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Postpartum MoodDisorders
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Primary Objectives
Review the range of pregnancy related
mood disorders
Discuss the risk factors for developing a
pregnancy related disorder
Identify screening strategies
Review treatment options during pregnancy
and postpartum
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Secondary Objectives
Review the prevalence of mood disorders
in women
Investigate the etiology of pregnancy
related mood disorders
Discuss the familial implications of these
illnesses
Discuss prevention strategies
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Major Depressive Disorder
Leading cause of disability
Prevalence of 5-9%
Lifetime risk of 10-25%
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Peripartum Depressive Disorders
Antepartum Depression
Postpartum Blues
Postpartum Depression (PPD)
Postpartum Psychosis (PPP)
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Antepartum Depression
Symptoms often seen in non-depressedpregnant women Sleep and appetite disturbance
Diminished libido
Low energy
Pregnancy related conditions are associatedwith depressive symptoms Anemia
Gestational diabetes
Thyroid dysfunction
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Postpartum Blues
Aka baby blues
Characteristics:
Mild mood swings Irritability
Anxiety
Decreased concentration Insomnia
Tearfulness
Crying spells
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Postpartum Blues
Occur within 2-3 days of delivery
Symptoms peak on 4th or 5th postpartum day
Symptoms resolve within 2 weeks
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Postpartum Depression
Same DSM IV criteria as for non-pregnancyrelated depression
Symptoms usually begin in initial 12months after delivery
Symptoms often seen as normal for newmothers caring for a newborn
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Symptoms of PPD
Change in somatic function
Significant anxiety
Intense irritability and anger
Feelings of guilt
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Symptoms of PPD
Sense of being overwhelmed
Unable to care for baby
Feelings of inadequacy
Not bonding with the baby
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Postpartum Psychosis
Usually a manifestation of bipolar disorder
Typically presents within 2 weeks of
delivery
May develop few months after birth as
delusional depression
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Signs and Symptoms of PPP
Severe insomnia
Rapid mood swings
Anxiety
Psychomotor restlessness
Delusions and hallucinations
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Fetal Implications
Increased rate of:
Preterm birth
Low birth weight
Small head circumference
Low APGAR scores
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Familial Implications
Postnatal depression in men
Interference with maternal-infant bonding,
increases moms sense of shame and guilt
Influences infant development
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Familial Implications
Negative interactive patterns with infant
Children exposed to maternal psychiatric
illness have:
Higher incidence of conduct disorders
Inappropriate aggression
Cognitive and attention deficits
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Prevalence
Postpartum blues occur in 4080% of
women
PPD affects 1030% of women
Postpartum psychosis is rare
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Antepartum Depression
Prevalence 10% of all pregnancies
Increased risk for women with history of
affective illnesses
Relapses most common in the first trimester
1/3 of all cases represent first episode of
depression
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Prevalence in Active Duty
Positive depression screen
Antepartum
Postpartum
Suicide ideation rate
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Risk Factors for PPB
History of depression or premenstrual moodchanges
Depressive symptoms during pregnancy
Family history of depression
Concern about child care
Psychosocial impairment
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PPD Risk Factors
Personal history of depression
Family psychiatric history
Marital conflict
Lack of perceived social support
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PPD Risk Factors
Lack of emotional & financial support from
partner
Living without a partner
Unplanned pregnancy
Previous miscarriage
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PPD Risk Factors
Having contemplated terminating
current pregnancy
Poor relationship with own mother
Not breastfeeding
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PPD Risk Factors
Unemployment in the mother
Lifetime history of depression in partner
Stressful life events in previous 12 months
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PPD Risk Factors
Child care related stressors
Sick leave during pregnancy
High number of prenatal visits
Congenitally malformed infant
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Risk Factors for PPP
History of bipolar disorder
History of psychosis prior to pregnancy
Family history of psychosis
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Co-morbidities
Decreased weight gain during pregnancy
Increased rate of tobacco use
Increased rate of alcohol and illicit drug use
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Etiology
No clear etiology
Possibly due to combination of:
Genetic susceptibility
Hormonal changes
Major life events
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Etiology
Investigators have examined the role of:
Estrogen
Progesterone Thyroid hormone
Testosterone
Cholesterol
Corticotropin-relasing hormone
Cortisol
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Screening - Overview
Important to identify proper timing of
screening
Avenues include both informal and formal
techniques
Various formal screening tools available
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Screening - Timing
Antepartum visits
During hospital stay
Postpartum visits
Well child visits
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Screening - Tools
Becks Depression Inventory (PDI)
Postpartum Depression Screening Scale
(PDSS)
Edinburgh Postnatal Depression Scale
(EPDS)
