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Perinatal Perinatal Mood And Anxiety Mood And Anxiety Disorders Disorders Pec Indman EdD, MFT Pec Indman EdD, MFT
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Page 1: Perinatal Mood And Anxiety Disorders Pec Indman EdD, MFT.

PerinatalPerinatalMood And AnxietyMood And Anxiety

DisordersDisorders

Pec Indman EdD, MFTPec Indman EdD, MFT

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Every year, more than 400 000 infants are Every year, more than 400 000 infants are born to mothers who are depressed, which born to mothers who are depressed, which makes makes perinatal depression the most perinatal depression the most under diagnosed obstetric complication under diagnosed obstetric complication in Americain America. Postpartum depression leads . Postpartum depression leads to increased costs of medical care, to increased costs of medical care, inappropriate medical care, child abuse inappropriate medical care, child abuse and neglect, discontinuation of and neglect, discontinuation of breastfeeding, and family dysfunction and breastfeeding, and family dysfunction and adversely affects early brain development.adversely affects early brain development.

Pediatrics 2010;126;1032-1039 © 2011 Pec Indman EdD, MFT

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© 2011 Pec Indman EdD, MFT

MYTHS OF MOTHERHOODMYTHS OF MOTHERHOOD

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© 2011 Pec Indman EdD, MFT

MYTHS ABOUT PERINATALMYTHS ABOUT PERINATALMOOD DISORDERSMOOD DISORDERS

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© 2011 Pec Indman EdD, MFT

HISTORICAL INFORMATIONHISTORICAL INFORMATION(risk factors)(risk factors)

• Psychiatric history (including meds)• History of sexual abuse or trauma• Fertility problems• Perinatal loss• Previous pregnancy, birth, or

postpartum difficulties

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© 2011 Pec Indman EdD, MFT

IS IT PREGNANCY OR IS IT PREGNANCY OR DEPRESSION?DEPRESSION?

• Mood is labile, teary Mood is labile, teary Self esteem is Self esteem is

normalnormal• Sleep: bladder or Sleep: bladder or

heartburn may awaken. heartburn may awaken. Can fall asleep Can fall asleep

• No suicidal ideologyNo suicidal ideology• Energy: may tire, rest Energy: may tire, rest

restoresrestores• Pleasure: joy and Pleasure: joy and

anticipation anticipation (appropriate worry)(appropriate worry)

• Appetite: increasesAppetite: increases

• Mood: persistent gloomMood: persistent gloom• Low self-esteem, guiltLow self-esteem, guilt• Sleep: early a.m. Sleep: early a.m.

awakeningawakening• Suicidal thoughts, plans, Suicidal thoughts, plans,

or intentionsor intentions• Energy: rest does not Energy: rest does not

restore. Fatiguerestore. Fatigue• AnhedoniaAnhedonia• poor appetitepoor appetite

Yonkers K. and Little B, eds. Management of Psychiatric Disorders in Pregnancy, 2001

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© 2011 Pec Indman EdD, MFT

DEPRESSION IN PREGNANCYDEPRESSION IN PREGNANCY

• About 15-21% of women experience depression in pregnancy up to 38% in low SES (Alfonso DD, et al. Birth 1990;17:121-130, Marcus, S. Can J Clin Pharmacol Vol 16 (1) Winter 2009Can J Clin Pharmacol Vol 16 (1) Winter 2009)

• 50-75% relapse after discontinuing medication 50-75% relapse after discontinuing medication when pregnantwhen pregnant ((Cohen LS, et al. Psychother Psychosom. 2004 Jul-Aug;73(4):255-8)

• Over 40% resume medication Over 40% resume medication ((Cohen LS, et al.. Psychother Psychosom. 2004 Jul-Aug;73(4):255-8)

• Most are undetected and under treated Most are undetected and under treated ((Marcus, S., Depression during Pregnancy:Rates, Risks, and Consequences. Can J Clin Pharmacol Winter 2009 Vol 16 (1)

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RISK BENEFIT RATIORISK BENEFIT RATIO Risks of Risks of Risks of Risks of UntreatedUntreated vs vs Medical Medical IllnessIllness TreatmentTreatment

© 2011 Pec Indman

NO RISK-FREE ZONE!!!NO RISK-FREE ZONE!!!

