Perinatal Mood Disorders: Identification, Screening and Overcoming Barriers February 26, 2008

1. Perinatal Mood Disorders: Identification, Screening and Overcoming Barriers February 26, 2008 Jen Perfetti, M.A., L.P.C. Licensed Counselor/Private Practice

2. Objectives • Recognize symptoms of postpartum depression and anxiety • Implementation of a brief screening tool • Finding resources: treatment and referral options • Self-help options for women with mild to moderate depression • Mobilizing treatment resources for women with moderate to severe depression • Supporting couples in the transition to parenthood

3. Signs, Symptoms & Risk Factors

4. Postpartum Blues • Prevalence: 50-80% of new mothers • Onset: Within hours or days of delivery • Duration: 10-14 days • Symptoms: emotional lability, anxiety, fatigue, insomnia, anger, sadness, irritability • Symptoms come and go • Considered normal

5. Postpartum Psychosis • Prevalence: 1/1000 births (.1%) • Onset: Usually occurs in 1st week following birth, sudden onset • Symptoms: Agitation, racing thoughts, rapid speech, severe insomnia, hallucinations, paranoia, irrational speech or behavior, threats of suicide and infanticide • A medical emergency requiring immediate care

6. Postpartum Depression (PPD) • Prevalence: 8-15% of new mothers • Up to twice as high for women living in poverty • Can begin anytime in first year • Lasts at least two weeks • Anxiety may be central • 30-70% may experience the disturbance for one year or longer

7. DSM-IV criteria for Postpartum Depression • 5 or more of the following symptoms: • Depressed mood, often accompanied by severe anxiety • Markedly diminished interest or pleasure in activities • Appetite disturbance • Sleep disturbance • Physical agitation or psychomotor slowing • Fatigue, decreased energy • Feelings of worthlessness or inappropriate guilt • Decreased concentration or inability to make decisions • Recurrent thoughts of death or suicidal ideation • Symptoms present most of the day, nearly every day for at least 2 weeks

8. Moms Report... • Overwhelmed • Anxious, worried • Feeling constantly tired • Awake with thoughts running through head • Crying often • Not enjoying being a mother • Feeling disconnected from their baby • Feeling like a bad or inadequate mother • Anger or extreme irritability toward others

9. Risk Factors for PPD • Symptoms of depression or anxiety during pregnancy • Past depression/mood disorders • Family history of depression • Perceived negative birth experiences • Quality of social support/marital satisfaction • Physical health problems in the mother or infant • Significant loss or life stress in the last year

10. Postpartum Depression & Anxiety • Intense anxiety often prominent feature • Can be confusing for woman or providers if only looking for depressive symptoms • Anxiety, particularly panic and fears/obsessions about the care and safety of the baby, may be initially reported as more distressing by women than depressed mood Matthey et al., 2003

11. Symptoms of Anxiety • Excessive worry • Difficulty controlling the worry • Restlessness or feeling keyed up • Fatigue • Difficulty concentrating or “mind going blank” • Irritability • Muscle tension • Sleep disturbance

12. Postpartum Onset Anxiety Disorders • Panic Disorder • Postpartum Obsessive/Compulsive Disorder • Posttraumatic Stress Disorder (See Handout)

13. Impact of PPD on Parenting & Infant Development

14. Impact of PPD on Parenting • Impaired ability to be involved in child’s physical care and play and to meet child’s normal needs for attention • Difficulty bonding with baby and resulting feelings of guilt and inadequacy • Anxiety about doing psychological or physical harm towards baby(Weissman et al., 1979) • Depressed moms show more matching of negative behavior states and less matching of positive behavior states (Field et al., 1990; Murray, Fiori-Cowley, Hooper & Cooper, 1996) • Depressed mothers hold more negative views of their interactions with their infants, and show more anger in interactions with their infants than non-depressed mothers (Weinberg & Tronick, 1998)

15. Bi-Directional Effects in Depressed Mother-Infant Interactions • Infants imitate a variety of adult facial expressions as early as 2 days after birth. • Mother’s depressed mood may induce a depressed state in the infant • Infant’s subsequent distress and unresponsiveness are likely to maintain and perhaps increase the severity of the mother’s depression (Field et al., 1982; Meltzoff & Moore, 1977; Meltzoff, 1990)

16. Consequences of PPD for Infant & Child Behavior & Development • Infants of depressed mothers show less interest, more anger and sadness and more fussiness than infants of non-depressed mothers (Weinberg & Tronick, 1998) • Clinical observations of infants: Sober, sad or flat affect, regulation difficulties, poor attention & eye contact, fewer vocalizations, and limited exploration of the environment (Clark et al., 1994)

