Understanding Perinatal Suicide Risk: Facts and Definitions

1. PERINATAL SUICIDE ANGELA STINNETT BSN, RN AND LUCY J. PURYEAR M.D.

2. SUICIDE: DEFINITION AND FACTS • The World Health Organization (WHO) defines suicide as the act of killing oneself. The act must be deliberately initiated with the full knowledge, or expectation, of its fatal outcome • The World Health Organization (WHO) estimates each year approximately 1 million people die from suicide, that represents a global mortality rate of 16/100,000 or one death every 40 seconds. By 2020 the rate of death will increase to one every 20 seconds. • In the last 45 years suicide rates have increased by 60% worldwide. Suicide is now among the three leading causes of death among those aged 15-44 (male and female). Suicide attempts 20X > completed suicides. Many adults think about suicide or attempt suicide. • Seriously thought about suicide: 9.8 million every year • Made a plan for suicide: 2.8 million every year • Attempted suicide: 1.3 million every year • Worldwide, 800,000 people die due to suicide every year • In North America Suicidal Ideation can be detected in13.1%-33% of pregnant women • 3 separate studies indicate that perinatal women have an average suicide rate of 2% to 7.9% • For comparison, According to the National Institute of Mental Health, average suicide rates among women were 4.1% in 2001, and 6.1% in 2017, both lower than the higher end of perinatal suicide rates.

3. Suicide terminology • Self-harm- Suspected or confirmed- is defined as the intentional, direct injuring of body tissue, done without the intent to take one’s own life. • Suicide Plan- Intentional harm of one’s self with the what, when, where, and how. • Suicide Attempt- A self-injurious act with some intent to die. ( there does not have to be injury or harm, just the potential for injury or harm) • Suicide Attempt Interrupted- Someone or something stops them during the attempt to end their life • Suicide Attempt Aborted- Takes steps towards making suicide attempt, but them stops themselves from completing the act • Suicide Behavior- Span of activities related to behaviors and thoughts of suicidal thinking, attempts, and completions. • Suicidal Ideation- Thinking and having thoughts of engaging in suicidal behavior

4. Discussing suicide Acceptable Terminology No Longer Acceptable Terminology Died of suicide Committed suicide Suicide death/Suicided Successful attempt/suicide Suicide attempt/Attempt to end his/her life Unsuccessful attempt/suicide Person living with suicidal thoughts or behavior Suicide ideator or attempter Suicide/Ended his/her life Completed suicide Expresses suicidal ideation Manipulative, cry for help, or suicidal gesture Working with Dealing with suicidal crisis Non-fatal attempt at suicide Failed attempt at suicide

5. Suicide Rates Increasing in Women, Adolescent Girls • Suicide rates in the United States are on the rise, especially in women. • Hypotheses Include: • In 2004, the FDA issued a black box warning for antidepressants which has resulted in a decrease in the use of antidepressants in adolescents. • Earlier onset of puberty may increase risk for depression, which is a risk factor for suicide. • Suicide rates tend to increase during times of economic downturn. • Lower marriage rates and higher divorce rates may contribute to social isolation, dissolution of family, and poverty, factors which increase risk for suicide. • Increased use of social media and cyberbullying. • Suicide Rates Increasing in Women, Adolescent Girls. (2016, July 13)

6. DID YOU KNOW? Women in their childbearing years account for the largest group of Americans with depression Postpartum depression is the most common complication of childbirth There are more new cases of mothers suffering from maternal depression each year than women diagnosed with breast cancer Despite the prevalence, maternal depression goes largely undiagnosed and untreated Smith, D. G. (2018, August 15). An Entirely New Type of Antidepressant Targets Postpartum Depression.

7. Recognizing Perinatal women at risk for suicide ideation Risk Factors • History of Abuse • Cultural/social influences • Socioeconomic status • Demographic factors • Comorbid psychiatric conditions Mnemonic: IS PATH WARM? I Ideation S Substance Abuse P Purposelessness A Anxiety T Trapped H Hopelessness W Withdrawal A Anger R Recklessness M Mood Change

8. Baby Blues and Postpartum Depression Baby Blues: 70%-80% of mothers experience baby blues. Usually starts within the first couple of days after delivery, peak around one week, and taper off by the second week postpartum. Symptoms include low mood, tearful, detached, overwhelmed, etc. Postpartum Depression: May starts off as baby blues, but lasts longer and becomes worse with time. The symptoms are more severe with insomnia or hypersomnia, decreased appetite, increased tearfulness, lack of energy and motivation, and may have an inability to care for the newborn. Suicidal thoughts may be present, thoughts of harming the infant are rare, but can occur. 10%-20% of mothers experience PPD *Depression can also occur during pre-conception, antepartum, intrapartum*

9. What causes postpartum depression? Baby Blues and Postpartum Depression’s actual cause is still unknown. Thought to be caused by both biological and psychological factors. One of the physical changes is a dramatic drop in the hormone levels of estrogen and progesterone, along with other chemical changes in the brain Other hormones changes may occur with the thyroid gland.