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© 2011 Pec Indman EdD, MFT

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© 2011 Pec Indman EdD, MFT

MEDICATIONS IN MEDICATIONS IN PREGNANCYPREGNANCY

• Studies of Prozac, Zoloft, Paxil, Effexor, Anafranil, Studies of Prozac, Zoloft, Paxil, Effexor, Anafranil, Deseryl, Serzone, Tricyclics Deseryl, Serzone, Tricyclics ((Bennett HA, Einarson, A. et al. Clin Drug Invest 2004;24 (3), NEJM. June 28, 2007;356;26)

• No No increasedincreased risk malformations, risk malformations, miscarriage, neonatal complications or miscarriage, neonatal complications or neurobehavioral developmental neurobehavioral developmental problemsproblems up to 71 mo up to 71 mo ((Nulman I, Rovet J, Stewart D, et al. Am J Psychiatry 2002;159:1889-18895, Einarson A, Koren G. Can Fam Physician. 2006 May 10; 52(5): 593–594)

• Paxil??Paxil?? >3,000 exposed to paroxetine 1st tri

No No increasedincreased risk risk (Einarson A. et al. Am J Psychiatry 2008; 165:749–752)

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© 2011 Pec Indman EdD, MFT

SSRI’s in PREGNANCY: PPHN?SSRI’s in PREGNANCY: PPHN?25,214 deliveries reviewed:25,214 deliveries reviewed:• Congenital cardiac disease?Congenital cardiac disease?

• 0.4% exposed babies 0.4% exposed babies (mom’s on SSRI)(mom’s on SSRI)

• 0.8% Non exposed babies0.8% Non exposed babies• PPHN? PPHN?

• 16% non exposed babies 16% non exposed babies • 0 in exposed group.0 in exposed group.

(Mayo Clin Proc. 2009;84(1):23-27)

• No increased rate! No increased rate! ((Antidepressant medication use and risk of persistent pulmonary hypertension of the newborn, Andrade, S, et al. Pharmacoepidemiol. Drug Saf. 2009 January 15., Wilson, K. et al. . Persistent Pulmonary Hypertension of the Newborn Is Associated with Mode of Delivery and Not with Maternal Use of Selective Serotonin Reuptake Inhibitors. Amer J Perinatol. 2010, July 6)

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© 2010 Pec Indman EdD, MFT

NEONATAL ABSTINENCE NEONATAL ABSTINENCE SYNDROME-SSRI’sSYNDROME-SSRI’s

• Can occur in up to 30% neonates exposed Can occur in up to 30% neonates exposed in uteroin utero

• Should monitor/observe up to 48 hrsShould monitor/observe up to 48 hrs• Sx: tremor, GI,respiratory, and sleep Sx: tremor, GI,respiratory, and sleep

disturbance disturbance ((Rachel Levinson-Castiel, Arch Pediatrics & Adolescent Medicine,

2006;160:173-176)

• No evidence discontinuation affected No evidence discontinuation affected neonatal outcome neonatal outcome (Warburton W. Hartzman C. and OberlanderT., Acta

Psychiatr Scand 2010:121: 471–479)

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PRENATAL ANXIETY PRENATAL ANXIETY TREATMENTTREATMENT

• Psychotherapy and adjuctive therapiesPsychotherapy and adjuctive therapies• SSRI’s (usually need higher dose)SSRI’s (usually need higher dose)• Benzo’s (lorazapam 1Benzo’s (lorazapam 1stst choice) choice)

• ““exposure to a benzodiazepine does exposure to a benzodiazepine does not significantly increase the risk for not significantly increase the risk for birth defects”birth defects”

• Calderon-Margalit R, Qiu C, Ornoy A, Siscovick DS, Williams MA.Am J Obstet Gynecol. 2009 Dec;201(6):579

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PRENATAL MEDICATIONSPRENATAL MEDICATIONS

• As blood volume increases in As blood volume increases in pregnancy, medications are diluted.pregnancy, medications are diluted.

