Perinatal Mood Disorders

1. Presented By: Heidi Haensel, MD, FRCPC March 20, 2019 Perinatal Mood Disorders

2. Disclosure: • I have not had in the past 3 years, a financial interest, arrangement or affiliation with one or more organizations that could be perceived as a direct or indirect conflict of interest in the content of this presentation.

3. Objectives: • To review the presentation of mood disorders (Depression and Bipolar Disorders) in pregnancy and postpartum • To discuss the impact of mood disorders in pregnancy and postpartum on the mother and infant • To discuss screening and management of mood disorders in pregnancy and postpartum

4. Depression in Pregnancy and Postpartum- a Common Problem • Between 5 and 16% of women will experience major depression at some point during their pregnancy • Between 4.2%–9.6% will experience a major depressive disorder between birth and 3 months postpartum • Estimates vary between 9.3% and 31% for the first year postpartum

5. Baby Blues – Even More Common • occur in 50-85% of women • Peak symptoms 3rd to 7th day after delivery; usually completely gone 3 weeks after delivery • Thought to be reaction to hormone changes post-pregnancy • Main feature is mood lability - “crying at the drop of a hat”; “moodiness” • Also anxiety, insomnia, poor appetite and irritability • Not as severe, persistent or pervasive as postpartum depression

6. Depression in Pregnancy and Postpartum – How to Recognize • Those with a history of depression carry the greatest risk • However, for 50-70% it is the first presentation of depression in their lifetime • If discontinuation of antidepressants near conception,75% relapse (often 1st trimester) • With abrupt discontinuation antidepressants during pregnancy, 70% have adverse effects, suicidality, hospitalization

7. Depression in Pregnancy and Postpartum – How to Recognize Symptoms: • Sad mood • Crying frequently • Changes in sleep: in post-partum, often not able to sleep when baby is sleeping • Appetite: diminished appetite in breastfeeding a concern • Decreased energy and motivation: not keeping up with baby or self care • Anhedonia: don’t enjoy, feel bonded to the baby • High anxiety frequently seen • May have thoughts of harm to self or to the baby: e.g. “They are better off without me”; smothering baby, leaving baby in a snow bank

8. Risks for Developing Perinatal Depression • Personal history of depression, depression in pregnancy – up to 50% develop postpartum depression • Previous postpartum depression • Family history of depression

9. Risks for Developing Perinatal Depression • Excessive anxiety during pregnancy; Lack of confidence in parenting skills/excess anxiety about baby • Poor social support – social isolation, recent move, poverty, cultural or language issues • Relationship or family conflict; Life/financial stress • Recent adverse life events (e.g., loss of close relative or friend); previous pregnancy loss • Intimate partner violence • Unintended pregnancy/ambivalence towards pregnancy • Infants with health problems or perceived difficult temperaments • Chronic/acute maternal health problems

10. Perinatal Depression - Impact • Impacts of untreated perinatal depression are much greater and farther-reaching than risks associated with antidepressant treatment • Impacts on pregnancy outcomes and child development derive from poorer prenatal care, more substance use in pregnancy, poorer nutrition and self-care, epigenetic effects of chronic stress • Postnatal impacts on relationships with family and spouse; attachment security of infant; confidence in parenting; sustaining breastfeeding; substance use • In turn, these impact the motor, language and social development of infants and children • Suicide and infanticide risks

11. Perinatal Depression - Impact Impacts for mother • poor self care, inadequate nutrition & weight gain, sleep disturbance, illicit drug use, smoking , alcohol abuse • emotional deterioration, increased anxiety • interpersonal/family conflict • increased risk pre-eclampsia, operative delivery, epidural, NICU • Suicide, attempted suicide, infant harm and infanticide Impacts for infant • preterm birth • lower birth weight • smaller head circumference • lower APGAR scores • Significant behavioural problems more likely • Sleep and eating disorders • Difficulties in regulating emotions and behavioureg. temper tantrums • Delayed language development • Lower rates of secure attachment

