PARTING WITH POSTPARTUM DEPRESSION JYOTI SACHDEVA, MD

PARTING WITH POSTPARTUM DEPRESSION JYOTI SACHDEVA, MD

INTRODUCTION Women affected with mood disorders disproportionately across the lifespan 20% adult females will experience a depressive episode at some point Depression risk is double in women compared to men Highest risk during reproductive years 1% women have Bipolar disorder Mood disorders affect quality of life, ability to fulfill roles at work, as parent, spouse, worsen medical outcomes

Diagnosis of Depressive episode Depressed mood Anhedonia (lack of pleasure) Psychomotor slowing, agitation Sleep disturbance (increased or decreased) Fatigue, poor energy Loss of or increased appetite Concentration difficulties poor self esteem Excessive guilt/ worthlessness Suicidal thoughts / recurrent thoughts of death Symptoms present most of the day, nearly every day over 2 wks much distress / functional impairment Not due to medication / substance / GMC Major depression-5 or more. Minor-2-4 One of the symptoms must be depressed mood or Anhedonia

Diagnosis of Manic Episode 3 of following- Inflated self esteem or grandiosity Decreased need for sleep More talkative than usual(pressured speech) Distractibility Increased goal directed activity (agitation) Excessive involvement in pleasurable activities which lead to painful consequences (spending sprees) Impaired functioning Not due to substance or GMC

Mood Disorders in women-general Considerations After an episode of depression risk for another episode is increased by 50% After 2 episodes risk of recurrence is increased by 80% After 3 episodes maintenance lifetime antidepressant therapy should be considered Major depression (unipolar) is most common type of depression Important to differentiate unipolar from bipolar depression (elicit h/o mania, hypomania) because treatment is very different

PERINATAL MOOD DISORDERS Mood disorders in pregnancy and postpartum period are common Prevalence is similar for pregnant and non pregnant women Higher risk in 2 nd and 3 rd trimester Under recognized and undertreated Profound implications- Obstetric and neonatal complications Impaired mother-infant interactions Maternal suicide Infanticide Pregnancy is NOT protective

Myths of Pregnancy/ Post partum Pregnancy and Postpartum is time of physiological and psychological change New mothers don t realize how much will change with their life Fathers and families are not prepared for change Hormonal changes/ nursing/ physical changes Sleep deprivation Role transitions, child care, expectations Loss of freedom and control

Social support is essential to ensure the mental health of women, children and their families during pregnancy and the postpartum period PSI Statement on Social support June 2001

Postpartum mood disorders Different types of Mood Symptoms in Postpartum period- Baby Blues Postpartum Depression Postpartum Bipolar disorder Postpartum Psychosis

Case 1- A women gives birth to a full term, healthy, wanted baby. For the first 3 days, she is tired but happy, on 4thday, husband remarks that house is a mess, She bursts into tears, saying how dare you criticize me at a time like this. Later that evening she starts sobbing after listening to a love song on the radio, she is surprised by her reaction. Over the next few days, she continues to cry often and react strongly to things that would normally be minor, although overall she remains happy about her baby. She wonders what is happening to her.

BABY BLUES 50-80% new mothers experience postpartum blues 20% women with the blues proceed to develop postpartum depression, thus the symptom should be monitored for progression Present in all cultures Symptoms begin 3-4 days after delivery Peak between 5-7 days and resolve by day 12

BABY BLUES Risk factors-stressful life events Interpersonal difficulties Work stress Infant with health problems Prior h/o depression Family h/o depression Depression during pregnancy h/o PMDD Biological attachment hypothesis-subjective expression of postpartum activation of a biological system that promotes mother-infant attachment Oxytocin plays a central role

BABY BLUES PHENOMENOLOGY Crying Crying often for feelings other than sadness Increased sensitivity to minor rebuffs Exaggerated empathy Still feel happy about baby Irritability May be preceded by emotional blunting for day 1-2 Central feature is marked mood lability as opposed to depressed or anhedonic mood (typical of MDD) TREATMENT-reassurance, validation, support

Case 2 Stacy is a 36 year old married professional who presents 4 wks after the birth of her first child. She has h/o prior anxiety and depression and was asymptomatic during pregnancy. Baby is full term, healthy and she is nursing 100% of time. She presents with persistent sad mood and severe anxiety, obsessive worry about health and well being of baby and inability to sleep. She is very disturbed by images of herself harming the baby, she worries that she may miss a step and inadvertently cause the baby to fall. She is getting so anxious that she is keeping all windows closed.