• Dosage may need to increase in 3Dosage may need to increase in 3rdrd

trimestertrimester

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© 2011 Pec Indman EdD, MFT

OTHER TREATMENTSOTHER TREATMENTS• Light Therapy Light Therapy ((Oren, D, et al.. Am J Psychiatry, April 2002,159:4)

• 49% improvement in scores in 3 weeks49% improvement in scores in 3 weeks• No adverse effects notedNo adverse effects noted

• Omega 3 Fatty Acids Omega 3 Fatty Acids (Freeman MP, Evidence-Based Integrative Medicine 2003:1(1):43-49)

• Up to 3 gm daily improved EPDS scoresUp to 3 gm daily improved EPDS scores

• ECTECT (Yonkers K. and Little B, eds.,Management of Psychiatric Disorders in Pregnancy, 2001)

• Few complications in pregnancy based on large Few complications in pregnancy based on large body of literaturebody of literature

• May be best choice for depression with May be best choice for depression with psychosispsychosis

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PSYCHOTHERAPY FOR PSYCHOTHERAPY FOR PRENATAL DEPRESSIONPRENATAL DEPRESSION

• Interpersonal Psychotherapy (IPT)• Cognitive-Behavioral therapy (CBT)• Group Therapy/Support• Couples counseling

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PSYCHOTHERAPY MODELSPSYCHOTHERAPY MODELS

• Interpersonal Psychotherapy Interpersonal Psychotherapy (IPT)(IPT)http://www.psychology.uiowa.edu/labs/idcrc/Library/IPT.pdf and http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2234626/)

• Cognitive-Behavioral Therapy Cognitive-Behavioral Therapy (CBT)(CBT) (Yonkers, K. et al. Obestet Gynecol 2011:117:961-77)

• Couples TherapyCouples Therapy ( (Apfel R and Handel M in Miller L. ed. Postpartum Mood

Disorders 1999)

• Group Group (http://www.jppr.psychiatryonline.org/cgi/content/abstract/10/2/124 and

http://ajp.psychiatryonline.org/cgi/content/abstract/158/4/638)

© 2011 Pec Indman EdD, MFT

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© 2011 Pec Indman EdD, MFT

MATERNAL OUTCOMES MATERNAL OUTCOMES ASSOCIATED WITH ASSOCIATED WITH

PRENATAL DEPRESSIONPRENATAL DEPRESSION

• Functional impairmentFunctional impairment• Poor nutritionPoor nutrition• Inadequate weight gainInadequate weight gain• Adverse behaviorsAdverse behaviors

• Smoking (20.4%)Smoking (20.4%)• Alcohol use (18.8%)Alcohol use (18.8%)• Drug use (5.5%) Drug use (5.5%)

(Bonari L. et al. Can J Psychiatry, Vol 49, No 11, November 2004)

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DEPRESSION/ANXIETY IN DEPRESSION/ANXIETY IN PREGNANCYPREGNANCY

Depression in pregnancy associated with:Depression in pregnancy associated with:• Low birth weight (under 2500 grams)Low birth weight (under 2500 grams)• Preterm delivery (less than 37 weeks) up to Preterm delivery (less than 37 weeks) up to

2X risk 2X risk ((Li D, Liu L, Odouli R, Hum Repod. 2009 Jan;24(1):146-53. Epub 2008 Oct 23, Bonari L. et al. Can J Psychiatry, Vol 49, No 11, November 2004

