Postpartum Depression, PGY 2 University of Kansas School of Medicine Wichita Family Medicine Residency Program at Wesley April 11, 2014 Objectives Recognize postpartum depression Distinguish postpartum depression from baby blues and postpartum psychosis Identify screening tools and how to utilize them Review treatment options 1
Burden 5-20% of US women during 6 months of delivery 1,2 ~500,000 women a year 7 May begin during pregnancy Up to 50% patients 15 20-50% lifetime risk of major depressive disorder (MDD) 6 Children at risk for delays and behavioral disturbances Postpartum Depression (PPD) Defined with criteria for MDD Onset within 4 weeks of delivery Symptoms Despondent mood Feelings of inadequacy Sleep and appetite disturbance Impaired concentration Ego-dystonic thoughts Suicidal ideation 2
PPD Risk Factors Personal or family history of mood disorder Lack of social support Domestic violence Substance abuse Low-income Complications 25-50% recurrence Impact on children Obstetrical complications Special Populations Pregnancy loss 3
Baby Blues Transient state of heightened emotional reactivity 1 50-80% of mothers Onset within 3-5 days of delivery Symptoms Crying easily Irritability Emotionally labile Poor sleep Nervousness Suicidal ideation NOT present Postpartum Psychosis Presence of delusions and/or hallucinations 1:500 to 1:1000 15 Onset within first several weeks Symptoms Greater disorientation and lability More likely to act on harmful thoughts 4
Characteristic Baby Blues PPD Onset Within 2-5 days postpartum Often within first month; may be up to one year Duration Days-weeks More than 2 weeks to more than one year Prevalence 50-80% 5-20% Severity Mild Moderate to Severe Suicidal Ideation Not present May be present Psychosis Not present May be present Screening Not diagnosis System for treatment or referral Barriers Physician Patient 5
Screening Who? Family physicians Pediatricians Obstetricians When? Timing Prenatal visits Postpartum visit Well-child visits How? Screening Edinburgh Postnatal Depression Scale (EPDS) 2-question screening tool PHQ-2 PHQ-9 Beck Depression Inventory Screen for co-existing mood disorders 6
Diagnosis Structured Clinical Interview for DSM Referral Medical disease TSH, CBC Treatment Antidepressants SSRI SNRI Therapy Cognitive-behavioral Interpersonal Hospitalization Prevention Family planning Screening PPD Resources 7
Resources 1. Miller LJ. Postpartum depression. JAMA 2002;287(6):762-765. 2. Hirst KP, Moutier CY. Postpartum major depression. Am Fam Physician 2010;82(8):926-933. 3. http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf 4. http://familydoctor.org/dam/familydoctor/documents/ppd_actionplan.pdf 5. http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?lact 6. Gjerdingen DK, Yawn BP. Postpartum depression screening: importance, methods, barriers, and recommendations for practice. J Am Board Fam Med 2007;20:280-288. 7. Shaw P. Identifying postpartum depression during the well-child visit: resources for screening, referral, and treatment. Presentation 2013. 8. Pawar G, Wetzker C, Gjerdingen D. Prevalence of depressive symptoms in the immediate postpartum period. J Am Board Fam Med 2011;24:258-261. 9. Chae SY, Chae MH, Tyndall A, Ramirez MR, Winter RO. Can we effectively use the two-item PHQ-2 to screen for postpartum depression? Fam Med 2012;44(10):698-703. 10. Gjerdingen D, Crow S, McGovern P, Miner M, Center B. Postpartum depression screening at well-child visits: validity of a 2-question screen and the PHQ-9. Ann Fam Med 2009;7:63-70. 11. Eberhard-Gran M, Slinning K, Rognerud M. Screening for postnatal depression a summary of current knowledge. Tidsskr Nor Laegeforen 2014;134(3):297-301. 12. Earls MF, Committee on Psychosocial Aspects of Child and Family Health. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics 2010;126:1032-1039. 13. Olson AL, Kemper KJ, Kelleher KJ, Hammond CS, Zuckerman BS, Dietrich AJ. Primary care pediatricians roles and perceived responsibilities in the identification and management of maternal depression. Pediatrics 2002;110:1169-1176. 14. Yawn, BP, Dietrich AJ, Wollan P, Bertram S, Graham D, Huff J, Kurland M, Madison S, Pace WD. TRIPPD: a practice-based network effectiveness study of postpartum depression screening and management. Ann Fam Med 2012;10:320-329. 15. DSM-V 8
Postpatrum Depression Resources Postpartum Depression Toolkit, American Academy of Family Physicians www.aafp.org/patient-care/nrn/studies/all/trippd/ppd-toolkit.html LactMed Drugs and Lactation Database http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?lact Maternal Infant Health Coalition www.mssconline.org Kansas Association for Infant & Early Childhood Mental Health PO Box 743, Newton, KS www.kaimh.org 785-218-8236 The Treehouse 151 N. Volusia, Wichita, KS www.wichitatreehouse.com 316-686-2600 Healthy Babies Sedgwick County Health Department 434 N. Oliver, Wichita, KS www.sedgwickcounty.org 316-660-7433 The Counseling Center at Mental Health Association (Mother s Embrace, Postpartum Recovery) 555 Woodlawn, Ste 102, Wichita, KS www.counselingcenteratmha.com 316-652-2590 Associates in Psychological & Family Services 833 Waco, Ste 200, Wichita, KS 316-263-2351 Cana Counseling 437 Topeka, Wichita, KS 316-263-6941
COMCARE-Centralized Intake Prairie View 934 Water, Wichita, KS 316-660-7540 Walk-in 8:00-8:30 AM 9333 21 st N., Wichita, KS 800-992-6292 The Therapy Center 7807 Funston, Wichita, KS 316-636-1188 Wichita Child Guidance Center 415 Poplar, Wichita, KS 316-686-6671, ext. 1613