in this population: mother s past psychiatric history previous perinatal loss psychosocial support including marital status severity of the infant s health status degree of worry & mom s coping skills rehospitalization after the initial stay (Miles et al, 2007; Garel et al, 2004; Mew et al,

13 Increased Psychiatric Comorbidity After Preterm Birth Correlation between PTSD symptoms and preterm delivery Increased PTSD symptoms in women who have had a traumatic birth experience. PTSD and depression are often comorbid Integrated care is needed between obstetricals mental health, and neonatology/pediatrics Will allow for the development of innovative assessment and treatment strategies to help the motherinfant dyad throughout the difficult first year and beyond after a preterm delivery. (Holditch-Davis et al, 2003; Rogal et al, 2007),

14 Perinatal Mood Disorders Depression

15 Perinatal Depression Symptoms that are common but may be different for general depression include: Feeling sad, irritable, hopeless, or overwhelmed Crying spells Guilty thoughts Feeling inadequate to take care of your baby Hypervigilance Scary thoughts Preoccupation with thoughts of death Lack of control Trouble concentrating Withdrawal from friends and family

16 Perinatal Mood Disorders Anxiety/Panic/OCD

17 Perinatal Anxiety/Panic Symptoms in Anxiety/ Panic include: Excessive worry Shortness of breath Racing heart Sweaty or cold clammy hands Feeling keyed up or on the edge Dizziness or light headed Chest tightness Scary thoughts

18 Perinatal Anxiety/Panic Some of these thoughts can become compulsive which means they are repetitive, Fear of going crazy or doing something uncontrolled Disoriented or that the world has become unreal Fears of contamination Fears that no one can take care of the baby like you can or that someone could do a much better job so she should just leave Fears of something bad happening to the baby or other family members

19 Perinatal Mood Disorder Bipolar Disorder

20 Risk of Recurrence During the Postpartum Period in Bipolar Disorder Consistently, the early postpartum period is a high risk time period for recurrence of bipolar and other psychiatric illnesses. Rates of relapse (usually a depressive episode) range from 60%-80%. Bipolar disorder is also associated with postpartum psychosis.

21 Pregnant Women with Bipolar Disorder Present a complex clinical challenge. Goal is to minimize the risk to the fetus, while limiting the impact of the psychiatric illness on the mother and her family. Decisions surrounding psychotropic use are difficult and associated with risks.

22 Postpartum Psychosis

23 Postpartum Psychosis A rare but devastating condition, with an estimated prevalence of 0.1%-0.2% (one to two per thousand) Women with Bipolar Disorder, risk is 100 times higher at 10% - 20% Psychiatric emergency & requires immediate treatment with a mood stabilizer & antipsychotic Onset usually 2-3 days postpartum Has a 5 % suicide & 4 % infanticide rate Risk for recurrent episode with subsequent pregnancy is 90%

24 Perinatal Mood Disorder ACOG President (2009) Dr. Gerald Joseph Made Postpartum Depression Is His Top Priority While in an ideal world, the newly delivered mother is at the peak of her reproductive health, with a beautiful child and, ideally, a supportive, loving family, this unfortunately is not always the case, Studies show that this is a most vulnerable time for our patients, especially those prone to depression or those with a history of depression. Complicating matters is that the new mother often can't bring herself to admit to any problems or negative emotions due to societal pressures, Instead of asking for help, she may feel guilty for not being 'grateful' or a 'good' mother.

25 Screening Instruments Edinburgh Postnatal Depression Scale (EPDS) Most commonly employed screening tool Beck Depression Inventory (BDI) Montgomery-Asberg Depression Rating Scale (MADRS) Hamilton rating Scale for Depression (HRSD) Nine Symptom Depression Checklist of the Patient Health Questionnaire (PHQ)

