Mental Health and Women s Health

Transcription

1 Disclosure information I have nothing to disclose. Mental Health and Women s Health Ellen Haller, M.D. Professor of Clinical UCSF Department of Learning Objectives Know what to do when a pt c/o PMS/PMDD Review risks/benefits of antidep during preg Learn about post-partum mental health

2 Premenstrual Syndrome Braverman 2007 PMS described for centuries & across cultures; term 1 st used in 1950s Most women have some PMS symptoms during some of their ~400 menstrual cycles More significant PMS symptoms in ~30% Premenstrual Dysphoric Disorder (PMDD) Cunningham J, 2009; Di Giulio, Reissing % Starts in 20s; worsens over time PMDD dx criteria in syllabus Is now formal dx in DSM-5 For up to 90%, PMDD not dx d For ~40% of pts reporting PMDD, correct dx = premenstrual exacerbation of other d/o Need to r/o other psych d/o and hypothy, then prospectively track sxs Symptoms Symptoms Irritable Depressed Fatigued Days of period Days of period x x x x x Symptoms Symptoms Irritable Depressed Fatigued Days of period Month Grade each symptom daily: None = 0 Mild = 1 Moderate = 2 Severe = 3 Days of period Month April, 2013 Grade each symptom daily: None = 0 Mild = 1 Moderate = 2 Severe = 3

3 Etiology Di Giulio, Reissing 2006 No abnormal levels of hormones No hormonal dysregulation Sensitivity to normal cyclical hormonal changes Which of the following interventions is proven to help reduce PMS symptoms? 1. Progesterone supplementation 2. The antidepressant, bupropion (Wellbutrin) 3. Calcium supplementation 4. Increasing salt intake PMS/PMDD Treatment Kroll, Rapkin, 2006 PMS Treatment with Calcium Thys-Jacobs et al, Am J OB Gyn 1998 Initial approach = basic wellness: Healthy diet Stop smoking Exercise Adequate sleep Stress management Multi-center, randomized, placebo controlled study, N= mg bid x 3 cycles 55% had >50% improvement in global sxs 36% with placebo 48% reduction in total sxs scores 30% with placebo Calcium relieved both emotional & physical sxs HOWEVER, recent study: SSRI better than Ca or PBO for pts with PMDD (Yonkers, 2013)

4 PMDD Treatment with SSRIs Efficacy of SSRIs in PMS Continuous dosing Luteal phase dosing AKA Intermittent dosing Help emotional & physical sxs In gen l, respond to lower doses & quicker Discontinuation sxs rare Margoribanks J et al, Cochran Library, 2013 OCPs for PMDD Joffe, Cohen, Harlow 2003 Not helpful: Progesterone alone & most combo OCPs May make sxs worse Helpful: Yaz Drospirenone 3 mg + ethinyl estradiol 20 mcg Yaz for PMDD Yonkers et al, 2005 Multi-site, DB, RCT N=450, all with PMDD, yo Daily ratings 24 days on & 4 days off (with inert pill)

5 Yaz for PMDD Yonkers et al, 2005 Found signif. diff betw groups Total sx score: 47% in active drug group over 3 tx cycles 38% in PBO group Response (50% in scores) 48% of active drug group 36% of PBO group Drop-outs: 15% vs 4% Most common SE = nausea & intermenstrual bleeding How common is depression in women? Kessler, % of all women will experience at least 1 episode of depression in their lives Boys & girls have equal rates of depression Beginning with puberty, rates for girls Overall, twice as common in women I feel miserable 32 yo with 6 mo h/o depressed mood and: -insomnia -low energy -poor concen. -decr appetite -less interest -passive SI -Fn at work impaired -Sxs began after parents announced div. -Had 1 prior episode depression

6 Treatment Plan for I feel miserable One year later... Course of Cognitive Behavioral Therapy (CBT) Rx with an SSRI Depression significantly improved Pregnancy NOT protective 10-20% of pregnant women dev MDD Risk factors for depression in preg: Prior h/o dep Poor social support Psychosocial stresses Ambiv about pregnancy Course of Depression in Pregnancy Cohen et al, 2006 N = 201 All with > 4 prior MDD episodes but in full remission Recurrence during pregnancy if stayed on meds = 26% Recurrence if d/c meds = 68% 50% in 1 st trimester 90% by end of 2 nd trimester

7 Treatment of Depression During Pregnancy Psychotherapy proven effective Interpersonal Psychotherapy (IPT) Cognitive Behavioral Therapy (CBT) Antidep Rx--main areas of concern: Congenital organ malformations Adverse effects in neonate Impact on child s development: Cognitive Behavioral Which is the most true statement about antidepressants in pregnancy? TCAs During Pregnancy Yonkers et al, SSRIs are completely safe 2. TCAs are contraindicated 3. Not enough data exists to help make an educated recommendation 4. An individualized risk-benefit assessment must guide decision-making 5. SSRIs are contraindicated

