LECTURE OBJECTIVES WHEN A PATIENT HAS A PERINATAL MOOD DISORDER (PMD) 3/14/2011

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1 DIAGNOSTIC & TREATMENT CONSIDERATIONS IN PERINATAL MOOD DISORDERS MERRILL SPARAGO, MD Volunteer Clinical Faculty UCLA Women s Life Center, Los Angeles Perinatal Mental Health Task Force, Private Practice LECTURE OBJECTIVES DESCRIBE THE PROCESS OF DIAGNOSTIC ASSESSMENT IN EVALUATING PERINATAL MOOD/ANXIETY DISORDERS (PMDS) PROVIDE A FRAMEWORK FOR UNDERDSTANDING THE USE OF MEDICATIONS IN PMDS DISCUSS PHARMACOLOGIC TREATMENT OF PMDS SORT THROUGH THE CONFUING AND CONTRADICTORY LITERATURE ABOUT PHARMACOTHERAPY IN PREGNANCY/POSTPARTUM WHEN A PATIENT HAS A PERINATAL MOOD DISORDER (PMD) THERE IS NO NON EXPOSED GROUP IN TREATING PMD S.ZACHARY STOWE, M.D. PATIENTS AND THE DEVELOPING FETUS OR NEWBORN ARE EITHER EXPOSED TO THE MORBIDITY AND MORTALITY OF THE ILLNESS, THE TREATMENT, OR BOTH. 1

2 WHEN TREATING A PERINATAL MOOD DISORDER (PMD) THE BEST TREATMENT STRATEGY IS TO MINIMIZE OR ELIMINATE ONE OF THE EXPOSURES WHENEVER POSSIBLE MEDICATIONS ARE USED ONLY WHEN OTHER TREATMENT OPTIONS SUCH AS THERAPY ARE NOT EFFECTIVE OR UNAVAILABLE/UNDESIRED BY THE PATIENT. MEDICATIONS SHOULD IDEALLY BE USED IN CONJUNCTION WITH THERAPY. WE TREAT WITH THE LOWEST POSSIBLE DOSE BUT I BELIEVE IF YOU ARE GOING TO TREAT, THEN TREAT WITH THE GOAL OF APPROACING/ACHIEVING REMISSION TO AVOID ONE OF THE EXPOSURES. THE TREATMENT TEAM PERINATAL MOOD DISORDERS (PMD S) ANALOGY TO ONCOLOGY: TREATING PERINATAL MOOD DISORDERS IS A TEAM EFFORT. WHENEVER POSSIBLE THE TEAM SHOULD INCLUDE AN EXPERT IN PMD S AS WOULD ONCOLOGIC ILLNESS OUR JOB IS TO INCREASE THE NUMBER OF PROVIDERS THE PROBLEM IS REFERRALS: YOU CAN BECOME PART OF THE SOLUTION THE OBSTETRICIAN/PSYCHIATRIST AND PERINATAL MOOD DISORDERS (PMD S) TO ENSURE THE BEST OUTCOME FOR MOM, BABY, FAMILY AND PHYSICIAN A CONSULTATION WITH AN EXPERT IN PERINATAL MOOD DISORDERS (EVEN IF IT S A CURBSIDE) SHOULD BE STRONGLY CONSIDERED 2

3 RISKS FACTORS ASSOCIATED WITH THE DEVELOPMENT OF PMD S HX MOOD, ANXIETY, PSYCHOTIC D/O. INFERTITLITY. UNPLANNED PREGNANCY. GESATATIONAL ABNORMALITIES. CONFLICTS IN RELATIONSHIP/POOR SOCIAL SUPPORT. LOW BW/NEONATAL HEALTH PROBLEMS (PPD). RISKS ASSOCIATED WITH PMD S MORBIDITY: POOR MATERNAL AND FETAL OUTCOMES MOM: POOR WEIGHT GAIN, POOR SELF CARE/EATING HABITS, INCREASED TOB AND ETOH USE, INCREASED OBSTETRICAL INTERVENTIONS FETUS: SGA, LBW, ALTERED CORTISOL RESPONSE, PRETERM BIRTH RISKS ASSOCIATED WITH PMD S MORTALITY: SUICIDE/ABORTION SECONDARY TO INTOLERABLE PSYHCIATRIC SX; INFANTICIDE 4% IN POSTPARTUM PSYCHOSIS (PPP). HOW ARE THEY MISSED: IS IT SHAME- ARE PATIENT S GIVING THEIR OB AN ACCURATE PSYCH HX? NOT ALWAYS. 3