• Small-for-gestational age Small-for-gestational age

Severe anxiety in pregnancy associated with:Severe anxiety in pregnancy associated with:• Constriction in placental blood supplyConstriction in placental blood supply• Heightened startle response in newbornHeightened startle response in newborn• Newborns more inconsolable, poor sleepNewborns more inconsolable, poor sleep

(Bennett HA, Einarson, A. et al. Clin Drug Invest 2004;24 (3)

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DEPRESSION IN DEPRESSION IN PREGNANCY RISKPREGNANCY RISK

• Women depressed at 18 wks Women depressed at 18 wks gestation had 3x risk of PPDgestation had 3x risk of PPD

• Depression at 32 weeks-6x riskDepression at 32 weeks-6x risk

Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy and Postpartum. American Psychiatric Publishing, Inc., 2005

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POSTPARTUM POSTPARTUM “BLUES”“BLUES”

• Occurs in 50-80%Occurs in 50-80%• Onset usually in first weekOnset usually in first week• Symptoms may persist from several Symptoms may persist from several

days to a few weeksdays to a few weeks

NORMALNORMAL

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BLUES OR BEYOND?BLUES OR BEYOND?

• SeveritySeverity

• TimingTiming

• DurationDuration

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POSTPARTUM DEPRESSIONPOSTPARTUM DEPRESSION• 15-20%, and15-20%, and 26-32% teens26-32% teens ((Currie ML and Radenmacher R, Pediatr Clin N Am 2004, 51:785-810, Gaynes BN, et al. Evid

Rep/Technol Assess (Summ) 2005:1–8.

• Symptoms often peak at 3-6 monthsSymptoms often peak at 3-6 months• Can become chronicCan become chronic• Untreated, 25% still depressed at one year Untreated, 25% still depressed at one year

postpartum postpartum (Leopold KA and Zoschnick, LB., The Female Patient. Aug

1997;22(8):40-49)

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SYMPTOMS OF POSTPARTUMSYMPTOMS OF POSTPARTUM DEPRESSION/ANXIETYDEPRESSION/ANXIETY::

• Sad mood, guilt, irritability, excessive worry, Sad mood, guilt, irritability, excessive worry, anxiety, or feelings unable to copeanxiety, or feelings unable to cope

• Sleep problems (often insomnia), fatigueSleep problems (often insomnia), fatigue• Symptoms or complaints in excess of, or Symptoms or complaints in excess of, or

without physical causewithout physical cause• Discomfort around baby, or lack of feelings Discomfort around baby, or lack of feelings

towards babytowards baby• Loss of focus and concentration (may miss Loss of focus and concentration (may miss

appointments)appointments)• Loss of interest or pleasure Loss of interest or pleasure • Appetite changes-poor appetite or weight gainAppetite changes-poor appetite or weight gain

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FREQUENT SYMPTOMS IN FREQUENT SYMPTOMS IN PRACTICEPRACTICE

Review of 133 womenReview of 133 women

1.1. ““felt really overwhelmed”felt really overwhelmed”

2.2. ““felt like my emotions were on a felt like my emotions were on a rollercoaster”rollercoaster”

3.3. ““have been very irritable”have been very irritable”

4.4. ““felt all alone”felt all alone”

5.5. ““felt like I wasn’t normal”felt like I wasn’t normal”(Beck C and Indman P., JOGNN, Sept/Oct 2005:34(5):569-576)

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THYROIDITIS OCCURS IN THYROIDITIS OCCURS IN ABOUT 10%ABOUT 10%

• Lab work to rule out thyroiditis:Lab work to rule out thyroiditis:

• Free T4Free T4• TSHTSH• Anti-TPOAnti-TPO• Anti-Thyroglobulin antibodiesAnti-Thyroglobulin antibodies• Best time to test 2-3 mo postpartumBest time to test 2-3 mo postpartum(Stagnaro-Green A., Best Pract Res Clin Endocrinol Metab. 2004

Jun;18(2):303-111.

