PERINATAL DEPRESSION

1. PERINATAL DEPRESSION Improving Treatment Through Collaboration P. Lynn Ouellette M.D. Director, MAPP Postpartum Depression Project

2. OVERVIEW Depression during pregnancy: rates, significance, Postpartum Depression: rates, risk factors, significance, risks of untreated PPD Screening for PPD Treatment of Perinatal Depression

3. MATERNAL DEPRESSION, ESPECIALLY PERINATAL DEPRESSION, IS A PUBLIC HEALTH PROBLEM

4. DEPRESSION DURING PREGNANCY

5. DEPRESSION DURING PREGNANCY • Between 10-20% of women will experience significant depression during pregnancy • This will be a first episode for one third • Most often this is unrecognized and untreated

6. SIGNIFICANCE Untreated depression during pregnancy is associated with serious risks, short and long term health and mental health consequences for mother and her baby.

7. RISKS OF UNTREATED DEPRESSION DURING PREGNANCY Premature delivery Low birth weight More likely to be colicky, irritable babies Poor compliance with prenatal care Poor nutrition Lower APGAR scores Increased rate of stillborns (six times in one study) Increased admissions to neonatal ICU

8. RISKS OF UNTREATED DEPRESSION DURING PREGNANCY • Higher rates of miscarriage • Higher risk of bleeding • More painful labor and higher use of analgesia • Increased alcohol and tobacco use • SUICIDE • POSTPARTUM DEPRESSION • Recurrent Major Depressions

9. LONGTERM CONSEQUENCES • Prenatal anxiety, depression, and high stress lead to increased maternal cortisol transmitted to the fetus via the placenta • Increasing research indicates that such fetal exposure to maternal adversity predisposes to: -cognitive and developmental delays -childhood behavioral and psychiatric illness -adult onset psychiatric illness -medical illness in adulthood(Type II diabetes, HTN, metabolic syndrome, etc) • Evidence shows that this can be mitigated by secure maternal attachment and strong mothering • BUT, maternal adversity such as prenatal depression and anxiety predisposes to postpartum psychiatric illness which further disrupts maternal infant attachment

10. POSTPARTUM DEPRESSION

11. THE MOST COMMON COMPLICATION OF CHILDBIRTH IS DEPRESSION

12. PPD AS A PUBLIC HEALTH PROBLEM • Over 4 million women give birth in America • One of every 8 new mothers experience depression • Over half a million women will suffer postpartum depression each year • Most common complication of childbearing • Causes serious and lasting effects on child health and family functioning 1 Wisner K et al. N Engl J Med. 2002;347:194-199; 2Wisner K et al. J Clin Psychiatry. 2001;62:82-86.

13. Epidemiology of Postpartum Episodes 70 60 50 40 Admissions/Month 30 20 Pregnancy 10 0 –2 Years – 1 Year Childbirth +1 Year +2 Years Peak lifetime prevalence for psychiatric disorders and hospital admissions for women occurs in the first 3 months after childbirth) Kendell RE et al. Br J Psychiatry. 1987;150:662-673.

14. SPECTRUM OF POSTPARTUM MOOD DISORDERS Postpartum Psychosis (0.1-0.2%) Postpartum Depression (10-15%) Postpartum Blues (50-85%) None

15. POSTPARTUM BLUES Very Common (80-85%) Onset within 3-5 days after delivery Symptoms include weepiness, sadness, fatigue, irritability Recommended “treatment” includes increased partner (and community) support, walking, rest and possibly joining a new mother’s group Symptoms should resolve by 10 days, if not, consider PPD

16. POSTPARTUM PSYCHOSIS • Very Uncommon, but severe (0.1-0.2%) • Includes agitation, paranoia, delusions, disorganized thinking and impulsivity • Often appears “organic” • Thoughts of harming the baby are frequently driven by delusions—Child must be saved from harm, child is malevolent, dangerous, has special powers, is Satan or God • Rates of infanticide associated with untreated postpartum psychosis have been estimated to be as high as 4%. A PSYCHIATRIC EMERGENCY REQUIRING IMMEDIATE INTERVENTION

17. POSTPARTUM DEPRESSION Usually develops slowly over the first three months, often beginning within the first 4 weeks, though some women have a more acute onset Signs and symptoms are those of Major Depression---depressed mood, irritability, loss of interest and appetite, fatigue, insomnia.

