F Mental Illness FMF-Toronto November 15, 2018 Advances in Care for Pregnant and Postpartum Women With Mental Illness Simone Vigod, MD, MSc, FRCPC Psychiatry, Women s College Hospital William Watson, MD, FCFP Family Physician, St. Michael s Hospital 1
Faculty/Presenter Disclosure Faculty: Dr. Bill Watson, Dr. Simone Vigod Program: FMF Toronto Nov 15/18 Relationships with commercial interests: No relationships to declare
Disclosure of Commercial Support This program has received no commercial financial support This program has received no commercial in-kind support
Mitigating Potential Bias - N/A
Speaker Bios Dr. Watson is an Associate Professor, Department of Family and Community Medicine, University of Toronto, and Staff Physician at St. Michael s Hospital Family Practice Unit. His interests include postpartum depression, parenting and child health. Dr. Simone Vigod is an Associate Professor, Department of Psychiatry, Faculty of Medicine, University of Toronto, and a Staff Psychiatrist and Lead of the Reproductive Life Stages Program at Women s College Hospital in Toronto. She has a research interest in women s mental health, and holds the Shirley A. Brown Memorial Chair for Women s Mental Health Research at Women s College Research Institute.
Objectives To identify the signs and symptoms of mental illness in pregnancy and postpartum, and what treatments might work To apply the latest advances in the efficacy and safety of psychological and pharmacological treatments for mental illness around the time of pregnancy To describe promising new interventions and healthcare models for the prevention and treatment of mental illness in pregnancy and postpartum. 6
Today s Talk Postpartum Mental Health 1. What is the problem? 2. What can we do about it? 3. What are the challenges to - and solutions for meeting the needs of our new parents with mental illness? 7
Why know about perinatal mood disorders? An important public health issue Risk of a Major Depressive Episode is up to 10% in pregnancy, 15% postpartum (higher than age-matched point prevalence in the nonpregnant population) Risk of bipolar disorder relapse is high in pregnancy and very high in the postpartum period
Scope of the problem It is not uncommon in my clinic to hear the following story 9
Case -Postpartum 32 year old G2P1, with 19 month old son Works full-time, husband travelling ++, Now 22 weeks GA in semi-planned pregnancy No clear history of depression, but always very independent, hard on self Very overwhelmed, tired, irritable, anhedonic, can t sleep, passive suicidal ideation What to do?
Think-pair-share Postpartum 32 year old G2P1, with 19 month old son Works full-time, husband travelling ++, Now 22 weeks GA in semiplanned pregnancy No clear history of depression, but always very independent, hard on self Very overwhelmed, tired, irritable, anhedonic, can t sleep, passive suicidal ideation 11
Postpartum Mental Illness Most common complication of childbirth 1 in 5 Canadian women 80,000 women and children per year 12
Scope of the problem More common than gestational diabetes, pre-eclampsia and other pregnancy-related health problems The most common mental illnesses are depression and anxiety, but other more serious problems such as mania and psychosis can occur Most women with psychiatric disorders become pregnant, so think about this pre-conception, in pregnancy and 13
Why should family docs know about perinatal mood disorders? Potential Impact of untreated mood disorders on mother, baby and family can be profound: Pregnancy: spontaneous abortion, poor prenatal care, substance use, poor fetal growth, preterm labour, suicide Postpartum: poor attachment/parenting, delayed infant motor, language and cognitive development, child behaviour problems, suicide/infanticide
Context in Family Practice Hospital/office setting Well baby, well family exam Other family members/relationships Resources
At a woman's first contact with primary care or her booking visit, and during the early postnatal period, consider asking the following depression identification questions (NICE guidelines, 2018) During the past month, have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things?