17. Maternal Behavior and Child Regulatory Capacities at 3-5 Years of Age • Intrusive and over-stimulating care by mothers with their 6 month-old infants is associated with symptoms of attention deficit hyperactivity disorder (ADHD) in kindergarten. • Insensitive and unresponsive maternal care in infancy predicts hostile, aggressive and other externalizing behaviors during preschool (Jacobvitz & Sroufe, 1987; Lyons-Ruth, Alpern & Repacholi, 1993; Shaw, et al., 1994)

18. Factors that May Mitigate Risk to Infants • Course/timing of depression – Chronicity • Mothers’ degree of sensitivity in parent-child interactions • Mothers’ personality, co-morbid psychopathology & relationship history • Availability of fathers/other caregivers • Length of maternity leave • Characteristics of the child – Temperament & Gender (Clark, Hyde, Essex, & Klein, 1997; Lyons-Ruth et al., 1986; NICHD Early Child Care Research Network, 1999; Weinberg & Tronick, 1996)

19. Screening

20. Why Screening is Important • Up to 50% of women with postpartum depression are missed by primary care physicians when screening instruments are not used.(Gale & Harlow, 2003; Steiner, 2002; Cooper& Murray, 1998) • Why are so many women missed? - Stigma - Minimize symptoms or attribute to average demands of being a new mom - Anxiety may be the prominent symptom

21. Media Attention and Stigma • Well publicized tragedies can help raise awareness among physicians and health care providers • May lead to an increase in early identification and treatment

22. Media Attention and Stigma • Media often does not distinguish psychotic features – labels all symptoms as “postpartum depression” • May increase stigma of women suffering from PPD • May decrease likelihood of asking for help - fear that others will think they would hurt their children

23. Media Attention and Stigma • Helpful to have women who are admired in our culture disclose PPD • Decreases stigma

24. Home Visitor Opportunities for Screening • During pregnancy: • 1st prenatal visit and/or 3rd trimester • 6 weeks & 3 months postpartum • Most cases of PPD begin within first 3 months postpartum (O’Hara, 1997) • Any visit during first year

25. Methods of Screening for PPD • Informal / Unstructured Screening • Clinical impressions: Is this mother acting depressed? How well is this mother functioning? • Effective in detecting only the most severe and chronic patients • (Olson, AL et.al.,2002)

26. Edinburgh Postnatal Depression Scale (EPDS)(Cox, Holden, & Sagovsky, 1987) • 10 items, score of 10 or higher indicates potential depression • Quick to administer and score • Free to reproduce; Available in English and Spanish • WAPC site-www.perinatalweb.org (both English and Spanish versions)

27. I have been able to laugh and see the funny side of things. t As much as I always could u Not quite so much now v Definitely not so much now • Not at all Things have been getting on top of me. wYes, most of the time I have not been able to cope at all vYes, sometimes I have not been coping as well as usual • No, most of the time I have coped quite well tNo, I have been coping as well as ever I have looked forward with enjoyment to things. t As much as I ever did u Rather less than I used to v Definitely less than I used to w Hardly at all I have felt so unhappy that I have had difficulty sleeping. w Yes, most of the time v Yes, sometimes u Not very often t No, not at all I have blamed myself unnecessarily when things went wrong. t No not at all u Hardly ever v Yes, sometimes w Yes, very often I have felt sad and miserable. w Yes, most of the time v Yes, quite often u Not very often t No, not at all I have been anxious or worried for no good reason. w Yes, quite a lot v Yes, sometimes u No, not much t No, not at all I have been so unhappy that I have been crying w Yes, most of the time v Yes, quite often u Only occasionally t No, never I felt scared or panicky for no very good reason. w Yes, quite a lot v Yes, sometimes u No, not much t No, not at all The thought of harming myself has occurred to me. w Yes, quite often v Sometimes u Hardly t Never Column Total = _________ Column Total = _________ Total = ________ Edinburgh Postnatal Depression Scale (EPDS) Taken from the British Journal of Psychiatry June, 1987, Vol. 150 by J.L. Cox, J.M. Holden, R. Sagovsky Circle the number or each statement, which best describes how often you felt or behaved this way in the past 7 days…

28. Discussing Screening Results • “Your score indicates that you may be depressed. How does that fit with what you’ve been experiencing?” • “Your score isn’t in the range for likely clinical depression, but it sounds like you’re struggling right now. Let’s talk about what kinds of support would feel helpful.”

