Crying, Snappy, Worried Oh My!: Perinatal Mood and Anxiety Disorders Dr. Tiffany Willis Licensed Clinical Psychologist April 26, 2018 The Children s Mercy Hospital, 2016 The Children's Mercy Hospital, 2015
Objectives What are Perinatal Mood and Anxiety Disorders (PMADs)? What is the impact of PMADs on the parent child relationship and child development? What are the recommendations for screening for PMADs? What are the treatment modalities for PMADs? 2
What is your profession? 3
Up to 2 weeks Sadness and crying Exhaustion Irritability Difficulty sleeping Poor concentration Loss of appetite Baby Blues 4
What are perinatal mood and anxiety disorders? Perinatal depression Perinatal anxiety Obsessive Compulsive Disorder Posttraumatic Stress Disorder Postpartum psychosis 5
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What are some happy, positive words that stand out to you on these magazine covers?
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What do PMADs look like?
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Perinatal Depression Loss of joy in life and appetite Withdrawal from family and friends Intense irritability and anger Increases risk for preeclampsia Most often occurs in the first 3 months 1 in 7 women 22
Panic attacks Perinatal Anxiety Shortness of breath Chest or stomach pains Difficulty sleeping Mom feels like her mind will not quiet Excessive fearfulness about your baby s health Fairbrother et. al, 2016 23
Obsessive-Compulsive Disorder Intrusive thoughts about hurting or killing your baby Adaptive compulsive behaviors to prevent baby from being harmed, which are secondary to harmful thoughts. Persistent worry about your baby Checking on your baby excessively Often these thoughts are scary to the parent MOPAP, 2015 24
Posttraumatic Stress Disorder Avoidance of stimuli related to traumatic event Increased arousal to stimuli that are reminders of the traumatic event Replaying of traumatic event Change in mood Distractibility 25
Who s your daddy? 10% paternal depression 18% for Headstart family Symptoms o Irritability o Emotional detachment o Withdrawal Most common 3-6 months after birth Men whose partners were depressed had significantly higher depression scores than did men whose partners were not depressed. Causes: Sleep deprivation, unhappiness with gender, unexpected pregnancy Goodman, 2008; Harmon, 2010; Sheehan, Kopelman, & O Hara, 2012 27
Postpartum Psychosis Confusion and disorientation Visual and auditory hallucinations or delusions Paranoia Bizarre behavior Insomnia Thoughts/attempts to hurt yourself or your baby BBC Newsnight Postpartum Psychosis https://www.youtube.com/watch?v=bcaubxpqifi 28
What are your reactions to that clip? 29
Suicide is the leading cause of death in perinatal women. 30
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What is the rate of postpartum depression in African American women? 35
PMAD in minority women: Postpartum depression is found at a higher rate than in Caucasian women (Howell et al., 2005; Keefe, 2016). Manifests itself differently than with Caucasian women (Amankwaa, 2003; Keefe, 2016). Is associated with more physical issues (back pain, tiredness, headaches) in comparison to Caucasian women (Howell et al., 2005). Is often treated through the use of self-talk or by confiding in family and/or friends. Often brings about feelings of guilt as African-American women feel that they can not live up to certain cultural ideas like the Strong Black Woman (Amankwaa, 2003). Kozhimannil et. al, 2011
PMAD in teen populations Highest impact subgroup 300k births per year Edinburgh appropriate for screening 37
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Risks for PMADs Traumatic Birth/Preterm Birth Low social support PMAD with previous children Pregnancy is unplanned or unwanted History of personal of familial mental health problems Diabetes (Pre-existing or gestational) Pre-existing life stressors (primary factors) o o o o o o Finances Housing Job Relationship problems/domestic Violence Legal problems Health problems Liu & Tronick, 2013; Segre, 2008; Carmen et. al, 2016
WHY DOES THIS MATTER FOR NEONATES? 40
So how does this impact the baby? 1. Attachment A. Physical Proximity B. Physical Touch C. Verbal Interaction D. Basic Needs Still face experiment o Emotional regulation o Resilience Healthy attachment serves as a protective factor for heart disease, depression, and infection. 2. Neurodevelopment Rat pups o Fewer synaptic connections o Slower physiological repair Hall et al, 2017; Gelfand & Teti, 1990; Hawes et. al, 2016; Melinder et. Al, 2010 41
So how does this impact the baby? 3. Future development Slower cognitive and language development Impaired feeding More disruptive behaviors 4. Mental health Higher rates of depression as adolescents Hall et al, 2017; Gelfand & Teti, 1990; Hawes et. al, 2016; Melinder et. Al, 2010; Diaz & Plunkett, 2018 42