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TREATMENT FOR POSTPARTUMTREATMENT FOR POSTPARTUM DEPRESSION/ANXIETYDEPRESSION/ANXIETY

• Individual/couples therapy, groupIndividual/couples therapy, group• CBT or Interpersonal Therapy (IPT)

• Antidepressant and/or antianxiety Antidepressant and/or antianxiety medication, Sleep meds medication, Sleep meds (Wisner KL, et al., N Engl J Med.

July 2002;347(3):194-199)

• Treat thyroiditis Treat thyroiditis • ECT, TMS (?)ECT, TMS (?)

INADEQUATE TREATMENT CAN LEAD TO INADEQUATE TREATMENT CAN LEAD TO CHRONIC DEPRESSION OR RELAPSECHRONIC DEPRESSION OR RELAPSE

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POSTPARTUM OBSESSIVE-POSTPARTUM OBSESSIVE-COMPULSIVE DISORDER COMPULSIVE DISORDER

(OCD)(OCD)

• 3% to 9% of new mothers may develop 3% to 9% of new mothers may develop obsessive symptomsobsessive symptoms

(Abramowitz JS, et al. Anxiety Disorders 2003. 17:461-478, Chaudron, LH and Neha Nirodi. Chaudron, LH and Neha Nirodi. Arch Arch

Womens Ment Health, March, 2010;1434-1816.Womens Ment Health, March, 2010;1434-1816.))

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SYMPTOMS OF SYMPTOMS OF POSTPARTUM OCDPOSTPARTUM OCD

• Intrusive, repetitive, and persistent thoughts or Intrusive, repetitive, and persistent thoughts or mental picturesmental pictures

• Thoughts often are about hurting or killing the Thoughts often are about hurting or killing the babybaby

• Tremendous sense of horror and disgust about Tremendous sense of horror and disgust about these thoughts (ego alien)these thoughts (ego alien)

• Thoughts may be accompanied by behaviors Thoughts may be accompanied by behaviors to reduce the anxietyto reduce the anxiety

• Repetitive counting, checking, cleaningRepetitive counting, checking, cleaning(Abramowitz JS et al. Arch Womens Ment Health (2010) 13:523–530)

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TREATMENT FOR OCDTREATMENT FOR OCD

• Psychotherapy and psychoeducationPsychotherapy and psychoeducation

• Medication (SSRIs, anxiolytics, Medication (SSRIs, anxiolytics,

antipsychotics), usually need higher antipsychotics), usually need higher doses of SSRIdoses of SSRI

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POSTPARTUM PANIC POSTPARTUM PANIC DISORDERDISORDER

• May occur in about 10% of postpartum May occur in about 10% of postpartum womenwomen

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© 2011 Pec Indman EdD, MFT

SYMPTOMS OF PANIC SYMPTOMS OF PANIC DISORDERDISORDER

• Episodes of extreme anxiety: excessive or obsessive worry or fears

• Shortness of breath, chest pain, sensations of choking or smothering, dizziness

• Hot or cold flashes, trembling, palpitations, numbness or tingling sensations

• Restlessness, agitation, or irritability• Fear she is going crazy, dying, or losing control• Attack may awaken her from sleep• Often no identifiable trigger for panic

(Sichel D and Driscoll JW. Women’s Moods, 1999)

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TREATMENT FOR PANIC TREATMENT FOR PANIC DISORDERDISORDER

• Psychotherapy• SSRIs (higher dose to tx anxiety)• Antianxiety medication PRN

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POSTTRAUMATIC STRESS POSTTRAUMATIC STRESS DISORDER (PTSD)DISORDER (PTSD)

• 1-6% of postpartum women1-6% of postpartum women(Beck CT. Nursing Research. July/Aug 2004; 53(4):216-224)

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SYMPTOMS OF PTSDSYMPTOMS OF PTSD

