Solving Clinical Challenges inPostpartum Depression and Mood Disorders
Marlene Freeman, MDAssociate Professor of Psychiatry, Harvard Medical SchoolAssociate Director, Perinatal and Reproductive PsychiatryMedical Director, CTNIMassachusetts General HospitalBoston, Massachusetts
Disclosure• The faculty have been informed of their responsibility to disclose to the
audience if they will be discussing off-label or investigational use(s) of drugs, products, and/or devices (any use not approved by the US Food and Drug Administration).– Dr. Freeman will be discussing off-label use and/or investigational use of
prescription medications/medical devices in the presentation and will identify those issues.
• Applicable CME staff have no relationships to disclose relating to the subject matter of this activity.
• This activity has been independently reviewed for balance.
Solving Clinical Challenges
All questions/cases in this presentation were submitted by clinicians within the Psych Congress database which includes conference
attendees, newsletters subscribers, and more.
An Approach to Postpartum Mood Disorders• Part I: Diagnostic nosology, accurate diagnosis, and screening• Part II: Pharmacologic treatments• Part III: Risk/benefit, side effect management• Part IV: Nonpharmacologic treatments
Part I:Diagnostic Nosology, Accuracy, and Screening
What clinicians asked:• What is your most salient question used to get at postpartum
depressive symptoms?
• How often do you see psychotic symptoms in postpartum depression?
• Which screening tools do you recommend for postpartum depression?
Postpartum Mood and Anxiety Disorders• Postpartum Blues • Postpartum Depression
– DSM-5: Postpartum onset specifier– Onset within 4 weeks of delivery
• Postpartum Psychosis• Postpartum Episodes of Bipolar Disorder• Postpartum Anxiety Disorders or Symptoms
Postpartum Depression• 10% to 15% of women experience
major depressive episodes after delivery
• Symptoms similar to non-puerperal major depressive episodes– Depressed mood, insomnia, fatigue,
anhedonia, suicidal ideation – Anxiety is prominent, often marked
obsessions, hypochondriasis are present
• Impairment of functioning
Nonacs R, et al. J Clin Psychiatry. 1998;59 Suppl 2:34-40.
Negative Effects of Maternal Depression on the Child
• Insecure attachment• Behavioral problems• Cognitive function• Increased risk of abuse,
neglect
• Childhood psychiatric diagnoses and symptoms
• Adherence with preventive measures
• Thoughts of harming infant
Civic D, et al. Matern Child Health J. 2000;4(4):215-221. Cicchetti D, et al. Dev Psychopathol. 1998;10(2):283-300. Feldman R, et al. J Child Psychol Psychiatry. 1999;40(6):929-939. Murray L, et al. J Child Psychol Psychiatry. 1999;40(8):1259-1271. Murray L, et al. J Child PsycholPsychiatry. 1996;37(8):927-935. Sharp D, et al. J Child Psychol Psychiatry. 1995;36(8):1315-1336. Kotch JB, et al. Child Abuse Negl. 1999;23(4):305-319. Cadzow SP, et al. Child Abuse Negl. 1999;23(9):845-853. Jennings KD, et al. J Affect Disord. 1999;54(1-2):21-28. McLennan JD, et al. Pediatrics. 2000;105(5):1090-1095. Weissman MM, et al. Am J Psychiatry. 2006;163(6):1001-1008.
Ms. A• Ms. A is a 29-year-old mother with a history of panic disorder and
MDD. She remained in remission throughout pregnancy, continuing a low dose of an SSRI.
• She presented to her postpartum obstetric visit stating that she is not feeling well. After some hesitancy to elaborate, she states she has been having thoughts about hurting her baby, specifically thoughts that she might put a pillow over the baby’s face. She expresses love for her baby, appears to be bonding well, but is extremely anxious, having difficulty sleeping, is frequently tearful, and has not been able to enjoy anything.
• She was reluctant to seek help because she was afraid that her baby will be taken away from her if she seeks help.
MDD = major depressive disorder; SSRI = selective serotonin reuptake inhibitor.