Also consider asking about anxiety using the 2-item Generalized Anxiety Disorder scale (GAD-2): Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge? [10] Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying? [10]
If a woman responds positively to either of the depression identification questions in recommendation 1.5.4, is at risk of developing a mental health problem, or there is clinical concern, consider: (NICE guidelines, 2018) https://pathways.nice.org.uk/pathways/antenatal-and-postnatal-mental-health using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9) as part of a full assessment referring the woman to a mental health professional
postpartum 19
A FAMILY Issue A meta-analysis of 74 studies (n > 40,000) generated a pooled estimate for paternal depression of 8.4% (95% CI 7.2% to 9.5%) Maternal and paternal mental illness are at least moderately correlated (r~0.30) 20
Risk Factors Personal/Family History Treatment Discontinuation Inadequate Social Support Major Life Stress, including a child who is ill, financial stress, relationship issues, intimate partner violence or with no risk factors at all! 21
Consequences Negative effects on daily function, sense of well being, experience of pregnancy and parenthood Poor parent-child attachment, including limited responsiveness or over-intrusiveness Delayed infant motor, language & cognitive development, child socioemotional and behaviour problems Suicide and Infanticide (rare)
Consequences The U.K maternal mental health alliance estimates that perinatal depression, anxiety and psychosis carry a total long-term cost to society equal to about 1.4 billion $CAN for each one-year cohort of births in Canada.
Interventions Most postpartum mental illnesses are treatable! Mild Moderate Severe Patient and Family Education and Support 24
Anxiety Disorders Postpartum Depression Obsessive Compulsive Disorders Posttraumatic stress disorders COMMON MENTAL DISORDERS 25
Severity Mild Minimum symptoms for diagnosis, and only a small amount of impact on a person s life and relationships or where person can still function well though this requires significant effort. Moderate Many symptoms are present, and there is some impact on a person s ability to function well on a daily basis. Severe Most symptoms needed to diagnose are met with clear, observable impact (e.g. inability to work, care for children). 26
Very Severe - Postpartum psychosis 27 year old woman, G1P0, with bipolar disorder, type 1, with multiple episodes of mania with psychosis, with several hospitalizations Pregnancy unplanned, but wanted, and well during pregnancy --- but stopped her medication prior to delivery. Presents 1 week postpartum for baby weighing disheveled, confused, and whispers to you that she thinks her husband may be poisoning the baby
Postpartum Psychosis Rare: < 1 in 1000 deliveries 90% within 4 weeks of delivery Marked by confusion, thought disorder Small but serious risk of suicide/infanticide Risk Factors Younger age, primiparity, sleep/biological rhythm disturbance, discontinuation of medication in women with bipolar and psychosis Psychosocial risk factors play less of a role Medical emergency Call 911, do not leave mother alone with baby Likely requires hospitalization, and treatment with mood stabilizer and/or antipsychotic medication
Approach to Treatment All Educate about mental illness, impact and treatment options (include support systems when possible) Routinely monitor symptoms throughout pregnancy Address concurrent social, substance use and medical problems Severe Illness Psychotropic drugs, referral to specialist services, with hospitalization and/or ECT in severe cases Moderate Severity of Illness Consider psychological treatments such as cognitive behaviour therapy (CBT), interpersonal therapy (IPT) in group, couple or indiviual format Mild Severity of Illness (e.g. mild depression/anxiety/ adjustment disorder) Consider low-intensity psychological treatments such as peer support, guided self-help, non-directive counselling 29 Adapted from: Vigod et al The BMJ 2016
All - Psychosocial Treatments Educate patient & family on symptoms Encourage self-care strategies Psychosocial support nurse home visits, lactation support, peer-support, online and in-person postpartum support groups 30
Psychological Treatments Cognitive Behaviour Therapy (CBT) THOUGHTS I am not a good parent THOUGHTS I am a good parent FEELINGS Sad and lonely BEHAVIOURS Avoid friends and family FEELINGS Less sad and lonely BEHAVIOURS Go out to park with parents 31
Psychological Treatments Interpersonal Therapy 32
Antidepressants For moderate to severe symptoms of common disorders 1 st line: Selective Serotonin Reuptake Inhibitors (SSRI) or Serotonin Norepinephrine Reuptake Inhibitors (SNRI) with most data on older medications (e.g. fluoxetine, sertraline, paroxetine, citalopram) 2 nd line: Other first-line antidepressants (e.g. Mirtazapine): Less data in lactation but nature and magnitude of risks likely similar 3rd Line: Tricyclic Antidepressants need monitoring, others (e.g. Monoamine oxidase inhibitors) rarely used DOXEPIN AND BUPOPRION PROBABLY ONLY ONES NOT TO USE 33