4 PMD S: CONCEPTION AND PREGNANCY INCIDENCE 12-20%. ANXIETY AND DEPRESSION CAN DECREASE CHANCE OF CONCEPTION. THERE IS NOT CONVINCING EVIDENCE THAT TREATING DEPRESSION AND ANXIETY DURING CONCEPTION INHIBTS FERTILITY. PMD S: IS PREGNANCY PROTECTIVE? NO!!! PMD S: IS PREGNANCY PROTECTIVE? DEPRESSION Cohen LS, JAMA Feb 2006 n=201 PROSPECTIVE STUDY OVERALL 43% OF WOMEN RELAPSED - 21% RELAPSED WHO CONTINUED ANTIDEPRESSANTS - 68% RELAPSED WHO D/C ANTIDEPRESSANTS - OVERALL 5X RISK OF MOOD EPISODE WHEN STOPPING TREATMENT 4

5 PMD S: IS PREGNANCY PROTECTIVE? BIPOLAR DISORDER Viguera AC, et.al. Am J Psych, Dec PROSPECTIVE STUDY - OCCURNECE OF MOOD EPISODE DURING PREGNANCY 71% - 2X INCREASE RISK OF MOOD EPISODE FOR WOMEN WHO STOPPED THEIR RX. - TIME TO RECURRENCE 4X SHORTER. - ALMOST 50% RELAPSE IN 1 ST TRIMESTER - 5X INCREASE IN WEEKS SPENT ILL, MOSTLY DEPRESSED OR MIXED - 11X INCREASE IN TIME TO RECURRENCE RAPID D/C VS TAPER. IN GENERAL PT S ON LITHIUM FARED BETTER - PMD S: IS PREGNANCY PROTECTIVE? BOTTOM LINE/WHAT CAN BE DONE IF YOU ARE DEPRESSED IN PREGNANCY YOU WILL MOST LIKELY CONTINUE TO BE DEPRESSED IN PREGNANCY OR THE POSTPARTUM PREGNANCY/DELIVERY DOES NOT CURE OR TREAT PERINATAL MOOD DISORDERS!!!!! HOSPITALIZATION RATES ARE 7X BASELINE RATE IN FIRST 30 DAYS POSTPARTUM FOR PATIENT S WITH A HISTORY OF MOOD/ANXIETY DISORDERS CLINICAL OUTCOMES CAN BE IMPROVED WITH PRECONCEPTION PLANNING (WHENEVER POSSIBLE) AND PARTNERSHIP WITH A PERINATAL MENTAL HEALTH SPECIALIST EVEN IF IT S A CURBSIDE.. MY CELL IS PERINATAL MOOD DISORDERS PRIMARY DIFFERENTIAL - BABY BLUES - DEPRESSION/MAJOR DEPRESSION/BIPOLAR DISORDER - POSTPARTUM DEPRESSION - POSTPARTUM DEPRESSION WITH PSYCHOTIC FEATURES - POSTPARTUM PSYCHOSIS - SCHIZOAFFECTIVE DISORDER 5

