POSTPARTUM MOOD DISORDERS Identification and Treatment Cheryl Carroll CNM, PMHNP Psych Retreat Greensboro, NC

Transcription

1 POSTPARTUM MOOD DISORDERS Identification and Treatment Cheryl Carroll CNM, PMHNP 2017 Psych Retreat Greensboro, NC

2 Postpartum Depression DSM 5 Major Depressive Disorder Diagnostic Criteria specifer: with peripartum onset Peripartum - Mood Disorder with most recent episode occurring during pregnancy or 4 weeks* following delivery WHO International Classification of Diseases 10 th Revision requires onset of episode within 6 weeks of delivery. Various definition of timing found were from 4 weeks to 12 months postpartum Fifty percent of these women will experience symptoms during the pregnancy NCNA 2017 Psych Retreat

3 Early Assessment

4 Prevalence 1 in 7 women experience peripartum depression (approximately 650, 000) or 10-15%. Some sources site 25% Syphilis 74,702 Chlamydia 1,536,658 Gonorrhea 395,216 HIV 8,500 Hepatitis B 0.6 6% Hepatitis C 1-4% Gestational Diabetes % Proteinuria % Pre-Eclampsia 2-8%

5 Etiology Unknown specified cause, rather likely combination of contributing factors Hormonal Changes (progesterone, estrogen, TSH, oxytocin, cortisol) Genetic Factors Slow Recovery from Birth Injury Traumatic or Disappointing Birth Experience Conditioned Response

6 Risk Factors Financial Difficulty Poor social support Unemployment Single Separation, Deployment, Divorce, Death of Partner Restriction of Activity History of a Mood Disorder

7 Risk Factors Young women < 20 years and Primiparas >35 White and Native women are more likely to report symptoms Latinas and women of African descent are more likely to experience multiple adversities and less likely to receive services Postpartum mood disorders may not differ by race or ethnicity Disparity recognized with initiation and continuation of treatment

8 Clinical Manifestations Unrelenting sadness or irritability Insomnia or hypersomnia Little or no interest in the baby s activities Unable to engage with baby Inappropriate guilt Decreased self worth Frequent crying Recurrent thoughts about death of self and/or infant Marked change in appetite Relationship discord

9 Screening Tools EPDS Edinburgh Postnatal Depression Scale

10 SCORING This is a screening tool not a diagnostic test.

11 To Physicians and Other Healthcare Practitioners: If you are not asking these questions of each postpartum patient, you do not know how she is feeling. Have you had PPD before? Do you have a history of depression? Are you sleeping okay when your baby sleeps? Any changes in your appetite? Are you experiencing anxiety or panic? Are you afraid to be alone with your baby? Do you feel more irritable or angry than usual? Are you worried about the way you feel right now? What worries you the most about the way you feel? Are you afraid you might lose control? Are you afraid of the thoughts you are having? Do you wonder if you're a bad mother? If you are breastfeeding, how important is that to you? Do you ever have thoughts about hurting yourself? Do you find it hard to make decisions? Does your husband know how you are feeling? How do you feel about taking medication if it helps you feel better? Are there other stressful events that are impacting the way you feel? Is there anything you are afraid to tell me, but think I should know? Tips For Professional and Family Support: Do not assume that if she looks good, she is fine. Do not tell her it's normal to feel this way after having a baby. Do not assume this will get better on its own. Do encourage her to get a comprehensive evaluation. Do take her concerns seriously. Do let her know you are there if she needs you. Postpartum Stress Center Questions to Consider For Physicians 2014 The Postpartum Stress Center, LLC Page 1 Disclaimer: These materials are made available for personal use provided there is proper attribution, no changes are made, and no fee is charged.

12 Differential Diagnosis Normal Physiologic Changes Baby Blues Minor Depression BiPolar Depression Postpartum Psychosis

13 Labs CBC Thyroid Panel: TSH, thyroxine (free T4), triiodothyronine (T3), anti-thyroid peroxidase antibody Vitamin D Vitamin B 12

14 Considerations Who is at home? What and who are her support options? What is her feeding method? What is her birth control method? What medications and supplements does she take? What recreational drugs is she using? Is her baby preterm, full term, sick or well

15 Essentials of Wellbeing for the Postpartum Woman Rest Adequate Nutrition Physical Activity Hygiene Positive Human Contact with Other Adults

16 Treatment Modalities Psychotherapy Individual and/or Couples Medication Combination

17 Delayed or Inadequate Treatment Risk for chronic mood disorder Increased risk for suicide Interferes with maternal infant bonding Interferes with breastfeeding Dysfunctional Family Dynamics