8 SSRIs During Pregnancy Bakker, 2012; Diav-Citrin & Ornoy, 2012; El Marroun et al, 2012 No incr rate of congenital malformations BUT, paroxetine may be different Cardiac malformations Now Class D per FDA Level II UTZ at wks Perinatal Effects of SSRIs Levinson-Castiel, 2006 Neonatal adaptation syndrome % exposed neonates Multiple sxs reported Agitation, jitteriness, sleep disturbance Tremor Rigidity Feeding problems Excessive crying Typically resolve w/in 48 hrs w/o medical intervention Consider or d/c of antidep. prior to delivery SSRIs and PPHN Hanley GE & Oberlander RF, 2013 and Wilson et al, /1000 of all live births Manifests w/in 1 st day of life Mortality rate ~10% SSRIs may incr risk 1.8-6X Recent study found key risk factor was C- section before onset of labor (incr risk x5) Other antidepressants during pregnancy Cole et al, 2007; Yonkers et al, 2009 Bupropion: no evidence of congenital malformations Duloxetine, escitalopram, mirtazapine, nefazodone, venlafaxine, and duloxetine Fewer reports; no evidence of congenital malformations

9 Which statement is true? Child development is adversely impacted by: 1.In utero exposure to SSRIs 2.Mother s ability to successfully practice mindfulness 3.Level of severity of mother s depression 4.Presence of depression in the father 5.In utero exposure to heavy metal music Child Development After Fetal Exposure Nulman et al, 2012 Prospective study of kids of depressed women 1. Venlafaxine (n=62) 2. SSRIs (n=62) 3. Untreated depression (n=54) 4. Non-depressed Controls on no meds (n=62) Intelligence and behav outcomes measured when 3-6 yo Grps 1, 2 & 3 had lower IQs and incr behav problems than grp 4 Severity of maternal dep in preg & at testing is what predicted child behav What about risk of autism? Rai et al 2013 What about risk of autism? Rai et al 2013 ASD affect ~1-2% Dysfunctional serotonin signaling may play role in pathogenesis Swedish study; antidep during preg. 1,679 ASD 16,845 controls with data on antidep use Incr risk for ASD if took antidep compared to women with dep who did not Antidep use explained 0.6% of the cases of ASD Assoc found; not clear if causation Hard to determine impact of depression itself Severity not quantified More ill pts more likely to be on meds Unclear if other exposures e.g. Drugs, Etoh...

10 Deciding to Rx Antidep in Pregnancy Yonkers et al, 2009; El Marroun et al, 2012; Diav-Citrin & Ornoy, 2012 Need to perform individual risk:benefit analysis Post-partum mental health Assess severity of anxiety/ depression & h/o response to treatment Document other exposures alcohol, cigs, Rx & OTC drugs Document informed consent I just feel so tired Differential Diagnosis Persistent Depressive D/O 37 yo primip No prior h/o depression Now 7 wks postpartum Sxs: depressed mood fatigue overwhelmed and ashamed anxious about caring for baby; fears mistake appetite insomnia--even when baby asleep AKA Dysthymia Bipolar d/o Substance abuse/dependence Sleep deficit Medical conditions Anemia Thyroid dysfunction Intimate partner abuse Post-partum depression (PPD)

11 Post-partum depression occurs after what percent of live births? % % % % % Spectrum of Postpartum Mood Changes Transient, nonpathologic Postpartum Blues risk for MDD 50% to 70% Serious, disabling Postpartum Depression 2/3 have onset by 6 wks postpartum 10-15% Medical emergency Postpartum Psychosis 70% are affective (bipolar, MDD) 0.01% Cohen LS. Depress Anxiety. 1998:1: PPD Risk Factors Bloch et al, 2005 Psychosocial stress h/o depression h/o PMDD Prior h/o PPD (50% risk) Depression during current pregnancy Therefore,

12 Edinburgh Postnatal Dep Scale Cox, item questionnaire Score of >12 indicates probable PPD In public domain; it s been included in your syllabus PPD Management Recommendations Yonkers et al, 2011; Carter et al, 2010; Apter et al, 2011; Studd & Nappi, 2012 Reassurance & support Postpartum Support International Psychotherapy Interpersonal Psychotherapy (IPT) Cognitive Behavioral Therapy (CBT) Medications Pharmacotherapy for PPD Yonkers et al, 2011; Apter et al, 2011; Studd & Nappi, 2012 Relatively few studies have evaluated antidep specifically for PPD No study compares psychotx & pharmacotx BOTTOM LINE: Assume Rx for PPD has same response as in other depression Psychotropic Drugs During Lactation Davanzo et al, 2011; Sharma & Sharma, 2012 All are excreted in human breast milk As a class, have more data in breastfeeding than any other Sertraline, paroxetine, NTP & IMI are most evidence-based meds Great resource: Lactmed (NIH)

13 Summary PMS/PMDD are real d/o Prospective charting useful tool Mgmt = basic wellness calcium SSRIs intermittently or Yaz SSRIs continuously Depression is more common in women For pregnant pts, complete an individualized risk-benefit analysis 3 classes of postpartum mood disorders Resources Office of Women s Health American Psychiatric Association patient info Center for Women s Mental Health at Mass Gen l Info on meds in breastfeeding (Lactmed)