26 Edinburgh Postnatal Depression Scale (EPDS) 1,2 Ask patient how they have been feeling OVER THE LAST 7 DAYS, not just today To use calculator, click on appropriate answer and score appears in box when all questions completed 1. I have been able to laugh and see the funny side of things * 2. I have looked forward with enjoyment to things * 3. I have blamed myself unnecessarily when things went wrong 3 points - Yes, quite often 2 point - Sometimes 1 point - Hardly ever 4. I have been anxious or worried for no good reason * 5. I have felt scared or panicky for no very good reason Edinburgh Postnatal Depression Score = /30 6. Things have been getting on top of me 7. I have been so unhappy, I have had difficulty sleeping 8. I have felt sad and miserable 9. I have been so unhappy that I have been crying 10. The thought of harming myself has occurred to me * Questions 1, 2, and 4 are scored in reverse order (0-3)

27 Perinatal Mood Disorders Screening Posted on the Mombaby.org website Resources for Health Care Professionals OB Practice Algorithms Edinburgh (English) Edinburgh (Spanish) Treatment Algorithm

28 Treatment

29 Perinatal Mood Disorders One size does not fit all!! Treatment Critical for the well being of the woman,baby and family Effective treatments are readily available Psychotherapy Medication Management Other, alternative Skilled assessment and treatment by mental health professionals in perinatal psychiatry makes a difference in outcomes

30 Psychotherapy During Pregnancy Psychotherapy can be an important form of treatment of depression during pregnancy and the postpartum period. Good data available for Cognitive-Behavioral (CBT) and Interpersonal Psychotherapy during pregnancy. Requires weekly visits and motivation/compliance by the patient.

31 Perinatal Mood Disorders Treatment Treatment must include both psychological and/or biological interventions Psychotherapy (individual and/or group) Increased social supports Exercise, good nutrition, adequate sleep Antidepressant medications if appropriate Careful monitoring

32 Medications

33 Why is the Use of Antidepressants During Pregnancy Controversial? Antidepressants are often considered luxury medications. Antidepressants are often prescribed in patients that do not meet full diagnostic criteria for MDD or other psychiatric illness. Discontinuation of antidepressants during pregnancy has risks.

34 Risk of Relapse of Major Depression in Pregnancy High risk of depressive relapse following antidepressant discontinuation during pregnancy ( Cohen et al, JAMA, 2006). Of 201 women in the sample, 86 (43%) experienced a relapse of major depression during pregnancy. Women who discontinued medication relapsed more frequently (68% vs 26%) compared to women who maintained medication (hazard ratio, 5.0; 95% confidence interval, ; P<.001). Pregnancy is not "protective" with respect to risk of relapse of major depression

35 Adverse Fetal Outcomes associated with Depression during Pregnancy Adverse outcomes have been documented in women with depression during pregnancy Cohort studies demonstrate that the rate of depression per 1000 deliveries increased significantly from 2.73 in 1998 to 14.1 in 2005, (p<0.001). New cohort study shows that depressed women were significantly more likely to have: Cesarean delivery, preterm labor, anemia, diabetes, and preeclampsia or hypertension compared with women without depression. Worse fetal outcomes included fetal growth restriction, fetal abnormalities, fetal distress & death. Bansil et al, 2010 J Women s Health

36 Risks of Untreated Antenatal Depression Associated with low maternal weight gain, increased rates of preterm birth, low birth wt, increased smoking, ETOH and other substances Increased ambivalence about the pregnancy and overall worse health status. Prenatal exposure to maternal stress has consequences for the development of infant temperament. Children exposed to perinatal maternal depression have higher cortisol levels than infants of mothers who were not depressed, and this continues through adolescence. Maternal treatment of depression during pregnancy appears to help normalize infant cortisol levels.

37 Current Use of Antidepressants in the United States and During Pregnancy CDC: Antidepressant use skyrockets 400% in past 20 years reported Oct 2011 Antidepressants are the most frequently used medications by people ages Nearly one in four women ages 40 to 59 are taking antidepressants. Less than 1/2 of those antidepressants had seen a mental-health professional in the past year (Data are from the National Health and Nutrition Examination Surveys, N= 12,637 participants about prescription-drug use, antidepressant use, length of use, severity of depressive symptoms and contact with a health professional).