10. Postpartum Anxiety and Postpartum Panic Disorder • Decreases in estrogen and progesterone • Overwhelmed feeling of the responsibility • Feeling fearful or panicky • Sleep deprivation • A constant sense of worry or dread • Trouble sitting still • Dizziness or nausea • Very nervous and is recurrent • Shortness of breath • Chest pain • Claustrophobia • Dizziness • Heart palpitations • Numbness and tingling in the extremities • Go in waves

11. Postpartum Post Traumatic Stress disorder (PTSD) 9% of women experience postpartum post-traumatic stress disorder (PTSD) following childbirth. Traumas could include • Prolapsed cord • Unplanned C-section • Use of vacuum extractor or forceps to deliver the baby • Baby going to NICU • Feelings of powerlessness, poor communication and/or lack of support • Women who have experienced a previous trauma, are at a higher risk for experiencing postpartum PTSD. • Women who have experienced a severe physical complication or injury related to pregnancy or childbirth, such as severe postpartum hemorrhage, unexpected hysterectomy, severe preeclampsia/eclampsia, perineal trauma (3rd or 4th degree tear), or cardiac disease. • SYMPTOMS • Intrusive re-experiencing of a past traumatic event (which in this case may have been the childbirth itself) • Flashbacks or nightmares • Avoidance of stimuli associated with the event, including thoughts, feelings, people, places and details of the event • Persistent increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response) • Anxiety and panic attacks • Feeling a sense of unreality and detachment

12. Bipolar mood disorder Bipolar I Mood Disorder • Periods of severely depressed mood and irritability • Extremely elevated mood • Rapid speech • Little need for sleep • Racing thoughts, trouble concentrating • Continuous high energy • Overconfidence • Delusions (often grandiose, but including paranoid) • Impulsiveness, poor judgment, distractibility • In the most severe cases, delusions and hallucinations • Bipolar II Mood Disorder • Periods of severe depression • Periods when mood much better than normal • Rapid speech • Little need for sleep • Racing thoughts, trouble concentrating • Anxiety • Irritability • Continuous high energy • Overconfidence

13. Risks among perinatal women with bipolar disorder Pregnant and postpartum women with bipolar disorder more frequently have significant mental health and early mothering challenges than other perinatal women undergoing psychiatric treatment. The findings indicate the importance of properly identifying the disorder and developing specific treatments for women during and after pregnancy. • Brown University. (2014, February 24). Higher risks among perinatal women with bipolar disorder. ScienceDaily. • Retrieved August 21, 2019 from www.sciencedaily.com/releases/2014/02/140224124206.htm

14. Borderline Personality Disorder (BPD) Borderline Personality Disorder (BPD) is a condition characterized by difficulties regulating emotion. Signs and Symptoms • Unstable and extreme emotions (sadness, irritability, anxiety) • Efforts to avoid being abandoned • A history of intense and unstable relationships with people • Not having a clear sense of identity • Impulsiveness (e.g. spending lots of money, sex, substance abuse, reckless driving, binge eating) • Increase in self-harm and/or suicidal behaviors • Ongoing feelings of emptiness • Feelings of anger that may be intense, inappropriate or difficult to control • Being paranoid or feeling disconnected from the world when under stress • Mother's with BPD • May struggle with their relationship with their baby • May not feel the way they think that they should feel about the baby • May also find caring for the baby difficult i.e. crying baby • Can cause problems with emotional connections and relationships with baby

15. Postpartum Obsessive Compulsive Disorder (OCD) You do not have to be diagnosed with OCD to experience these common symptoms of perinatal anxiety. It is estimated that as many as 3-5% of new mothers and some new fathers will experience these symptoms. • Obsessions, also called intrusive thoughts, which are persistent, repetitive thoughts or mental images related to the baby. • Occurs “out of the blue” • Compulsions, where the mom may repeat behaviors/actions often to reduce her fears and obsessions. For example: clean/reclean, checking/rechecking lights & locks, counting/recounting objects. • A sense of horror about the obsessions, upsetting to mother • Fear of being left alone with the infant • Hypervigilance in protecting the infant • Moms with postpartum OCD know that their thoughts are bizarre and are very unlikely to ever act on them.

