Elizabeth Hopfenspirger, MSN, RN, FNP-BC

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1 Elizabeth Hopfenspirger, MSN, RN, FNP-BC

2 Identify the six types of perinatal mood disorders Discuss the various screening tools used in diagnosing perinatal mood disorders Discuss possible treatments used in perinatal mood disorders Identify informational and support resources

Postpartum depression is now considered a major public health problem (Almond, 2009) Many consider it to be the leading childbirth complication 10-20% of women suffer (Zauderer,

3 Postpartum depression is now considered a major public health problem (Almond, 2009) Many consider it to be the leading childbirth complication 10-20% of women suffer (Zauderer, 2009) Can happen up to 1 year (some studies state 2 years) postpartum Baby Blues time frame: 80% experience. Immediately following birth and up to 2-4 weeks postpartum (PSI, 2010)

4 Postpartum Depression Postpartum Anxiety Postpartum OCD Postpartum Psychosis Postpartum PTSD Postpartum Panic disorder Many women have a combination of at least two of the above (Bennett & Indman, 2003)

5 Symptoms can start anytime during pregnancy or the first year postpartum. They include the following: Feelings of anger or irritability Lack of interest in the baby Appetite and sleep disturbance Crying and sadness Feelings of guilt, shame or hopelessness Loss of interest, joy or pleasure in things you used to enjoy Possible thoughts of harming the baby or yourself 15% of postpartum women will experience. (PSI, 2010)

6 The symptoms of anxiety during pregnancy or postpartum might include: Constant worry Feeling that something bad is going to happen Racing thoughts Disturbances of sleep and appetite Inability to sit still Physical symptoms like dizziness, hot flashes, and nausea 6% of pregnant women and 10% of postpartum women will experience. (PSI, 2010)

7 Symptoms of postpartum OCD can include: Obsessions, also called intrusive thoughts, which are persistent, repetitive, spontaneous thoughts or mental images related to the baby. These thoughts are very upsetting and not something the woman has ever experienced before. Compulsions, where the mom may do certain things over and over again to reduce her fears and obsessions. This may include things like needing to clean constantly, check things many times, count or reorder things. A sense of horror about the obsessions Fear of being left alone with the infant Hypervigilance in protecting the infant 3-5% of new mothers experience. (PSI, 2010)

8 Symptoms of postpartum psychosis can include: Delusions or strange beliefs Hallucinations (seeing or hearing things that aren t there) Feeling very irritated Hyperactivity Decreased need for or inability to sleep Paranoia and suspiciousness Rapid mood swings Difficulty communicating at times Occurs in.01% of births. It s very rare and the onset is usually sudden, most often within the first 4 weeks postpartum. (PSI, 2010)

9 Symptoms of postpartum PTSD might include: Intrusive re-experiencing of a past traumatic event (which in this case may have been the childbirth itself) Flashbacks or nightmares Avoidance of stimuli associated with the event, including thoughts, feelings, people, places and details of the event Persistent increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response) Anxiety and panic attacks Feeling a sense of unreality and detachment Occurs in 1-6% of postpartum women. Due to real or perceived trauma during delivery or postpartum period. (PSI, 2010)

10 A specific form of anxiety in which the woman experiences physical symptoms such as: shortness of breath chest pain sensations of choking, dizziness, derealization hot or cold flashes trembling restlessness palpitations numbness tingling Occurs in 1-6% of postpartum women. Due to real or perceived trauma during delivery or postpartum period. (Zauderer, 2009)

11 Symptoms of prenatal depression and anxiety include: Sadness and unusual weepiness Lethargy Anxiety Insomnia Fear of pregnancy Low appetite Rumination Regret Intense fears Occurs in 13-15% of pregnancies. (PSI, 2010)

12 71% who go off their medications during pregnancy will have a relapse before the end of pregnancy 50% of women with bipolar d/o are 1 st diagnosed in the postpartum period Women who stopped mood stabilizers had 2x risk of recurrence, 4x more rapidly than women on medication Most recurrences were depressive or mixed, often in the 1 st trimester (PSI, 2010)

13 Bipolar I: Alternating periods of depression and elevated mood/mania Elevated mood symptoms euphoria or agitation, decreased need for sleep, increased productivity, pressured speech, increased energy With hypomania, functioning is improved, whereas with mania, functioning is impaired. (PSI, 2010)

14 Bipolar II: Over 60% misdiagnosed with unipolar depression Depression symptoms more severe than unipolar depression Considered a PPD imposter History may include: Treatment resistant depression Poor response to antidepressants Mood swings, moody Mania/hypomania May not cause functional impairment (PSI, 2010)