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Becks Depression Inventory
Self administered survey
21 questions scored 03
Score of over 17 indicates that patient
would benefit from professional assistance
56% of postpartum women with postpartum
depression identified in one study
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Postpartum Depression
Screening Scale 94% sensitive and 96% specific in initial
trials
35 item self-administered questionnaire
Uses 5 point scale
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Edinburgh Postnatal Depression
Scale 10 item questionnaire
Each response scored 03, with total score
of 30 possible
Scores > 12 or 13 identify most women
with postpartum depression
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EPDS
Score > 12 reported as 100% sensitive and
95% specific in detecting major depression
Studies comparing EPDS vs PCM
evaluation of patient show EPDS has a
higher incidence of detecting anddiagnosing postpartum depression
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Evaluation and Diagnosis
Labs- CBC, TSH
Consider urine drug screen if history of
drug use/abuse
DSM IV diagnosis criteria
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Diagnosis
DSM IV modifier
ICD coding
Postpartum depression 648.4
Major depression 296
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Treatment
Factors to address:
Biological
Psychological
Social
Demonstrated maximal clinical responsewith biopsychosocial approach
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Treatment
Psychosocial therapies
First choice for those with mild to moderate
symptoms of PPD
Cognitive-behavioral therapy
Interpersonal psychotherapy- focuses onpatients interpersonal relationship andchanging roles
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Psychosocial Therapies
Group therapy
Helps to increase support network
Family and marital therapy
More rapid recovery
More appreciative of partners contribution
Peer-support groups
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Psychosocial Therapies (cont)
Supportive psychotherapy
Groups that offer support and education
Postpartum Support International
www. postpartum.net
Depression After Delivery
www. depressionafterdelivery.com
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Interpersonal Therapy (IPT)
Short-term, manual-driven psychotherapy
Addresses four major problem domains:
Grief Interpersonal disputes
Role transitions
Interpersonal deficits
Shown to reduce symptoms in pregnantwomen
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Pharmacologic Therapy
No antidepressants are approved by theFDA for use during pregnancy
All psychotropic drugs are transferredthrough the placenta and breast milk
Consider prior history
SSRIs and TCAs have low detection inbreastfed infant serum
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Concerns for Psychotropic Use
Risk of pregnancy loss or miscarriage
Risk of organ malformation or teratogenesis
Risk of neonatal toxicity or withdrawal
syndromes
Risk of longterm neurobehavioral sequelae
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Neonatal Withdrawal TCAs
TCA withdrawal syndrome:
Jitteriness
Irritability Seizures
Anticholinergic effect of TCAs include: Functional bowel obstruction
urinary retention
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Neonatal Withdrawal - SSRIs
Transient symptoms of:
Irritability
Excessive crying
Increased muscle tone
Feeding problems
Sleep disruption Respiratory distress
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Long Term Sequelae
No significant difference in:
IQ
Temperament Behavior
Reactivity
Mood
Distractibility
Activity level
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Pharmacologic Therapy
Increase risk of suicide after initiation of
medication
If significant anxiety or insomnia present,
consider adding benzodiazepine
Close follow-up
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Antidepressant Choice
TCAs
Desipramine and Nortryptiline are preferred
Least anti-cholinergic affects
Minimize postural hypotension
SSRIs
Fluoxetine is the best studied
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Additional Considerations
Doses of both SSRIs and TCAs may need to
be increased in pregnancy secondary to:
Increased plasma volume Increased hepatic metabolism
Increased renal clearance
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Other Therapies
Hormonal Therapy
Increased risk of PPD if Depo-provera given
within 48 hrs of delivery Transdermal estradiol may improve symptoms
Treat severe anemia
Treat poorly controlled hypothyroidism
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Other Therapies (cont)
ECT
Few adverse effects to mom or infant
Good when rapid treatment is needed
For severe depression with psychotic symptomsor acute mania
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Length of Treatment
Based on patient history and severity of
symptoms
Continue 12 months after full remission
Continue meds through pregnancy to reduce
risk of relapse
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Referrals
Consider Psychiatric referral if:
Poor response to therapy
Relapse Major functional impairment
Suicidal or homicidal ideation
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Treatment of Postpartum
Psychosis Medical emergency
Patient should be hospitalized until stable
While psychotic, mom cannot adequately
care for self or infant
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Treatment of PPP (cont)
Medications focused on controlling bothpsychosis and mood swings
Combination therapy often necessary
Most will not be able to continue
breastfeeding
ECT may be highly effective
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Prevention
Monitor for signs in high risk women
Educate women and family members beforechildbirth
Counseling and increase social support prior to
delivery
Consider starting therapy during third trimester orimmediately after delivery
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Conclusion
Postpartum mood disorders are common
Military population has multiple risk factors
for developing postpartum depression Important to screen patients in a variety of
settings.
Treatment of postpartum depressionimportant for maternal and familial wellbeing