Mental Health for Women s Health

Transcription

1 Mental Health for Women s Health Ellen Haller, M.D. WomenCare Mental Health Program Depression UCSF UCSF Department of Learning Objectives Know what to do when a pt c/o PMS Gain knowledge about anxiety disorders Be able to review risks/benefits of antidepressants during pregnancy Learn about post-partum mental health

2 Premenstrual Syndrome & Premenstrual Dysphoric Disorder PMS described for centuries & across cultures 30-80% of women have some PMS symptoms during some of their ~400 menstrual cycles More significant PMS symptoms in ~30% PMDD in only 3-8% PMDD DSM dx criteria in syllabus

3 Which of the following interventions is proven to help reduce PMS/PMDD symptoms? 1. Progesterone supplementation 2. The antidepressant, bupropion (Wellbutrin) 3. Calcium supplementation 4. Increasing salt intake PMS/PMDD Treatment Initial approach = basic wellness: salt, caffeine, sugar, sodium, alcohol water, fresh fruit, whole grains Stop smoking Exercise Stress management PMS Treatment with Calcium (Thys-Jacobs et al, Am J OB Gyn 1998) Multi-center, randomized, placebo controlled study, N= mg bid x 3 cycles 55% had >50% improvement in global sxs 36% with placebo 48% reduction in total sxs scores 30% with placebo Calcium relieved both emotional & physical sxs

4 PMDD Treatment Serotonergic antidepressants Continuous dosing Luteal phase dosing AKA Intermittent dosing Efficacy of SSRIs in PMS Brown J et al, Cochran Library, 2009 OCPs for PMDD Not helpful: Progesterone alone & most combo OCPs May make sxs worse Helpful: Yaz Drospirenone 3 mg + ethinyl estradiol 20 mcg

5 Yaz for PMDD Yonkers et al, OB GYN 2005 Multi-site, DB, RCT N=450, all with PMDD, yo Daily ratings 24 days on & 4 days off (with inert pill) Yaz for PMDD Yonkers et al, OB GYN 2005 Found signif. difference betw groups Total sx score: 47% in active drug group over 3 tx cycles 38% in PBO group Response (50% in scores) 48% of active drug group 36% of PBO group Drop-outs: 15% vs 4% Most common SE = nausea & intermenstrual bleeding Which has the highest lifetime prevalence? 1. Mood disorders (particularly Major Depression) 2. Anxiety disorders 3. Psychotic disorders (including schizophrenia) 4. Personality disorders

6 Anxiety Non-Pathological Anxiety Normal, universal human experience Adaptive necessity in evolution Two major components: 1. Psychic phenomena Worry Avoidance of danger 2. Physical phenomena Hyperarousal Flight or fight response Anxiety Disorders Anxiety when no real danger exists Most common psychiatric d/o Lifetime prev = 31.2% Devastating consequences on quality of life Often not detected or treated

7 Prevalence of Anxiety Disorders in Women & Men (data from Kessler, National Co-Morbidity, 2007) Approach to Treatment of Anxiety Disorders R/O gen l medical condition or effect of substance(s) Education & support Cognitive-behavioral therapy (CBT) Medications I just can t stand it, Doc 28 yo F attorney: Constantly fears she ll be humiliated they must think I m weak or stupid Anxious when speaking publicly Knows fear is unreasonable Avoids speaking whenever possible Functioning is impaired

8 Social Phobia DSM Criteria Irrational, excessive fear of humiliation &/or embarrassment Anxiety, panic, fear Recognition that fear is excessive Avoidance of social or performance situations Impaired functioning &/or significant distress Duration > 6 mos Course of Treatment Brief course of CBT Begun on citalopram with good result Functioning improved; good performance evaluation 5 months later... Pt. w/ sudden onset of: incr anxiety insomnia & vivid dreams nausea dizziness electric-like sensations in arms On vacation and forgot medication SSRI Discontinuation Syndrome

9 I can t stop worrying 31 yo female, married, stay-at-home mom Calls office frequently with various nonspecific somatic complaints Symptoms include: feeling keyed up constant ruminations about kids, home, health, & marriage poor concentration poor sleep muscle tension and pain Generalized Anxiety Disorder (GAD) DSM Criteria Excessive anxiety & worry > half the days in a month Worry about many things Symptoms of motor tension, hyperarousal Significant distress or impairment Duration > 6 mos Course of Treatment 1st tried buspirone (Buspar) Useful in people who ve never taken a benzodiazepine (i.e. Xanax, Valium) Takes time to work Didn t work for her Then Rx d clonazepam (Klonopin) Can be used safely in most cases without abuse Chronic Rx may lead to cognitive sxs, habituation (cont )