38 Pharmacotherapy in Pregnancy All psychotropics cross the placenta and none are approved by the FDA for use during pregnancy. Unethical to conduct randomized placebo controlled studies on medication safety in pregnant women. Thus, most information about the reproductive safety of drugs comes from case reports and retrospective studies. Prevalence of SSRI s in pregnancy is ~11%

39 Outcome data on Antidepressant Medications in pregnancy Intrauterine fetal death -No evidence Einarson et al. (2009) concluded no increased risk of Major Congenital Malformations (MCM) with SSRI use in the 1 st trimester. Growth impairment- Possible for fluoxetine: premature birth (14.3% late, 4.1% early, 5.9%, control), low birth weight and length No differences in cognitive function, verbal comprehension, expressive language, mood, arousability, activity levels distractibility, behavior problems, temperament (TCA, FLX) SSRI Discontinuation Syndrome vs Pulmonary HTN of Newborn

40 Antidepressants Tx in Pregnancy: Neonatal Outcomes SSRI withdrawal is possible but usually these are transient (restlessness, rigidity, tremor) Late SSRI exposure carries an overall risk ratio of 3.0 (95% CI, ) for a neonatal behavioral syndrome -Moses-Kolko et al, JAMA, 2005 Warburton et al. (2010) concluded that when controlled for maternal mental illness severity reducing exposure to SSRI in the last 2 weeks before delivery did not have a significant clinical effect on improving neonatal health

41 Primary Pulmonary Hypertension of the Newborn 2006, case control study showed SSRI exposure after 20 weeks gestation increased risk (4-5x higher) of PPHN with absolute risk of <1%. (N. England J. Med, 2006) Recent studies show increased risk of PPHN with multiple other risk factors and absolute low risk with SSRI exposure C-section, high maternal BMI, AA or Asian heritage Study concluded that large BMI and C-section had greater risk than SSRI exposure. (Pediatrics, 2007) Swedish Medical Birth Register 3 rd trimester exposure showed increased risk of 2.4 (Pharmacoepidemiology Drug Safety, 2008)

42 Paroxetine and Pregnancy In 2005, FDA began investigated risks associated with antidepressant use in pregnant women Results of Investigation: Infants born to women taking Paroxetine (Paxil) may be at double the risk for cardiovascular birth defects (4%) compared to other antidepressants (2%) Sept. 2005, U.S health officials warned against the use of Paxil in the first trimester due to potential birth defects in infants, though relationship may be incidental Further research is necessary, involving adequate, well-controlled studies to prove the effects of Paxil on the fetus

43 Risk of Autism with SSRI Use Croen LA, Grether JK, Yoshida CK, Odouli R, Hendrick V. Antidepressant Use During Pregnancy and Childhood Autism Spectrum Disorders. Arch Gen Psychiatry Jul 4. [Epub ahead of print] PMID:

44 What to do? SSRIs (especially fluoxetine and sertraline) and TCAs relatively safe even during first trimester SSRIs (especially sertraline) and TCAs relatively safe in breast-feeding. (Risk of fluoxetine accumulation in breastmilk and TCA-induced seizures Avoid Paroxetine (unless risk/benefit analysis dictates otherwise) Insufficient information about newer antidepressants (SNRI s), and trazodone Bupropion: FDA risk category changed from B to C

45 Psychotropics Used in the Treatment of Bipolar Disorder Lithium Anticonvulsants-- Older anticonvulsants have 2x higher risk of major birth defects Valproic Acid Carbamazepine Other (newer) anticonvulsants Lamotrigine Antipsychotics

46 Lithium vs Anticonvulsants LITHIUM Ebstein s cardiac malformation 0.05% risk vs 0.1% base rate Neonatal hypothyroidism Diabetes Insipidus (rare) Polyhydraminos (rare) FDA Pregnancy Category D VALPROIC ACID Spina bifida (1%-5% risk) Structural defects of the heart, limbs and face FDA Pregnancy Class D CARBAMAZEPINE Spina bifida (1% risk) Structural defects of the face (dysmorphic facies) Secreted in breast milk FDA Pregnancy Category C

47 Newer Anticonvulsants Limited data is available with the newer agents such as gabapentin, lamotrigine, oxcarbazepine and topiramate. Lamotrigine has good safety record to date. No increased risk of birth defects. The benzodiazepines may have increased risk of cleft lip and palate (0.7%) All are secreted in breast milk FDA pregnancy class C

