April 11, 2014 for 41 st Annual Child Abuse Conference La Sierra University, Riverside, CA

Transcription

1 Maternal Mental Health Disorders: Symptoms, Assessment, and Interventions Lisa Dryan, LCSW Chair of the Inland Empire Perinatal Mental Health Collaborative and Director of Mental Health for Harmony Behavioral Health at The Wylie Center April 11, 2014 for 41 st Annual Child Abuse Conference La Sierra University, Riverside, CA Many slides in this presentation were taken with permission from a presentation by Margaret Howard, Ph.D. on April 19, 2011 at California Baptist University

2 Inland Empire Perinatal Mental Health Collaborative Vision: To promote maternal and family mental health by raising awareness, decreasing stigma and providing effective resources for women experiencing perinatal mood disorders. Mission: To increase prevention efforts, screening, and treatment of women with perinatal mood disorders to reduce child abuse and to promote long term quality of life of the mother and her family.

3 Who Joined? The Wylie Center California State University San Bernardino San Bernardino County Behavioral Health Riverside County Department of Mental Health Riverside and San Bernardino County Public Health Riverside County WIC Many area hospitals and non-profits First 5 San Bernardino Inland Regional Center Women who have experienced these disorders And many, many more.

4 Why We Came Together? Garrison Burchett

5 Risk for Homicide The Center for Disease Control states that your highest lifetime risk for homicide is in the first year of life Most likely at the hands of a parent: Reasons: Mental Health Substance Abuse Domestic Violence

6 Historical vs. current thinking Pregnancy once thought to be protective against major mood disorders Current data suggest prevalence of major depression does not change as a function of pregnancy Evans et al BMJ 2001;323:

7 Maternal Suicide Leading cause of death in women within first year after giving birth in England and Australia * More lethal and violent means of suicide than in non-perinatal women Increased suicide attempts following fetal demise or infant death Lindahl V et al., Arch Womens Ment Health 2005;8:77-87; Comtois KA et al., Am J Obstet Gynecol 2008;199:120.e1-5.

8 Suicide During Pregnancy 41% of violent deaths of pregnant women were due to suicide.

9 How Many People May be Suffering? According to Postpartum Support International, between 15 20% of pregnant/postpartum women have experienced a maternal mental health disorder. One study by Samantha Meltzer- Brody, M.D., MPH from the Univ. of North Carolina s Center for Women s Mood Disorders, up to 35% of women living in poverty experience a perinatal mood disorder.

10 Prevalence of Chronic Disease in Pregnancy (%) MDD Htn DM Asthma 9 6 Prevalence Obstetric screening for depression should occur as routinely screening for diabetes Evans et al BMJ 2001;323: Centers for Disease Control

11 Why should we care? Why should we screen and treat? Anxiety and stress are emerging as having a more potent impact on fetal neurodevelopment than depression. At 17 mos kids with high cortisol levels in amniotic fluid performed more poorly on Bayley tests than controls. 4th World Congress, O Donnel in press, Goodman & Goodman 2011

12 According to the American Academy of Pediatrics: Postpartum Depression (PPD) is the most common complication of childbearing

13 Teen mothers are at increased risk. There is no more Adolescent Family Life Program in Riverside County. What about SB County?

14 Maternal Mental Health Disorders

15 Common Types of Maternal Mental Health Disorders 90% 70% - 85% of all mothers 80% 70% 60% 50% 40% 30% 20% 10% 3% - 5% of all births 15% - 20% of all women who give birth 0.01% 1 to 2 of 1,000 births Postpartum Obsessive Compulsive Disorder Postpartum Depression Baby Blues Postpartum Psychosis 0% Postpartum Obsessive Compulsive Disorder Postpartum Depression Baby Blues Postpartum Psychosis

16 New study on 10,000 women 21% had PPD 33.4% started in pregnancy 19.35% had thoughts of harming themselves Wisner, KL, JAMA Psychiatry, March 2013

17 Postpartum Blues Mood swings, anxiety, irritability, tearfulness Prevalence 15-85% Not a psychiatric diagnosis Onset within 72 hours, resolves within 2 weeks Responds to support and reassurance 20-25% 25% will develop MDD Occurs transculturally Henshaw C et al., J Psychosom Obstet Gynaecol 2004;25:267-72; Beck C et al., J Affect Disord 2009;113:77-87.