Postpartum Depression: Obsessions and Compulsions
• Obsessions are often present • Obsessions more common than compulsions/rituals• Obsessions more common in PPD (57%) than in non-puerperal
MDD (36%)• OCD in 9% to 11% of postpartum women• 37.5% report subsyndromal OCD• Aggressive obsessions > contamination > checking rituals
OCD = obsessive-compulsive disorder; PPD = postpartum depression.Miller ES, et al. J Womens Health. 2015;24(10):825-830. Wisner KL, et al. J Clin Psychiatry. 1999;60(3):176-180. Zambaldi CF, et al. ComprPsychiatry. 2009;50(6):503-509. Arnold LM. Prim Care Companion J Clin Psychiatry. 1999;1(4):103-108.
Differentiating OCD and PsychosisPostpartum OCD
• Thoughts are ego-dystonic• Disturbed by thoughts• Avoid objects or being with their
newborn• Very common disorder• Low risk of harm to baby
Postpartum Psychosis• Thoughts are ego-syntonic• May not be distressed by thoughts• May not show avoidant behaviors• Not common disorder• High risk of harm to baby
Brandes M, et al. Arch Womens Ment Health. 2004;7(2):99-110.
Ms. A: Treatment• Ms. A was started on an SSRI. Clonazepam was started with the
idea that it would be used to manage her anxiety until the SSRI started to work.
• She was agreeable to starting psychotherapy.• After several weeks, she experienced partial remission but was
still struggling, and was admitted to an intensive outpatient program for 1 week. She also had the dose of her SSRI increased, and gradually felt better over the course of the next several months.
• Obsessive thoughts improved along with depressive symptoms, becoming less frequent as she continued treatment.
Risk for Postpartum Illness: History of Psychiatric Illness
• Depression during pregnancy is a robust predictor of postpartum illness
• History of PPD or PP psychosis: 50% to 70% risk of recurrence• History of bipolar disorder: 30% to 50% risk of PP illness• History of recurrent MDD: Up to 30% risk of PPD
Cohen LS, et al. Psychiatr Clin North Am. 2010;33(2):273-293. Pearlstein T, et al. Am J Obstet Gynecol. 2009;200(4):357-364.
Postpartum Depression in Fathers• About 10% of fathers experience depression and/or high burden
of depressive symptoms in the year postpartum• Correlation between maternal and paternal depression • Risk factors: Maternal depression, prenatal depressive
symptoms, relationship quality, birth concerns, younger age (20s), financial worry, low education level/socioeconomic status
Bergström M. Birth. 2013;40(1):32-38. Paulson JF, et al. JAMA. 2010;303(19):1961-1969. Gawlik S, et al. Arch Womens Ment Health. 2014;17(1):49-56.
Adm
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ons
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onth
60
50
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30
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-2 Years -1 Year Childbirth +1 Year +2 Years
Pregnancy
Highest risk of hospitalization for new mothers is 10 to 19 days postpartum, increased outpatient contacts first 3 months
Risk of Psychiatric Hospitalization during Pregnancy and Postpartum
Kendell RE, et al. Br J Psychiatry. 1987;150:662-173. Munk-Olsen T, et al. JAMA. 2006;296(21):2582-2589.
Postpartum Psychosis• 1 to 2 per 1000 pregnancies• Rapid, dramatic onset within first 2 weeks• High risk of harm to self and infant• Suspect bipolar disorder
– Underlying diagnosis: Affective psychosis (bipolar disorder or schizoaffective disorder)
– Family and genetic studies, index episode follow-up
Nonacs R, et al. J Clin Psychiatry. 1998;59 Suppl 2:34-40. Jones I, et al. Ann Med. 2001;33(4):248-256. Spinelli MG. Am J Psychiatry. 2009;166(4):405-408.
Risk Factor % that Developed Postpartum Psychosis
Hospitalization for psychotic episode during the pregnancy 44%
Hospitalization for a psychotic episode prior to the pregnancy 14.5%
Any previous psychiatric hospitalization 9.2%
Previous hospitalization for bipolar mood episode 2.0%
Baseline population risk 0.07%
Risk Factors for Postpartum Psychosis
Harlow BL, et al. Arch Gen Psychiatry. 2007;64(1):42-48.
Diagnosis?• Majority have bipolar disorder or schizoaffective disorder (72%–
80%)• Schizophrenia (12%) • More likely to be related to an affective disorder than not• Risk factors
– History of postpartum psychosis – Previous psychosis – Bipolar disorder– Previous psychiatric hospitalizations
Spinelli MG. Am J Psychiatry. 2004;161(9):1548-1557. Spinelli MG. Am J Psychiatry. 2009;166(4):405-408.
