Perinatal Depression

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1 Perinatal Depression Developed by - Tammie Evers, BSN, RNC-MNN Lisa Fikac, MSN, RNC-NIC Expiration date - 12/11/16

2 This continuing education activity is provided by Cape Fear Valley Health System, Training and Development Department, which is an approved provider of Continuing Nursing Education by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. 1.5 Contact hours will be awarded upon completion of the following criteria: Completion of the entire activity Submission of a completed evaluation form Completion a post-test with a grade of at least 85%. The planning committee members and content experts have declared no financial relationships which would influence the planning of this activity. Microsoft Office Clip Art is the source for all graphics unless otherwise noted.

3 Describe the etiology, risk factors, and clinical presentation for perinatal depression Discuss the clinical management for perinatal depression

4 Depression is the leading cause of disease-related disability among women. Women of childbearing age are at the highest risk for major depression Between 15-30% of all women experience some type of pregnancy related depression or anxiety When depression occurs during the perinatal period, the effects can be devastating for the woman, her children, and her family Perinatal depression covers a wide range of mood disorders that may affect women and occur during pregnancy or within the 12 months following delivery of the baby Perinatal depression may occur as a major or minor depression Sometimes, the distinction between major and minor depression is difficult to make Major depression is a distinct clinical syndrome that has a clearly indicated treatment. Defining minor depression is a little more complex Minor depression is an impairing, yet less severe, set of depressive symptoms that does not have a clearly indicated course of treatment

5 In order to be considered a major depressive disorder, there must be at least 5 symptoms for at least 2 weeks - Insomnia or hypersomnia Psychomotor agitation or sluggishness Fatigue Changes in appetite Feelings of worthlessness or guilt Decreased concentration Suicidal thoughts Loss of interest in daily activities No matter what the type of depression, perinatal depression is frequently unrecognized because the many discomforts of the perinatal period are similar to symptoms of depression The occurrence of depression during this time frame can interfere with bonding and the ability of the mother to recognize and respond to the infant's cues Many who recognize symptoms of depression may not seek treatment due to - Denial Shame Fear Guilt Lack of energy The continuum of perinatal depression includes - Prenatal depression "Baby blues" Postpartum depression Postpartum psychosis

6 Risk factors for perinatal depression include - History of postpartum depression with a previous pregnancy History of bipolar disorder or manic-depressive behaviors Family history of postpartum depression Premenstrual or oral contraceptive associated mood changes Obsessive personality Stressful life events o Lack of social support o Few socioeconomic resources o Poor self-esteem o Poor coping skills o Single, separated, or divorced o Significant loss in the last year o Previous miscarriage or stillbirth o Substance use/abuse o History of sexually transmitted infections (STIs) History of physical or sexual assault or abuse History of severe premenstrual dysphoric disorder (PMDD) Metabolic disorders such as hypo- or hyperthyroidism, thyroiditis Complications of pregnancy and delivery o Such as preterm or multiple births o Infant with congenital anomalies or health problems The Role of Hormones in Perinatal Depression Some literature sources indicate that postpartum depression may be related to the sudden decrease in estrogen, progesterone, and cortisol levels during the postpartum period. Excitement and elation are evident during pregnancy when placental hormone levels are high. Following delivery, there is a sudden decrease in hormone levels, and postpartum depression appears. There is still controversy regarding the possible role of high prolactin levels in the breastfeeding woman and the association with an increased risk of postpartum depression or postpartum psychosis. This is because prolactin inhibits the release of progesterone.

7 Besides the effects on mother-infant bonding, perinatal depression has other potential negative impacts on infants, such as - Higher rates of infant hospitalization Use of fewer preventive health practices o Such as the "back to sleep" infant sleeping position Greater use of corporal punishment Inattentiveness to infant cues which may lead to - o Overstimulation of the infant o Poor infant feeding outcomes Impaired development of - o Emotions o Language o Attention o Cognitive skills Additional potential impacts on the mother include - Relationship difficulties with her partner Increased risk of further depressive episodes This may be disabling when depression lasts for a prolonged amount of time This may be the first manifestation of a previously undiagnosed bipolar disorder

8 Prenatal depression affects between 10-20% of women. Women who have a history of depression are 5 times more likely to have a recurrence of depression symptoms during their pregnancy. Those women at risk for developing depression during pregnancy frequently include those who are - Unmarried Unemployed In poor health Many women who experience depression during their pregnancy are rarely screened or treated. Screening is important since it may prevent future episodes of depression. Not treating depression during pregnancy may result in - o Preeclampsia o Premature delivery o Low birthweight infant Women who experience depression during their pregnancy are more likely to experience postpartum depression Clinical Presentation Symptoms of prenatal depression include -

9 Crying Sleep problems that are not due to frequent urination Fatigue Appetite disturbance Loss of enjoyment of activities Anxiety Poor fetal attachment

