Postpartum Depression Learning for Babies

Transcription

1 Postpartum Depression Learning for Babies Michael Caucci MD Assistant Professor of Clinical Psychiatry and Obstetrics and Gynecology Vanderbilt University Medical Center 11/3/2016 Disclosure Statement I have no drug company-sponsored grants, am not on any drug company advisory committees, or involved in other engagements that would incur financial bias to this presentation. Some information presented is antecdotal and designated as such. Presentation Objectives To be able to assess for and differentiate between postpartum low mood and postpartum depression To predict risk associated with postpartum depression and other postpartum disorders To formulate a safe, evidence-based postpartum treatment plan 1

2 Identification and Treatment Distinguishing what is psychologically normal for each stage of pregnancy and postpartum vs psychiatric disease Risks, effects, and course of untreated disease during and after pregnancy Triage, management and treatment options Medication and its effect on pregnancy, fetus, neonate, and breastfeeding Normative Perinatal Symptoms Versus Symptoms of Mood Disorders Perinatal Symptoms Feeling slow or less active, lowenergy Mild emotional lability Crying during commercials, being easily frustrated Disturbed sleep Situational low mood or anxiety Poor concentration Change in appetite Psychiatric Illness Suicidal, homicidal thoughts / thoughts of infanticide / violent behavior Extreme, emotional lability out of character for the person Anhedonia, apathy, or grandiosity out of character for the person Overwhelming hopelessness / helplessness Psychosis Worthlessness, inappropriate guilt, burdensomeness, or loneliness Major Depressive Episode (1) 5 during the same two-week period and deviates from baseline function present nearly every day. (S) -Change in sleep (I) - Either depressed mood or diminished interest / pleasure (G)- Feelings of worthlessness or excessive / inappropriate guilt (E)-Change in energy level: fatigue / loss of energy (C)- Diminished ability to think / concentrate or indecisiveness (A)- Unintentional change in weight or appetite (P)- Change in psychomotor activity: agitation / retardation (S)-Recurrent thoughts of death (suicide) 2

3 Defining an Illness Postpartum Depression DSM-IV TR: (what all data, screens, recommendations, etc. are based on) With Postpartum onset = Onset of episode within 4 weeks postpartum DSM-5: (Official in 2013, but not commonly used) With PeripartumOnset -Applied to current or most recent episode with symptom onset during pregnancy or within 4 weeks postpartum Other terms Perinatal, antepartum, antenatal, puerpartum, postnatal Screening for Depression (2-4, 53) ACOG Recommendations Screen at least once during the perinatal period. Women with psychiatric risk factors or history warrant particularly attention. Screening must be coupled with appropriate follow-up and treatment. Ob/Gynshould be prepared to initiate medical therapy and or refer for mental health care. Systems should be in place to ensure follow-up for diagnosis and treatment. Identification and Treatment Distinguishing what is psychologically normal for each stage of pregnancy and postpartum vs psychiatric disease Risks, effects, and course of untreated disease during and after pregnancy Triage, management and treatment options Medication and its effect on pregnancy, fetus, neonate, and breastfeeding 3

4 Postpartum Risks of Untreated Depression Postpartum Syndromes (5, 6) Postpartum Depression: ~ 25% -50% Postpartum Psychosis: 1-2/1000 live births ~15 % in bipolar patients Postpartum Suicide: exact incidence unknown. (51, 52) Postpartum OCD Neonatal effects (15, 20, 21) No studies show a link to malformation. Low birth weight Parenting Disrupted mother-infant bonding. (15, 20, 21) Potential harm to or neglect of the infant by depressed mother (15, 20, 21) Neurodevelopmental Long-term effects on offspring (15, 20, 21) Sudden Infant Death Syndrome (22) Postpartum Syndromes Postpartum Baby Blues Postpartum Depression Postpartum Mania / Hypomania Postpartum Psychosis Postpartum OCD Postpartum Blues (5, 6) Most common 50-85% of adult females within the 2 weeks Transient and technically not a disorder Symptoms Reactivity of mood / irritability Tearfulness Mild depression, anxiety Confusion and forgetfulness Headaches, fatigue Up to 20% postpartum blues Major Depressive Episode within the first year postpartum. (7, 8) 4