15 Perinatal Mood & Anxiety Disorders can affect any woman of any age, race or economic background who: Is pregnant Has given birth within the last year (living or stillborn) Has ended a pregnancy or miscarried *Causes & Risk Factors (PSI, 2010)

16 PHQ-9 Edinburgh Postnatal Depression Scale (EPDS) Postpartum Depression Screening Scale (PDSS) Postpartum Depression Predictors Inventory Revised (PDPI-R)

Nine-item Likert depression module Consists of actual criteria on which the diagnosis of major depression is based Relatively high positive predictive

17 Nine-item Likert depression module Consists of actual criteria on which the diagnosis of major depression is based Relatively high positive predictive value, due to its brevity Considered to be the best available depression screening tool for primary care Non-specific for PPD (Gjerdinger & Yawn, 2007)

18 The EPDS was developed for screening postpartum women in outpatient, home visiting settings, or at the 6 8 week postpartum examination A ten-item scale, typically self-administered, requiring about five minutes to complete Has been utilized in 23 countries and carries a significant level of sensitivity (86%) and specificity (78%) in identifying those at risk of or potentially suffering from either prenatal or postpartum depression. (Gjerdinger & Yawn, 2007)

19 Developed to indicate the existence and degree of symptoms that make up PPD. Used to screen for PPD and is the first step in a series of testing for PPD Self-administered, 35-item Likert scale (Beck & Gable, 2003)

20 Consists of seven dimensions sleeping/eating disturbances anxiety/insecurity emotional lability mental confusion loss of self guilt/shame suicidal thoughts (Beck & Gable, 2003)

21 The PDPI is a tool to identify women at risk for developing postpartum depression. Guide questions are given for 13 risk factors. The clinician uses these questions during the interview process. (Beck et al., 2006)

22 Risk factors prenatal depression life stress social support prenatal anxiety marital relationship/ satisfaction history of depression self-esteem unwanted/unplanned pregnancy marital status socioeconomic status child care stress infant temperament maternity blues (Beck et al., 2006)

23 You can't concentrate. You can't focus. You can't remember what you were supposed to do. You feel like you're in a fog. You feel disconnected. You feel strangely apart from everyone, like there's an invisible wall between you and the rest of the world You are afraid that this is your new reality and that you've lost the "old you" forever.

24 Maybe you're doing everything right. You're thinking "Why can't I just get over this?" You feel like you should be able to snap out of it, but you can't. You are afraid that if you reach out for help people will judge you. Or that your baby will be taken away. You feel a sense of dread all the time, like something terrible is going to happen.

25 You feel guilty because you don't feel the happiness or connection that you thought you would. You may wonder whether your baby would be better off without you. You feel hopeless, like this situation will never ever get better. You feel weak and like a failure. You can't sleep. You are so, so tired, but you can t sleep.

26 Stigma/taboo Women have to do it all SUPER MOM! Judgment Fear Guilt/Shame American cultural and societal expectations/pressures

27 Pharmacotherapy Cognitive Behavioral Therapy (CBT) Therapeutic interventions Social Support

28 The choice of an antidepressant should be guided by the patient s prior response to antidepressants and the side-effect profile of a given medication. Selective serotonin reuptake inhibitors (SSRIs) are ideal first-line agents because some are anxiolytic, nonsedating, and well tolerated. et al., 2010) (Cohen SSRI is first-line treatment sertraline mg fluvoxamine mg citalopram 20-40mg escitalopram 10-20mg fluoxetine 20-60mg (PSI, 2010)

29 Which is greater risks of medicating or risks of not medicating? Have you maximized non-pharmacologic interventions? Which medication to choose Effectiveness Side effect profile Studies during pregnancy and breastfeeding FDA pregnancy risk category Dosing strategies at different stages in pregnancy (MedEdPPD, 2010)

30 Side-effect profile Will it increase sedation in a woman who is already tired from pregnancy? Will it interfere with sleep in a woman who is already repeatedly waking up at night? Will it increase constipation in a woman whose GI tract is already compromised? Will it cause orthostatic hypotension, which could reduce placental perfusion? (MedEdPPD, 2010)

31 Is the woman breastfeeding? Is the medication so sedating that she won t have energy for parenting? Will the medication cause her to sleep through her baby s cries? Will she be more troubled by weight gain due to extra pregnancy weight? Will sexual side effects be more problematic because her sexual desire is already decreased? (MedEdPPD, 2010)

32 Consider better-studied agents: SSRIs: sertraline, escitalopram, fluoxetine TCAs (despiramine, nortryptiline) Avoid when possible: bupropion (preconception, pre-eclampsia) paroxetine (1 st and 3 rd trimesters) Take into account plans to breastfeed (MedEdPPD, 2010)