POSTPARTUM DEPRESSION Postpartum period is a time of increased vulnerability for depression Post Partum Depression is most Common complication of childbearing Prevalence rates of 13-19% within the first 3 months of delivery Symptoms often under recognized as confused with sleep deprivation and fatigue of a new mother and / or baby blues Societal expectation is that this is time of joy Mothers feel guilty expressing emotional pain at this time Appropriate treatment is not offered for fear of effect on new born Depression and anxiety can occur at anytime in pregnancy or first year post partum PMAD is new term replacing PPD

Symptoms of Post partum depression Symptoms consistent with major depressive episode Marked anxiety, tendency to ruminate, obsess over the health and wellbeing of baby Other presentations-despondent, sluggish, exhausted Unexplained physical symptoms Lack of interest in sex Uninterested in pregnancy or activities of the infant Guilt and shame Feelings of worthlessness, hopelessness Concerns about their capacity to be an adequate mother Common to have disturbing aggressive obsessional thoughts although they have no intention of harming the baby (ego dystonic)

RISK FACTORS FOR POST PARTUM DEPRESSION Prior psychiatric history -Without a prior psychiatric history risk of developing PPD is 10% -With a history of Major depression, the risk of postpartum depression increases to 25% -With a history of post partum depression, risk increases to 50% Depression during pregnancy Family psychiatric history Unmarried status Poor social support

RISK FACTORS FOR POST PARTUM DEPRESSION Unplanned pregnancy Marital conflict Bereavement Preterm birth, complicated pregnancy or delivery Primi parity Advanced maternal age Bipolar disorder h/o PMS, PMDD

Screening for perinatal depression United States Task force on preventive services recommends screening when coupled with system changes that increase treatment availability ACOG-insufficient data to recommend routine screening Benefit to screening high risk groups-women with h/o depression or who acknowledge stress Edinburgh Postnatal depression scale (EPDS)-for early identification of symptoms in perinatal women A score of 12 or greater in pregnancy or greater than 10 in postpartum period indicates likelihood of depression but not severity

Bipolar Disorder in Pregnancy and Postpartum Period Prevalence is about 1% May present as postpartum psychosis Symptoms may be misdiagnosed as unipolar depression Risk of relapse is tightly linked with medication noncompliance Number of agents used for Bipolar disorder are teratogens Management of Bipolar disorder during pregnancy and postpartum is complicated so Psychiatric involvement is a must

Bipolar Disorder in Pregnancy and Postpartum Period Women with Bipolar disorder are at high risk of illness relapse during pregnancy and postpartum Pregnancy offers no protection for Bipolar disorder relapse 80-100% women who discontinue mood stabilizer medication during pregnancy will experience relapse soon after discontinuation; these rates 2-3 x higher than pregnant bipolar women who continue medication in pregnancy Relapses are more likely to be depressed or mixed episodes (instead of manic)

Bipolar Disorder in Pregnancy and Postpartum Period In pregnant and non pregnant women who discontinued lithium, risk of relapse in past partum period was 3 times higher compared to non pregnant women Rapid and severe relapse or severe, rapid onset of first episode of illness in post partum may help differentiate bipolar depression from unipolar depression SCREENING MDQ-13 13 point questionnaire that screen for h/o manic episode

Treatment of PPD Mild Reassurance Supportive therapy Group therapy Psychoeducation Interpersonal therapy Cognitive behavioral therapy

TREATMENT OF PPD Moderate to severe depression- antidepressants are indicated Informed consent and involvement of family / significant other in treatment is important Individualized risk benefit considerations One important consideration is does the mother plan to nurse? Drugs where relative infant dose is <10% maternal plasma level are considered safe for lactating mothers

Alternative Somatic Treatments ECT- Suicidality Psychotic depression Inability to tolerate medications Trans cranial magnetic stimulation-emerging as an effective noninvasive treatment but not widely available Dietary calcium Exercise/ yoga therapy Massage therapy Bright light therapy OFA Estrogen-insufficient data to support, risk of thromboembolic events