Postpartum Psychosis• Psychiatric emergency• Estimated that 4% of women with postpartum psychosis commit
infanticide– Actual rates of infanticide are difficult to estimate, as infanticide
may be underreported
Spinelli MG. Am J Psychiatry. 2004;161(9):1548-1557. Spinelli MG. Am J Psychiatry. 2009;166(4):405-408.
Screening for Postpartum Depression
Postpartum Psychiatric Illness: Detection
• PPD is frequently missed• Overlap with “normal” postpartum experience: Decreased sleep,
fatigue, overwhelmed, anxiety (“normal” or not)• Multiple contacts with health care providers provide opportunity
for detection• Edinburgh Postnatal Depression Scale (EPDS): Frequently used,
10-item, self-rated
Cox JL, et al. Br J Psychiatry. 1987;150:782-786.
Siu AL, et al. JAMA. 2016;315(4):380-387.
Screening Instruments• Edinburgh Postnatal Depression Scale (EPDS)• Patient Health Questionnaire 9-item (PHQ-9)• Patient Health Questionnaire 2-item (PHQ-2)
Pitfalls: Risks of Screening without a Net• Screening itself does not lead to better outcomes
– Several studies indicate that screening in obstetric setting has not yielded higher rates of treatment engagement
– Women receiving care often receive suboptimal treatment– Low rates of follow-up on referrals, especially if mental health treatment is off-site – Recent review: No evidence from any well designed studies that screening
leads to better depression outcomes – 22% rate of treatment engagement after screening (review, Byatt et al, 2015)– Increased with health care provider education and provision of interventions
• Screening must be accompanied by– Adequate numbers of well-trained treaters to provide assessments and care to
women who screen positive for PPD – Care needs to be available and delivered in a timely fashion– Treatment options must reflect heterogeneity of depression detected and patient
preferencesYonkers KA, et al. Psychiatr Serv. 2009;60(3):322-328. Flynn HA, et al. J Womens Health. 2006;15(10):1195-1204. Smith MV, et al. Gen Hosp Psychiatry. 2010;32(5):544-548. Nelson DB, et al. J Matern Fetal Neonatal Med. 2013;26(12):1155-1161. Thombs BD, et al. J PsychosomRes. 2014;76(6):433-446. Byatt N, et al. Obstet Gynecol. 2015;126(5):1048-1058.
What clinicians asked:• What is your most salient question used to get at postpartum
depressive symptoms?
• How often do you see psychotic symptoms in postpartum depression?
• Which screening tools do you recommend for postpartum depression?
What clinicians asked:• What is your most salient question used to get at postpartum
depressive symptoms?– Are you able to enjoy your baby?
• How often do you see psychotic symptoms in postpartum depression?– Consider postpartum psychosis a separate entity and a
psychiatric emergency• Which screening tools do you recommend for postpartum
depression? – EPDS
Part II: Pharmacologic Treatments
What clinicians asked:• Can you speak to your opinions on managing lithium responders
pre-pregnancy and postpartum?
• Do you recommend continuing SSRIs during a woman’s entire pregnancy?
• I have been hearing about a 60-hour infusion of a GABA modulator medication for the treatment of postpartum depression. Please tell me more about it.
• Which antidepressants are safe when a patient is breastfeeding?
GABA = gamma-aminobutyric acid.
Breastfeeding• …The experience of breastfeeding is special
for so many reasons – the joyful bonding with your baby, the cost savings, and the health benefits for both mother and baby…– www.womenshealth.gov/breastfeeding/why-breastfeeding-is-
important/index.html• …Time to declare an end to the breastfeeding
dictatorship that is drowning women in guilt and worry just when they most need support...
Lemmon GT. Breastfeeding is a Choice, Let’s Treat it that Way. May 11, 2012. www.huffingtonpost.com/gayle-tzemach/breastfeeding_b_1509658.html. Accessed August 10, 2018.