Screening The Debate Edinburgh Postpartum Depression Scale 43
National Perinatal Association Position Statement on Perinatal Mental Health Screening Training on perinatal mental health conditions Routine screening for pregnant and postpartum women and their partners Treatment and referral system for identified conditions Mother Pregnancy At least once, ideally each trimester Screening timeline for PMADs 6 week Ob/Gyn visit Postpartum 2 months 4 months 6 months Partner 2 months 4 months 6 months 44
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I LOVE this article! 46
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Just bring it up! N.E.E.E.O I always like to check in with new moms about mood (Normalize) Usually, the first couple of weeks you may feel exhausted and overwhelmed. You may notice yourself crying a lot or barking at dad/your partner/the kids/the mailman. (Explain and add humor!) But we expect that after a few weeks, those feelings start to mellow out. (State the Expectation) However, for some moms, those feelings stick around. (Educate) How has your mood been? (Provide an Opportunity) 48
Questions to facilitate a conversation with moms about perinatal depression and anxiety How are you feeling about being pregnant/a mother? What are the things you are most happy/concerned about? How is your partner doing? Are you able to enjoy and connect with your baby? 49
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Therapy Interventions 1. Individual therapy 3. Dyadic therapy o Cognitive Behavioral Therapy o Watch Wait and Wonder o Psychodynamic Therapy o Circle of Security o Solution Focused Therapy o Child Parent Psychotherapy o o Dialectical Behavioral Therapy Interpersonal Therapy o Parent Child Interaction Therapy 2. Couples therapy o Emotion Focused Therapy 4. Group therapy o o Support/Process group Mother-Infant Therapy Group (12 weeks structured group) 51
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Resources National Perinatal Association Postpartum Support International Postpartum Progress The Pregnancy and Postpartum Resource Center-Kansas City, MO Coffective, LLC app 56
Questions? 57
References Amankwaa, L. C. (2003). Postpartum depression among African-American women. Issues in Mental Health Nursing, 24, 297-316. Amankwaa, L.C. (2003). Postpartum depression, culture, and African-American women. Journal of Cultural Diversity, 10(1), 23-29. Diaz, N. M., & Plunkett, B. A. (2018). Universal Screening for Perinatal Depression. NeoReviews,19(3). doi:10.1542/neo.19-3- e143 Gaynes, B., Gavin, N., Metzger-Brody, S., Lohr,K., Swinson, T., Gartlehner, G., et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evidence report/technology assessment no. 119. (Prepared by the RTI-University of North Carolina Evidenced-based Practice Center, under contract no. 290-02-0016). AHRQ publication no. 05-E006-2. Rockville, MD: Agency for Healthcare Research and Quality, 2005. Gelfand, D. M., Teti, D.M., (1990). The effects of maternal depression on children. Clinical Psychologist Review, (10), 329-353. Goodman, J. H. (2008). Influences of maternal postpartum depression on fathers and on father-infant interaction. Infant Mental Health Journal, 29, 6, 624-643 Griogoriadis S., Wilton, A.S., Kurdayak P.A. et al (2017). Perinatal suicide in Ontario, Canada: a 15 year population-based study. CMAJ; Aug 28; 189 (34): E1085-1092Hall, S. L., Hynan, M. T., Phillips, R., Lassen, S., Craig, J. W., Goyer, E., Hatfield, R.F., Cohen, H. (2017). The neonatal intensive parenting unit: an introduction. Journal of Perinatology, 1-6. Harmon, K. (2010, May 18). Fact or Fiction: Fathers Can Get Postpartum Depression. Retrieved April 04, 2017, from https://www.scientificamerican.com/article/fathers-postpartum-depression/ Howell, E. A., Mora, P. A., Horowitz, C. R. & Leventhal, H. (2005). Racial and ethnic differences in factors associated with early postpartum depressive symptoms. Obstetrics and Gynecology, 105(6), 1442-1450. Liu, C. H. Trunick, E. (2013). Re-conceptualizing Prenatal Life Stressors in Predicting Post-partum Depression: Cumulative-, Specific-, and Domain-specific Approaches to Calculating Risk. Pediatric and Perinatal Epidemiology.; 27(5):481-90. Paulson, J.F., Bazmore, S.D. (2010). Prenatal and postpartum depression in fathers and its association with maternal depression. JAMA, 303(19), 1961-1969. Screening for perinatal depression. Committee Opinion No. 630. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015; 125:1268-71. Serge, L.S., O Hara, M. W., Arndt, S., Stuart, S., (2007).The prevalence of postpartum depression: The relative significance of three social status indices, Social Psychiatry and Psychiatric Epidemiology. (2007). Vol. 42, No. 4: pp. 316-321. 58