POSTPARTUM DEPRESSION. Shanna M. Combs, MD, FACOG

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1 POSTPARTUM DEPRESSION Shanna M. Combs, MD, FACOG

2 I can hear the breathing of my sleeping newborn son in his bassinet next to the bed.i feel like I am playing hide-and-seek from my own life, except that I just want to hide and never be found. I want to escape my body. I don t recognize it anymore. I have lost my resemblance to my former self. I can t laugh, enjoy food, sleep, concentrate on work, or even carry on a conversation. I don t know how to go on feeling like this: the emptiness, the endless loneliness. Who am I? I can t go on. -Marie Osmond, Behind the Smile: My Journey out of Postpartum Depression

3 Postpartum Depression Approximately 15% of women will experience clinically significant depression during the postpartum period Postpartum depression and anxiety disorders can begin immediately after birth and up to a year after delivery

4 Postpartum Depression Despite multiple contacts with health care professionals, postpartum depression most often is undiagnosed and therefore untreated People who interact with postpartum women have an opportunity to try and identify these women Delay in diagnosis is the biggest contributing factor in the length of the postpartum depression

5 Postpartum Depression Untreated postpartum depression poses serious and long term health risks to mother and child Suicide risk of postpartum depression Suicide rate is increased 70 fold Need to assess suicidality Children of mothers with postpartum depression are at risk for poor growth as well as attachment, cognitive, and behavioral disturbances

6 Postpartum Depression as a Public Health Problem Depression is the leading cause of disease-related disability among women Over 400,000 women suffer from perinatal depression every year Depression is a communicable disease between mother and child Serious and lasting effects on child health and family functioning

7 Postpartum Depression The most common complication of childbirth is depression

8 BABY BLUES

9 Baby Blues Usually develops 3-5 days after delivery Hallmark is emotional reactivity Occurs in 70-80% of all new mothers Normal reaction to hormonal changes, stress of having a baby, and lack of sleep Does not require treatment Resolves within 1-2 weeks

10 POSTPARTUM DEPRESSION

11 Postpartum Depression Prevalence 15% of postpartum women = 1 out of 7 mew mothers Higher risk groups Young Low socioeconomic status Poor social support Family history of mood disorders Personal past history of depression 25-40% risk of postpartum depression Prior postpartum depression 30-50% recurrence risk

12 Risk Factors for Postpartum Depression Depression during pregnancy is the best predictor of postpartum depression History of depression Prenatal anxiety Family history of depression Obstetrical complications at delivery Complicated pregnancy Neonatal loss or illness Difficult infant temperament

13 Risk Factors for Postpartum Depression Ambivalence about pregnancy Marital conflict Lack of social support Number of children Recent loss History of sexual abuse Low self esteem Recent stressful life events Breastfeeding difficulties

14 Presentation of Postpartum Depression Usually develops slowly over the first 3 months, most often beginning within the first 4 weeks, though some women have a more acute onset More persistent than baby blues, and may affect mom s ability to care for the baby Signs and symptoms are the same for major depression Depressed mood Irritability Loss of interest and appetite Fatigue Insomnia Often complain of being physically and emotionally exhausted, but unable to sleep

15 Presentation of Postpartum Depression Classic symptoms of depression with some typical features Often express concerns about her ability to care for her baby or anxiety about the baby s well-being Anxiety symptoms are common Women are often unable to sleep even when given the opportunity

16 Presentation of Postpartum Depression Frequently have intrusive, obsessive ruminations, usually focused on the baby, often violent in nature One study showed 50% of women with postpartum depression had these thoughts These thoughts do not increase harm to the baby, but must be distinguished from actual psychosis

17 Duration of Postpartum Depression Untreated depression often persists for months to years after childbirth, with lingering effects on physical and psychological functioning following recovery 25-50% of women have episodes lasting 7 months The most significant factor in the duration of postpartum depression is delay in receiving treatment

18 Risks of Untreated Postpartum Depression To mother: Diminished capacity to care for self and baby Substance abuse Increased healthcare costs Stressful impact on relationship between woman and her partner Suicidal thoughts more likely to be accompanied by homicidal thoughts Kindling phenomenon: Development of a chronic low grade depression with more susceptibility to repeated episodes of major depressive disorder