18. PRESENTATION OF POSTPARTUM DEPRESSION Common characteristics: • Women are often unable to sleep even when given the opportunity to do so • Often anxiety is a major component • Frequently (up to 50% of women) have intrusive, obsessional ruminations, or images, usually focused on the baby, often violent in nature, but they are egodystonic and there is not a problem with reality testing i.e. non-psychotic. One study showed 50% of women with PPD had these. Such obsessional thoughts do not increase the risk of harm to the baby and are important to distinguish from psychosis.

19. RISK FACTORS FOR PPD • Depression during pregnancy is the best predictor of post partum depression • Prenatal anxiety • History of depression, especially PPD • Recently having stopped antidepressants prior to pregnancy • Family history of depression • Pregnancy or obstetrical complications at delivery

20. OTHER RISK FACTORS • Neonatal loss or illness • Difficult infant temperament • Lack of social support or marital conflict • Recent loss or stressful life events • History of sexual abuse • Low self esteem • Breastfeeding difficulties

21. POSTPARTUM DEPRESSION Maine Statistics: 41.4%, confidence interval 38.2–44.7%, reported no postpartum depression 50.8%, confidence interval 47.5–54.1%, reported low to moderate postpartum depression 7.7%, confidence interval 5.9–9.5%, reported severe depression PRAMS Surveillance Data from 2000 of the Prevalence of Three Levels of Self-Reported Postpartum Depression in Seven PRAMS States

22. RISKS OF UNTREATED PPD To mother: Stressful impact on relationship between woman and her partner. Suicidal thoughts more likely to be accompanied by homicidal thoughts Kindling phenomenon---development of a chronic low grade depression with more susceptibility to repeated episodes of MDD Severe postpartum psychiatric disorder is associated with a high rate of death from natural and unnatural causes, particularly suicide Suicide risk in the first postnatal year is increased 70-fold

23. RISKS OF UNTREATED PPD To child: • Poor weight gain • Sleep problems • Less breastfeeding-depressed mothers more likely to discontinue breastfeeding • Impaired mother infant interactions leading to poor attachment • Impaired maternal health and safety practices

24. RISKS OF UNTREATED PPD Attuned infant-caregiver interactions promote brain neurological “wiring”. Future , hyperactivity, conduct disorders and school behavior problems Delays in language and social development Increased risk of depression Maternal depression is an “Adverse childhood experience” ACE, often it is not the only adversity

25. MATERNAL POST PARTUM MOOD IS ONE OF THE STRONGEST PREDICTORS OF NEUROCOGNITIVE DEVELOPMENT IN CHILDREN MEASURED UP TO AGE SIX

26. Perinatal depression has a significant impact on the current and future health of mother and child and stresses the functioning of the family. TREATMENT OF DEPRESSION IN THE MOTHER IS AN EARLY INTERVENTION OR PREVENTION FOR THE CHILD

27. NEED FOR PATIENT EDUCATION • Lack of knowledge about PPD, treatment options, and community resources is common in postpartum women and their families, and frequently leads to delay in seeking treatment • Delay in treatment for PPD results in a longer illness and increased risk of recurrent episodes • Information about PPD should be provided to women in the prenatal period, soon after delivery, and further encounters with healthcare providers in the first postpartum year.

28. SCREENING FOR PERINATAL DEPRESSION Postpartum depression is often not recognized Despite the availability of validated screening tools, PPD remains under diagnosed Absence of screening often means untreated depression and poor outcomes for the mother, her newborn, and family Postpartum depression can be screened for with simple and validated screening tools It is also possible to screen for antenatal depression

29. VALIDATED SCREENING TOOLS EPDS- Edinburgh postnatal Depression Screen PHQ-9 Patient Health Questionnaire PHQ-2 PPDS Postpartum Depression Scale Beck Depression Inventory-II Center for Epidemiological Studies-Depression Scale (CES-D)

30. PHQ-2 Over the past two weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things: 0 – Not at all 1—Several days 2—More than half the days 3—Nearly every day 2.  Having little interest or pleasure in doing things: 0 – Not at all 1—Several days 2—More than half the days 3—Nearly every day If positive should be followed by the PHQ-9