18 Postpartum Depression is NOT related to: planned vs. unplanned status education race religion sex of infant mode of delivery

19 ..but is related to: (Risk Factors) Prior PPD Mental health problems during pregnancy or at any other time in her life. Family history of mental health problems Diminished social support, (especially marital) Current or history of stressful life events (e.g. trauma, poverty, unwanted pregnancy) Adolescence with psychosocial stress Multiple births ¹Wisner et al (2006) JAMA for review

20 I I never thought I would have postpartum depression..i thought I would be overjoyed.instead I felt completely overwhelmed. This baby was a stranger to me. I didn t t feel joyful. I attributed feelings of doom to simple fatigue and figured that they would eventually go away. But they didn t; in fact, they got worse. I wanted her to disappear. I wanted to disappear. At my lowest points, I thought of swallowing a bottle of pills or jumping out the window of my apartment. Brooke Shields, 7/2005

21 .including mothers who adopt their babies 28% of a sample of 86 women reported depressive sx within 4 wks of adoption Mothers who adopt their babies also experience: -Sleep deprivation -Significant stress -Role change -Social pressure to be happy - Often preceded by infertility, home study -22% were infants w/special needs Payne J et al, Arch Women s Ment Health 13: , 2010

22 AND including MEN In a 2011 study published in Pediatrics, 7 percent of fathers were assessed as depression. Depressed fathers reading to kids: 41% Non-Depressed fathers reading to kids: 58% Fathers with depression are 3 x more likely to spank their child as nondepressed fathers. R. N. Davis, M. M. Davis, G. L. Freed, S. J. Clark. Fathers' Depression Related to Positive and Negative Parenting Behaviors With 1-Year-Old Children. Pediatrics, 2011; DOI: /peds

23 More on Dad s Depression in fathers in the postnatal period is associated with later psychiatric disorders in their children, independently of maternal postnatal depression. This is an important opportunity for public health intervention. J Am Acad Child Adolesc Psychiatry April; 47(4):

24 Postpartum depression I know I should be happy, but I m not

25 Symptoms of Perinatal Depression Symptoms include prolonged periods of: Low mood and Irritability; Poor quality and lack of sleep Inability to feel pleasure; Fatigue; Appetite disturbance Guilt Decreased concentration Indecisiveness; Feelings of worthlessness and/or despair; Thoughts about harming herself; Thoughts of harming her infant or other children. Episodes last two weeks or more and may last for a period of weeks or for longer than a year. Women experiencing these symptoms need immediate mental health evaluation and treatment.

26 ANXIETY DISORDERS POSTPARTUM

27 Symptoms of Postpartum Obsessive Compulsive Disorder (OCD) Horrifying, intrusive thoughts of stabbing or suffocating a newborn child Unwanted images of throwing or dropping a baby Disturbing thoughts of sexually abusing a child Fear of accidentally harming a child through carelessness Intrusive thoughts of accidentally harming the fetus by exposure to medications, environmental toxins, chemicals, or certain foods Fear of being responsible for giving a child a serious disease such as herpes or AIDS Fear of making a wrong decision (i.e., getting inoculations, feeding certain foods, taking antidepressants) leading to a serious or fatal outcome

28 Postpartum Obsessive Compulsive Disorder (OCD) Compulsions Hiding or throwing out knives, scissors, and other sharp objects Avoiding changing soiled diapers for fear of sexually abusing a child Avoiding feeding a child for fear of accidental poisoning Repeatedly asking family members for reassurance that no harm or abuse has been committed Avoidance of certain foods, medications, or normal, everyday activities for fear of harming the fetus Monitoring self for perceived inappropriate sexual arousal Avoiding news articles and TV shows related to child abuse or infanticide Repeatedly and excessively checking in on a baby as he/she sleeps Mentally reviewing daily tasks and events in an attempt to get reassurance that no one has not harmed a child or been responsible for harm to a child

29 Depression & Anxiety Go Hand in Hand

30 What do women say? I don t feel like myself. I get angry for the littlest things I feel very alone I know this isn t normal, but I can t change it. I am just so overwhelmed I stopped watching the tv because if a news story comes on about a child, I won t be able to get it out of my head.

