"THE FOURTH TRIMESTER" : RECOGNITION, DIAGNOSIS, & MANAGEMENT OF POSTPARTUM BLUES & DEPRESSION

Transcription

1 "THE FOURTH TRIMESTER" : RECOGNITION, DIAGNOSIS, & MANAGEMENT OF POSTPARTUM BLUES & DEPRESSION Kellie Flood-Shaffer, MD, FACOG Chairman, Women s Health acclaim Physician s Group OBJECTIVES Define and discuss postpartum blues and depression (PPD) Review current Texas laws and statutes regarding evaluation and management Review prevalence of postpartum blues and depression in USA Consider guidelines for the Primary Care Provider for initiation and continuation of care DISCLOSURES Paid speaker for TEVA Pharmaceuticals (Paragard) 1

2 DEFINITION PER DSM IV Subcategory of Major depressive disorder with onset during the puerperium with sad mood lasting at least 2 wks beginning within 4 weeks of delivery & accompanied by at least 4 other symptoms; When diagnosing PPD, the symptoms of depression use the acronym SIGECAPS: Sleep- insomnia or hypersomnia Interest- loss of interest or pleasure Guilt- feelings of worthlessness Energy- fatigue Concentration- diminished ability to think or make decisions Appetite- eating too much or too little Psychomotor- generalized slowing of movements Suicidality- preoccupation with death or hopelessness WHO ARE THESE WOMEN? INCIDENCE/PREVALENCE 50-80% of postpartum women experience Baby Blues All cultures endorse evidence of postpartum blues Usually peaks at 3-5 days postpartum, self-limited Tearfulness, mood lability and emotional reactivity 25-40% of postpartum women experience Postpartum Depression(PPD) Closely associated with first pregnancy Closely associated with prior history of depressive disorder Closely associated with substance abuse/dependence Nearly always requires active intervention (varying degrees) **Some estimates suggest up to 18% of new fathers experience PPD** 2

3 WHO IS THIS WOMAN? HOUSE BILL 341-THE ANDREA YATES BILL In an attempt to address this public health problem, the State of Texas enacted legislation, House Bill (also known as the Andrea Yates Bill ), which went into effect on September 1, This law requires healthcare providers who treat pregnant women to provide them with resource information regarding counseling for postpartum depression and other emotional traumas associated with pregnancy and parenting. DO YOU KNOW What (local) resources are available in your community for management, therapy and ongoing treatment for depression? Including postpartum depression Do you provide your patients with this information? 3

4 POSTPARTUM DEPRESSION/TEXAS LAW Texas HB2079, 2016, designated May as Postpartum Depression Awareness Month. Governor Greg Abbott s proclamation: This month will be dedicated to educating the public about maternal mental health & the resources available to new mothers struggling with anxiety, depression & other conditions. budget for the biennium, I proposed additional funding to provide screenings & treatment for postpartum depression to women s health services for low-income women. By raising awareness and increasing the likelihood of early detection, we can help women from all walks of life. At this time, I encourage all Texans to learn more about this important issue. Together, we can work toward a brighter future for the Lone Star State. Month_2016.pdf POSTPARTUM DEPRESSION/TEXAS LAW HB3318, potentially the first infanticide law in the United States, was introduced in 2009 by Representative Jessica Farrar (D-Houston) and would apply to women who commit the crime within 12 months of giving birth. If jurors find a defendant guilty of murder, they can take testimony about postpartum issues into consideration during the trial s punishment phase History of depression First pregnancy Being very young Significant stress Lack of social support Relationship issues Unrealistic parenting expectations High-needs infant Weak support system Unplanned pregnancy Substance abuse or dependence RISK FACTORS 4

5 CAUSES Operative Delivery Adverse pregnancy outcome Neonatal Hospitalization Hormonal Shifts ( low estrogen & progesterone, altered thyroid hormones) Altered Body Image Sleep Deprivation/sleep disturbances Fatigue Feelings of inadequacy ( not a good mother ) Perceived lack of relationship/social support Depressed mood or severe mood swings* Excessive crying* Difficulty bonding with baby Withdrawal from family and friends Loss of appetite or overeating Insomnia or hypersomnia Overwhelming fatigue* or loss of energy Reduced interest & anhedonia Intense irritability and anger Feelings of worthlessness, shame, guilt or inadequacy Diminished ability to think clearly, concentrate or make decisions Severe anxiety and panic attacks Thoughts of self-injury or injury to baby Recurrent thoughts of death or suicide SYMPTOMS COMPLICATIONS For mothers. Untreated : can last for months or longer. Can become a chronic depressive disorder. Risk of psychosis or fugue state Treated: increased risk of future episodes of major depression For fathers. Can have a ripple effect, causing tremendous emotional strain Risk of depression for father may also increase. Already at increased risk of depression, whether or not their partner is affected. (change in marital relationship, competition for partner s affection, adjustment to partner s changing body, feelings of inadequacy) For children. Children of untreated mothers are more likely to have emotional & behavioral problems (sleep disorders & feeding difficulties, excessive crying, failure to thrive & attention-deficit/hyperactivity disorder). Delays in language development are more prevalent 5