32. OBSTACLES TO SCREENING Lack of time Lack of familiarity with screening tools Lack of protocols for positive screen Lack of easy assess to mental health resources Lack of reimbursement

33. GUIDELINES FOR PERINATAL DEPRESSION SCREENING • Antenatal early risk assessment and screening during pregnancy. • ACOG recommends the PHQ-2 once per trimester • If at high risk (prior history, neonatal loss, obstetrical complications, etc): • Upon discharge from hospital. Need to assess support plan post discharge. Visiting nurse follow-up visit a good time • At postpartum visit with OB/Midwife • At early (2 week) follow up appointment if high risk • At routine 6-7 week visit • Well-child visit is an ideal time to look for signs of PPD in the mother (See pediatric provider frequently first year) The American Academy of Pediatrics recommends "routine, brief, maternal depression screening conducted during well-child visits” • Other possibilities are visiting nurse visits, lactation consultants

34. Obstacles to Treatment Stigma Shame Fear of losing children Fear of medication Over half of women referred to mental health services do not get there

35. Patient Perspectives Goodman et al. looked at perceived barriers to treatment in pregnant women who were not mentally ill They were given questionnaires regarding treatment that they would potentially participate if they wanted help for depression. 92% would likely participate in individual psychotherapy 35% would take medication for depression 14% would participate in group therapy Goodman, Birth 2009 mar 36 (1) 60-9

36. Patient Perspectives Women identified barriers as being: lack of time 65% Stigma 43% childcare issues 33% Most women preferred to get treatment in their OB’s office, either from their OB provider or a mental health professional. Goodman, Birth 2009 mar 36 (1) 60-9

37. APA/ACOG Guidelines Obstetrics & Gynecology (September 2009)and General Hospital Psychiatry (September/October 2009).    The Management of Depression During Pregnancy: A Report from the American Psychiatric Association and The American College of Obstetricians and Gynecologists.

38. For women wishing to become pregnant: Women stable on antidepressants (mild or no symptoms for 6 months or longer) possibly consider tapering before pregnancy Discontinuation may not be appropriate for women with a history of severe, recurrent illness (or psychosis, bipolar disorder, or suicide attempts) Women with suicidal or acute psychotic symptoms should be referred for aggressive psychiatric treatment.

39. Pregnant women currently on medication: Those who wish to stay on medication, consult with psychiatrists and OB/GYN to discuss the risks Stable women may attempt discontinuation depending on their history. Women with a history of recurrent depression are at a high risk of relapse if medication is discontinued.   Women with recurrent depression or who have symptoms despite their medication may benefit from psychotherapy to replace or augment medication Women with severe depression (with suicide attempts, functional incapacitation, or weight loss) should remain on medication. If a patient refuses medication, alternative treatment and monitoring should be in place, preferably before discontinuation.

40. ALL PREGNANT WOMEN: Regardless of circumstances, a woman with suicidal or psychotic symptoms should immediately see a psychiatrist for treatment. 

41. TREATMENT OF DEPRESSION DURING PREGNANCY

42. TREATMENT OF DEPRESSION DURING PREGNANCY • Pregnancy is not protective with respect to new onset or recurrent mood disorders • Thoughtful consideration needs to be given to the risks of untreated psychiatric illness • Thoughtful treatment decisions can be made regarding the use of psychotropics during pregnancy • Weighing the relative risks of medication treatment should be done on an individualized case by case basis. • Maintaining euthymic mood during pregnancy is crucial • NO DECISION IS PERFECT; NO TREATMENT IS RISK FREE.

