Mental Health Series for Perinatal Prescribers Perinatal Depression
Perinatal Depression
Timing of symptoms Maternal depression is present before or during pregnancy at least 60% of the time DSM-5 and ICD 10 reflect this change Perinatal onset
Fetal Programming Entringer, Buss, Wadhwa (2015) Psychoneuroendocrinology
Risks of untreated perinatal mental illness on offspring Obstetric / neonatal complications Miscarriage Birth defects Preeclampsia Preterm birth Low birth weight Operative deliveries NICU admissions Sudden infant death syndrome Childhood Behavioral complications Poor infant self-regulation Insecure attachment Developmental delays Attention deficit hyperactivity disorder Anxiety disorders Conduct disorders
EPDS Screening Scores 10 are suggestive of depression Scores 13 (postpartum) and 15 (antenatal) confer greater specificity for a major depressive episode Screening has no value unless services are available Gibson et al (2009) Acta Psychiatr Scand
Antenatal Mood symptoms Demographics Incidence of 8-13%, 20-25% in minority and low SES populations Anxiety/depression comorbidity 50% Past or current abuse is an important risk factor Phenomenology Health related anxiety, worst case scenarios regarding birth Exacerbated if history of miscarriage/ adverse perinatal outcome Wenzel et al 2005; Ross et al 2006; Meltzer-Brody et al 2013
Antenatal depression relapse Specialty perinatal psychiatric clinics (n=201) 70% of women who maintain their antidepressant remain well 30 % of women who discontinue antidepressants remain well Obstetric clinics (n=778) 80% remained well in pregnancy or postpartum irrespective of antidepressant use in pregnancy IMPORTANT RISK FACTORS for relapse Depression in the 6 months prior to conception Lifetime history of 4 or more depressive episodes Duration of depressive illness over one s life Comorbid psychiatric disorders Cohen et al (2006) JAMA ; Yonkers et al (2011) Epidemiology
These don t treat everything! Motivate behavioral change
Postpartum Depression One out of 7 new mothers 14.5% Prevalence as high as 60% in adolescents and inner city mothers Over 4 million American women give birth annually 500,000 women will suffer postpartum depression annually Risk factors: Prior history of depression, Prior history of PPD, antenatal depression or anxiety, Family history, limited social support, marital discord, premature or medically complicated birth
Phenomenology Anxiety, worry, overwhelmed GAD is more common in postpartum women than the general population Thoughts racing Brain won t shut off Insomnia Panic symptoms OCD Obsessions (irrational) of harm befalling loved ones, harming infant Compulsions Checking repeatedly on infant won t let child out of my sight Breastfeeding/pumping schedule Preventing contact with germs Self blame Inadequate mother Suboptimal delivery/medical complications Marrs et al (2009) J Aff Disorders
Prevention of postpartum depression Wisner et al (2004) Am J Psychiatry
Antidepressant selection 3. If at max tolerated dose with some improvement, combination treatment 4. Develop plan for follow-up with behavioral health 1. Treat to remission 2. Maintain dose to which patient remits for 6-12 months 3. Develop plan for follow-up with PCP or OB Byatt: MCPAP for moms toolkit https://www.mcpapformoms.org/toolkits/toolkit.aspx
Dosing across pregnancy Sit et al (2008) J Clin Psych
Insomnia Diphenhydramine(Benadryl, Unisom) 25-50mg Antihistamines Doxylamine (Unisom) 25-50 mg First line treatments Hydoxyzine pamoate (Vistaril) 25-100mg Triazolopyridine antidepressant Trazodone (Desyrel) 25-100mg Second line treatments Benzodiazepines Tricyclic antidepressant Uncategorized antidepressant Lorazepam (Ativan) 0.25-1.0mg Atypical antipsychotic Amitriptyline (Elavil) 10-100mg Mirtazapine (7.5 30mg) Seroquel (12.5 50mg) Doxepin (Silenor) 3, 6, 10, 25mg Nortriptyline (Pamelor) 10 100mg Behavioral Approaches http://www.cci.health.wa.gov.au/resources/infopax_doc.cfm?mini_id=50
Bipolar disorder Lower prevalence of ~ 1-5% in general population Mania, hypomania, mixed symptoms Probes Postpartum highs Cumulative lack of sleep and not tired Exceptionally high productivity Physically restless and/or highly energized Rapid thoughts and pressured speech Aggressive, impatience, irritability that is different from baseline Activities with high potential for adverse consequences (substance use, sexual promiscuity, excessing spending, speeding car) Ask about family history of bipolar and severe postpartum illness History of worsening mood on antidepressants
Screening for bipolar disorder Mood Disorder Questionnaire http://www.dbsalliance.org/pdfs/mdq.pdf Is Your Depressed Patient Bipolar? Kaye NS, JABFM www.jabfm.org/content/18/4/271.full
Perinatal Prescribers can break the Cycle of Depression Screen for and treat depression Early infant intervention Depressed Mom Offspring at disadvantage Screen for depression Treat depression Motivate behavioral change Support systems/safe environ Reproductive planning
Thanks for your attention! mosesel@upmc.edu postpartumpgh@gmail.com