10 Course of Treatment Then, referred to psych Added sertraline; gradually d/c d clonazepam CBT w/ focus on catastrophizing thoughts Thought stopping Worry time Progressive muscle relaxation Course of Treatment Did well; then became pregnant Is antidepressant safe in pregnancy? Which is the most true statement about antidepressant Rx in pregnancy? 1. SSRIs are contraindicated 2. SSRIs are completely safe 3. Not enough data exists to help make an educated recommendation 4. An individualized risk-benefit assessment must guide decision-making 5. TCAs are contraindicated

11 Medications During Pregnancy Major areas of concern: Congenital organ malformations Perinatal adverse effects Long-term behavioral sequelae Antidepressant Rx During Pregnancy Antidepressant Rx During Pregnancy Fluoxetine (Prozac) Approx 1,200 exposed infants reported Minor malformations reported by Chambers, % vs 6.5%, P = 0.03 Chambers also reported perinatal complications associated with 3rd trimester use Several other authors report no difference from controls

12 Antidepressant Rx During Pregnancy Paroxetine (Paxil and Paxil CR) Retrospective study of 3,581 preg women (Louik et al, 2007) risk cardiovascular malform. for paroxetine OR /14 infants had ventricular septal defects Separate study of 4,291 babies exposed to SSRIs found no differences (Hallberg 2005) FDA reclassified as Class D drug Antidepressant Rx During Pregnancy citalopram, fluvoxamine, sertraline No evidence of increased risk of malformations bupropion, duloxetine, escitalopram, mirtazapine, nefazodone, venlafaxine Fewer reports; no evidence of congenital malformations Perinatal Effects of SSRIs Multiple sxs reported in 30% of exposed neonates Agitation, jitteriness, sleep disturbance Tremor Rigidity Feeding problems Excessive crying Typically resolve w/in 48 hrs w/o medical intervention Due to either w/drawal or serotonergic hyperstimulation Consider or d/c of antidep. prior to delivery Levinson-Castiel, 2005

13 Child Development After Fetal Exposure Nulman et al, 2002 Prospective study exposed throughout pregnancy TCAs (n=46) Fluoxetine (n=40) Controls (n=36) Followed children up to 71 months No differences found in: Global IQ Language Behavior Temperament IQ was negatively assoc with duration of depression Deciding to Rx Antidep in Pregnancy ACOG Practice Bulletin, 2008 Need to perform individual risk:benefit analysis Assess severity of anxiety/ depression & h/o response to treatment Document other exposures alcohol, cigs, Rx & OTC drugs Document informed consent Post-partum mental health

14 I just feel so tired 37 yo primip No prior h/o depression Now 7 wks postpartum Sxs: depressed mood fatigue overwhelmed and ashamed anxious about caring for baby; fears mistake appetite insomnia--even when baby asleep Post-partum depression occurs in what percent of women? % % % % % Spectrum of Postpartum Mood Changes Transient, nonpathologic Serious, disabling Medical emergency Postpartum Blues risk for MDD 50% to 70% Postpartum Depression 2/3 have onset by 6 wks postpartum 10% Postpartum Psychosis 70% are affective (bipolar, MDD) 0.01% Cohen LS. Depress Anxiety. 1998:1:18-26.

15 PPD Risk Factors Unsupportive partner/rel. conflict/stress FH depression or bipolar d/o h/o depression h/o PMDD Prior h/o PPD (50% risk) Depression during current pregnancy Post-partum blues Pearlstein 2009, Cohen 2010 Edinburgh Postnatal Depression Scale 10 item questionnaire Score of >12 indicates probable postpartum depression

16 PPD Management Recommendations Reassurance & support Postpartum Support International Psychotherapy Interpersonal Psychotherapy (IPT) Cognitive Behavioral Therapy (CBT) Medications Cohen, 2010 Pharmacotherapy for PPD Payne JL, 2007; ACOG Practice Bulletin, Apr 2008 Relatively few studies have evaluated antidep specifically for PPD No study compares psychotx to pharmacotx Fluoxetine shown better than PBO Double-blind trial of sertraline vs NTP showed both effective and no difference betw them BOTTOM LINE: Assume Rx for PPD has same response as tx for other depression Psychotropic Drugs During Lactation Di Scalea TL, Wisner KL, 2009 All are excreted in human breast milk As a class, have more data in breastfeeding than any other Sertraline, paroxetine, NTP & IMI are most evidence-based meds

17 Summary PMS/PMDD are real d/o Prospective charting useful tool Mgmt = basic wellness calcium SSRIs intermittently or Yaz SSRIs continuously Anxiety d/o are most common psych d/o Prevalence in women CBT, BZD, antidep very effective For pregnant pts, complete an individualized risk-benefit analysis 3 classes of postpartum mood disorders Resources Office of Women s Health American Psychiatric Association patient info Center for Women s Mental Health at Mass Gen l Chart on meds in pregnancy Info on meds in breastfeeding