33 Avoid abrupt discontinuation upon learning of an unexpected pregnancy For SSRIs and TCAs, pharmacokinetic changes may necessitate dose increase as pregnancy progresses For TCAs, serum levels can guide dosing Consider partial dose taper during last month of pregnancy to minimize neonatal adverse effects (MedEdPPD, 2010)

34 CBT cognitive restructuring vs. exposure therapy Therapeutic intervention psychologist, psychiatrist, NP, CNS, LICSW, counselor Social Support family support, support groups, doulas, faith communities

Mother Worsening symptoms Marital distress Poor maternal-infant attachment Poor self-care, nutrition and sleep Increased risk of substance abuse Inc.

35 Mother Worsening symptoms Marital distress Poor maternal-infant attachment Poor self-care, nutrition and sleep Increased risk of substance abuse Inc. risk of suicide Inc. risk of domestic violence Failure to implement preventative health and injuryprevention practices for the child (Gjerdinger & Yawn, 2007)

36 Infant Preterm birth Low birth weight Low Apgar scores Elevated cortisol and catecholamine levels Lower serotonin and dopamine levels Sleep disturbances Infanticide Increased risk for infant undernutrition and poor growth Child Reduced school attainment Difficulties in forming close relationships Lower self esteem Enuresis; sleep problems Inc. risk of psychosocial problems antisocial behavior Behavioral and emotional problems in children somatization, hyperactivity, conduct and emotional maladjustments Adult mental health problems (Avan et al., 2010)

37 Family Disruptive family functioning Marital distress/discord/divorce Paternal postpartum depression Marital dissatisfaction may persist and/or increase, even when depression levels decrease Child abuse and neglect Costs: $30-50 billion in lost productivity and medical costs (Gjerdinger & Yawn, 2007) (Goodman, 2004)

National Postpartum Support International (www.postpartum.net) Marce Society (www.marcesociety.com) MedEd (www.mededppd.

39 National Postpartum Support International ( Marce Society ( MedEd ( Crisis HotLines (Crisis Connection: ; PPSM HelpLine: PPSM; Suicide Prevention Line: ) Awareness Websites Jenny s Light ( Blogs Postpartum Progress (postpartumprogress.com)

40 Mission: To improve and save lives by increasing awareness of all perinatal mood disorders, including postpartum depression.

Almond, P. (2009). Postnatal depression: A global public health perspective. Perspectives in Public Health, 129(5), 221-226. Avan, B., Richter, L.M., Ramchandani, P.G., Norris, S.A., & Stein, A.

41 Almond, P. (2009). Postnatal depression: A global public health perspective. Perspectives in Public Health, 129(5), Avan, B., Richter, L.M., Ramchandani, P.G., Norris, S.A., & Stein, A. (2010). Maternal postnatal depression and children s growth and behavior during the early years of life: Exploring the interaction between physical and mental health. Archives of Disease in Childhood, 95, Beck, C.T. (1992). The lived experience of postpartum depression: A phenomenological study. Nursing Research, 41(3), Beck, C.T. & Gable, R.K. (2003). Postpartum depression screening scale: Spanish version. Nursing Research, 52(5), Beck, C.T., Records, K., & Rice, M. (2006). Further development of the postpartum depression predictors inventory-revised. JOGNN, 35, Bennett, S.S., & Indman, P. (2003). Beyond the blues. Prenatal and postpartum depression. San Jose, CA: Moodswings Press. Cohen, L.S., Wang, B., Nonacs, R., Viguera, A.C., Lemon, E.L., & Freeman, M.P. (2010). Treatment of mood disorders during pregnancy and postpartum. Psychiatric Clinics of North America, 33(2),

42 Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). British Journal of Psychiatry, 150. Gjerdingen, D.K., & Yawn, B.P. (2007). Postpartum depression screening: Importance, methods, barriers, and recommendations for practice. Journal of the American Board of Family Medicine, 20(3), Goodman, J.H. (2004). Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. Journal of Advanced Nursing, 45 (1), Lanza Di Scalea, T., & Wisner, K. (2009). Antidepressant medication use during breastfeeding. Clinical Obstetrics and Gynecology, 52(3), Postpartum Support International (PSI) Zauderer, C. (2009). Postpartum depression: How childbirth educators can help break the silence. The Journal of Perinatal Education, 18(2),

International Childbirth Education Association. Postpartum Doula Program

International Childbirth Education Association Postpartum Doula Program Part 3: Postpartum Emotions Objective: Describe the range of possible postpartum emotions. List two factors that affect postpartum