• Recurrent nightmaresRecurrent nightmares• Extreme anxietyExtreme anxiety• Reliving past traumatic eventsReliving past traumatic events

• • sexualsexual

• • physicalphysical

• • emotionalemotional

• • childbirthchildbirth

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TREATMENT FOR PTSDTREATMENT FOR PTSD

• PsychotherapyPsychotherapy• SSRIs and/or antianxiety medicationSSRIs and/or antianxiety medication

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• 50% bipolar women who discontinued meds 50% bipolar women who discontinued meds relapsed in first 3 months of pregnancy,relapsed in first 3 months of pregnancy,

• 70% relapsed by 6 months 70% relapsed by 6 months ((Am J of Psychiatry, 2007 Dec;164(12):1817-24)

• Valproic Acid has up to 5% risk neural tube Valproic Acid has up to 5% risk neural tube defectsdefects

• Lithium has 0.05% risk of Ebstein’s anomaly in Lithium has 0.05% risk of Ebstein’s anomaly in 1st trimester. Best choice for bipolar disorders1st trimester. Best choice for bipolar disorders

• Preconception counseling is criticalPreconception counseling is critical

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POSTPARTUM POSTPARTUM BIPOLAR DISORDERBIPOLAR DISORDER

• In women with BD rates range up to 82%In women with BD rates range up to 82%• Time of increased vulnerability for relapseTime of increased vulnerability for relapse• Closely associated with postpartum psychosis Closely associated with postpartum psychosis

(Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy and Postpartum. American Psychiatric Publishing, Inc., 2005. Sharma, V. et al. Am J Psychiatry 2009; 166:1217–1221)

• Up to 21.6% of primary care patients dx’d with Up to 21.6% of primary care patients dx’d with unipolarunipolar depression may have an undiagnosed depression may have an undiagnosed bipolar disorder. bipolar disorder. (Smith, DJ. Et al., Br J Psychiatry 2011 10.1192/bjp.bp.110.083840f)

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SYMPTOMS OF BIPOLARSYMPTOMS OF BIPOLAR

• Mania or hypomania (“moody”)Mania or hypomania (“moody”)• Depression (PPD “imposter”)Depression (PPD “imposter”)• Rapid and severe mood swingsRapid and severe mood swings

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TREATMENT OF BDTREATMENT OF BD

• Prophylaxis with a mood stabilizer or Prophylaxis with a mood stabilizer or neuroleptic is recommended at the end of neuroleptic is recommended at the end of pregnancy (36 weeks gestation)pregnancy (36 weeks gestation)

• Careful observation for symptomsCareful observation for symptoms

• High RiskHigh Risk postpartum postpartum mania/psychosismania/psychosis

(Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy

and Postpartum. American Psychiatric Publishing, Inc., 2005)

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POSTPARTUM PSYCHOSISPOSTPARTUM PSYCHOSIS

• Occurs in 1-2/1000Occurs in 1-2/1000• 50% of 150% of 1stst time moms with no previous time moms with no previous

psych hospitalization psych hospitalization ((Valdimarsdóttir U. et al. 2009. PLoS Med

• 6(2): e1000013)

• 5% suicide and 4% infanticide rate5% suicide and 4% infanticide rate(Sit, D. et al. Journal of Women’s Health 2006: 15(4), Doucet, S. et al, JOGNN 2009, 38, 269-279)

Melanie Blocker-Stokes Andrea Yates Jennifer Mudd Houghtaling

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SYMPTOMS OF POSTPARTUM SYMPTOMS OF POSTPARTUM PSYCHOSISPSYCHOSIS

• Usually begins 48-72 hours postpartumUsually begins 48-72 hours postpartum• Most develop symptoms within 2-4 weeksMost develop symptoms within 2-4 weeks• Visual or auditory hallucinationsVisual or auditory hallucinations• Early symptoms restlessness, agitation, Early symptoms restlessness, agitation,

irritabilityirritability• Confusion, paranoia, extreme moodswingsConfusion, paranoia, extreme moodswings• Delusional thinking (infant death, denial of Delusional thinking (infant death, denial of

birth, need to kill baby)birth, need to kill baby)(Sit, D. et al. Journal of Women’s Health 2006: 15(4), Doucet, S. et al, JOGNN 2009, 38, 269-279.)