19 Risks of Untreated Postpartum Depression To Child: Poor attachment, bonding, and less nurturing maternal interaction Poor weight gain Sleep problems Less likely to breastfeed Less likely to receive preventative healthcare and child safety practices Poor cognitive, language, and motor development Behavioral problems Future depression and anxiety disorders Risk of future medical illnesses: Maternal depression is an Adverse Childhood Experience

20 Impact of Postpartum Depression Diminished maternal ability to function in many roles particularly the core parenting role has long lasting adverse effects on child s health, cognitive and emotional development, and ongoing risk to mother s emotional physical and social well-being Treatment for mother is early intervention for the child

21 POSTPARTUM PSYCHOSIS

22 Postpartum Psychosis Typical onset is within 2 weeks after delivery, first symptoms often within hours Earliest signs are restlessness, irritability, and insomnia Often very labile in presentation Often looks organic with a lot of confusion and disorientation Most often consistent with mania or a mixed state

23 Postpartum Psychosis Includes agitation, paranoia, delusions, disorganized thinking and impulsivity Thoughts of harming the baby are frequently driven by delusions Child must be saved from harm Child is malevolent, dangerous, has special powers, is Satan or God Rates of infanticide associated with untreated postpartum psychosis have been estimated to be as high as 4 %

24 Postpartum Psychosis Warrants emergency level care and usually requires inpatient hospitalization Medication treatment is necessary

25 SUICIDE IN THE POSTPARTUM PERIOD

26 Suicide in the Postpartum Period Any indication of self-harm or suicidal ideation should be taken seriously Suicide risk in the first postnatal year is estimated to be increased by 70 fold

27 SCREENING AND TREATMENT

28 Despite multiple contacts with medical professionals following the birth of a child, postpartum depression most often goes undiagnosed. All women should be considered at risk for postpartum depression. Implement Universal Screening.

29 Screening Edinburgh Postnatal Depression Scale 10 question survey Available in multiple languages Score 0-30 >10: possible depression Question 10 addresses suicidality Always evaluate

30 Edinburgh Postnatal Depression Scale In the past 7 days: 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 4. I have been anxious or worried for no good reason 5. I have felt scared or panicky for no very good reason

31 Edinburgh Postnatal Depression Scale In the past 7 days: 6. Things have been getting on top of me 7. I have been so unhappy that I have had difficulty sleeping 8. I have felt sad or miserable 9. I have been so unhappy that I have been crying 10. The thought of harming myself has occurred to me

32 Treatment Options Medications Anti-depressants, usually SSRI Sertraline preferred due to minimal reported side effects in infants, especially for breast-feeding mothers Therapy Interpersonal psychotherapy Cognitive behavioral therapy Behavioral Activation

33 PATIENT EDUCATION

34 Need for Patient Education Lack of knowledge about postpartum depression, treatment options, and community resources is common in postpartum women and their families, and frequently leads to a delay in seeking treatment Delay in treatment for postpartum depression results in a longer illness Information about postpartum depression should be provided to women in the prenatal period, soon after delivery, and further encounters with healthcare providers in the first postpartum year

35 What do women need to talk about? Negative childbirth experiences-especially with trauma Concerns about their infants-their temperaments, health issues Interactions with their babies and caring for them How this time differs from their expectations Feelings of isolation

36 What do women need to talk about? Loss- Prior employment role Closeness with spouse or older child Feelings of frustration, inadequacy in mothering Breastfeeding difficulties Loss of care and attention received during pregnancy Ambivalence about returning to work and sense of loss when that is a necessity

37 Patient Resources Postpartum Support International Mental Health America of Greater Tarrant County JPS 10 th floor MHMR Crisis Line

38 References Screening for perinatal depression. Committee Opinion No American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125: Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ. Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol 2011;118: Siu AL and the U.S. Preventive Services Task Force (USPSTF). Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315(4): Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 2005;106: Williams Obstetrics, 22 nd edition Roy-Byrne, PP. Postpartum blues and unipolar depression: Epidemiology, clinical features, assessment, and diagnosis. Rob-Byrne, PP. Postpartum blues and unipolar depression: Prevention and treatment.