James F. Paulson, Ph.D. Associate Professor of Psychology, Old Dominion University Pediatric Psychologist, Children s Hospital of The King s Daughters
Common terms Antenatal Postnatal Postpartum Perinatal depression IS depression Major Depressive Disorder Minor Depression Relapsing Depression Continued or worsening Dysthymia and/or Depression
A. Five or more of the following symptoms have been present during the same 2-wk period and represent a change from previous functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure 1. Depressed mood most of the day, nearly every day 2. Loss of interest or pleasure in activities 3. Significant weight 52 or to loss 4more gain change in appetite 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive or inappropriate guilt 8. Decreased ability to think/concentrate or indecisiveness 9. Recurrent thoughts of death; suicidal ideation
Depressed mood
Depressed mood Anhedonia Loss of interest or pleasure in activities Joy Engagement Enjoyment Attachment Drive Enthusiasm
Perinatal hormone changes in mother?
Prior research on Cortisol Prolactin Estrogen Progesterone Thyrotrophin Thyroxine Some small effects, many null results While evidence for an etiologic role is lacking for most hormones, changes in certain hormonal axes may contribute to depressive mood changes in some women following childbirth. Hendrick V, Altschuler LL, & Suri R (1998). Hormonal changes in the postpartum and implications for postpartum depression. Psychosomatics, 39 (2).
High life stress Childcare stress Social support problems Partner relationship problems Difficult infant temperament Socioeconomic status Unplanned pregnancy Effect sizes range from.14-.56 Beck CT (2001). Predictors of postpartum depression: An update. Nursing Research, 50 (5), 275-285.
Perinatal hormone changes in mother Change in life roles Re-negotiation of relationship Sleep deprivation Demands of care Psychosocial stressors Financial Recreation Work-life balance Friendships Extended family
Prenatal: 10%-30% Postnatal: 10%-20% Poor Child and Family Outcomes Compromised Parenting Treat the mother and you treat the child? insecure attachment social incompetence difficult temperament mental health problems disruptive behavior parental insensitivity depression less positive parenting poor adult adjustment less (Weissman attention et to al., child 2006) parent-child conflict harsh 151 depressed parentingmother-child marital pairs difficulties divorce Treated mother, not child Remission: 33% of children No remission: 12% of children
Do fathers really get postpartum depression? - multiple sources
it s typical male behaviour, making pregnancy and childbirth all about them!
US Bureau of Labor Statistics (2011)
US Bureau of Labor Statistics (2011)
US Bureau of Labor Statistics (2011)
US Bureau of Labor Statistics (2011)
Child development and family Until 1980s, minimal influence Breadwinners Scientific literature was a few pages Now: some influence If we have enough time and money left over, it s probably a good idea to include fathers Depression 74% of all studies published since 2000 56% published since 2004 Usually an afterthought Lamb, M. E. (2010). The Role of the Father in Child Development (5th ed.). Hoboken, NJ: Wiley.
Widely varying estimates 1.2% to 25.5% different times during pregnancy and postpartum different measures different study locations
Reference lists of major articles Research Databases: MEDLINE PsycINFO EMBASE Google Scholar Dissertation Abstracts International Ancestry approach
Reported rate of depression in fathers between 1 st trimester and 1 year postpartum not recruited based on maternal mental health problem adult fathers
256 Potentially eligible studies identified 163 Excluded based on title/abstract review 93 Retrieved for full-text review 50 Excluded for lack of appropriate information 43 Articles included in the meta-analysis
Location United States: 17 studies International: 26 studies Sample size 23 to 10,975 (most between 80 and 307) Total fathers in meta-analysis: 28,004
Sample Size (sqrt) 120 100 80 60 < 1% 34% 40 20 0 0% 10% 20% 30% 40% Proportion Depressed
Sample Size (sqrt) 120 100 10.4% (+/- 2.1%) 80 60 40 20 0 0% 10% 20% 30% 40% Proportion Depressed
30% 25% 20% 15% 10% 5% 0% 1st and 2nd Trimester 3rd Trimester Birth to 3 months Postpartum 3-6 months Postpartum 6-12 months Postpartum Depression Rates Across Time Periods
20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% United States International
Rate of Maternal Depression Meta-Estimate: 60% r =.31 (+/-.08) 50% 40% 30% 20% 10% Association between Parents' Depression Rates (study level) 0% 0% 5% 10% 15% 20% 25% 30% 35% Rate of Paternal Depression
At Eternity s Gate, Vincent Van Gough
Diagnosis is identical (DSM-5) Coping is more externalized/distracting (v. ruminative) Anger and irritability may be more prominent Under-reporting
Under-detection and treatment 15%-23% positive for depression or anxiety 4-5% are referred receive care Teach referral sources to screen (Ask the question!) Less experienced interviewers miss milder depression depression in older individuals depression in men Goodman, J. H., & Tyer-Viola, L. (2010). Detection, treatment, and referral of perinatal depression and anxiety by obstetrical providers. [Research Support, Non- U.S. Gov't]. Journal of Women's Health, 19(3), 477-490. doi: 10.1089/jwh.2008.1352 Eaton WW, Neufeld K, Chen LS, Cai G. A comparison of self-report and clinical diagnostic interviews for depression: diagnostic interview schedule and schedules for clinical assessment in neuropsychiatry in the Baltimore epidemiologic catchment area follow-up. Arch Gen Psychiatry. 2000;57(3):217-222.