6 POSTPARTUM BLUES - INCIDENCE: 50-75% OF LIVE BIRTHS. - PRESENTS 1 ST WEEK PP. - RESOLVES BY WEEK 2. -SX: OVERWHELMED, ANXIOUS, MOOD LABILITY, CRYING. -SLEEP IS PRESERVED. -NO HOPELESSNES SI/HI/OBSESSIONS. POSTPARTUM DEPRESSION (PPD) % OF LIVE BIRTHS - ETIOLOGY: UNKNOWN, RAPID SHIFT IN GONADAL STEROIDS, THYROID FUNCTION, CORTSIOL, PROLACTIN - PRESENTATION: ANYTIME FROM THE IMMEDIATE POSTPARTUM TO A YEAR OUT (EVEN FURTHER ) - ANXIOUS DEPRESSION, INSOMNIA, HOPELESSNESS, FEARS OF BEING A BAD MOTHER/HARM COMING TO THE BABY, GUILT % HAVE OBSESSIVE THOUGHTS: INTRUSIVE REPETITVE EGO-DSYTONIC THOUGHTS INCLUDING HARMING THE BABY; - REALITY TESTING AND JUDGMENT INTACT ACOG SCREEN THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS (ACOG) RECOMMENDS A TIMELY SCREENING METHOD- ASKING THE FOLLOWING QUESTIONS: (A) OVER THE PAST 2 WEEKS, HAVE YOU EVER FELT DOWN, DEPRESSED, OR HOPELESS? (B) OVER THE PAST 2 WEEKS, HAVE YOU FELT LITTLE INTEREST OR PLEASURE IN DOING THINGS? 6

7 MY POSTPARTUM TRIPLE SCREEN 1) CAN YOU SLEEP WHEN THE BABY IS SLEEPING/HAVE YOU SLEPT? 2) ARE YOU FEELING HOPELESS, HAVING THOUGHTS OF HARMING YOURSELF OR OTHERS INCLUDING THE BABY? 3) WHAT WOULD STOP YOU FROM ACTING ON THOSE THOUGHTS? IF ANY OF THESE ARE YES OR I DON T KNOW IT IS NOT THE BABY BLUES AND THERE NEEDS TO BE A CLINICAL INTERVENTION PPD WITH PSYCHOTIC FEATURES - PPD WITH PSYCHOTIC FEATURES IS NOT PPP - PSYCHOTIC SX: DELUSIONS/HALLUCINATIONS DISORGANIZED THOUGHT LACK OF INSIGHT - CLINICAL PRESENTATION: SEVERE DEPRESSION MOOD CONGRUENT DELUSIONS AND HALLUCINATIONS AGITATED/LETHARGIC - PSYCHOTIC FEATURES INCREASE THE RISK OF SUICIDE/INFANTICIDE PPD TREATMENT OPTIONS #1 RULE MOM MUST SLEEP!!!!! PSYCHOTHERAPY INTERPERSONAL (IPT); COGNITIVE BEHAVIORAL (CBT) PSYCHODYNAMIC/INSIGHT ORIENTED GROUP/FAMILY *MOST SUCCESSFUL OUTCOMES WITH A COMBINATION OF MEDICATION AND THERAPY 7