18 Breastfeeding A beautiful experience for the most part

19 Breastfeeding Benefits Economic Savings Accelerates Uterine Involution Reduces Maternal Stress by increasing oxytocin, prolactin, neuroendorphin peptides Enhances Weight Loss Prolongs postpartum anovulation Decreases the risk of CVD cumulative effect Decreases the risk of DM II Decreases the risk of breast and ovarian cancer Decreases the risk of infant mortality Sense of Accomplishment

20 Negatives Effects of Breastfeeding Physically Uncomfortable Intrusive Demanding Unshared Responsibility Burdensome Guilt Inducing Lack of Privacy Lack of Flexibility Disempowering

21 Family Affair Household Impact

22 Family Affair 10 25% of partners experience a mood disorder during the postpartum period Impaired maternal infant bonding Altered or delayed infant development Child Psychopathology Cognition delay Increased risk of infanticide

23 Postpartum Medication Use Successful in pregnancy, typically stay with it Use what has been efficacious in the past Start low Avoid polypharmacy if possible

24 SSRIs Low Infant Serum Concentration <10% Paroxetine Sertraline Fluvoxamine Higher Infant Serum Concentration Citalopram Fluxoetine Venlafxine Desvenlafaxine

25 SSRIs cont Escitalopram less studied but likely compatible Duloxetine little data but may be compatible Minacipran very little data

26 Atypical Antidepressants Bupropion likely compatible, but consider alternative use in mothers of premature infants or infants with seizures Mirtazapine likely compatible Agomelatine very little data Vertioxetine very little data

27 Serotonin Modulators Trazodone may be compatible, however data is limited Nefazodone Data is limited, Generally not recommended secondary to riks of hepatotoxicity Vilazodone too little data

28 Tricyclics Considered Compatible Nortriptyline Amitriptyline Clomipromine Desipramine Imipramine Not Recommended Doxepin (30 hour half life)

29 MAOIs Not Recommended Very little information High SE Profile Multiple Food Interactions

30 Benzodiazapines Short Term Medication Choose a low dose with a short half life and no metabolite Lorazepam Short half life, no metablite Clonazepam No active metabolite, but long half life Diazepam - Avoid

31 Hypnotics Zolpidem Considered compatible with breastfeeding Zaleplon Considered compatible with breastfeeding

32 Antihistamines Used for sleeplessness and anxiety Hydroxyzine, Diphenhydramine, Doxylamine, Levocitirizine, Citirizine are drying to breast milk

33 Stimulants Seem compatible with breastfeeding Low concentrations in breast milk and infant serum level Less available information on atomoxetine

34 AntiPsychotic 1 st Generation Likely Compatible Haloperidol Chlopromazine Very Little Data Perphenazine Trifluoperazine Zuclopenthixol

35 AntiPsychotic 2 nd Generation Likely Compatible Olanzapine most studied suggests compatibility Quetiapine suggested compatibility Paliperidone Lurasidone likely compatible at low dosage but needs more study Very Little Data Ariprazole Asenapine Ziprasidone

36 Antipsychotic cont Clozapine is not recommended secondary to increased risk of hematologic toxicity Lithium Mixed reviews. Requires drug levels at same schedule as adult. Requires more mature kidney function, so possibly a cumulative effect.

37 Anti Epileptics Likely Compatible with Breastfeeding Topiramate (Low) Gabapentin (Low) Levitiracetam (Low) Carbamazepine Lamotrigine (High serum concentration 90% of maternal serum) Phenytoin Valproate Incompatible with breastfeeding Phenobarbital Primidone Diazepam

38 Substance Use Inhibitors Buprenorphine likely compatible Disulfiram Very little available data. May alter the taste of breast milk Methadone likely compatible, low milk and infant serum concentration Naltrexone likely compatible, however too little data available Varenicline Too little data available

39 Patient Resources You are the diagnostic tool most effective for these women

40 Patient Resources Postpartum Support International Postpartum Stress Center County Health Department Private and Public Health Care Facilities

41 Professional Reources Maternal Mental Health Now online training Postpartum Action Institute 2 day training course Santa Barbara, California Postpartum Stress Center 12 hour Training course Rosemont, Pennsylvania Postpartum Support International 2 day course Portland, Oregon The Seleni Institute, Perinatal Mood Anxiety Disorders 2 day course New York, New York

42 CONTACT INFO, REFERENCES, ETC. Cheryl Carroll CNM, PMHNP Women s Health Alliance ccarroll27@hotmail.com 2017 Psych Retreat GREENSBORO, NC