CASE 3 A highly publicized California case-23 year old mother killed her 6 wk old son by first throwing him in traffic, hitting him with a blunt object and then running over him with the family car For 2 wks Sheryl Massip s family recognized something was wrong with her. 5 days before she killed her child, her husband sent her away to her mother s home to spend a night, to get some rest because they thought that would solve the problem. She came back but they sent her away again. On 27 th of April 1987, Monday before she killed her child, she came home from spending the night with her mother and she sent to the doctor and said- Doctor, what s wrong with me? I am hallucinating, I can t sleep. Something is wrong with me. Help me. He looked at her and said, Oh, you are just suffering from baby blues,

CASE 3 contd After her arrest, Massip continued to manifest severely disorganized thinking, telling investigators that a black object, which wasn t really a person with orange hair and white gloves had kidnapped her baby. She reported hearing voices telling her put him out of his misery. Baby had been colicky, would not stop vomiting and cried 15-18 hours per day She was found not guilty on insanity grounds (diagnosed with postpartum psychosis)

POSTPARTUM PSYCHOSIS 1-2 women per 1000 births Rate essentially unchanged over time or cultures etiologic association between psychiatric disorder and childbirth rather than psychosocial factors For all women chance of being admitted to a psychiatric hospital during first 4 wks postpartum is increased about 18 times relative to chances of same during pregnancy (Paffenbarger 1982) Primiparas and women with h/o Bipolar disorder are at much higher risk

PHENOMENOLOGY Onset between day 3 and 14 of postpartum period Rare for a case to develop in first 3 days of postpartum period Episodes tend to be severe Characterized by a mixture of delirium and psychosis with confusion, prominent delusions and hallucinations. Mostly meet criteria for an affective episode either depressive or manic Only 5% are thought to be schizophrenia / other disease

PHENOMENOLOGY Studies show that majority postpartum psychoses are Bipolar affective episodes Mood stabilizers taken in 3 rd trimester and postpartum period (specifically lithium )have been shown to be protective for postpartum psychos in women with h/o same When comparing postpartum with nonpostpartum psychoses- perplexity a subjective experience of confusion was evident in 50%of postpartum group and only 5% of control group PP-more hallucinations, delusions, emotional lability, homicidal ideation, disorganized speech, tends to be more severe

DIFFERENTIAL DIAGNOSIS Imperative to r/o Bipolar disorder in case of PPeliciting prior h/o mania, family h/o Bipolar illness D/D-Schizophrenia,schizoaffective disorderconfirmed by longitudinal course of illness, past history, symptoms r/o Delirium-Toxic, metabolic, neurologic causes need to be ruled out Tumor, TBI, CNS infections (including syphilis, HIV), CVA, Seizures and postictal states, hepatic and electrolyte disturbances, diabetic conditions, toxic exposures, anoxia and vitamin deficiencies

CONSEQUENCES Potential risks for patient, infant and family Poor care of baby Suicide Infanticide-1-3 in 50, 000 births Risk of subsequent episodes Many women with h/o PP and /or infanticide commit suicide

RISK FACTORS Primiparas H/o Bipolar disorder h/o postpartum psychosis Marital conflict Sleep deprivation Inadequate social support

TREATMENT PPP is a psychiatric emergency Timely evaluation and management is essential Aggressive inpatient involuntary treatment is required Combination of antipsychotics, mood stabilizers may be necessary ECT is also a good treatment choice

TAKE HOME MESSAGE Pregnant and Postpartum women are specially vulnerable to mood and anxiety symptoms It is important to recognize and treat these symptoms It is important to be vigilant for these symptoms in women at risk Untreated symptoms can have dire consequences With appropriate treatment symptoms can be easily treated Discuss concerns with obstetrician/ Primary physician/ Psychiatrist

Help is available!! Call 513-475-8248 Schedule an appointment-dr. Jyoti Sachdeva, MD for evaluation, consultation, individualized treatment plan I offer appropriate pharmacotherapy, Supportive, Cognitive behavioral, Insight oriented Psychotherapy, wellness education and Life Coaching UC Women's health Center 7675Wellness Way 4 th Floor Westchester, OH 45069

Other Resoucres- Linder Center of Hope-513-536-HOPE (4673) Central Community Health Board (CCHB)-513-559-2097 Greater Cincinnati Behavioral Health services- 513-354-7000 Central Clinic-513-558-5801 Talbert House-513-221-HELP(4357).

It takes a whole village to raise a child but we need to remember that it was the mother who had the baby, and she needs our help too. Jane Honikman Founder Postpartum Support International