8 PPD PHARMACOTHERAPY - SSRIS (FLUOXETINE, PAROXETINE, CITALOPRAM, S- CITALOPRAM, SETRALINE, FLUVOXAMINE) PRIMARY TREATMENT - SNRIS (VENLAFAXINE, DULOXETINE) MAY BE EFFECTIVE BENZODIAZEPINES: INSOMNIA/ANXIETY - PPD WITH PSYCHOTIC FEATURES OR SEVERE REFRACTORY DEPRESSIVE SYMPTOMS: ATYPICAL ANTIPSYCHOTIC (OLANZAPINE, RISPERIDONE, ARIPIPRAZOLE, QUETIAPINE, ZIPRASIDONE) **** MORE ON MEDS TO COME**** POSTPARTUM OBSESSIVE/COMPULSIVE DISORDER (PPOCD) - 2-3%; MORE COMMON IN PRIMIPAROUS WOMEN - PEUPERIUM IS A RISK FACTOR FOR NEW ONSET OCD SYMPTOMS OCCUR IN THE EARLY POSTPARTUM, OFTEN COMORBID PPD - ETIOLOGY UNKNOWN, ALTERATIONS IN GONADAL STEROIDS AND INFLUENCE ON NEUROTRANSMITTER SYSTEMS (5-HT; DA) - AVOIDANT/OCPD MAY BE A RISK FACTOR* - COURSE CHRONIC AND OFTEN ACCOMPANIED BY DEPRESSION AND FEELING OF GOING CRAZY *FARUK ET. AL., 2007 PP OCD CORE SYMTPOMS OBSESSIONS AND COMPULSIONS OBSESSIONS: INTRUSIVE, UNWANTED, EGO DYSTONIC, REPETITIVE THOUGHTS THAT CAUSE SIGNIFICANT DISTRESS. *NOT RUMINATIONS ABOUT DAILY LIFE STRESSORS. MOST COMMON: HARMING THE BABY, CONTAMINATION, SYMMETRY. COMPULSIONS: REPETITIVE BEHAVIORS DIRECTED AT DECREASING ANXIETY OF OBSESSIONS BEHAVIORAL (OBSERVABLE) AVOIDANCE, HIDING OBJECTS, WASHING/CLEANING OR ORGANIZING MENTAL (INOBSERVABLE) COUNTING, UNDOING, RATIONALIZING, LOGIC 8

9 PP OCD TREATMENT - PATIENT EDUCATION: NOT AT INCREASED RISK OF HARMING THE BABY (COMORBID DEPRESSION MAY INCREASE RISK OF SELF HARM. - PSYCHOTHERAPY: CBT (PREFERRED) INTERPERSONAL THERAPY (DEPRESSION) GROUP FAMILY POSTPARTUM OCD PHARMACOTHERAPY - SSRIS (FLUOXETINE, PAROXETINE, CITALOPRAM, S- CITALOPRAM, SETRALINE, FLUVOXAMINE) PRIMARY TREATMENT, OFTEN NEED HIGHER DOSES THAN FOR DEPRESSION - SNRIS (VENLAFAXINE, DULOXETINE) MAY BE EFFECTIVE BENZODIAZEPINES: INSOMNIA/ANXIETY - ATYPICAL ANTIPSYCHOTIC (OLANZAPINE, RISPERIDONE, ARIPIPRAZOLE, QUETIAPINE, ZIPRASIDONE) - GLUTAMATE ANTAGONISTS (GALANTAMINE) POSTPARTUM PSYCHOSIS (PPP) - EPIDEMIOLOGY -.1% 100X HIGHER IN WOMEN WITH BIPOLAR DISORDER (10%). - PPP: CONSIDERED A MANIFESTATION OF BIPOLAR DISORDER UNTIL PROVEN OTHERWISE - ALSO INCREASED RISK IN PATIENTS WITH SCHIZOAFFECTIVE DISORDER, SCHIZOPHRENIA - ETIOLOGY MAY BE RELATED TO PROFOUND DROP IN ESTROGEN/PROGESTERONE WITH CHILD BIRTH. GENETIC FACTORS CHROMOSOME 16P13* *JONES AND CRADDOCK,

10 POSTPARTUM PSYCHOSIS CLINICAL PRESENTATION CORE SYMPTOMS INCLUDE: MOOD LABILITY DELUSIONS FIXED FALSE BELIEFS HALLUCINATIONS PERCEPTUAL DISTURBANCES PERCEIVED AS COMING EXTERNALLY RATHER THAN INTERNALLY THOUGHT DISORDER/DELIRIUM COGNITIVE DISORGANIZATION PSYCHOSIS * APPROXIMATELY 4% OF WOMEN WITH PPP COMMIT INFANTICIDE * *WISNER ET. AL., 1994 POSTPARTUM PSYCHOSIS CLINICAL PRESENTATION (CONT.) NO INSIGHT INTO THE NATURE OF THE SYMPTOMS EGO SYNTONIC - BELIEVED TO BE IN LINE WITH REALITY (THIS DISTINGUISHES DIAGNOSIS FROM OCD) OFTEN PRESENTS LIKE A DELIRIUM WAXING AND WANING OF SYMPTOMS ALTERED LEVEL OF AROUSAL ORIENTATION/SENSORIUM IMPAIRED CONFUSION MEMORY LOSS BIZARRE BEHAVIOR CAN FLUCTUATE WITH MOMENTS OF LUCENCY POSTPARTUM PSYCHOSIS DELUSIONAL CONTENT - RELIGIOUS DELUSIONS ANDREA YATES - DELUSIONS OF CONTROL - GRANDIOSE DELUSIONS - PARANOID - BIZARRE CONTENT - COMMAND HALLUCINATIONS INCREASED RISK OF INFANTIDCIDE 10