10 Postpartum blues or the "baby blues" is a passing phase of emotions. Often characterized as a mild transient mood disturbance. Onset coincides with the normal physiologic drop in estrogen and progesterone. o Some have questioned if this might be the cause for this emotional event. The "baby blues" affects as many as 60-80% of new mothers. Clinical Presentation The "baby blues" typically occur 3-5 days after delivery. Therefore, this usually happens after the mother has been discharged from the hospital. Symptoms of the "baby blues" include - Feeling overwhelmed Irritability and restlessness Frustration Anxiety Sudden mood changes - from excited one minute to crying the next Feeling weepy and crying without any apparent reason Exhaustion Trouble falling or staying asleep Loss of appetite With good family support and adequate rest, symptoms usually subside by the second postpartum week. In general, "baby blues" do not interfere with or affect mom's ability to care for her infant.

11 Research has shown that symptoms of postpartum depression are no different than the symptoms of major depression. The key is that onset occurs during the postpartum period. Postpartum depression affects 10-20% of new mothers. Clinical Presentation The greatest risk for postpartum depression occurs around the fourth postpartum week, but can happen at any time during the first year postpartum. When diagnosing postpartum depression, the woman must present with a depressed mood or loss of interest or pleasure in daily activities for at least 2 weeks. Additionally, at least 4 of the following symptoms must be present - Weight change in the absence of dieting Insomnia or hypersomnia Psychomotor agitation or sluggishness Fatigue or loss of energy Feelings of worthlessness or guilt Decreased ability to think or concentrate Recurrent thoughts of death or suicide

12 Postpartum psychosis is a very rare condition that usually includes auditory hallucinations and delusions. Visual hallucinations are less frequent. Postpartum psychosis affects one or two women per thousand, but requires emergency hospitalization. Differential diagnoses to be considered when diagnosing postpartum psychosis include - Major depression with psychotic features Bipolar disorder Schizoaffective disorder Unspecified functional psychosis Brief psychotic disorder Studies have shown that most cases of postpartum psychosis are a variation of bipolar disorder that is triggered by childbirth. Clinical Presentation Symptom onset is often sudden and unexpected. Symptoms usually occur within 48 hours to 2 weeks after giving birth. The clinical presentation usually progresses rapidly after initial symptoms appear. Postpartum psychosis differs from postpartum depression by the presence of - Manic features o This is the main feature of postpartum psychosis. Delusions Hallucinations - visual, auditory, olfactory

13 o o May include commands to hurt oneself or the baby Often includes religious themes The risk of suicide is ~5%, and the risk of infanticide is ~4% Confusion and perplexity Mood lability

14 Assessment Clinical management of perinatal depression begins with recognition of its existence. Assessment should include - A good history that looks at - o Risk factors for perinatal depression o Symptoms associated with the spectrum of perinatal depression Physical examination may reveal - o Hypo- or hyperthyroidism o Dyspnea o Heart palpitations o Tremors Observation of maternal interactions with - o Infant o Family and friends o By herself Evaluation of - o Sleeping patterns o Appetite Evaluation of psychosocial factors - o Poor social support networks o Expression of concern about a difficult labor and delivery o Unplanned and/or unwanted pregnancy o Feelings of being unloved o Poor relationship with mother o Detachment from reality o Disturbances in thinking, feeling, and behavior o Poor interactions with infant, family, and staff o Inability to relax Discuss the mother's plans for her infant and herself Perinatal depression screening tools may be used. The Edinburgh Postnatal Depression Scale (EPDS) is a well-validated screening tool for the detection of patients at risk for postpartum depression The EPDS is a self-completed screening tool developed to assist primary healthcare providers in detecting mothers suffering from postpartum depression.

15 The EPDS consists of 10 short statements that cover - o Mood o Guilt o Coping o Suicidal ideation From 4 possible responses for each statement, the mother picks the one closest to how she has been feeling during the past week. EPDS has a 93% predictive value for depression. However, it does not help in detecting - o Anxiety disorders o Phobias o Personality disorders Interventions Request a psychiatric evaluation as needed. Psychotherapy on an individual and/or group level may be helpful. Hospitalization may also be needed. Support groups may also be of assistance. Whenever a mother expresses thoughts of suicide or harming her baby, always take those thoughts seriously and initiate a referral immediately! Teach the mother and significant others the signs and symptoms of depression and mania and when to seek professional help. Antidepressants may be used but can trigger the onset of mania. Support coping mechanisms. Facilitate time for the mother to be alone and away from the baby. Reinforce self-care activities. Encourage and allow mom to ventilate feelings. Provide reality orientation. Support and facilitate bonding with infant. Encourage mothering behaviors and the assumption of the maternal role. Assist the mother in learning parenting skills.

16 Provide positive reinforcement of appropriate mothering skills. Support the significant other and family in caring for the mother. Encourage family support. Listen to the family's concerns and take them seriously. Facilitate family participation in learning infant care. Explain psychological changes during the postpartum period. Assist the family in providing a safe home environment. o Encourage the removal of potentially harmful objects and weapons from the home. o Facilitate help for the mother once she arrives home.