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Benzodiazepines May be required for concurrent management of anxiety and/or sleep in severe cases Contradictory data on increased risk of cleft palate/lip with 1 st trimester exposure Best to avoid in 1 st trimester Theoretical risk of neonatal withdrawal and of toxicity in breast-feeding Use shorter half-live drugs lorazepam, clonazepam Monitor infants 35
Medications for bipolar and psychosis Lithium: Passes into breast milk and toxicity can be substantial therefore CLOSE monitoring if used. Anticonvulsants: Valproate teratogenic in pregnancy, so avoid in reproductive age woman. Lamotrigine, passes into breast milk (median 30% of maternal levels) theoretical risk of rash, although no cases of Stevens Johnson Syndrome reported Antipsychotics: Minimal data in breast-feeding - Clozapine and Olanzapine not recommended due to risk of blood abnormalities and EPS respectively 36
Novel Treatments 37
Summary Women and men can present with a spectrum of psychiatric illnesses in the postpartum period. There are substantial risks to untreated psychiatric disorders during this time Choice of treatment involves a risk-benefit analysis unique to each patient s level of severity and preferences
TEMPERATURE CHECK 39
Screening and Case Finding Whooley Questions Likelihood ratio 8 for postpartum depression and 5.8 to 6.0 for the other common mental disorders 40
What are the challenges? Only 1 in 5 women receive adequate treatment (and probably even fewer men!) 41
What are the barriers? Stigma, shame, lack of knowledge about signs and symptoms, not knowing that effective treatments exist For Dads specifically: Acceptability: Concerns about use of medication during pregnancy and breastfeeding - A need to manage one s own problems - A tendency to downplay problems Access: Lack of locally accessible and affordable specialized - A sense treatments; of resignation set appointment that nothing times, will help care for other children, transportation 42
The Canadian Context Universal healthcare Opportunity to study health of population Patient level health records anonymously linked through a unique identifier for every Ontario resident (ICES) Ontario, Canada Population ~14 million 43
Service use disparities 21.4% Mental Health Service Use by Immigrant Women in the First Postpartum Year (%) Vigod et al. AWMH 2017 13.1% 15.1% 15.8% 17.1% 17.3% 10.4% Canadian Born East Asia & Pacific Southern Asia Sub-Saharan Africa Europe & North America North Africa & Middle East Latin America & Caribbean 44
Service use disparities Chances of coming to the ED without a prior outpatient visit Barker et al. AWMH 2016 45
Standardized rate per 100,000 Service use disparities 1 Perinatal Suicide Rates Grigoriadis et al. CMAJ 2017 39.2% had no mental health contact in the 30 days prior to death 77% of postpartum women had seen a pediatrician 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 LHIN number Northwest LHIN 46
What are the solutions? Education and Awareness (TODAY!) Screening & Case-Finding (Whooley Qs) Innovative models to improve timely access to care. 47
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E-Health Interventions Attractive strategy to reach more women and men > 90% of parents have access to a mobile device and/or internet that would allow for participation A systematic review of 11 trials evaluating online psychological interventions included 7 small RCTs - benefits for the treatment of postpartum depression were similar to those of in-person care. 49
Identify more women Over 950 Canadian women have downloaded the app since April 2017 Close to 350 have given a DNA sample to help further the search for a cure! 50
Online Peer Support https://www.postpartum.net 51
Online Psychological Support 100 women recruited in a matter of weeks --- 50% of whom agreed to wait 10 weeks so they could be a comparison group for research --- from 13 out of 14 Ontario Local Health Integration Networks (LHINs) 52
Virtual psych care Ongoing randomized controlled trials for: 1) Psychotherapy with a highly trained therapist; and 2) Psychiatric care with a reproductive psychiatrist In partnership with the Ontario Telemedicine Network and Sinai Health System Currently funded by the Ontario Ministry of Health and Long Term Care and University of Toronto 53
Local Referral Resources https://www.toronto.ca/community-people/children-parenting/pregnancy-andparenting/postpartum-depression-and-anxiety/services-in-toronto/non-urgent-services-intoronto/toronto-services-for-perinatal-mental-health/ 54
Questions/Discussion simone.vigod@wchospital.ca 55
Please fill out your session evaluation now! Complete a session evaluation one of two ways: FMF app Session # 146 Fmf.cfpc.ca Session topic: Advances in care for pregnant and postpartum women 56