A case based discussion of depression across the reproductive life cycle of an EFM.

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1 A case based discussion of depression across the reproductive life cycle of an EFM. VALERIE K DAVIS, MD RMO/P, MANAMA JANUARY, 2014

2 Identifying data: 36 year old married G4P4Absp1 mostly stay-at-home mother who is 11 weeks pregnant. CC: I need my Lexapro refilled (20 mg)

3 Current symptoms Fatigue/exhaustion Unrelenting nausea Doesn t feel like doing anything Gym rat too tired to work out Difficulty falling asleep (longstanding) Felt down several days within the last 2 weeks Eating all the time

4 Denies Anhedonia Thoughts of self harm Anxiety Low self esteem Hopelessness Helplessness Inability to function as required at home or in part time work

5 Patient perspective Currently doing quite well Last bad bout was 2012 when RMOP increased her Lexapro from ten to 20 mg Multiple previous episodes Requesting refill but no dosage adjustment

6

7

8 Is she clinically depressed? Why does it matter? How does the clinician decide?

9 Take home points Symptoms of pregnancy overlap with symptoms of depression Many patients can or will self correct; if not, clinician should do so Obtaining rating scales can be extremely helpful for following the course of depression Aim for remission as always

10 Patient s past history Onset age 13 dysthymic in teens First severe episode (agitated form) in 20 s, not pregnant, only episode with suicidal ideation, responded to medication & psychotherapy Second agitated depression occurred postpartum, while taking 20 mg of Lexapro. Responded to 30 mg; later weaned to 10 mg. Multiple lesser episodes while taking Lexapro, adjusts dosage from 10 to 30 mg, some response to psychotherapy but feels medication is most helpful

11 PPH & FH No suicide attempts No hospitalizations No hypomania or mania No OCD symptoms Premenstrual mood symptoms for several years which resolved FH: mother, 4/4 maternal aunts MDD, no bipolar

12 OB/Psychosocial history First pregnancy 2006, attempted to wean Lexapro but relapsed and resumed at 20 mg Delivered healthy full term child Her firstborn developed leukemia and died as a toddler While he was undergoing treatment, she was pregnant and experienced a miscarriage Subsequently got pregnant again and delivered her now eldest child 5 months after her baby died.

13 Is pregnancy protective, as once thought? (next slide courtesy of RMOP Steve Young)

14 Is Pregnancy is not protective Rates of Depression Similar 14-23% of Women Meet Diagnostic Criteria for Depression During Pregnancy 1 BMJ Reported higher rates of Depression at 32 wks compared to 8 weeks Post Partum 2 OCD May increase High Rate of Relapse for Bipolar Patients who discontinue meds 1 Gaynes Evid Re/Technol Assess (Summ) 2005:1-8 2 Evans Br Med Jnl 2001;323:257-60

15 Ob/Psychosocial hx Severe/agitated postpartum depression following the birth of her second son, despite being on 20 mg Lexapro Remitted with adjustment to 30 mg of Lexapro, later weaned to 20 mg again, then 10 mg. Breastfeed all 3 children and intends to breastfeed Normal pregnancy, engaged in adequate prenatal care

16 Psychosocial resources and stressors Grew up in a house of laughter that was strict religiously (e.g., no same sex swimming) Husband is her best friend, but she feels the one thing they cannot discuss is the baby s death, and asks her not to talk about it with others Parents were emotionally and instrumentally supportive during the extended illness and dying Graduate degree, enjoys FS lifestyle Doesn t have a nanny by preference, next post not one with inexpensive domestic help available Children s ages will be 3 and 5 at delivery Planned pregnancy Spiritual, believes her son is in heaven of some sort.

17 Her internal strengths Nothing can be worse than what we went through losing my son, so I just don t get anxious any more. Sees herself as an optimist with a sense of humor. Easily makes friendships

18 Postpartum Depression Predictors (*Cheryl Beck) Depression during Pregnancy may be the strongest predictor for PPD. Bipolar disorder may be the strongest predictor for PPD esp psychosis Prenatal anxiety History of previous depression, PPD, PMDD Recent or significant ongoing stressful life events Low socioeconomic status Inadequate social support single Marital dissatisfaction Low self-esteem Childcare stress Difficult infant temperament? Unplanned vs. unwanted pregnancy Family history

19 What to do today? Wean and discontinue Lexapro? Continue Lexapro? Switch to some other antidepressant? Increase the Lexapro? Add other treatment?