17 Like most medications, antidepressants can have unwanted side effects. Antidepressants can interact with other medications, including over-the-counter medications and herbal remedies. St. John's Wort, or hypericum, is an herbal remedy used by some to help relieve the symptoms of depression. Selective seratonin reuptake inhibitors (SSRIs) were introduced in the mid-1980s and have gradually replaced tricyclics as the class of choice during pregnancy due to enhanced efficacy and tolerability. Caution mothers to discuss any medications they are taking, prescribed, over-thecounter and/or herbal, with their physician before taking the medications along with their antidepressant. Congenital Risks of Prenatal Exposure to SSRIs Several studies have looked at the association between SSRI use and the occurrence of congenital defects. After meta-analysis, it was found the risk of most defects is small. However, paroxetine(paxil ) was found to significantly increase the risk of atrial and ventricular septal defects (ASD and VSD).

18 Neonatal Risks of Prenatal Exposure to SSRIs Studies have shown neurobehavioral, cardiac, and respiratory effects in neonates exposed to SSRIs near term. Resulting adverse effects include - Neonatal abstinence syndrome (NAS) o Approximately 30% may experience withdrawal. Persistent pulmonary hypertension (PPHN) o Incidence is 6 times greater than in unexposed infants. Cardiac dysrhythmias o Approximately 10% may experience this within the first 48 hours of life. Infants experiencing withdrawal from SSRIs may experience - Irritability Jitteriness Respiratory distress Transient tachypnea Hypoglycemia Hypertonicity Weak cry Most infants do not need treatment, and symptoms significantly subside by 2 weeks of age. However, when withdrawal is severe, the infant may need pharmacologic management with phenobarbital. Symptoms generally disappear by 2 months of age; even in the breastfeeding infant. If SSRIs are used during pregnancy, the lowest dose to create the desired clinical effect should be used. The baby should be monitored for 48 hours after birth for signs of NAS. Risks of Neonatal Exposure to SSRIs in Breast Milk

19 Breastfeeding for women using SSRIs is generally considered safe. SSRI levels are usually undetectable or negligible. However, there have been reports of occasional adverse effects such as - o Sleep disturbances o Irritability o Poor feeding o Drowsiness

20 American Psychological Association. (2010). Publication Manual of the American Psychological Association, 6th Edition. Washington, DC: Author. Baisch, M. J., Carey, L.K., Conway, A.E., and Mounts, K.O. (2010). Perinatal depression: A health marketing campaign to improve screening. Nursing for Women s Health, 14(1), Bar-Oz, B., Einarson, T., Einarson, A., Boskovic, R., O Brien, L., Malm, H., et al. (2007). Paroxetine and congenital malformations: Meta-analysis and consideration of potential confounding factors. Clinical Therapeutics, 29(5), Courtney, K. (2009). Use of SSRIs in pregnancy: Neonatal implications. Nursing for Women s Health, 13(3), Doucet, S., Dennis, L., Letourneau, N., & Blackmore, E.R. (2009). Differentiation and clinical implications of postpartum depression and postpartum psychosis. JOGNN, 38, F.A. Davis Company. (2013). Taber s Online. (Retrieved October 25, 2013). Kaminsky, L.M., Carlo, J., Muench, M.V., Nath, C., Harrigan, J.T., & Canterino, J. (2008). Screening for postpartum depression with the Edinburgh Postnatal Depression Scale in an indigent population: Does a directed interview improve detection rates compared with the standard self-completed questionnaire? The Journal of Maternal- Fetal and Neonatal Medicine, 21(5), Louik, C., Lin, A. E., Werler, M. M., Hernandez-Diaz, S., & Mitchell, A. A. (2007). First-trimester use of selective serotonin-reuptake inhibitors and the risk of birth defects. New England Journal of Medicine, 356(26), Mattson, S., & Smith, J.E. (2011). Core Curriculum for Maternal-Newborn Nursing, 4th Edition. St. Louis, MO: Saunders Elsevier. Misri, S., Kendrick, K., Oberlander, T.F., Norris, S., Tomfohr, L., Zhang, H., & Grunau, R.R. (2010). Antenatal depression and anxiety affect postpartum parenting stress: A longitudinal, prospective study. The Canadian Journal of Psychiatry, 55(4),

21 New York State Department of Health. (2006). Perinatal depression. Retrieved January 31, 2011, from the New York State Department of Health Web site: _depression.htm Ramos, E., St-Andre, M., Rey, E., Oraichi, D., & Berard, A. (2008). Duration of antidepressant use during pregnancy and risk of major congenital malformations. British Journal of Psychiatry, 192(5), Segre, L.S., O Hara, M.W., Arndt, S., & Beck, C.T. (2010). Screening and counseling for postpartum depression by nurses: The women s views. MCN, 35(5),

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