16. Postpartum Psychosis • 0.1 - 0.2% of births • Break from Reality • Delusions or strange beliefs • Hallucinations (seeing or hearing things that aren’t there) • Feeling very irritated • Hyperactivity • Decreased need for or inability to sleep • Paranoia and suspiciousness • Rapid mood swings • Difficulty communicating at times • Delusions and Beliefs make sense to her, very real and often religious • Immediate treatment for a woman going through psychosis is imperative (2019, June 14). Andrea Yates Fast Facts

17. postpartum OCD and postpartum Psychosis • Postpartum Psychosis • Thoughts are ego-syntonic • Rarely distressed by thoughts • Do not have avoidant behaviors • Experience hallucinations/delusions/illogical or irrational thoughts • Periods of delirium or mania • Not common disorder • High risk for baby • Out of touch with reality Postpartum OCD • Thoughts are ego-dystonic • Disturbed or distraught by thoughts, “Am I going crazy?” Intrusive or obsessive thoughts • Repetitive or excessive behavior (excessive washing, checking on baby) • Avoid objects or being with baby, but wants to keep the baby safe, fear of baby being harmed • Low risk of harm to baby • Often misdiagnosed as psychosis

18. schizophrenia • Chronic, severely debilitating psychiatric disorder that affects ~1% of the population worldwide. • Diagnosed between the ages of 15 and 30. • Hallucinations, delusions and paranoid thoughts also avolition, anhedonia, and cognitive deficits, such as poor function, attention, and impaired working memory. • Rat studies show that maternal stress in pregnancy increases the risk for onset of schizophrenia. • Higher rate of unplanned and unwanted pregnancies • Increased risks during pregnancy include preterm deliveries, lower mean birth weight, increased incidence of intrauterine growth retardation (IUGR), premature death, and increased possibility of a psychotic breakdown during pregnancy or the post-partum period. “Women with previously diagnosed schizophrenia or bipolar disorder have up to a 50% chance of becoming psychotic after delivery. These women need to be closely monitored after delivery and if their medication was stopped during the pregnancy, it needs to be restarted immediately.” Dr. Lucy Puryear

19. Perinatal suicide studies • The U.S. Study • 2% were pregnant at the time of suicide and 3% were within 1st year postpartum. • Pregnancy and Postpartum is associated with a high rate of mental health disorders, including depression (13%-20%) and anxiety (10%-20%). • 30% of pregnant women with depression experience SI and 20% of postpartum death is through suicide making it the 2nd most commonly cause of postpartum death. • More than half of the women who died by suicide had mental disorders. The most common being mood disorders (95%), anxiety disorders, (9%) and schizophrenia (5%). • It suggested that perinatal women exhibited similar risk factors to non-perinatal women, which would aid in screening factors. • 32% of perinatal women had a prior history of suicide attempt and 28% had known substance or alcohol abuse at the time of death. • Hispanic women were more likely to die by suicide while pregnant (10% of suicides among pregnant women) or within 1 year of pregnancy (9% of postpartum suicides)

20. Perinatal suicide studies The Canadian Study • The largest number of suicides in the perinatal period were in the last trimester of pregnancy and, especially in the last quarter of the first year postpartum. • The perinatal suicide rate was 2.58 per 100,000 live births. • Fewer than half the women who died by suicide did not receive any mental health services 30 days before their death, even though they did see their OB providers. • Perinatal women used more lethal means of suicide vs non-perinatal women. (i.e. hanging, jumping, vs overdose) • Most women who died by suicide had mental illness, not just psychotic disorders, but mood or anxiety disorders. • Lower socioeconomics and more rural locations resulted in high death by suicide rates due to lack of mental health services.

21. Perinatal suicide studies The Denmark Study • Postpartum psychiatric mothers had a 70% increased risk of suicide during the first year after delivery. • History of mental illness played a significant role in the number of perinatal suicides. 20% with baby blues and postpartum depression, and 0.1% with postpartum psychosis. • Decreased education level, immigration status, and low socioeconomics were noted to have higher death by suicide rates. • A history of self harm or previous suicide attempt, and substance abuse was a strong factor in the increased rate of perinatal suicide. • Stillbirth was not significantly associated with perinatal suicide.

22. This story is shared in memory of Alexis Joy D’Achille. • Baby Adriana was born on August 30, 2013 • “It was literally watching somebody you love just completely fall apart and unravel.” • Alexis had trouble breastfeeding • Would hear phantom baby cries in the night • Tearful every morning after long sleepless weeks • She was convinced her daughter was connecting with other people, but not with her • During delivery the baby had a nuchal cord which doctors think left Alexis with PTSD • She constantly worried that the traumatic birth hurt the baby and she swore she saw signs of this • When they went to see a physician he told Steven D’Achille “she’s too pretty to kill herself” • 5 weeks after giving birth Alexis was 10 pounds lighter than her pre-pregnancy weight • Went to seven different hospitals and facilities in her last 13 days • “It was literally watching somebody you love just completely fall apart and unravel.” • 2 month wait to see a psychiatrist • 6 weeks after Alexis delivered she took her own life All pictures - Holohan, M. (2019, May 15). Wife's death compels dad to help other moms with postpartum disorders.

