PERINATAL MOOD DISORDERS: CLINICAL PEARLS OF COUNSELING
Alisa Burpee, PhD
September 2019
DISCLOSURES
Dr. Burpee maintains a private practice in Seattle, WA. She has no financial relationships with commercial interests.
LEARNING OBJECTIVES
1. Distinguish between normative and non-normative distress
2. Define perinatal mood and anxiety disorders (PMADs) and prevalence rates
3. Identify risk factors for PMADs
4. Increase ability to accurately and effectively screen and refer
PREGNANCY
A complex experience encompassing the following shifts:
Physical
Hormonal
CognitiveMaternal preoccupation
Emotional
WHAT IS A PERINATAL MOOD & ANXIETY DISORDER (PMAD)?
Range of distress:
85% of women experience significant distress postpartum
80% experience the “baby blues” or postpartum reactivity If persists beyond 2-3 wks, reassess for PMD
PMAD occurs in 20% of childbearing women Often depression and anxiety coexist Commonly becomes evident 2-3 mos after delivery
Prevalence rates: Postpartum Depression 7-15% Generalized Anxiety Disorder 7-10% Obsessive Compulsive Disorder 5% Panic Disorder 1-5% Post-Traumatic Stress Disorder 6-10% Postpartum Psychosis 0.01-0.02%
20% PMAD
80% Baby Blues
85%Distress
INTRUSIVE THOUGHTS
Involved in each of the PMADs
90-100% of new parents experience unwanted thoughtsUsually related to harm
AvoidanceMay not report due to fear of being deemed “unfit”
Ego-dystonic No increased risk of actual harm
“I don’t know what’s best for my baby”
“Everyone is better at this than me”
“My baby will… have a defect, fail to thrive, be obese”
“I shouldn’t have had this baby”
IMPLICATIONS OF UNTREATED MATERNAL MENTAL ILLNESSChronicity
Increased risk of:Preeclampsia
Preterm labor
Disengagement from prenatal care and self-care
Maladaptive coping
Increased severity
Social withdrawal
Suicide
For infant: Low birth weight
Feeding and sleep challenges
Difficult temperament
Attachment difficulties
Increased cortisol, excessive fear, difficulty regulating emotions
ETIOLOGY/RISK FACTORSBiological Heredity
Hormonal
Poor nutrition
Poor sleep
Psychological Cognitive
Perfectionism
Introversion
Interpersonal sensitivity
History of abuse
Pregnancy history
Social and Environmental Culture
Finances and employment
Responsibility
Support network Martial strain
Housing
Poverty
Age
Mode of delivery
Breastfeeding
SCREENING Follow up question:“Is there anything about what you are experiencing right now that concerns you?” Impact on daily functioning
Sample Script:
Emotional distress is very common during and after pregnancy. It’s hard to predict who might struggle.
Paying attention to risk factors can help us stay alert to any problems that arise.
Let me know if you are bothered by any thoughts or feelings (e.g., sadness, worry, anger)
These might be normal, but they can also be symptoms of a mental health problem.
The earlier we address them, the faster we can help you feel better.
SCREENING TOOLS
1. Two Question Screen
2. PHQ9
3. Edinburgh
4. GAD
5. YBOCS
Limitations: follow up needed for comprehensive assessment and diagnosis.
SCENARIO #1
A mother presents 8 days postpartum confiding that she is overwhelmed and exhausted. She said she has moments of feeling proud and believing she is doing a good job followed by feeling like a failure. She indicates she hasn’t really felt like eating and hasn’t had much time to take care of herself The care team has recently discovered her daughter has ankyloglossia “tongue-tie” which is causing difficulty with feeding. She also reported she has been short with her husband on multiple
occasions.
SCENARIO #2
A 28yo married woman is engaging in her first prenatal visit at about 10 weeks. She wants to know if the wine she sipped at her husband’s work event several weeks ago could cause a birth defect. She asks many questions about if and how it is safe for
her to interact with her cats. She also asks diligent questions about nutritional recommendations and foods she should avoid. She confides in you that she is
spending a lot of time preoccupied with these considerations. She is also worried her stress about the pregnancy is affecting her child negatively. The visit concludes with a diagnosis of a yeast infection and prescribed antibiotics. She expresses reluctance to take the medication for fear of harming her infant even after you have realistically
discussed the level of risk.
TAKE AWAYS
A large majority of pregnant and new mothers will experience some distress (85%)
A significant portion (80%) will experience “baby blues” which arises approx. 1 wkpostpartum and resolves in 2-3 wks
If distress and symptoms last beyond this timeframe, discuss and screen for a PMAD20% of childbearing women meet criteria for a PMAD
Effective screening and early intervention can effectively manage symptoms and reduce negative impacts to the well-being of mom and baby
QUESTIONS
REFERENCES
Manzella, Christiane. (2019). Maternal mental health intensive online: Perinatal mood and anxiety disorders. Online Training. Seleni.org/maternal mental health training.
American Psychiatric Association. (2017). Diagnostic & Statistical Manual of Mental Disorders 5, American Psychiatric Publishing
Swedish Perinatal Center. Retrieved from: https://www.swedish.org/locations/center-for-perinatal-bonding-and-support
SPECIAL ISSUES
Dads
Fertility
Teen Pregnancy
Low income and minorities
LGBTQ
Immigrants and refugees
WHEN TO REFER FOR RX
Anytime history of bipolar, schizophrenia, psychosis, MDD, OCD
Symptoms not alleviated by psychotherapy