Update on Postnatal Depression Lee Tak Shing, Dominic MBChBHons", MD, MRCPsych, FHKAM, FHKCPsych PND Normal adjustment Transient & mild Understandable Blues Transient & mild PND Persistent Dysfunctional Out of proportion Postpartum psychosis Voices, delusions Onset usu w/in 2 wks 11# prevalence 6 wks pp 5000+ PND each year What is PND? Textbook Symptoms Mood disorders Out of control: malignant sadness Persistent >2 wks" Severe # of symptoms" Functional impairment Low mood, lack of enjoyment Lack of interest, lack of drive Lack of energy Insomnia Retardation Poor appetite, weight loss Impaired concentration Negative cognitions Suicidal ideas
Local Symptoms Special Symptoms Tearfulness Irritability Anger Unexplained medical symptoms Excessive worries of infant health Admissions with no medical diagnosis Eliciting symptoms Illness Experience Probing questions How do you sleep? How are you coping? Baby easy to look after? How was the zuoyue arranged? It is common to feel depressed and stressed in first few days. Have you ever had such experience? Suicidal ideas don t panic" 1. Not worth living 2. Vague, fleeting ideas 3. Plan 4. Action How to diagnose PPD? Risk Factors DSM criteria 5 symptoms x >=2 weeks + dysfunction Real life Persistent symptoms day in, day out" Dysfunctional Loss of control not my usual self" Distress Early morning wakening, retardation, or suicidal ideas Gene x Environment interaction Lack of social support Poor marital relationship and spousal violence Concurrent life events Past hx of depression, esp. in postpartum Personality vulnerability Infertility Graves Disease Expatriats?
In$law is more important than husband Fewer PND for Women w Peiyue 13-week BDI (mean, 95% CI) 14 12 10 8 6 4 2 others poor/very poor mother-in-law relationship Complications of PND 42# of HK PPD remained depressed at 2 years postpartum Maternal and paternal unemployment Separation and divorce Children emotional and behavioural disorder Child abuse Suicide How to identify PPD? Screening Scales Sharpen clinical awareness Screening scale Edinburgh Postnatal Depression Scale EPDS 10 items on mood symptoms past 7 days no somatic items one item on self harm ideas 9/10 cut$o% for HK Chinese women Item 1 & 3 reversely scored
Cox, J.L. Holden, J.M. and Sagovsky, R. (1987). Detection of postnatal depression. Br. J. Psychiatry 150: 782-786. Lee, D.T., etal (1997) Detecting postnatal depression in Chinese. Br.J. Psychiatry 172: 433-437. " #$%&'()*+(CEPDS 2.1),-./ 012345 6+78 9:;<=>?1@23ABCD@EFG>HIJKLMNFOPQRS>TUVWIJHXYK Z[;\]^>_WHI`Aa^TUVWHIJKbc; BIdefK g1hijklmnk g2hop"klmnk g3h\qrmnk g4hfstujk MNXYg2h+:vwF4xyop"kz{IdefKL }n~ ÄÅÇGÉÑK vtuvwx; 1. BQÖdÜájàHFâAäãåçK 6. éèüêëíbaìaîbï\tñk g1h }ÇóFnK g1h oèòklb{\qôök g2h ujçóõúèk g2h jklb\qùûkõnôöük g3h Çó K g3h op"klb{qùûkõnôöük g4h Ä \QK g4h BF {QôöüK 2. B ß8 ìhf K 7. Bé\åçAÇ K g1h }ÇóFnK g1h op"klmnk g2 h ujçóõúèk g2h jklmnk g3h Çó K g3h \qrmnk g4h Ä \QK g4h FstujK 3. ÆÜêØ kab±\ µ K 8. BId T ªºK g1h op"klmnk g1h op"klmnk g2h jklmnk g2h ÆklmnK g3h \qrmnk g3h \qrmnk g4 h ujmnk g4h FstujK 4. Bæøæ Id çk 9. B\åçdƒK g1h FstujK g1h op"klmnk g2h jk g2h jklmnk g3h jklmnk g3h ]^z mnk g4h qrmnk g4h ujmnk Antenatal depressive symptoms are best predictor of PPD 5. Bæøæ Id K 10. BDT º«K g1h ÆèklmnK g1h ÆèklmnK g2h jklmnk g2h jklmnk g3 h \qrmnk g3h é mnk g4h FstujK g4h ujmnk Postnatal Depression is a Misnomer Antenatal depressive symptomatology is one of the most powerful predictors of PND Substantial proportion of postnatal depression begins in the pregnancy Antenatal depression shared similar risk factors with postnatal depression Perinatal depression rather than postnatal depression is a more accurate description of the psychopathology Epidemiology Fallacy of protected pregnancy in traditional teachings low risks, esp 2nd trimester Contemporary epidemiologic studies showed 10# $ 20# prevalence US, UK, Australia, Japan, Portugal, Uganda Hormonal protection is a myth Adverse consequences Adverse consequences AN depression is associated with PND Maternal neglect and poorer AN care Alcoholism and drug abuse Maternal anxiety increases uterine artery resistance Higher rate of Caesarean section Growth retardation Lower birth weight and born early SGA preclampsia Inferior performance on neonatal behavioural assessment Attention deficit and hyperactivity