6 BARRIERS TO CARE Socioeconomic Availability of or Access to qualified counselors and therapists Stigma: Personal pride/embarrassment Partner pride/embarrassment (domestic violence may also play a role) Societal misinformation Cultural taboos (Religion, ethnicity, race, country of origin) DIAGNOSTIC TESTING Edinburgh Depression Questionnaire Interview patient and possibly family within HIPAA parameters Labs: TSH, T3 & T4, estradiol, progesterone levels Consider drug screening if appropriate by history or index of suspicion TREATMENTS General Patient counseling on: Increase rest via strategic napping and sharing nighttime feeding duties* Accept help from family and friends (for babysitting, nighttime feeding, housekeeping, etc.) Connect with other new moms (blogs, support groups, Stroller-Fit) Create time to take care of yourself (Mommy s day out) Avoidance of self-medicating with alcohol and/or other drugs Psychotherapy Trained Psychologist, Counselor, Psychiatrist Medications:* Single, higher dose medication preferred over multiple meds Antidepressants (SSRIs) Mood stabilizers Antipsychotics *Breastfeeding can present challenges/opportunities Electroconvulsive Therapy (ECT) 6

7 Antidepressants Tricyclic/Heterocyclic- not used as frequently as in past Amitriptyiline Nortryptiline Desipramine MEDICATIONS SSRI-most commonly used especially postpartum (lactation safety) Fluoxetine Paroxetine Sertraline Citalopram Other-also commonly used Bupropion Duloxetine Venlafaxine MEDICATIONS Mood stabilizers Lithium carbonate not recommended in pregnancy or lactating women Carbamaxine Valproic acid not recommended in pregnancy MEDICATIONS Antipsychotics Most of the patients in this category will likely need some hospitalization and lactation is no longer an option. Haloperidol Chlorpromazine Thiothixene Quetiapine Respiradone 7

8 LIFESTYLE & HOME REMEDIES Healthy lifestyle and dietary choices (yoga, meditation, exercise) Ask for help (family, friends, professional) Avoid Isolation (support groups, family, friends) Set realistic expectations Make time for yourself (spa day, massage therapy, talk therapy, journaling/blogging) Take time for your marriage and other children ALTERNATIVE THERAPIES Herbals (St. John s Wort), vitamins/minerals(sam-e, Vit B, omega 3 fatty acids), Acupuncture, Light therapy-----unfortunately, data dose not show improvement over placebo with any of these. COPING & SUPPORT Requires long-term investment (patient, family, providers) and frequent visits Most successful in an interdisciplinary environment for most patients (Ob/Gyn, PCP, Pediatrician, Counselor) May require multiple therapeutic modalities Social Media playing a larger role Social and cultural perspectives must be considered stigma surrounding postpartum depression is wide-spread & can have devastating consequences PREVENTION Appropriate & in-depth psychiatric history at pre-conceptual counseling visit, reevaluate at initial prenatal visit (personal and family history are vital) Ask patient about mental health at each prenatal visit Edinburgh depression questionnaire (during and after pregnancy). Provide resources Early postpartum visit at 2 wks with Edinburgh questionnaire Traditional postpartum visit at 6 wks with Edinburgh questionnaire Early counseling and intervention as indicated with therapy and/or medication 8

9 MEDIA The Dark Side of the Full Moon The intimate story of pregnancy and postpartum mood and anxiety disorders as well as psychosis and the complicity within the medical community to effectively screen, refer, and treat the 1.3 million mothers affected each year in the United States. follow two moms on a life-changing journey, revealing the inconsistencies of care when maternity and new motherhood meet madness; exposing the complicated web where no one is asking, no one is listening, and help is not available. The intimate story of pregnancy and postpartum mood and anxiety disorders as well as psychosis and the complicity within the medical community to effectively screen, refer, and treat the 1.3 million mothers affected each year in the United States Director: Maureen Fura MEDIA 1.When The Bough Breaks is a feature length documentary about postpartum depression and postpartum psychosis. Narrated and Executive Produced by Brooke Shields, this shocking film uncovers this very public health issue which affects one in five new mothers after childbirth. The film follows Lindsay Gerszt, a mother who has been suffering from PPD for six years. Lindsay agrees to let the cameras document her and give us an in depth look at her path to recovery. We meet women who have committed infanticide and families who have lost loved ones to suicide. Babies are dying, women aren't speaking out and the signs are being missed. When The Bough Breaks takes us on a journey to find answers and break the silence 2. Will be released May 2017 RESOURCES FOR YOU & YOUR PATIENTS Behind the Smile: My Journey Out of Postpartum Depression by Marie Osmond, Marcia Wilkie (Contributor), Judith Moore (Contributor) Warner Books (2001) Beyond The Blues: Prenatal and Postpartum Depression by Shoshana Bennett and Pec Indman; Moodswings Press (2002) Overcoming Postpartum Depression & Anxiety by Linda Sebastian LPC (1998) Postpartum Depression: Every Woman's Guide to Diagnosis, Treatment, and Prevention by Sharon L. Roan; Adams Media Corp. (1998) This Isn't What I Expected: Overcoming Postpartum Depression by Karen Kleiman and Valerie Davis Raskin; Bantam Books (1994) 9

10 REFERENCES Diagnostic and Statistical Manual of Mental Disorders IV 2008 Diagnostic and Statistical Manual of Mental Disorders V, 2013 Use of Psychiatric Medications During Pregnancy and Lactation; ACOG Practice Bulletin Number 92, April 2008 Clinical Updates in Women s Health--ACOG Vol 1 #2, Depression in Women, 2002 Vol VII #5, Mood and Anxiety Disorders, 2008 THANK YOU FOR YOUR ATTENTION 10