12. Bipolar Disorder in the Perinatal Period • Rates the same as general population (2.1%) • Pregnancy confers risk for exacerbation of symptoms (45-50% report this) • Many women discontinue medications abruptly in pregnancy; 50% will relapse • Postpartum period conveys increased risk for onset of Bipolar Disorder or relapse • 25%–30% recurrence rate in the immediate postpartum and relapse rates at 3-6 months postpartum of 67%–82%. • Rate of postpartum psychosis is 10–20% among women with bipolar disorder. • In Bipolar Type 2, hypomanic symptoms in pregnancy can be misattributed as “nesting behavior”, and in postpartum they can be attributed to elation about the baby • Diagnosis often missed until mood swings into depression

13. Postpartum Psychosis • Rare; 1 to 2 per 1000 births • If first onset psychosis, usually is a first presentation of bipolar disorder • Symptoms develop typically 2 to 3 days after delivery, but may develop up to 4 weeks after • Prodrome of worsening insomnia and agitation • Symptoms of lability, disorganized thoughts and behaviour, bewilderment, poor memory • Progresses rapidly • Bizarre thoughts often involve the baby; e.g. the baby is an alien, dead, replaced • Infanticide: 1-3 per 50,000 births; suicide also a risk • Postpartum psychosis is an emergency, and requires hospitalization and psychiatric management

14. Perinatal Mood Disorders - Screening • Bipolar Disorder – no validated tool for perinatal period; rely on diagnostic interview • Depression – Edinburgh Postnatal Depression Scale • See the “new” Ontario Antenatal Record for screening tools and schedule • Screening in pregnancy recommended, as well as 6 weeks postpartum

15. Edinburgh Postnatal Depression Scale • Validated for use in postpartum and pregnancy; self-report • Can be used for partners and adoptive parents as well • Puts less emphasis on sleep and appetite as symptoms, as these are commonly disrupted in pregnancy and postpartum; more emphasis on anxiety symptoms and cognitive symptoms of depression • Is not the “gold standard” – this is still the diagnostic interview

17. Also Consider: • Anxiety disorders • Adjustment disorder with depressive symptoms • Grief • Personality disorders, especially Borderline Personality Disorder • Domestic violence • Stressful life circumstances • Substance misuse

18. Perinatal Mood Disorders - Treatment

19. Bipolar Disorder in the Perinatal Period • Ideally, consultation with a psychiatrist prior to conception to discuss relapse risks and risks of medication • Generally psychiatric management recommended throughout pregnancy; requires close monitoring for emergence of relapse • Consult regarding medications: • Mother Risk • or FRAME Clinic at Victoria Hospital 519-685-8500 ext. 58293 • Need high support in immediate postpartum; extended hospital stay (3 to 5 days) recommended • Promote medication adherence and good self-care, especially sleep

20. Perinatal Bipolar Disorder - Medications • Atypical antipsychotics, lamotrigine are safest in pregnancy • Lithium – risks of neonatal toxicity at birth and through breast milk; cardiac risk is less than original estimates • Valproic acid – confers greatest risk of neural tube defects; only use if no other medications work; use 5 mg folic acid daily • Detailed second trimester ultrasound recommended for women on lithium or antiepileptic medications

21. Depression in the Perinatal Period • Treatment should take into account history of symptoms, preferences of woman • Mild to moderate depression – psychotherapeutic interventions first line • Moderate to severe depression – indication for medications

22. Psychotherapy in Perinatal Depression • Psychoeducation • Lifestyle interventions – promoting sleep, nutrition, exercise, social support • Healthy Babies, Healthy Children referral • Strong research evidence on benefit of friendly home visitor

23. Psychotherapy in Perinatal Depression • Evidence-based psychotherapies: • Supportive Psychotherapy • Cognitive-Behaviour Therapy • Interpersonal Therapy • Remember to screen for Employee Assistance Program or Benefits to access community psychotherapy • Postpartum Mood Disorders Support Groups • Elgin PPMD Support Group • Vesta Parenting Centre

24. Medications in Perinatal Depression • Most antidepressant medications in pregnancy have not been shown to confer risks above the baseline risk of malformations • Exception is: Wellbutrin – increased risk of left ventricular outflow obstruction; paroxetine in first trimester – increased cardiac and limb defects • Most antidepressant medications are very compatible with breastfeeding • Fluvoxamine, Effexor and Wellbutrin have increased exposure through breastmilk and require more monitoring

25. Perinatal depression – when to refer • Complex, treatment resistant depression • Very severe symptomatology • Depression with psychosis

26. QUESTIONS? • Heidi.Haensel@lhsc.on.ca • 519-685-8500 ext 76673