Treatment Recommendations: Postpartum Depression
• Moderate to severe depression– Consider role of antidepressants; discuss risks and benefits
with mother• Use lowest effective doses• Consultation with experts• Maximize non-medication alternatives
Study Design and Size Medication Studied – Result
Appleby et al, 1997 Placebo-controlled, N=87; CBT studied in same trial Fluoxetine – superior to placebo
Yonkers et al, 2008 Placebo controlled, N=70 Paroxetine – not superior to placebo
Wisner et al, 2006 RCT, sertraline vs nortriptyline, N=109 Sertraline vs nortriptyline – no significant difference
Hantsoo et al, 2013 Placebo-controlled RCT, N=36 Sertraline – superior to placebo
Bloch et al, 2012 N=40, all received brief psychodynamic therapy, RCT to sertraline or placebo
Both groups improved – no significant difference for sertraline vs placebo
Sharp et al, 2010 RCT, antidepressant selected by general practitioner or counseling, N=254 Antidepressants – superior to placebo
Misri et al, 2012 Open trial, N=15 Citalopram – open study
Misri et al, 2004 N=35, all received paroxetine, half randomized to CBT also Paroxetine – no control group
Stowe et al, 1995 Open-label; N=21 Sertraline – open study
Cohen et al, 1997 Open-label; N=19 Venlafaxine – open study
Suri et al, 2001 Open-label; N=6 Fluvoxamine – open
Nonacs et al, 2005 Open-label; N=8 Bupropion – open
Antidepressant Trials for the Treatment of PPD
RCT = randomized controlled trial.Appleby L, et al. BMJ. 1997;314(7085):932-936. Yonkers KA, et al. J Clin Psychiatry. 2008;69(4):659-665. Bloch M, et al. J Clin Psychiatry. 2012;73(2):235-241. Wisner KL, et al. J ClinPsychopharmacol. 2006;26(4):353-360. Misri S, et al. J Clin Psychiatry. 2004;65(9):1236-1241. Stowe ZN. Depression. 1995;3(1-2):49-55. Cohen LS, et al. J Clin Psychiatry. 2001;62(8):592-596. Suri R, et al. Am J Psychiatry. 2001;158(10):1739-1740. Nonacs RM, et al. Int J Neuropsychopharmacol. 2005;8(3):445-449. Kim DR, et al. Expert Opin Pharmacother. 2014;15(9):1223-1234.
Antidepressant Treatment during BreastfeedingMost studies of infant exposure to antidepressants show low levels of
drug in breast milk and infant serum Few case reports of adverse effects• Doxepin: Infant had clinical effects of vomiting, sedation • Fluoxetine: Case report of high infant blood levels, colicky symptoms
– In women who took fluoxetine during pregnancy, followed postpartum while nursing: Slower infant growth in non-randomized study
• Citalopram: Sleep trouble in infant• Nefazodone: Case report—drowsiness, lethargy, inability to maintain body
temperature in a premature baby• Bupropion: Possible seizure in an infant
Weissman AM, et al. Am J Psychiatry. 2004;161(6):1066-1078. Burt VK, et al. Am J Psychiatry. 2001;158(7):1001-1009. Frey OR, et al. Ann Pharmacother. 1999;33(6):690-693. Lester BM, et al. J Am Acad Child Adolesc Psychiatry. 1993;32(6):1253-1255. Chambers CD, et al. Pediatrics. 1999;104(5):e61. Schmidt K, et al. Biol Psychiatry. 2000;47(2):164-165. Yapp P, et al. Ann Pharmacother. 2000;34(11):1269-1272. Chaudron LH, et al. J Clin Psychiatry. 2004;65(6):881-882.
FluoxetineDue to long half-life, may be more likely to be found at detectable levels in infant serum, especially at higher doses. Reasonable for use if a woman has had a good previous response to it and reasonable to consider if used during pregnancy
Sertraline Consistent reports of low levels of exposure, relatively large amount of study
Citalopram, escitalopram Less systematic study of mom-baby pairs compared with sertraline and paroxetine, observed low levels of exposure to infant via breastfeeding
Paroxetine Consistent reports of low levels of exposure, relatively large amount of study. Use limited by commonly experienced withdrawal symptoms, may be more sedating than other SSRIs
BupropionPaucity of systematic study; a few case reports in older infants that demonstrate low levels of exposure via breastfeeding. May be advantageous in smokers. Reasonable for use if women have had good previous response. One case report of possible infant seizure
Venlafaxine, desmethyl-venlafaxine Higher levels of desmethylvenlafaxine found in breast milk than venlafaxine. No adverse events reported
TCAs Considered reasonable for breastfeeding if use clinically warranted; few adverse effects in babies and generally low levels of exposure reported
Mirtazapine, nefazodone, MAOIs, duloxetine Systematic human lacking in the context of breastfeeding
Breastfeeding and Antidepressants
MAOI = monoamine oxidase inhibitor; TCA = tricyclic antidepressant. Weissman AM, et al. Am J Psychiatry. 2004;161(6):1066-1078. Burt VK, et al. Am J Psychiatry. 2001;158(7):1001-1009.