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TREATMENT FOR POSTPARTUM TREATMENT FOR POSTPARTUM PSYCHOSISPSYCHOSIS

• REQUIRES REQUIRES IMMEDIATE HOSPITALIZATIONIMMEDIATE HOSPITALIZATION• AntipsychoticsAntipsychotics• Mood stabilizers (antidepressants as needed)Mood stabilizers (antidepressants as needed)• PsychotherapyPsychotherapy• ECTECT

(Sit, D. et al. Journal of Women’s Health 2006: 15(4), Yonkers KA, et al.. Am J Psychiatry. 2004;161:608-620)

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WHY TREAT MOMS?WHY TREAT MOMS?• Increased incidence of childhood

psychiatric disturbances• Impaired cognitive and language

development in children• Potential for child abuse and neglect• Negative impact on marital/family

relationships• Increased risk chronic depression and

relapse(Field T. et al., Infant Behavior & Development 2004;(27):216-229,Hart S. et al., Infant Behavior & Development 1998; 21(3):519-525,Murray L and Cooper PJ.,. Psychological Medicine 1997;27(2):253-260)

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BREASTFEEDING AND BREASTFEEDING AND ANTIDEPRESSANTSANTIDEPRESSANTS

• AAP now recommends 1 year of AAP now recommends 1 year of breastfeeding. breastfeeding.

• ““Paxil and Zoloft usually produce Paxil and Zoloft usually produce undetectable infant levels.” undetectable infant levels.” ((Weissman AM. et al. Am J

Psychiatry 2004;161:1066-1078)

• Studies of exposed infants show no Studies of exposed infants show no differences in IQ or neurobehavioral differences in IQ or neurobehavioral development development (Yoshida K, et al. Br J Clin Pharmacol. 1997

Aug;44(2):210-1)

See also M. Freeman, J Clin Psychiatry, Feb. 2009. 70:2

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BREASTFEEDINGBREASTFEEDING• Depressed moms breastfed for shorter Depressed moms breastfed for shorter

durationsdurations• Experienced breastfeeding more Experienced breastfeeding more

negatively than non-depressed negatively than non-depressed (Individual and

Combined Effects of Postpartum Depression in Mothers and Fathers on Parenting Behavior. Paulson, Dauber, and Leiferman. Pediatrics, 118(2), Aug 2006:659-668)

• Increased breastfeeding difficultiesIncreased breastfeeding difficulties• Decreased levels of breastfeeding self-Decreased levels of breastfeeding self-

efficacy efficacy (Dennis CL & McQueen K. The Relationship Between Infant-

Feeding Outcomes and Postpartum Depression. Pediatrics 2009;123:e736-e751)

© 2011 Pec Indman EdD, MFT

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SCREENINGSCREENING• Edinburgh Postnatal Depression Scale Edinburgh Postnatal Depression Scale

(EPDS), (EPDS), 1987 Cox, et. al.1987 Cox, et. al.

• Score of Score of >> 10 10 refer for evaluation refer for evaluation• Validated in pregnancy, free, many languagesValidated in pregnancy, free, many languages

• PHQ9, PHQ4, PHQ2: not well studied for PHQ9, PHQ4, PHQ2: not well studied for perinatal use, but frequently used perinatal use, but frequently used www.depression-www.depression-

primarycare.org/clinicians/toolkits/materials/forms/phq9/primarycare.org/clinicians/toolkits/materials/forms/phq9/

• Postpartum Depression Screening Scale Postpartum Depression Screening Scale (PDSS), (PDSS), 2002 Cheryl Beck D.N.Sc. www.wpspublish.com2002 Cheryl Beck D.N.Sc. www.wpspublish.com

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WHEN SHOULD WE SCREEN?WHEN SHOULD WE SCREEN?