20 Risks of Psychotropic medication in Pregnancy Is it safe for the baby? isn t the right question The right question is which tough choice is least risky for mother and baby Baby has long term stake in maternal mental health Mother and baby have long term stake in infant wellbeing Other parent also has a stake and an opinion Other children also have a stake Prescriber has a stake and plenty of anxiety

21 Risks of depression in pregnancy Suicide Less treatable/refractory mood disorder Poor self care, nutrition, sleep Drug, Alcohol, and tobacco use Exposure to other medications Negative impact on parenting other children Maternal stress may alter fetal HPA axis 1 Possible association with pre-term delivery, low birth weight, developmental delay, behavioral problems 2,3 1 Stowe ZN CNS Spectrums (2): Chaudron LH Am J Psychiatry 2013; 170: Dayan J Psychosom Med 2006;68:938-46

22 Factors to consider in EFM s case History of severe episodes Unsuccessful attempt to wean in prior pregnancy, robust and rapid relapse Strong biological risk factors FH, phenomenology, adolescent onset Hx of relapse while on adequate dose of Lexapro Known recurrent form of MDD Modest response to psychotherapy Patient preference

23 My documentation Imp: Major depression, recurrent, severe, in full remission by exam and PHQ corrected for pregnancy. Hx of 1) severe episodes, 2) quick and robust relapse during first pregnancy after unsuccessful attempt to wean Lexapro, 3) strong biological risks factor of multiple episodes, 4) relapsing despite adequate dose of SSRI medication, 5) early onset in teens, 6) early postpartum onset, 7) associated agitation, 8) strong FH in female relatives. All of these factors are consistent with a strong biological intrinsic predisposition and a very high risk for relapse if she were taken off Lexapro for this pregnancy. With multiple previous episodes, there is also concern about loss of full remission were she to experience an extended unmedicated period due to pregnancy.

24 My documentation cont d Plan: 1) Explained to pt that I felt benefits of continuing current medication outweighed risks, she concurs and would be opposed to stopping medication. Explained that Lexapro is less well studied than other antidepressants, but specifically reviewed MGH and Mayo Clinic lay info written handouts which note relative safety of SSRI s as a class, and one study of Lexapro referenced from MGH site. Specifically educated that fetal brain develops all 3 trimesters. 2) Pt returning to DC in one month and will resume grief related therapy there.

25 What to do next month or next 2 trimesters? Should she increase dosage to 30 mg, and, if so, when? Should she start psychotherapy, and, if so, what kind? CBT ( is it me? ) IPT ( it s him ) Grief therapy Couples therapy

26 Impact of childbearing on psychiatric admission

27 Postpartum syndromes include Baby Blues 8/10 PPD umbrella term: Depression 1/7 OCD 3-4/100 Anxiety 1/7 Adjustment disorders 1/10 Postpartum Psychosis 1/1000

28 Postpartum depression Should she increase dosage to 30 mg, and, if so, when? Should she start psychotherapy, and, if so, what kind? CBT IPT Grief therapy Couples therapy

29 What 2 symptoms should worry us most after she delivers?

30 Postpartum emergencies Suicide Psychosis

31 Risk factors associated with suicide Psychosis Co-morbidity Panic attacks Thoughts about alternate caregivers, partner remarrying Ideas/thoughts that baby would be better off without her is of grave concern

32 Postpartum OCD is not Psychosis Pregnancy and postpartum period highest risks for onset or exacerbation Obsessive subtype most common presentation thoughts/images/fears of causing harm without intent.

33 Postpartum psychosis Most common underlying diagnosis is Bipolar Affective Disorder Clinical emergency (estimated risk of infanticide, suicide 1/20)

34 Thoughts of harming baby: high risk Mother has delusional beliefs about the baby - e.g. that the baby is a demon, being tested by God Thoughts of harming baby are ego-syntonic (mother thinks they are reasonable and/or feels tempted to act on them) Mother has a history of violence Mother has labile mood and/or impulsive behavior Mother unable to care for self or baby Wisner KL et al: Postpartum disorders: phenomenology, treatment approaches, and relationship to infanticide. In Spinelli MG, ed: Infanticide, Washington DC: American Psychiatric Press, 2003

35 Other concerns down the road Breastfeeding PMDD return? Perimenopause? Advice re further childbearing? Advice re MH care?

36 MGH Center for Women s Mental Health website: Womensmentalhealth.org Data have accumulated regarding the use of various antidepressant medications during breastfeeding. Available data on the use of tricyclic antidepressants (TCAs), fluoxetine, paroxetine, and sertraline during breastfeeding have been encouraging and suggest that the amounts of drug to which the nursing infant is exposed is low and that significant complications related to neonatal exposure to antidepressants in breast milk appear to be rare. Typically very low or non-detectable levels of drug have been detected in the infant serum, and one recent report indicates that exposure to medication in breast milk does not result in clinically significant blockade of serotonin (5-HT) reuptake in infants.

37 Recommendations for SSRI for in Lactation Start with lowest possible dose Monotherapy if possible Avoid fluoxetine, all other things being equal Once decision is made, treat effectively Education, support, reassurance Pediatrician and obstetrician likely to be supportive

38 What happens at menopause? Involutional and climateric melancholia no longer considered valid Many peri and post menopausal women enjoy new found freedom from parenting duties & responsibilities vs. empty nest Inconclusive but data suggest some women are uniquely vulnerable during the perimenopausal period in particular One theory is sleep disturbance and/or vasomotor sx increase vulnerability to mood disorder

39 Life course of her mood disorder Frequent adjustments from ten to 30 mg with multiple break through episodes less than ideal control Explore the idea that she may wish to limit her family size within a strong, nonjudgmental alliance

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