Brexanolone (SAGE-547) Allopregnanolone/Neurosteroids
• Allosteric modulator of GABAA receptors• Phase 2 trial of SAGE-547 for the treatment of PPD• Severe depressive symptoms; with a HAM-D score ≥ 26; onset
between third trimester and 1 month postpartum • Randomized to receive either SAGE-547 (n=10) or placebo
(n=11); blinded infusion taking place over 60 hours• At 24 hours, participants receiving SAGE-547 experienced a 19.0
point mean reduction in their HAM-D scores (P=.006), compared to 8.4 points in the placebo group; 7/10 participants receiving SAGE-547 achieved remission, at 60 hours, as compared to 1 /11 placebo patients (P=.008)
HAM-D = Hamilton Rating Scale for Depression. MGH Center for Women’s Mental Health. womensmentalhealth.org/posts/10832/. Accessed July 3, 2018. Kanes SJ, et al. Hum Psychopharmacol. 2017;32(2).
Pregnancy and Postpartum: Risks of Discontinuing Medication
• Retrospective comparison of recurrence rates, pregnant (N=42) vs nonpregnant women (N=59) with bipolar disorder
• Rates of recurrence after discontinuation of medication– Similar for pregnant and nonpregnant women, except more
depressive episodes in pregnant women (overall recurrence rate = 55%)
– Women at increased risk of recurrence postpartum (70% vs 24%; 2.9 × more likely to have recurrence than nonpregnant women after same time course)
– Recurrence risk greater after rapid discontinuation (< 2 weeks) than gradual (2–4 weeks)
Viguera AC, et al. Am J Psychiatry. 2000;157(2):179-184.
Postpartum Relapse: Bipolar Disorder• Pharmacotherapy strongly influences rate of relapse
Lithium• Lithium: First-trimester risk of cardiovascular malformations
– Ebstein’s anomaly: 0.1% to 0.2% (RR = 10–20)– RR for cardiac malformations is 1.2 to 7.7 and the risk for
Ebstein’s anomaly rises from 1/20,000 to 1/1000• Lithium
– Complicated by maternal GFR changes during pregnancy. Excreted more rapidly—may need to increase dose
– After delivery, GFR decreases rapidly, should follow lithium levels during labor and delivery, adjust dose as needed
RR = risk ratio; GFR = glomerular filtration rate.Yonkers KA, et al. Am J Psychiatry. 2004;161(4):608-620. Newport DJ, et al. Am J Psychiatry. 2005;162(11):2162-2170.
Mood Stabilizers and Breastfeeding
American Academy of Pediatrics Committee on Drugs. Pediatrics. 2001;108(3):776-789.
• Lithium– Toxicity reported in cases with infant serum levels at 0.1 to 0.5
× the maternal level – Contraindicated at one time by the American Academy of
Pediatrics• Revised to classification “Drugs That Have Been Associated
With Significant Effects on Some Nursing Infants and Should Be Given to Nursing Mothers With Caution”
Mood Stabilizers and Breastfeeding (cont’d)
Lithium and Breastfeeding – N=10 mother-baby pairs– Mothers stable, lithium monotherapy 600 to 1200 mg/day– Babies’serum levels 0.09 to 0.3 meq/L (average 0.16) – Transient increases in elevated infant TSH, BUN, Cr
Recommendations—Consider lithium when1. Bipolar disorder in mother who is stable2. Lithium monotherapy (or simple regimen)3. Adherence to infant monitoring (lithium level, TSH, BUN, Cr immediately
postpartum, 4 to 6 weeks of age, and then every 8 to 12 weeks)4. Healthy infant5. Collaborative pediatrician
BUN = blood urea nitrogen; Cr = creatinine; TSH = thyroid-stimulating hormone.Viguera AC, et al. Am J Psychiatry. 2007;164(2):342-345.