29. Formal TreatmentOptions

30. Treatments for Women with Postpartum Depression • Psychotropic Medication • Individual Psychotherapy • Group Psychotherapy • Mother-Infant/Family Psychotherapy

31. Psychiatric Evaluation - First Step In All Treatment Modalities • Preferably by mental health professional with experience in the evaluation of perinatal mood disorders • Purpose: • Diagnosis – PPD? Anxiety? Other comorbid conditions that require attention? • Safety Assessment: Harm to self and/or infant

32. Use of Medication During Breastfeeding • Risks and benefits to the mother and infant must be weighed carefully when considering medication • There is insufficient long-term data documenting the outcomes of infants exposed to antidepressants during pregnancy and through breastfeeding. • No psychotropic medication has been proven to be safe for infants who are breastfeeding • The importance of capable parenting which is compromised by depression and the benefits of breast feeding should be weighed in the decision making process American Academy of Pediatrics, 2002 Wisner, 2002

33. What You Can Do To Support Moms & Babies: A Home Visitor’s Toolbox

34. Be Alert for Risk of Depression, Starting in Pregnancy • You are in a prime position to observe mom over time • Start a dialogue about risk and symptoms early to engage her in looking with you at the issue • Assess mother’s risk for developing PPD early in pregnancy (focus on previous history of mood/anxiety disorder, partner support, life stress) • Begin “prevention planning” together if risk is elevated -- put supports in place early

35. Make the Connection: Refer when PPD Suspected • Boundaries: You are not responsible for managing or treating symptoms of PPD, but you can facilitate a connection to a mental health professional • Use your relationship with mom as a basis to explore & problem solve around concerns related to seeking help • Stigma • Depression as sign of weakness • Cultural expectations (of mothers; of therapy) • Fear (losing children, unfamiliarity with treatment process, etc) • Barriers (cost, transportation, childcare, etc)

36. Self-Help Options for Moms With Mild to Moderate Depression

37. #1 – Promote Self Care “God could not be everywhere, therefore he created mothers” – Hebrew proverb • Women often focus or feel they should focus far more on the care of others than themselves • Encourage and give permission to mothers to incorporate self-care into their daily routines as a means of preventing PPD & anxiety, as well as coping with it

38. Realistic Expectations • Slow down pace • Assess expectations around house, food, socializing • Allow time for bonding

39. Nurture Yourself • Take time for yourself • Treat your emotional needs with respect • Connect with others

40. Spirituality • Use prayer or reflection as a calming time • Spiritual community may be a good support

41. Take Breaks • Do something you like to do, not something you have to do • Schedule brief breaks like at a job – refreshes you

42. Sleep • Sleep or rest during day when baby is sleeping • Develop a routine to relax before bed

43. Exercise • Increases feelings of well-being • Helps you sleep better • Can reduce symptoms of depression • Can give you greater control over feelings of anxiety

44. Nutrition • Try to increase the number of healthy foods you consume each day • Watch out for junk food, alcohol, and caffeine • Omega 3 fatty acids/DHA

45. Omega-3 Fatty Acids/DHA • Placebo-controlled clinical trial showed significant reduction of depression (Stoll et al., 1999) • Cultures with greater seafood consumption have lower rates of depression • American women generally reduce or eliminate fish during pregnancy and breastfeeding due to concern about mercury • Recommended amount: 2-4 caplets per day (>650 mg/day EPA +DHA combined; >300 mg/day as DHA) • Fish oil is best source - make sure screened for mercury/PCBs

46. Activate Circle of Support • Mom’s Groups • Dads/Significant Others* • Family Members* • Friends • Neighbors • Co-Workers • Faith Communities *Assess support/conflict ratio

47. Connect Mom to Informal Supports for PPD • Phone Support in WI: • Postpartum Adjustment, Support, and Education (Warm line) (920-924-8539) • Local Support Groups: • Postpartum Support International (PSI) Wisconsin Chapter (www.postpartum.net) • Web Based Support & Information: • Postpartum Depression Bulletin Board (http://messageboards.ivillage.com/iv-pppd) • Depression After Delivery (DAD) (www.depressionafterdelivery.com)

48. #2 – Supportive Communication • Listening as a skillful, active intervention • Understanding must precede action • Don’t assume mother has others in her life to provide this type of emotional support • Don’t underestimate the healing power of supportive listening & empathy for both mother and infant

49. #3 – Support Mother/Infant Relationship • Suggest using part of visit to “just be with” baby in one-to-one ‘special time’ • Developmentally appropriate play • Soothing activities (massage, cuddling/lullaby) • Singing/music • Making daily tasks playful • Face to face interaction • Smiling, even when you don’t feel like it • When fussy, wonder with mom about what baby is needing • Support/reinforce her positive efforts toward reading baby’s cues & providing support (Clark, 2006)

50. #3 – Support Mother/Infant Relationship • “Speak for baby” to highlight cues & reactions to mom’s efforts • Amplify baby’s initiatives toward mom • Model gentle handling & responsivity toward baby • Non-judgmental developmental guidance • Dispel myths about spoiling young babies (Clark, 2006)