Risk Factors past abortion, miscarriage, infertility reject pregnancy and considered abortion past depression or psychiatric history medical history or complications marital status, immigrants, education, employment, income, financial di&culties poor social support, life events, marital discord drug and alcohol abuse 6# of HK mothers have antenatal depression AN Depression Symptoms AN Depression assoc w more epidural, C$section, pre$ term, SGA, pre$eclampsia Broken sleep not related to nocturia" Lack of appetite, poor weight gain Irritability, poor temper, tearfulness Depressed mood, anxiety, panic attacks Negative thoughts, excessive worries e.g. fetal malformation" Atypical somatic symptoms Head$Start Programme Antidepressants Serotonin Selective Reuptake Inhibitor Fluoxetine Prozac", Sertraline Zoloft", Escitalopram Lexapro" Paroxetine Seroxat" $$$ fetal abnormality STAR*D study SNRI Venlafaxine, Mirtazepine Tricyclics Amitriptyline, Nortriptyline breast feeding"
Adapted from Trivedi MH, et al. Am J Psychiatry. 2006;163:28-40. STAR*D Results: Unresolved Depression Symptoms % More than 2/3 of patients had unresolved symptoms STAR*D Study (N=2,876) 67% 10 Remission Mild symptoms Moderate Severe symptoms Very severe symptoms 9 33% 28% symptoms 12% 4% 8 23% 7 6 5 4 3 2 1 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Depressive symptoms (QIDS-SR score) after up to 12 wk antidepressant treatment Antidepressants Serotonin Selective Reuptake Inhibitor Fluoxetine Prozac", Sertraline Zoloft", Escitalopram Lexapro" Paroxetine Seroxat" $$$ fetal abnormality STAR*D study SNRI Venlafaxine, Mirtazepine, Duloxetine Tricyclics Amitriptyline, Nortriptyline breast feeding" Length of Randomized, Double-Blind, Placebo-Controlled Studies in Relapse and Recurrence 6 Months 1 Year 2 Years Venlafaxine XR 1-3 * Duloxetine 4 Escitalopram 5 Bupropion 6 Sertraline 7,8 Paroxetine 9 *In the venlafaxine XR study, patients had at least 3 prior episodes of depression in their lifetime. Sertraline has been studied in 2-year recurrence prevention as monotherapy but failed to show a significant difference vs. placebo at end point. Paroxetine has been studied in 2-year recurrence prevention in combination with psychotherapy/clinical management sessions with or without augmentation, but not as monotherapy. In patients with recurrent depression, no significant difference was seen between paroxetine and placebo. 1. Simon JS, et al. J Psychiatr Res. 2004;38:249-257. 2. Montgomery SA, et al. J Clin Psychiatry. 2004;65:328-336. 3. Data on file, Wyeth Pharmaceuticals Inc. 4. Detke MJ, et al. Eur Neuropsychopharm. 2004;14:457-470. 5. Rapaport MH, et al. J Clin Psychiatry. 2004;65:44-49 6. Weihs KL, et al. Biol Psychiatry. 2002;51:753-761. 7. Keller MB, et al. JAMA. 1998;280:1665-1672. 8. Wilson KCM, et al. Br J Psychiatry. 2003;182:492-497. 9. Reynolds CF, et al. N Engl J Med. 2006;354:1130-1138. = demonstrated relapse/recurrence prevention at end point. Antidepressants Serotonin Selective Reuptake Inhibitor Fluoxetine Prozac", Sertraline Zoloft", Escitalopram Lexapro" Paroxetine Seroxat" $$$ fetal abnormality STAR*D study SNRI Venlafaxine, Mirtazepine, Duloxetine Tricyclics Amitriptyline, Nortriptyline breast feeding" Side E%ects Nausea, insomnia, agitation, anxiety Warn and be sensitive about sexual repulsiveness No long term side e%ects Discontinuation syndrome slow withdrawal" 2 weeks onset start treatment asap" Persistence investment " Family supervision Neonatal Withdrawal Syndrome Health Canada warning Aug 9 2004 feeding and or breathing di&culties, seizures, muscle rigidity, jitteriness, constant crying bupropion, citalopram, fluoxetine, fluvoxamine, mirtazapine, paroxetine, sertraline, venlafaxine careful weighting of pros and cons is important