31 Postpartum Psychosis

32 POSTPARTUM PSYCHOSIS IS RARE Only 1 2 of every 1000 women who give birth will experience this. That means 600 to 1200 women and infants are at risk in the Inland Empire

33 Andrea Yates Family history of bipolar disorder, MDD Was pregnant or lactating Isolated due to homeschooling children Discharged from inpt psych hospitalization on May 22 Meds: haldol, remeron, effexor, Outpt follow-up--haldol d/c d remeron and effexor continued and told by MD to think positively Mood stabilizer was never prescribed

34 Symptoms of Postpartum Psychosis Euphoria; Over-activity; Decreased sleep; Loquaciousness; Flight of ideas; Increased sociability; Disinhibition; Irritability; Violence and delusions which are usually grandiose or religious in content; Highly disorganized speech; and Extreme excitement. Some switch from mania to depression (or vice versa) within the same episode.

35 Psychosis is a Medical Emergency Do not delay for any reason.

36 Other less know maternal mental health issues PTSD and traumatic births Rape and its impact on birth Complications from Eating Disorders Panic disorders Etc.

37 TREATMENT Support groups Family / friend support Exercise as indicated by MD Sunshine Relaxation / meditation / yoga Cognitive Beh. Tx Interpersonal Tx

38 MEDICATION Weigh risks of fetal or infant exposure to untreated maternal mental health disorder against risks of exposure to medication

39 Questions to ask History of mental illness Number of children in the home and ages. When did she last give birth? How long is she / he (don t forget fathers) sleeping each night? Has she / he gone without sleep for 48 hours or more and it wasn t due to the infant? What kind of social support is available for this family? Is she receiving care from a medical MD for her pregnancy? Has she / he recently been in an inpatient program or under the care of a psychiatrist? Has she ever had a miscarriage, stillborn, or other traumatic birth problem? Did she receive tx for this? Is she / he using any substances?

40 Let s get ahead of the curve and give women and families what they need? Mother-Infant in-patient hospitalization where mother and child are NOT separated unless it is therapeutically necessary. One is opening at Long Beach Community Hospital in a few weeks Mother-Infant Day Treatment program. There are currently 4 in the US. WHY DON T WE DO THIS IN THE INLAND EMPIRE?

41 What Happens to Children When Mother s Mental Illness is Left Untreated? Just the Facts

42 Depressed mothers are less likely to: Tell stories Read stories Sing songs Engage in verbal repetition Offer explanations Ask questions Are less synchronized with their infants and children

43 Depressed Mothers exhibit: perception of infants as bothersome preoccupation / withdrawal / irritability anxious or avoidant attachment positive interactions (talking, gazing, playing)

44 Toddlers of Depressed Mothers: Have lower frustration tolerance Are less easily soothed Are more angry, irritable, tearful Mild stress more likely to result in higher anxiety

45 The Good News: There is clear evidence that as maternal depression improves, there is a significant reduction in reported behavioral problems of their children.

46 New Mother s Support Group Started in Jan, 2009 No funding WIC clinic in Rubidoux Now has a PEI grant of 1.2 million dollars to provide support groups in Riverside County Amy Larsen, R.N (951) Want to do the same in San Bernardino County

47 To Screen or Not to Screen and the Avoidance of Unintended Consequences

48 What You Can Do To Help? Listen more than you speak if you suspect someone has a mental health problems If you suspect postpartum psychosis, this is a medical emergency and person should be taken immediately to a hospital or dial 911. Refer to the CARES line at RCDMH if the person has MediCal: (800) , to non-profit mental health treatment programs for those who have no private insurance or MediCal, or to private insurance if applicable. Refer to Wylie Center. Under our Kaiser Grant we will be able to provide individual, family, and couples counseling Refer to Riverside County Public Health and their FREE COUNTY-WIDE support groups in English and Spanish at (951) or (951) Get involved with NAMI (National Alliance for Mental Illness) Call your legislator and insist on increased spending for a broad range of mental health treatment programs.

49 Useful Websites (Inland Empire Perinatal Mental Health Collaborative)

50 Questions? We have to think about mental health care in a public health framework. Public health measures solved rickets, cholera, people dying when they were 30. But when it comes to mental illness, we re not treating sick people (Dee Roth, a member of the National Advisory Council of the federal Substance Abuse and Mental Health Services Administration (SAMHSA) from Mother Jones, 2013 Schizophrenic. Killer. My Cousin by Mac McClelland)