Short self-administered questionnaires Edinburgh Postnatal Depression Scale Developed for postpartum women 10 items (0-3). Total >12 : Positive Screen Fathers: Lower threshold: >9 Cox, J. L., Chapman, G., Murray, D., & Jones, P. (1996). Validation of the Edinburgh postnatal depression scale (EPDS) in non-postnatal women. [Journal; Peer Reviewed Journal]. Journal of Affective Disorders, 39(3), 185-189. Areias, M. E., Kumar, R., Barros, H., & Figueiredo, E. (1996). Comparative incidence of depression in women and men, during pregnancy and after childbirth. Validation of the Edinburgh Postnatal Depression Scale in Portuguese mothers. [Research Support, Non-U.S. Gov't]. The British journal of psychiatry : the journal of mental science, 169(1), 30-35.
Adapted Edinburg Postnatal Depression Scale Please check the answer which comes closest to how you have felt IN THE PAST WEEK, not just how you feel today. IN THE PAST SEVEN DAYS. I have been able to laugh and see the funny side of things: As much as I always could Not quite so much now Definitely not quite so much now No, not at all Things have been getting on top of me: Yes, most of the time I haven t been able to cope at all Yes, sometimes I haven t been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever I have looked forward with enjoyment to things: As much as I always could: Not quite so much now Definitely not quite so much now No, not at all I have been so unhappy, that I have had difficulty sleeping: Yes, most of the time Yes, some of the time Not very often No, never
I have blamed myself unnecessarily when things went wrong: Yes, most of the time Yes, some of the time Not very often No, never I have felt sad and miserable: Yes, most of the time Yes, some of the time Not very often No, never I have felt worried and anxious for no very good reason: As much as I always could Not quite so much now Definitely not quite so much now No, not at all I have been so unhappy, that I have been crying: Yes, most of the time Yes, some of the time Not very often No, never I have felt scared or panicky for no very good reason: Yes, most of the time Yes, some of the time Not very often No, never The thought of harming myself has occurred: Yes, most of the time Yes, some of the time Not very often No, never
Based on an open discussion with patient Requires more detail History Other conditions Medical status Impairment Needed for referral?
Disrupted parenting Less positive interaction Less reading More harsh discipline & spanking Adverse emotional and behavioral outcomes at 3.5yrs Increased psychiatric disorder at age 7 Language development
Rate of Maternal Depression Meta-Estimate: 60% r =.31 (+/-.08) 50% 40% 30% 20% 10% Association between Parents' Depression Rates (study level) 0% 0% 5% 10% 15% 20% 25% 30% 35% Rate of Paternal Depression Paulson, J. F., & Bazemore, S. D. (2010). Prenatal and postpartum depression in fathers and its association with maternal depression: A meta-analysis. JAMA, 303(19), 1961-1969.
Depressed Mother: 3-8x odds of Depressed Father In the first postnatal year father s depressive symptoms are influenced by Mother s depressive symptoms Mother s neuroticism Quality of marital relationship Father s neuroticism Dudley, M., Roy, K., Kelk, N., & Bernard, D. (2001). Psychological correlates of depression in fathers and mothers in the first postnatal year. Journal of Reproductive & Infant Psychology, 19(3), 187-202.
Parental depression is not individual, it s a systems problem Why do fathers and mothers more often get depressed together? What does this tell us about depression in early parenthood for either parent? Misery loves company Depression is contagious
One partner gets depressed The other partner gets depressed The relationship suffers
maternal parenting paternal parenting
coparenting
Include the whole family Even if someone isn t present, ask about them Create the expectation that everyone is all in When working with other providers, convey this expectation
Promote screening efforts Screening can be as simple as asking the question: How have you been doing lately? Have you been feeling down or depressed lately? Screening measures are: EASY! Fast Good for mothers and fathers (even the EPDS) Backed by good science
Help referral sources make good and orienting referrals More specific is better (e.g., I want you to see Dr. Jones at... ASAP ) Focus on family Depressed parents put kids and families at risk for poor outcomes Moms and dads should know this and act for their family, if not for themselves Provide as much info on treatment as you can Does not have to entail drugs Probably doesn t entail laying on a couch and talking about your mother The referred-to may be able to prime you on how to orient patients
Include the family Assess couples issues Treatment may be indirect: Couples focus Problem-solving or organization focus Job focus Expectation evaluation and setting Adapt established models to circumstances of new parenthood
Perinatal depression occurs in parents disrupts relationships disrupts coparenting affects the early family affects child development
James F. Paulson, Ph.D. Associate Professor of Psychology Old Dominion University JPaulson@odu.edu
http://www.youtube.com/watch?v=apzxgebzht0