5 PostpartumDepression (5, 6) Overall incidence: 10-15% About 2/3 of patients will have their first symptoms within the first six weeks postpartum. Significant depression as well as anxiety and or obsessive symptoms. Postpartum Depression Risk Factors 120% History of depression (6, 9) Depressive episode during pregnancy (6, 9) History of postpartum depression (6, 9) Active or history of an eating disorder (10) History of premenstrual dysphoric disorder (10) Family history of perinatal depression? (55) Heritability estimated at 44-54% vs 32% in non-perinatal depression Percent Incidence 100% 80% 60% 40% 20% 0% ~100% Especially 3 Especially PMDD rd trimester (10) (10) ~50% ~35% ~25% ~25% ~2% No History History of History of Major History of History of of Major Bipolar Depression Postpartum Postpartum Depression Depression Disorder during Depression Bipolar Pregnancy Depression Postpartum Manias Postpartum hypomania (12) Present in 9-20% of those with bipolar disorder Onset within the first 24 hours postpartum Often mistaken for the normal joy of delivery" Postpartum mania Limited data, but cumulative incidence theorized to be 0.03% (13) 5

6 Postpartum Psychosis Incidence is % in the general population (6, 11, 13). 70% of cases have an underlying affective disorder such as bipolar or major depression. This can develop in those with no history of psychiatric illness as well. (14) Onset (6, 11) 26.3 years of age; occurs within the first 2-4 weeks postpartum (as early as 2-3 days postpartum). Symptoms: Severe mood swings, confusion, having delusions of the changeling, hallucinations, decreased need for sleep (11). Prognosis is very good with treatment: With treatment relapse risk is 23% vs 66% without treatment. (14) 75-86% will remain symptom-free after treatment. (11) Postpartum Psychosis Risk Factors History of bipolar affective disorder History of postpartum psychosis Family history of bipolar affective disorder History of postpartum psychosis History of poor sleep Percent Incidence 35% 30% 25% 20% 15% 10% ~15% 30-70% 5% 0%? ~ %??? No History General population History of Major Depression History of Bipolar Disorder Mood episodes during Pregnancy History of Postpartum Depression History of Postpartum Psychosis Postpartum OCD In general ~ 90% of postpartum women have mild, transient intrusive thoughts similar to postpartum OCD Incidence % at 6 weeks postpartum Rapid onset: Mean onset postpartum 2 4 weeks Commonly comorbid with postpartum depression 57% with postpartum depression (intrusive or infanticidalthoughts) vs. 39% with no postpartum depression (obsessional thoughts or OCD like symptoms) Symptoms can persist after resolution of depression. 50% of women with standard OCD reported: Childbirth was the precipitant of the illness Worsening of symptoms in the postpartum period 6

7 Postpartum OCD Obsessions Contamination = 75% Symmetry / Exactness = 33.3% Aggressive Thoughts = 33.3% Higher incidence than standard OCD Severity of symptoms does not differ between both types of OCD (postpartum vs. standard). Symptoms are highly distressing or seen as foreign. There is no elevated risk of aggressive harm to infant if mother has: No psychosis No severe personality disorder Compulsions Ritualistic behaviors (156) Cleaning / Washing = 66.7% (156) Checking = 58.3% (156) Avoidant behavior Avoidance of the feared situation Asking others to care for the baby Avoiding behaviors or objects associated with obsessions Removing the objects from the room Identification and Treatment Distinguishing what is psychologically normal for each stage of pregnancy and postpartum vs psychiatric disease Risks, effects, and course of untreated disease during and after pregnancy Triage, management, and treatment options -The treatment of postpartum disorders starts during pregnancy Medication and its effect on pregnancy, fetus, neonate, and breastfeeding Triage (3) Outpatient Treatment Current mild-moderate mood, anxiety, or stress disorder No current symptoms, but has a history of severe psychiatric illness Schizophrenia or postpartum psychosis Postpartum depression Bipolar disorder, mania or hypomania. A recent episode of severe depression or anxiety No response to pharmacotherapy or psychotherapy in the past Coexisting anxiety, eating disorder, or substance use disorder Emergent Care / Inpatient Current symptoms of severe psychiatric illness Danger to self or others Psychosis, mania, or severe depression, anxiety or stress disorder. Severe eating disorder Moderate-severe addiction with potentially dangerous intoxication and or withdrawal. 7

8 Immediate Postpartum Management (24) Outline the treatment plan Give copy of plan to all involved (team, family, parent) List all pharmacological and other treatments. Recommendations Plan for lactation Support and rest in early postpartum period Minimize sleep deprivation Mobilize support for the mother, partner, mother/infant relationship Initiate early parenting skills Provide regular assessments and monitoring for relapse Length of stay should be longer if monitoring maternal mental state and or pharmacological exposure effect on the infant. Weighing the Risks and Benefits of Medication Degree of impairment caused by active psychiatric disease Effect of psychiatric medication on pregnancy, fetus, breastfeeding Workup and Required Information Chief complaint / current symptoms Stage of pregnancy Prevailing symptoms Symptom Severity Current treatment? Effective? Form of contraception -(pre-pregnancy and postpartum only) Do they plan on breastfeeding? Past symptoms History of psych illness Symptom Severity Past treatment? Effective? Substance use history Rule out substance induced disorder Medical history Rule out psychiatric disorder secondary to a general medical condition. Further questions Risk factors and elements of history to address with specific psychiatric illnesses and other issues that would support initiation of medication Patient Choice: When you think about how impairing your disorder was at its worst do you feel you would be able to tolerate those same symptoms throughout your pregnancy with potential worsening after delivery and still be able to function and care for yourself and your child? 8