23. Steven D’Achille started The Alexis Joy D’Achille Foundation for Postpartum Depression. “One thing I’ve definitely learned was that mental health does not discriminate. It doesn’t care who you are. It could be anyone. It could be any woman”. “This is the last picture ever taken of Alexis with our daughter Adriana. The following morning Alexis took her life. #MyWishForMoms is that no mom feels like Alexis did. #MyWishForMoms is that every mom gets to watch their babies grow up. #MyWishForMoms is that no mom feels like their loved ones are better off without them here and that no mom feels they are a burden”. Steven D’Achille • All pictures - Holohan, M. (2019, May 15). Wife's death compels dad to help other moms with postpartum disorders. https://youtu.be/deSxZAQ_I8M

24. Mental health Screening for perinatal women • ACOG recommends depression screening for all women at least once during the perinatal period • Majority of childbearing women with depression are neither identified nor treated. • Stigma associated with mental illness deters women from accessing care • There is a shortage of both mental health care professionals and perinatal specialists. • Limited financial and personal • Screening for mental health should be routine Screening tools used at TCH The Women’s Place are the Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ9)

25. Interpreting the EPDS, EPDS3, PHQ9, and Pittsburgh sleep quality index (PSQI) EPDS-Maximum score of 30 < than 8 depression not likely 9-11 depression possible 12-13 fairly high possibility of depression 14 or higher probable depression……at TCH 10 or greater is a positive screen and needs further evaluation for depression Always review #10 as it covers suicidal ideation EPDS-3-This focuses on 3 main questions in the EPDS, #3, #4, #5 which comprises the subscale of anxiety in the EPDS PHQ9-Maximun score 27 0-4 minimal depression 5-9 mild depression 10-14 moderate depression 15-19 moderately severe depression 20-27 severe depression Always review #9 as it cover suicidal ideation The Pittsburgh Sleep Quality Index (PSQI)-Maximum score is 21 (the higher to score the worse the sleep quality) Each question has a scale of 0-3 0-very good sleep 1-Fairly good sleep 2-Fairly bad 3-Very bad

26. Safe-t Suicide assessment five step evaluationand triage • In patient consult • SWAT team • 911- MAT • 713-970-7520 - MCOT • Methodist ED • Crisis Clinics • Welfare check • Step 1 Identify Risk Factors • Step 2 Identify Protective Factors • Step 3 Conduct Suicide Inquiry • Step 4 Determine Risk • Step 5 Document Risk

27. Treatment and Care for perinatal suicidal patients • Medication management • Antidepressants • Benzodiazepines • Antipsychotic • Mood Stabilizers • Sleep Aids • Education • Multidisciplinary Team • Psychotherapy • Psychodynamic therapy • Cognitive behavioral therapy (CBT) • Group therapy • Social workers • Herbal supplements • Bright light therapy • Combination therapy *Many of these medications especially the antidepressants can take up to 5-6 weeks to become therapeutic, they need to be tapered up, then when discontinued they need to be tapered down. Stopping these medications “cold turkey” can cause withdrawal symptoms and can worsen depression*

28. RESOURCES FOR SUICIDE IDEATION National Suicide Prevention HOTLINE 1-800-273-8255 Crisis Intervention of Houston HOTLINE: 832-416-1177 Texas Children’s The Women’s Place 832-826-5281 Methodist Hospital ED, Texas Medical Center Texas/Postpartum Support International 1-800-944-4773 The Center for Postpartum Family Health 713-561-3884 The Harris Center for Mental Health and Intellectual Development Disabilities (IDD) NeuroPsychiatric Center 713-970-7070 Legacy Community Health Services 713-830-3000 Ben Taub Community Behavioral Health Program 713-643-3691/713-526-4243 Postpartum Depression HOTLINE 1-800-PPD-MOMS Psychology Today-Pregnancy, Prenatal, Postpartum Therapist in Houston -https://www.psychologytoday.com/us/therapists/pregnancy-prenatal-postpartum/tx/houston

29. Conclusion Overall, available evidence indicates that perinatal women, especially pregnant/postpartum women are more likely than the general population to endorse suicidal ideation. Recognizing women who are at risk is key, by assessing their neurobiological, psychosocial, and psychopathological risk factors. Implementing rigorous and multidisciplinary approaches through screening programs will identify women at high risk of suicidal behaviors and providing resources such as medication management, therapy, availability, and community awareness. By removing the stigma and accepting the women who have mental illnesses, and also letting these women know that they can get help, we can all give them a fighting chance.

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