SSRI in Pregnancy Early pregnancy Ventricular septal defect Late pregnancy Pulmonary hypertension of the newborn Neonatal withdrawal syndrome Relapse of Major Depression During Pregnancy in Women Who Maintain or Discontinue Antidepressant Lee S. Cohen, MD Lori L. Altshuler, MD Bernard L. Harlow, PhD Ruta Nonacs, MD, PhD D. Jeffrey Newport, MD Adele C. Viguera, MD Rita Suri, MD Vivien K. Burt, MD, PhD Victoria Hendrick, MD Alison M. Reminick, BA Ada Loughead, BA Allison F. Vitonis, BA P Zachary N. Stowe, MD Context Pregnancy has historically been described as a time of emotional wellbeing, providing protection against psychiatric disorder. However, systematic delineation of risk of relapse in women who maintain or discontinue pharmacological treatment during pregnancy is necessary. Objective To describe risk of relapse in pregnant women who discontinued antidepressant medication proximate to conception compared with those who maintained treatment with these medications. Design, Setting, and Patients A prospective naturalistic investigation using longitudinal psychiatric assessments on a monthly basis across pregnancy; a survival analysis was conducted to determine time to relapse of depression during pregnancy. A total of 201 pregnant women were enrolled between March 1999 and April 2003 from 3 centers with specific expertise in the treatment of psychiatric illness during pregnancy. The cohort of women was recruited from (1) within the hospital clinics, (2) selfreferral via advertisements and community outreach detailing the study, and (3) direct referrals from the community. Participants were considered eligible if they (1) had a history of major depression prior to pregnancy, (2) were less than 16 weeks gestation, (3) were euthymic for at least 3 months prior to their last menstrual period, and (4) were currently or recently ( 12 weeks prior to last menstrual period) receiving antidepressant treatment. Of the 201 participants, 13 miscarried, 5 electively terminated their pregnancy, 12 were lost to follow-up prior to completion of pregnancy, and 8 chose to discontinue participation in the study. Main Outcome Measure Relapse of major depression defined as fulfilling Structured Clinical Interview for DSM-IV [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition] Diagnosis (SCID) criteria. Results Among the 201 women in the sample, 86 (43%) experienced a relapse of major depression during pregnancy. Among the 82 women who maintained their medication throughout their pregnancy, 21 (26%) relapsed compared with 44 (68%) of the 65 women who discontinued medication. Women who discontinued medication relapsed significantly more frequently over the course of their pregnancy compared with women who maintained their medication (hazard ratio, 5.0; 95% confidence interval, 2.8-9.1; P.001). Conclusions Pregnancy is not protective with respect to risk of relapse of major depression. Women with histories of depression who are euthymic in the context of ongoing antidepressant therapy should be aware of the association of depressive relapse during pregnancy with antidepressant discontinuation. JAMA. 2006;295:499-507 REGNANCY HAS HISTORICALLY been described as a time of emotional well-being, providing protection against psychiatric disorder. 1,2 However, systematic data to support this impression are sparse. A prospective communitybased study described similar rates of depression in gravid and nongravid women 3 and, more recently, a second study noted the persistence of depressive symptoms during pregnancy. 4 The high risk of depressive relapse following discontinuation of maintenance antidepressant therapy in nongravid patients treated with antidepressants has been well established. 5 The determination of risk of relapse following discontinuation of antidepressants during pregnancy or in those women who maintain treatment with these medications during pregnancy has not been previously investigated. Clinicians need such information to collaborate effectively with patients to tailor careful risk-benefit assessments with regard to antidepressant drug use for www.jama.com Author Affiliations are listed at the end of this article. Corresponding Author: Lee S. Cohen, MD, Perinatal and Reproductive Psychiatry Clinical Research Program, Department of Psychiatry, Massachusetts General Hospital, WACC 812, 15 Parkman St, Boston, MA 02114 (lcohen2@partners.org). 2006 American Medical Association. All rights reserved. (Reprinted) JAMA, February 1, 2006 Vol 295, No. 5 499 Management Antidepressants Vs. Psychotherapy Balance the risk between Fetal safety: teratogenicty and neurobehavioral toxicity Suicidal risk and adverse physical e%ects of depression Speedy recovery Psychosocial Marital counselling most husbands are just ignorant", in$law conflicts Maid, letters, CSSA, rehousing, Sick leaves