9 Calculating Treatment Risk Severity Flow Chart Scoring: - Mild = (0-3) - Moderate = (4-5) - Severe = (6-12) Yes Are symptoms present? No: 0 Eating Disorders Psychosis Mania Depression / Anxiety Any past symptoms? 6 6 Mild: 1 Yes No: 0 See Eating disorders Moderate: 3 Eating Disorders Psychosis Mania Depression / Anxiety Severe: 6 See Eating disorders 6 Mild: 2 Mild: 1 Subtotal Current (0-6) + Subtotal Past (0-6) = Total (0-12) Once complete, proceed to Determining Treatment Direction Moderate: 4 Severe: 6 Moderate: 3 Severe: 5 Direction of Treatment 1. Effective Current Treatment 2. Ineffective Current Treatment; Effective Past Treatment 3. Ineffective Current Treatment; No / Ineffective Past Treatment. 4. No Current Treatment; Ineffective Past Treatment. 5. No CurrentTreatment; Effective Past Treatment 6. No Current or Past Treatment Treatment Risk Category* Mild Moderate Severe D. Taper medication once in B. Continue medication and encourage counseling. counseling. C.Counseling first. If limited effect from counseling, maximize dosage. If intolerant of medication, transition to the effective / another treatment. E. Counseling only A1. If limited effect from A2. Encourage counseling counseling, then start / and restart the effective / start / restart the effective / another / a treatment. another / a treatment. Start / Restart Maintenance Maximize / Transition Discontinue Counseling only * Risk category after application of Tie Breakers - Always consider the patient s choice. Once complete, proceed to Treatment Options by Disorder Direction of Treatment Types Of Treatment Counseling is always recommended if feasible Short-term Cognitive Behavioral Therapy (15, 25) Interpersonal Psychotherapy (15, 25) Antidepressants Rule out bipolar disorder Discontinuation of medication On medication Start / Restart Maintenance Maximize / Transition ECT Placentophagia/ Placentotherapy (54) Hormone replacement? Factors That Support Use Of Medication Patient prefers a medication (9) No access to counseling (9) Poor response to therapy in the past (9) Unable to tolerate medication taper in the past. Postpartum illness Current Psychotic or manic symptoms Severe illness currently History of severe illness History of psychotic disorder 9

10 A Stepwise Progression Of Treatment Supportive counseling x 2 weeks Avoid multiple trials of different agents or polypharmacy, if possible. If effective: Continue supportive therapy If ineffective: Start formal psychotherapy ( 8 sessions) If effective: Continue Psychotherapy If ineffective: Initiation of medication in addition to counseling ( 2 months on a stable dose) If effective: Continue treatment If ultimately ineffective: ECT: only if symptoms are mood related and are severe, treatment resistant If effective: Continue treatment If ineffective: Reassess Identification and Treatment Distinguishing what is psychologically normal for each stage of pregnancy and postpartum vs psychiatric disease Risks, effects, and course of untreated disease during and after pregnancy Triage, management and treatment options Medicationand its effect on pregnancy, fetus, neonate, and breastfeeding Pregnancy Risks of Antenatal Antidepressant Exposure The rate of malformations does not seem to be any more common than at random (~3%). Within this rate exposure to SSRI appears skewed toward cardiac anomalies There are conflicting data on fetal malformations, pregnancy complications, and fetal growth. The bottom line: Safe to use antidepressants in pregnancy in appropriate patients. 10

11 PostpartumRisks of Antenatal Antidepressant Exposure Neonatal abstinence / discontinuation syndrome Occurs in 15-30% of cases (22, 28, 29) Especially when exposed in late pregnancy. Symptoms are mild and transient (22, 28) Onset within the first day of life. (30) Resolution in 75% of cases within 3-5 days (30) Risk factors: Antidepressants + benzodiazepines, third trimester exposure, and increased doses of medication. (31, 32) Other postpartum risks of antenatal exposure Neonatal respiratory distress (34) Jaundice (34) Feeding problems (34) Convulsions (33) Neurodevelopmental Abnormalities (24, 35-37) No consistent evidence Dosing of Medication and Metabolism during Perinatal Period (26) There is an increase in metabolism of medication > 20 weeks EGA. May require dosage increase, divided dosing. There is a decrease in metabolism 2 4 weeks postpartum (26, 27) If side effects do occur, taper dosage. (27) If there are no side effects, continue pregnancy dose for 6 weeks postpartum before tapering or discontinuing. (27) Normal metabolism returns by ~ 12 weeks postpartum. (26) Perinatal Psychotropic Medication Treatment Approach Address breast-feeding early on. Have access to home ovulation predictor kits or home pregnancy tests. Allow at least two months of stability on new medicine or off medicine and tolerance of any side effects before attempting pregnancy. Starting medications: be sure the patient: Hasestablished psychotherapy Is in the severe riskcategory Has chosen medicationmanagement Has failedto respond to eight or more sessions of psychotherapy Discontinuing medications: be sure the patient: Has established psychotherapy Is in a mild risk category Is having significant side effects You are planning on switchingto a different agent Neverdiscontinue a medication abruptly 11