Postpartum Psychosis: Acute Treatment• Inpatient psychiatric hospitalization • Rule out medical conditions• Length of stay depends on clinical condition• Many women will need to stop breastfeeding• Primary pharmacotherapy: Mood stabilizer and an antipsychotic,
with medications for anxiety, insomnia, and agitation as needed – Sequential use of benzodiazepines, antipsychotics, lithium, and
ECT proposed
ECT = electroconvulsive therapy.Sit D, et al. J Womens Health. 2006;15(4):352-368. Bergink V, et al. Am J Psychiatry. 2015;172(2):115-123.
Postpartum Psychosis: Acute Treatment (cont’d)
• Inpatient Protocol – Sequential use: N=64– Step 1: Benzodiazepine (lorazepam), 3 days – 6% remitted (n=4)– Step 2: Antipsychotic: haloperidol or atypical – 19% remitted (n=12)– Step 3: Lithium – 73% remitted (n=48)– Step 4: ECT – none underwent– Total of 98% remission; only 1 patient did not fully remit
• Most women responded to by addition of lithium– Sustained remission at 9 months postpartum in 80%
• Affective diagnosis more associated with remission than non-affective
• Relapse rates higher with antipsychotics than with lithium
Bergink V, et al. Am J Psychiatry. 2015;172(2):115-123.
Treatment after Discharge• Little data to inform length of care
– 6 to 12 months of pharmacotherapy– Psychotherapy and close monitoring
• Treatment planning for adequate sleep, support, help in meeting the needs of caring for a baby
• Close monitoring is required for safety– Psychoeducation of family and friends
What clinicians asked:• Can you speak to your opinions on managing lithium responders
pre-pregnancy and postpartum?
• Do you recommend continuing SSRIs during a woman’s entire pregnancy?
• I have been hearing about a 60-hour infusion off a GABA modulator medication for the treatment of postpartum depression. Please tell me more about it.
• Which antidepressants are safe when a patient is breastfeeding?
What clinicians asked:• Can you speak to your opinions on managing lithium responders pre-
pregnancy and postpartum?– Case by case decisions; lithium is not contraindicated; may be the
best option throughout pregnancy and postpartum in a woman who has responded to lithium
• Do you recommend continuing SSRIs during a woman’s entire pregnancy?– If clinically warranted, yes
• I have been hearing about a 60-hour infusion off a GABA modulator medication for the treatment of postpartum depression. Please tell me more about it.– Discussed in previous slides
• Which antidepressants are safe when a patient is breastfeeding? – Most known about SSRIs; strongly consider past responses
Part III:Side Effect Management
What clinicians asked:• How often do you see SSRI withdrawal in a baby after delivery?
• What is the best way to select medications in a postpartum depression patient who wants to continue breastfeeding?
• In your opinion, what is the best way to educate patients about the management of medication side effects?
Antidepressants during Pregnancy:Later Pregnancy Considerations
• Reports of suspected neonatal syndrome: “Withdrawal” or “toxicity,” complications after in utero exposure to SSRIs; low birth weight; prematurity
• Overall studies do not adequately control for maternal mental health condition, adequate blinding of exposure in neonatal assessments
• Tapering does not appear to decrease occurrence when confounders assessed
Suri R, et al. Am J Psychiatry. 2007;164(8):1206-1213. Moses-Kolko EL, et al. JAMA. 2005;293(19):2372-2383. Jordan AE, et al. J MaternFetal Neonatal Med. 2008;21(10):745-751. Oberlander TF, et al. Arch Gen Psychiatry. 2006;63(8):898-906. Warburton W, et al. Acta PsychiatrScand. 2010;121(6):471-479.
Avoiding PregnancyASK ABOUT BIRTH CONTROL METHODS AND DOCUMENT
Interactions with OCPs– May decrease efficacy of OCPs
• Carbamazepine• Oxcarbazepine• Topiramate• St. John’s Wort• Modafinil, armodafinil
– OCPs may decrease lamotrigine levels
OCPs = oral contraceptives pills.
What is the best way to select medications in a postpartum depression patient who wants to continue breastfeeding?
• What has the patient responded to in the past? Efficacy is the main driver
• SSRIs have the most available data– For first trials, start with an SSRI
• Is she a smoker? Consider bupropion
In your opinion, what is the best way to educate patients about the management of medication side effects?