43. PSYCHOTROPIC DRUG USE IN PREGNANCY FDA Category labeling is often misunderstood and interpreted to mean that the risk increases from A to B to C, etc That is NOT the case. No distinction is made between human and animal data Often is not updated New FDA labeling will be released in 2013 and will eliminate the categories. Pregnancy and lactation subsections would have three components: a risk summary, clinical considerations and a data section. Standard language: “Use the medication in pregnancy when clearly needed”; when risk of treatment is outweighed by risk of underlying disorder Pregnancy registries are sparse across psychotropics

44. SSRI USE DURING PREGNANCY • Recent findings and more data inform the pharmacologic treatment of depression during pregnancy • Consistent conclusions that the absolute risk of SSRI exposure in pregnancy is small1-3 • Recent case-control studies reveal inconsistent data regarding teratogenic risk of individual SSRIs4-9 • Reproductive safety data on SSRIs exceeds what is known about most other medicines used in pregnancy 1 Louik C, et al. N Engl J Med 2007; 2 Einarson TR, Einarson A. Pharmacoepidemiol Drug Saf 2005; 3Einarson A, et al. Am J Psychiatry 2008; 4 Alwan S, et al. N Engl J Med 2007; 5 Greene MF. N Engl J Med 2007; 6Hallberg P, Sjoblom V. J Clin Psychopharmacol 2005; 7Wogelius P, et al. Epidemiology 2006; 8www.gsk.ca/english/docs-pdf/PAXIL_PregnancyDHCPL_E-V4.pdfDear Healthcare Professional (3/17/08); 9www.fda.gov/medwatch/safety/2005/Paxil_dearhcp_letter.pdf Dear Healthcare Professional (3/17/08)

45. Antidepressant Drug Treatment During Pregnancy • SSRI’s most commonly used • More limited reproductive safety data available for SNRI’s compared to SSRI’s, i.e.. venlafaxine, duloxetine • Data on bupropion includes growing number of exposures supporting absence of increased risk for malformation • Buproprion registry over 500 • Retrospective analysis of 1200 exposed infants • Prospective study of 105 infants

46. “POOR NEONATAL ADAPTATION” AND SSRI USE DURING PREGNANCY Consistent data: Late trimester exposure to SSRIs is associated with transient irritability, agitation, jitteriness, and tachypnea in 10-30% babies exposed in utero Studies do not control for maternal mental health condition, blinding of exposure in neonatal assessments Effectiveness of discontinuing or lowering the dose late in pregnancy aimed at reducing the risk of neonatal toxicity has not been prospectively studied

47. “Poor Neonatal Adaptation” and SSRI Use During Pregnancy No correlation between measures of umbilical cord blood levels of SSRIS and the risk if developing neonatal symptoms No difference in symptoms between two groups compared : infants born to mothers who had taken SSRIS but tapered 2 weeks prior to delivery vs. those who continued Lowering the dose of antidepressants does, however, increase the risk for maternal postpartum depression Levinson-Castiel R, et al. Arch Pediatr Adolesc Med. 2006;160:173-176. Chambers CD, et al. N Engl J Med. 2006;354:579-587. Sit, D, et al. Pre-publication communication Warburton et al, Acta Psychiatr Scand 2010; 121(6): 471-9.

48. Risk for PPHN Associated With Late Trimester Exposure to SSRI Inconsistent Findings: One report showed increased risk by 6-fold (Chambers 2006) (with this highest estimate of 6-fold increase 1% of exposed infants would be affected) Lower association seen with Källén and Olausson, 2008 NO association seen in three studies Limitations: Small number of SSRI exposures Recall bias with respect to early versus late SSRI exposure Recent data suggests lower risk than Chambers et al PPHN correlated with cesarean section, race, body mass index, and other factors not related to SSRI use** Data supporting an association is weak FDA revised its warning as a result ** Hernández-Díaz S, et al. Pediatrics. 2007;120:e272-e282. Kallen , August 2008 ; Pharmacoepidemiol Drug Safety Chambers CD, et al. N Engl J Med. 2006;354:579-587. Hernández-Díaz S, et al. Pediatrics. 2007;120:e272-e282

49. TREATMENT OF PPD

50. TREATMENT OF PPD Selection of treatment: • First requires good evaluation, review of prior history and assessment for suicidality/dangerousness • Individual psychotherapy--CBT /IP Interpersonal and cognitive behavioral therapy very effective for mild to moderate PPD • Support group • Community support programs • Medication • ECT • Hospitalization O'Hara MW, et al. Arch Gen Psych. 2000;57:1039-1045. Stuart S, et al. J Psychother Pract Res. 1995;4:18-29. Appleby L, et al. BMJ. 1997;314:932-936.