11 POSTPARTUM PSYCHOSIS (PPP) A MEDICAL EMERGENCY* IF THE DIAGNOSIS IS POSTPARTUM PSYCHOSIS, YOU MUST TAKE IMMEDIATE AND ALL NECESSARY ACTION TO MINIMIZE RISK OF SELF HARM/INFANTICIDE: THEREFORE: IMMEDIATE HOSPITALIZATION IS THE TREATMENT FOR PPP. FAMILY WATCH IS NOT SUFFICENT PHARMACOTHERAPY MOOD STABILIZERS, ANTI-PSYCHOTICS, SEDATIVES, ECT WHAT S AFTER THE DIAGNOSIS? WHEN MEDICATION IS NEEDED DETERMINING WHETHER A MEDICATION IS NEEDED IS ALWAYS DONE ON A CASE BY CASE BASIS AN EVALUATION OF PERINATAL MOOD DISORDERS MUST INCLUDE A COMPLETE HISTORY OF THE ILLNESS INCLUDING ALL MEDICATIONS THAT HAVE BEEN TRIED, HAVE FAILED, OR HAVE BEEN SUCCESFUL. ILLNESS SEVERITY, HOSPITALIZATIONS, AGE OF ONSET, NUMBER OF EPSIODES, CORE SYMTPOMS, HERALD SYMPTOMS, H/O PERINATAL MOOD DIORDERS /PMDD. RESPONSIVENESS OR LACK THEREOF TO OTHER LESS RISKY FORMS OF TREATMENT PLANNED PREGANCY OR UNPLANNED PREGNACY, COURSE OF PREGNANCY, DELIVERY COMPLICATIONS, SOCIAL SUPPORT WHEN MEDICATION IS NEEDED 2 A COMPREHENSIVE HISTORY, EXAM, AND RISK BENEFIT ASSESSMENT NEEDS TO BE DONE ON A CASE BY CASE BASIS IN PARTNERSHIP WITH THE PATIENT AND WHENEVER POSSIBLE THEIR PARTNER, TO PROVIDE A CLINICAL RECOMMENDATION AND INFORMED CONSENT THE ANALYSIS MUST ALWAYS INCLUDE THE DATA IN THE PATIENT VS. THE DATA IN THE LITERATURE. DATA IN THE PATIENT CAN OFTEN TRUMP DATA IN THE LITERATURE THERE IS NO BEST MEDICATION IN PREGNANCY 11

