Perinatal Mood and Anxiety Disorders Contact Information Sonja Bohannon-Thacker, MSW, LCSW, CCTP sonja.bohannonthacker@cabarrushealth.org What are we talking about when we say PMAD? Depression Anxiety Disorders Panic Disorders Obsessive-Compulsive Disorder Post-Traumatic Stress Disorder Bipolar Disorder All of these disorders affect people at varying times in life. BUT, There is a marked increase during pregnancy and the PP period. 15-23% of pregnant women experience depression-the rate is higher for teens and women living in poverty 1
Wisner's research with 10.000 women found that: 21% of those women had postpartum depression 33.4% of those had onset during pregnancy 40% had the first onset during the postpartum period The most common diagnosis was unipolar depression 22.6% of these women were diagnosed with Bipolar disorder 66% of women diagnosed with MDD had a comorbid anxiety disorder Source: Wisner KL, Sit DKY, McShea MC, et al. JAMA Psychiatry 2013 from 2015 PSI Baby Blues or PP depression? Baby Blues Onset typically from delivery to day 3 Often peaks between day 3 and 7 Typically resolved within 14 days Symptoms: Tearfulness Frustration/irritability Exhaustion Difficulty sleeping Poor appetite Typically resolves without intervention PP Depression Onset can be any time within the first year. Frequently after 6 weeks PP Symptoms: More intense than those of Baby Blues and many more symptoms likely present Typically requires social support and psychotherapy and often medication May require psychiatric intervention with atypical antipsychotic medications or combination medications. May require hospitalization and antipsychotic medication 2
Depression: Symptoms in the Postpartum Period Sadness, tearfulness* Exhaustion Physical complaints that are unexplained Fear of caring for infant Appetite changes* Lack of joy or pleasure* Sleep disturbance* Anxiety Poor concentration* Isolating Irritability Feeling like she is not herself Hopelessness Feelings of inadequacy Helplessness Guilt* Shame Lack of connection with infant Feelings of being overwhelmed Suicidal thoughts Unwilling/unable to care for self or infant Homicidal thoughts (RARE) Anxiety: Symptoms in the Postpartum Period Agitation- easily frustrated Inability to sit still/rest Excessive concern about her own or infants health Hypervigilance Appetite changes-rapid weight loss Difficulty staying asleep Constant worry Racing thoughts Physical symptoms: Racing heart Shortness of breath Tingling of the head, hands, feet Where will I find childcare I can afford? I think something is wrong with my baby I just can t be still My head hurts, I feel short of breath Why won t she stop crying? I m afraid I will not be The mother my baby needs I think maybe my thyroid is off and maybe I need to have an MRI. What if my son grows up and wants to know about his father and then he blames me that he s not in his life. 3
Panic: Symptoms in the Postpartum Period Extreme anxiety Shortness of breath, chest pain, sensations of choking, smothering, dizziness Hot or cold flashes, trembling, rapid heart rate, numbness of tingling sensations Restlessness, agitation or irritability Excessive worry or fear Awakens in panic state Indman and Bennett state in Beyond the Blues that the 3 greatest fears among women in the postpartum period are: Fear of dying Fear of going crazy Fear of losing control OCD: Symptoms in the postpartum period Data shows that 70% of women with a history of OCD have a recurrence during pregnancy. Classic OCD symptoms: Cleaning, checking, counting, ordering, cleanliness Intrusive, repetitive thoughts Tremendous guilt and shame Horrified by intrusive thoughts Hypervigilance Engagement in activities/behaviors to avoid harm Source: Buttolph &Holland qtd. In Pregnancy Blues: What Every Woman Needs to Know About Depression During Pregnancy by Shaila Kulkarni-Misri, 2005 PTSD: It s relation to Traumatic Birth Experience Birth is not always experienced as a beautiful thing When the pregnancy was not intended or a result of a traumatic experience When women are at odds with their medical provider or nursing provider this can be traumatic When there is an unexpected delivery experience or birth outcome this can be traumatic Symptoms: Negative thoughts and mood Persistent and distorted sense of blame Reliving past traumatic events Feelings of estrangement Recurrent nightmares Source: Beck, CT (2004) Birth Trauma: In the Eye of the Beholder, Nursing Research, 53, 28-35. 4
Bipolar Disorder and Psychosis: Bipolar Disorder Symptoms: Mood swings Excessive happiness, energy Excitement Productivity that doesn t make sense Unusual, weird behaviors Behaviors that may seem to be based in delusional thinking Grand gestures/actions out of character for the individual Depression Source: Bennett, S and Indman, P (2015) Beyond the Blues. 20 Psychosis Symptoms: Hallucinations Delusional thinking Mania Confusion Paranoia Changing symptoms Fortunately only 1-2 women per thousand experience this. Unfortunately of those women there is a 5% suicide rate and a 4% infanticide rate. Making a Diagnosis Where does it begin? Initial Screenings: Edinburg Postnatal Depression Screening (EDPS) PHQ 9 Client self reporting concerns Family members seeking help and support Provider concerns What s next? Talk openly with the client about your concerns Get family involved if the client will agree Help the client understand that, She is not alone, she is not to blame and she can get better with help Assess the urgency of the situation -- What is your emergency plan? Make a referral -- Who is your referral source? Offer resources for support -- What support resources exist? formal & informal Don t drop the ball -- Follow-up Things of Note When There is a Fetal Loss: PMAD is still possible in addition to grief Try to avoid asking how are you? or are you ok? instead try how are you doing today? Remember that everyone grieves differently and partners may be at odds in their grief. Help normalize the differences and encourage acceptance of a whatever works for you attitude. Pose the idea of more than grief gently but do bring it up if you are concerned. Don t assume PMAD-- Grief is Powerful! 5
When working with PP women: Discuss the importance of rest-sleep deprivation is torturous Support Breastfeeding-it s not always easy and failure is a definite trigger Encourage simple activity-a walk to the mailbox, or around the house Encourage a well balanced diet-lots of fluids and not too much caffeine Encourage allowing others to help Be prepared with quality resources specific to your community. Therapists that have specialized training in working with women with PMAD Doctors that are confidant in providing medication management to BF women Support groups SPECIFIC to issues of PMAD PSI resources Resource: Beyond The Blues Understanding and Treating Prenatal and Postpartum Depression & Anxiety by Shoshana S. Bennett Pec Indman Community Support for New Families, A Guide to Organizing a Postpartum Parent Support Network in Your Community by Jane Honikman Therapy and the Postpartum Women by Karen Kleiman Postpartum Support International (PSI) Postpartum.net 1-800-944-4PPD PSI provides telephone support; professional training and supports a network of individuals committed to supporting women and their families when dealing with perinatal mood and anxiety disorders. There website is a great place to start! 6