• Highlight the most common side effects• Start at low doses• Check-in frequently• Advise patients where to go for more information on the Internet
and where not to go – limit sites • Explain that benefits may take a while to occur; side effects can
occur immediately• Many side effects are short-lived
Part IV: Nonpharmacologic Treatments
What clinicians asked:• Are there best practice guidelines for frequency of supportive
health visits in the postpartum period?
• What are your top 3 recommendations for nonpharmacologic treatment for postpartum depression?
• What role might sleep hygiene play in helping patients deal with postpartum depression?
Postpartum Depression: Nonpharmacologic Strategies
• Maximize social supports• Psychoeducation of patient and family members• Group therapy and support groups• Interpersonal therapy (IPT)• Cognitive-behavioral therapy (CBT)
– Similar results: Fluoxetine vs 6 sessions CBT
Cohen LS, et al. Psychiatr Clin North Am. 2010;33(2):273-293. Pearlstein T, et al. Am J Obstet Gynecol. 2009;200(4):357-364. Appleby L, et al. BMJ. 1997;314(7085):932-936.
CAM/Integrative Treatments
CAM = complementary and alternative medicine; SAMe = S-adenosylmethionine.Parker G, et al. Am J Psychiatry. 2006;163(6):969-978. Freeman MP, et al. Acta Neuropsychiatrica. 2006;18, 21-24. Su KP, et al. J ClinPsychiatry. 2008;69(4):644-651. Nemets B, et al. Am J Psychiatry. 2002;159(3):477-479. Deligiannidis KM, et al. Psychiatr Clin North Am. 2010;33(2):441-463.
• Omega-3 fatty acids—add-on • Exercise—add-on • Folate—add-on• SAMe—?monotherapy (no specific study)• St. John’s wort—similar to antidepressants but less known• Acupuncture—monotherapy or add-on• Bright light therapy—monotherapy or add-on• Massage—add-on
Ms. C• Ms. C is a 35-year-old married woman who works in marketing, and had her first
baby 3 weeks ago. • She has a history of 2 episodes of MDD in the remote past, and anxiety consistent
with generalized anxiety disorder. She had been treated with sertraline prior to planning pregnancy, and tapered off of it prior to conception. She was able to function well without medication during her pregnancy.
• She now presents extremely anxious and with low mood, feeling extremely guilty about having difficulty breastfeeding (baby initially not “latching on” well; also baby seems hungry and fussy after feeding).
• She was told by the lactation consultant to continue to try to breastfeed “on demand.” The patient feels very guilty about it, but she and her husband have supplemented with formula when the baby seems extremely hungry despite trying to nurse. She is awakening to try to breastfeed throughout the night.
• She is tearful, becoming progressively more depressed and anxious since giving birth, now unable to enjoy anything. She feels like she is a terrible mother. She is starting to dread being with her baby.
Postpartum Treatment• Prescribe Sleep!
– Sleep deprivation – similar to antidepressants regarding risk of induction of mania/hypomania (10%)
• Prescribe Support!– Good social support associated with quicker recovery, less
symptomatic; better prophylaxis against episodes
Colombo C, et al. Psychiatry Res. 1999;86(3):267-270. Johnson SL, et al. J Abnorm Psychol. 1999;108(4):558-566. Stefos G, et al. Acta Psychiatr Scand. 1996;93(6):420-426.
What are your top 3 recommendations for nonpharmacologic treatment for postpartum depression?
• Psychotherapy• Sleep • Support and interaction
What role might sleep hygiene play in helping patients deal with postpartum depression?
• My opinion is that its role cannot be overstated• Sometimes the difference between improvement vs worsening
course
Ms. C: Treatment Plan• Ms. C was counseled to allow her husband to give 1 to 2 night
time feedings per night, allowing her to get about 4 to 5 hours of consecutive sleep.
• She restarted sertraline, and has an upcoming appointment coming up with a therapist she has not yet met.
• After continuing to try to breastfeed for another 2 weeks, she decided to stop.
• Depression and anxiety were notably better after 4 weeks on sertraline, and after she stopped breastfeeding.
Postpartum Mood Disorders: Summary• The postpartum is a vulnerable window of time for many women• Women, children, and families are impacted • Effective, safe, accessible, and acceptable treatments are needed• Treatment considerations involve risks of medications, risks of the
untreated disorder• Unknowns
– Warrant collaborative treatment decisions, prioritizing patient preferences