12 TREATING PMDS WITH SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) SSRIs: USED TO TREAT DEPRESSION, ANXIETTY, OCD FLUOXETINE/PROZAC SERTRALINE/ZOLOFT CITALOPRAM/CELEXA S-CITALOPRAM/LEXAPRO PAROXETINE/PAXIL FLUVOXAMINE/LUVOX TREATING PMDS WITH SSRI S IN PREGNANCY: THE MESS MULTIPLE CONTRADICTORY STUDIES SUGGESTING OR REFUTING TERATOGENIC EFFECTS/ADVERSE FETAL EFFECTS PERSISTENT PULMONARY HYPERTENSION POOR NEONATAL ADAPTATION MULTIPLE CONFOUNDERS: IS MATERNAL DEPRESSION CONTROLLED FOR, STUDY DESIGN (RETROSPECTIVE, PRESCRIPTION LOGS (DID MOM ACTUALLY TAKE THE MEDICATIONS, DATA BASE REVIEW, ARE CLINICALLY SIGNFICANT ABNORMALITIES SEPARATED FROM THOSE THAT RESOLVE SPONTANEOUSLY TREATING PMDS WITH SSRI S IN PREGNANCY: THE MESS SORTING THROUGH THE DATA TAKES CONTINUED VIGILANCE STUDIES OFTEN HAVE MULTIPLE CONFOUNDERS IS MATERNAL DEPRESSION CONTROLLED FOR? STUDY DESIGN (RETROSPECTIVE, PRESCRIPTION LOGS (DID MOM ACTUALLY TAKE THE MEDICATIONS, DATA BASE REVIEW, ARE CLINICALLY SIGNFICANT ABNORMALITIES SEPARATED FROM THOSE THAT RESOLVE SPONTANEOUSLY NEW STUDIES COME OUT VERY FREQUENTLY, INFORMATION NEEDS TO BE INTEGRATED NOT SEPARATED. ONE STUDY DOES NOT THE STORY MAKE. 12

13 SSRI S IN PREGNANCY: WHY THE CONCERN/TERATOGENICITY NATURE S WAY 3% BASELINE RISK OF CM S, CV DEFECTS MOST COMMON AT 1% WHAT IS A MAJOR TERTAOGEN? EXPOSURE TO A MAJOR TERATOGEN DURING GESTATION RESULTS IN PREDICTABLE PATTERNS OF MALFORMATIONS ASSOCIATED WITH A CRITICAL PERIOD OF ORGANOGENESIS AND HAS A BIOLOGICALY PLAUSIBLE MECHANISM TO EXPLAIN THE TERATOGENICITY. EX: VALPROIC ACID, FOLATE CONSUMPTION AND NTD S SSRI S IN PREGNANCY: WHY THE CONCERN/TERATOGENICITY WHEN CONSIDERING THE LITERATURE AS A WHOLE: SSRI S AS A CLASS DO NOT MEET THE CRITERIA TO BE DEFINED AS A MAJOR TERATOGEN MORE ON PAXIL TO COME SSRI S IN PREGNANCY: WHAT S THE RISK THOUGH SSRI S AS A CLASS DO NOT APPEAR TO BE MAJOR TERATOGENS, THAT DOES NOT MEAN THEY ARE WITHOUT RISK. THERE IS STILL DEBATE ABOUT: CARDIOVASCULAR DEFECTS (SEPTAL WALL) RARE ANATOMIC DEFECTS IN STOMACH WALL AND SKULL FORMATION, ANENCEPHALY PPHN PNA SGA INCREASED RISK OF PRETERM BIRTH 13