48 Antipsychotics Teratogenic risks are probably low with the traditional neuroleptics (Haloperidol is safest). There is inadequate information available to ascertain risk of newer atypical antipsychotics, although safety profile is promising to date. Quetiapine has lowest transmission in breast milk (Stowe et al). All are secreted in breast milk FDA pregnancy class C (except for clozaril)

49 Conclusions: Treatment Perinatal psychiatric illness requires immediate intervention. Coordination of care between OB-GYN and trained mental health professionals is critical. Antidepressant medications can be safely used during pregnancy and lactation Assess risk of untreated illness versus greater risk of exposure. Chronic mental illness must be treated during pregnancy to prevent severe PPD. Patients with preexisting psychosis must be treated as a high risk pregnancy during and after delivery.

50 UNC Center for Women s Mood Disorders: Perinatal Psychiatry Program Clinical and Research Program that provides assessment, treatment and support for women in the perinatal period Collaboration of doctors, nurses, midwives, therapists, & social workers

51 Upcoming Programs April 27 th, 2013 Innovative Care of Perinatal Mood Disorders: Clinical Training Program 8:30a-2:30p Community Forum Katherine Stone~ Postpartum Progress 3:30-4:30p REGISTRATION:

52 References Andrade SE, McPhillips H, Loren D, Raebel MA, et al. Antidepressant medication use and risk of persistent pulmonary hypertension of the newborn. Pharmacoepidemiol Drug Saf Mar;18(3): Gavin N, Gaynes B, Lohr K, Meltzer-Brody S. et al Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 106: Cohen L, Altshuler L, Harlow B, Nonacs R Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 295(5): Chambers C, Hernandez-Diaz S, VanMarter L, Werler M Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med. 354(6): Delatte R, Meltzer-Brody S, Cao H, Menard K Universal Screening for Postpartum Depression: An Inquiry into Provider Attitudes and Practice American Journal of Obstetrics and Gynecology, 200(5):e63-4. Einarson A, Choi J, Koren G 2009 Incidence of major malformations in infants following antidepressant exposure in pregnancy: results of a large prospective cohort study. Canadian Journal of Psych, 54(4): McKenna K, Koren G, Tetelbaum M, Wilton L et al Pregnancy outcome of women using atypical antipsychotic drugs: A prospective comparative study. J Clin Psychiatry: 66:

53 References Meltzer-Brody S, Payne J, Rubinow D Postpartum Depression: Evolving Etiology & Treatment Considerations, Current Psych, 7(5): Meltzer-Brody S, Hartmann K, Miller W, Scott J A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecology. Obstet Gynecol.104(4): Oberlander TF, Warburton W, Misri S et al Neonatal Outcomes After Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants and Maternal Depression Using Population-Based Linked Health Data. Arch General Psychiatry :63: Sit D, Rothschild A, Wisner K A Review of Postpartum Psychosis, Journal of Women s Health: 15(4): Viguera A & Cohen L The course and management of bipolar disorder during pregnancy. Psychopharmacology Bulletin 34: Viguera A, Cohen L et al Managing bipolar disorder during pregnancy: weighing the risks and benefits. Can J Psychiatry Jun;47(5): Webb R, Abel K, et al Mortality in Offspring of Parents with Psychotic Disorders: A Critical Review and Meta-Analysis, Am J Psych:162: Yonkers K, Wisner K, Stowe Z, et al Management of Bipolar Disorder during pregnancy and the postpartum period. Am J Psychiatry:161:

54 References Einarson A, Choi J, Einarson TR, Koren G: Incidence of major malformations in infants following antidepressent exposure in pregancy: results of a large perspective cohort study. Can J Psychiatry 2009; 54: Warburton W, Hertzman C, Oberlander TF: A register study of the impact of stopping third trimester selective serotonin reuptake inhibitor exposure on neonatal health. Acta Psychiatr Scand 2010; 121: Robinson GE,, Psychopharmacology in Pregancy and Postpartum; FOCUS The journal of Lifelong Learning in Psychiatry (2012) volx p1-12.