• Ideally, preconception counseling

• Each trimester of pregnancy

• All well-baby checkups in first year

• NICU parents and teens high risk

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CONSEQUENCES OF UNTREATED CONSEQUENCES OF UNTREATED PERINATAL MENTAL ILLNESSPERINATAL MENTAL ILLNESS

• Decreased ability to parentDecreased ability to parent• Harsher disciplineHarsher discipline• Cognitive, emotional and developmental Cognitive, emotional and developmental

delays and deficitsdelays and deficits• Poor attachmentPoor attachment• Depressive disorders by age 15Depressive disorders by age 15(Hammen, C and P. Brennan, Arch Gen Psychiatry, 2003;60:253-258)

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FATHERSFATHERS• In a national studies reported in In a national studies reported in

2006 and 2010, 10% of new fathers 2006 and 2010, 10% of new fathers scored in the range of clinical scored in the range of clinical depression.depression.

• Maternal depression increased the Maternal depression increased the risk of paternal depression.risk of paternal depression.

(Paulson, Dauber, Leiferman, Pediatrics, 2006 Aug;118(2):659-68, Paulson, J and Bazemore, S. JAMA. 2010;303(19):1961-1969)

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TREATMENT CONSIDERATIONSTREATMENT CONSIDERATIONS

• History of the illness History of the illness • Degree of current illness Degree of current illness • Risks and benefits of Risks and benefits of

treatment optionstreatment options• Patient/patient’s family’s Patient/patient’s family’s

history and preferenceshistory and preferences

© 2011 Pec Indman

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TREATMENT GUIDELINESTREATMENT GUIDELINES

• Always r/o bipolar spectrum before Always r/o bipolar spectrum before starting SSRI’s. starting SSRI’s. http://www.psycheducation.org/depression/MDQ.htm

• Start at low dose and work upStart at low dose and work up• F/U frequently and treat to F/U frequently and treat to remissionremission! ! • Meds work best Meds work best withwith therapy therapy• Progesterone may worsen mood - caution Progesterone may worsen mood - caution

with progestin only OC’s or IUDwith progestin only OC’s or IUD

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RESOURCESRESOURCES

• Postpartum Support InternationalPostpartum Support International• www.postpartum.netwww.postpartum.net (great resources) (great resources)

• North American Society for Psychosocial North American Society for Psychosocial

OB/GYN OB/GYN www.naspog.orgwww.naspog.org April 22-25, April 22-25, 20122012

• www.mededppd.orgwww.mededppd.org (professionals and (professionals and consumer info)consumer info)

• www.womensmentalhealth.org www.womensmentalhealth.org (Mass (Mass General)General)

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RESOURCESRESOURCES• UIC Perinatal Mental Health Project UIC Perinatal Mental Health Project

800-573-6121800-573-6121 Free consultation for providersFree consultation for providers

• www.otispregnancy.orgwww.otispregnancy.org 866-626-866-626-68476847(Organization of Teratology Information Specialists-free patient (Organization of Teratology Information Specialists-free patient

handouts)handouts)

• www.motherisk.orgwww.motherisk.org (fetal and breastmilk exposure)

• www.infantrisk.orgwww.infantrisk.org (fetal and breastmilk exposure, phone app!)

• Depression During and After Pregnancy: A Resource for Depression During and After Pregnancy: A Resource for Women, Their Families, and Friends, Women, Their Families, and Friends, (free booklet Eng/Span)(free booklet Eng/Span) http://ask.hrsa.gov/detail_materials.cfm?ProdID=3924http://ask.hrsa.gov/detail_materials.cfm?ProdID=3924