14 SSRI S IN PREGNANCY: TERATOGENICITY GESTATIONAL EXPOSURE TO SSRIS HAVE BEEN ASSOCIATED (IN SOME STUDIES) WITH RARE DEFECTS IN GASTROINTESTINAL (OMPHALOCELE INCIDENCE 1:2,000), BONE FORMATION (CRANIOSYNOSTOSIS INCIDENCE 1 :5,000) AND NEUROLOGIC DEFECTS ANENCEPHALY (1:10,000) THE LITERATURE IS CONTRADICTORY AND OTHER STUDIES FIND NO ASSOCIATIONS IF IT IS TRUE THEN THE MOST COMMON ABNORMALITY OMPHALOCELE (SPONTANEOUS RESOLVED VS SURGICAL REPIAR) WOULD HAVE AN INCREASED RISK OF 1:1000 OR % OF HAVING A BABY WITHOUT CM S HELP ME UNDERSTAND THE BIOLOGIC MECHANISM LINKING THE THREE? SSRI S IN PREGNANCY: CARDIOVASCULAR MALFORMATIONS (CVM S) CVM S MOST COMMON CM; 1%, MOST COMMON ASD/VSD OFTEN ASYMTPOMATIC/RESOLVE SPONTANEOUSLY PAXIL: INITIAL DATA INDICATES PAXIL INC RISK OF CVM TO 2%. HOWEVER.THE LARGEST PROSPECTIVE AND DATABASE STUDY FOUND NO ASSOCIATION BETWEEN PAXIL AND CVM S RATE.7% EXPOSED/UNEXPOSED. AM J PSYCHIATRY INITIAL STUDIES DID NOT TAKE INTO ACCOUNT CLINICAL SIGNFIANCE OF LESIONS.ASYMTPOMATIC AND SYMTPOMATIC WERE COMBINED PEDERSON ET AL DATA BASE STUDY: SERTRALINE, FLUOXETINE, CITALOPRAM WERE ASSOCIATED WITH SEPTAL DEFECTS, WHILE PAXIL CAME OUT CLEAN? HOW DO YOU INTERPRET THIS? SSRI S IN PREGNANCY: PERSISTENT PULMONARY HYPERTENSION (PPHN) FAILURE OF PULMONARY VASCULATURE TO VASODIALTE INCIDENCE- 1:1000 LIVE BIRTHS PRESENTS WITH HYPOXEMIA, RESPIRATORY DISTRESS, REQUIRES NICU ADMISSION,INTUBATION,ECMO MORTALITY: 15% 14

15 SSRI S IN PREGNANCY: PPHN CHAMBERS ET AL, EXPOSURE TO FLUOXETINE AFTER WEEK 20 IN PREGNANCY RESULTS IN A SIX FOLD INCREASE IN RR OF PPHN SINCE THEN: NO STUDY HAS BEEN CONDUCTED THAT HAS ASSOCIATED SSRIS WITH A SIX FOLD INCREASE IN PPHN STUDIES HAVE RANGED FROM NO ASSOCIATION OF SSRI EXPOSURE TO PPHN TO RISKS OF 2-4% AT UCLA WE HAVE NEVER SEEN A CASE OF PPHN IN THE LITERATURE NO BABIES HAVE EVER DIED FROM EXPOSURE TO SSRIS IN THE PPHN GROUP WHILE FATALITIES ARE ASSOCIATED WITH THE SPONTANEOUS FORM OF PPHN BIOLOGIC MECHANISM: 5-HT EFFECTS ON SMOOOTH MUSCLE SSRI S IN BREAST FEEDING ALL MEDICATIONS PASS INTO THE BREASTMILK-THERE IS NO NON EXPOSURE, THERE IS NO BEST SSRI IN BREASTFEEDING SERTRALINE AND PAROXETINE GET EXCRETED INTO BREAST MILK IN LOWER CONCENTRATIONS THEN FLUOXETINE, CITALOPRAM, S-CITALOPRAM, AND FLUVOXAMINE EXPOSURE IN PREGNANCY IS ALWAYS GREATER THAN EXPOSURE DURING BREASTFEEDING POTENTIAL RISKS INCLUDE SEDATION, FEEDING DIFFICULTIES, MOOD STABILIZERS IN PMDS USED TO TREAT BIPOLAR DISORDER, REFRACTORY DEPRESSION - DIVALPROIC ACID/DEPAKOTE - LAMOTRIGINE/LAMICTAL - LITHIUM - TOPIRAMATE/TOPOMAX - CARBAMAZEPINE/TEGRETOL 15