12 Breastfeeding General considerations (38) All psychotropic medications are secreted into breast milk. Breast milk concentrations of medication will vary. Peak concentrations occur 6 to 8 hours after dosing. On-demand breast-feeding disrupts sleep relapse during the postpartum period. Neonatal Metabolic Considerations (39, 40) In full term infants 0-4 weeks postpartum: ~ 1/3 to 1/5 of the adult hepatic drug metabolism capacity. 2-3 months postpartum: will surpass adult metabolism. In preterm infants or infants with impaired hepatic metabolism Defer breast-feeding if on medication. Breastfeeding on Antidepressants (5, 15, 41-50) Drug Compatibility Percentage Dose Exposure (%) Reported Side Effects SSRI Citalopram Caution % (Avg. ~10%) Colic, poor suckle, drowsiness, irritability; irregular breathing, sleep disturbances, hypotonia/hypertonia Escitalopram Caution % (Avg ~8%) Necrotizing enterocolitis Fluoxetine Caution % (Avg. >10%) Transient irritability, sleep disturbances, colic; hypotonia, sedation, poor suckle, fever; hyperglycemia,glucosuria; peripheral cyanosis and unresponsiveness to stimuli Fluvoxamine Yes % Paroxetine Yes % (Avg <4%) Irritability, agitation, feeding problems, nervousness Sertraline Yes < % (Avg <2%) Hypotonia, drowsiness, ear problems, body growth problems; withdrawal syndrome after cessation of breast-feeding (agitation, poor suckle, high-pitched crying, insomnia) SNRI Venlafaxine Yes % - Duloxetine Caution % - Other Bupropion Yes ~2 % - Mirtazapine Yes % (Avg 1.5%) - Trazodone Yes 0.65% - Citations 1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. 2. Muzik, M: Psychiatric illness during pregnancy: Early detection, individualized care can promote health for mother and infant. Current Psychiatry 2012; 11(2): Stewart, DE: Depression during pregnancy. N EnglJ Med 2011; 365: Matthey, S, et. al.: Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale: Implications for clinical and research practice. Arch WomensMentHealth 2006; 9(6): Marchand, WR, et al: Psychopharmacologic management of depression in pregnant women and breastfeeding mothers. HospPhys 2008; Aug: Tam, WH and Chung, T: Psychosomatic disorders in pregnancy. CurrOpinOb/Gyn2007; 19: Leigh, B and Milgrom, J.: Risk factors for antenatal depression, postnatal depression and parenting stress. BMC Psychiatry 2008; 8: Newport, DJ, et. Al.: The treatment of postpartum depression: Minimizing infant exposures. Journal of Clinical Psychiatry 2002;63 [suppl7]: O Hara, MW, et al.: Controlled prospective study of postpartum mood disorders: Psychological, environmental, and hormonal variables. J AbnormPsychol1991; 100: Bloch, M et al, Risk factors for early postpartum depressive symptoms. General Hospital Psychiatry 2006; 28: Sit, D, et. Al.: A review of postpartum psychosis. J Women s Health 2006; 15: Sharma, v, et al. Bipolar II Postpartum Depression: Detection, Diagnosis, and Treatment. Am J Psychiatry 2009; 166: Harlow, BL, et al. Incidence of Hospitalization for Postpartum Psychotic and Bipolar Episodes in Women With and Without PriorPrepregnancyor Prenatal Psychiatric Hospitalizations. Arch Gen Psychiatry 2007;64: Wesseloo, R, et al: Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A Systematic Review and Meta-Analysis: Am J Psychiatry 2016; 173: Levey, L, et al.: Psychiatric disorders in pregnancy. NeurolClin2004; 22: Raphael, D, et al.: Treating anxiety during pregnancy: Just how safe are SSRIs? ClinPsychiatry 2008; 7: Ross, L and mclean, L.: Anxiety disorders in the peripartumand postpartum period: A systemic review. J Clinical Psych 2006; 67: Uguz, F, et al.: Postpartum-onset obsessive-compulsive disorder: Incidence, clinical features, and related factors. J linpsychiatry2007; 68:

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