16 MOOD STABILIZERS IN PMDS TERATOGENICITY - DIVALPROIC ACID: 4% RISK OF NEURAL TUBE DEFICITS, DECREASED IQ IN EXPOSED INFANTS - LAMOTRIGINE? CLEFT PALATE - LITHIUM: EBSTEINS ANAMOLY (CARDIAC) INCIDENCE 1:10000 GENERAL POPULATION, 1:2000 LITHIUM EXPOSED - TOPIRAMATE: HYPOSPADIAS - CARBAMAZEPINE: NT DEFECTS MOOD STABILIZERS IN BREAST FEEDING LACK OF SLEEP INCREASES RISK OF RELAPSE IN MOOD DISORDERS ALL MEDICTAIONS PASS INTO BREASTMILK LITHIUM IS CONTRAINDICATED IN BF OTHER MEDS MAY BE USED ALWAYS A RISK BENEFIT ANALYSIS ATYPICAL ANTIPSYCHOTICS IN PMDS USED TO TREAT PSYCHOSIS, MANIA, BIPOLAR DEPRESSION, SEVERE DEPRESSION, ANXIETY/OCD, REFRACTORY INSOMNIA OLANZAPINE/ZYPREXA QUETIAPINE/SEROQUEL RISPERIDONE/RISPERDAL ZIPRASIDONE/GEODON ARIPIPRAZOLE/ABILIFY AS A CLASS DO NOT APPEAR TO BE MAJOR TERATOGENS MORE DATA FOR OLANZAPINE AND QUETIAPINE, LIMITED DATA ON ARIPIPRAZOLE/ZIPRASIDONE, BF IS AGAIN A RISK BENEFIT ANALYSIS 16

17 PMD S WHAT CAN I DO? INCREASE KNOWLEDGE BASE OF PERINATAL MENTAL HEALTH AND TREATMENT DISCUSS RISK FACTORS THAT CONTRIBUTE TO PMD S. HELP NORMALIZE FEELINGS AND EDUCATE PATIENTS ABOUT PERINATAL MOOD ISSUES AND POSSIBLE TREATMENT OPTIONS. ADDRESS PSYCHOSOCIAL ISSUES INCREASES TRUST AND PATIENT SATISFACTION. GET A CONSULTATION/FORM A PARTNERSHIP WITH A THERAPIST OR MD THAT WITH EXPERTISE IN THIS AREA REFERENCES INFANTACIDE:PSYCHOSOCIAL AND LEGAL PERSPECTIVES ON MOTHERS THAT KILL, EDITED BY MEG SPINELLI, WASHINTON DC, AMERICAN PSYCHIATRIC PUBLISHING; JONES, I., CRADDOCK, N. SEARCHING FOR THE PUERPERAL TRIGGER: MOLECULAR GENETIC STUDIES OF BIPOLAR AFFECTIVE PUERPERAL PSYCHOSIS. PSYCHOPHARM BULLETIN, 2007 KIM J-H ET. AL., A CLOSER LOOK AT DEPRESSION IN MOTHER S WHO KILL THEIR CHILDREN; IS IT UNIPOLAR OR BIPOLAR DEPRESSION? J CLIN PSYCH 69: , 2008 MARCUS, S.M. DEPRESSION DURING PREGNANCY: RATES, RISKS, AND CONSEQUENCES. CAN J CLIN PHARMACOL 16:E15-E22, 2009 OVERPECK ET. AL., RISK FACTORS FOR INFANT HOMICIDE IN THE UNITED STATES. N ENGL J MED 339: , 1998 OVERPECK ET. AL., NATIONAL UNDERASCERTAINMENT OF SUDDEN UNEXPECTED DEATHS ASSOCIATED WITH DEATHS OF UNKNOW CAUSE. PEDIATRICS 109; , 2002 PARRY BL. POSTPARTUM PSYCHIATRIC SYNDROMES, IN COMPREHENSIVE TEXTBOOK OF PSYCHIATRY 6 TH ED, VOL 1 EDITED BY KAPLAN AND SADDOCK. PHIALDELPHIA, WILLIAM AND WILKINS UGUZ, FARUK ET. AL. POSTPARTUM-ONSET OBSESSIVE COMPULSIVE DISORDER: INCIDENCE, CLINICAL FEATURES, AND RELATED FACTORS WISNER KL ET.AL., SYMPTOMATOLOGY OF AFFECTIVE AND PSYCHOTIC ILLNESS RELATED TO CHILD BEARING. J AFFECT DISORD 1994; 30:

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