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Perinatal Mood Disorders

Learn about perinatal mood disorders, risk factors, screening measures, treatment options, and available resources in this 2-hour training.

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Perinatal Mood Disorders

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  1. Perinatal Mood Disorders Michigan Statewide PMD Coalition 2 Hour Training

  2. Objectives: • Differentiate between the Symptomsof the 6 Perinatal Mood Disorders • Describe at least 6 Risk Factors for Perinatal Mood Disorders • Identify recommended Screening Measures for Perinatal Mood Disorders • State at least 3 different Treatment Options for Perinatal Mood Disorders • Describe Resources available to persons interested in Perinatal Mood Disorders

  3. Mary Taber-Lind, Photographer

  4. Introduction • 20% of WOMEN and 10% of MEN will experience clinical depression in their lifetime • PMD occurs in 10-20% of all new mothers who give birth • One out of every 7-8 mothers • 400,000 per year reported nation wide • An estimated 50% of cases go undetected • PMD knows NO boundaries: it affects all races, all ages, all professions, all economic status levels. Strong, intelligent women have PMD. • Often “Missed”: Misunderstood/misdiagnosed/mistreated • 2003 Study- 86% of depressed pregnant mothers did not receive treatment (stigma, no screening, etc.) • Gotlib IH, Whiffen VE, Mount JH et al. J Consult ClinPsychol 1989:57:269 Prevalence rates assoc with depression in pregnancy and postpartum. • Brown, MA, Slochany JE. NursinClin North Am 2004:39:83 Two Overlooked Mood Disorders in Women • Marcus SM, Flynn HA, Blow FC, et al. Depressive symptoms among pregnant women screened in OB settings. J Womens Health 2003: 12:373

  5. The Myth

  6. The Reality

  7. Maternal Effects- Untreated PMD • Poor prenatal behaviors-nutrition, prenatal care, substance abuse • Poor parenting behaviors • Longer persistence of symptoms • Increased risk of PPD with subsequent children • Increased risk of relapse • Poor pregnancy outcomes: insufficient weight gain, decreased compliance with prenatal care, premature labor, small for gestational age infant • Muzik, M., Marcus, S., Heringhausen, J., Flynn, H. Primary Care: Clin in Office Practice 36:1:March 2009 Depression in childbearing women: When depression complicates pregnancy.

  8. Guilt and anxiety about parenting Loss of love for baby Difficulty enjoying baby, negative or disinterested toward baby, less active interactions, inability or lack of attempt to soothe baby, refusal to look at or hold baby, hostile expressions Effects on Maternal Attitude

  9. Effects on Infant and Children • Poor mother-infant attachment Irritability, lethargic, poor sleep • Language delays • Behavioral difficulties • Lower cognitive performance • Mental health disorders • Attention problems • Withdrawn/fussy/crying/temper • Sleep/feeding/eating disruptions • Kahn, et al. AJPH 2002:92:1312-1318 • Infant Behav Dev 2004:27:216-229 • Psychiatry 2004:67:63-80 • Bonari et al. Can J Psychiatry 2004:49:726-735

  10. Dads get Postpartum Depression too! • Virginia Medical School Study 5/10 • 28,000 New Dads screened - Meta Analysis of 43 published studies • 10.4% Scored positive using standardized depression tools (EPDS, CES-D, BDI, etc.) • Tx: Same as for Mom. Couples therapy. Meds. Self Help • Local Resources: Dads Monthly Support group 4th Tuesday • Websites: www.postpartumdads.org www.postpartumdadsproject.org www.postpartummen.com www.bootcampfornewdads.org • PSI chat with Dads - First Monday each month at www.postpartum.net JAMA, Prenatal and Postpartum Depression in Fathers and its Association with Maternal Depression. A Meta-Analysis By James F. Paulson; Sharnail D. Bazemore

  11. Mental illness during Pregnancy • Pregnancy is not protective • Prevalence: 9.4%-12.7% • Existing psychological disorders either stay the same or worsen during pregnancy (especially anxietyand OCD) • Women with mental illness during pregnancy have increased risk for Pre-term delivery, Cesarean Section, Low birth weight, NICU infants • 2003 Study- 86% of depressed pregnant mothers did not receive treatment (stigma, no screening, etc) • Whitlock, American Journal of Psychiatry 2007 • Marcus SM, Flynn HA, Blow FC, et al. Depressive symptoms among pregnant women screened in OB settings. J Womens Health 2003: 12:373

  12. “Whispers” Artprize 2015 Pam Coven

  13. Video “Speak Up When You’re Down” New Jersey 2007 5 min Contact nancy.roberts@spectrumhealth for copies in English and Spanish

  14. Onset: First 2 – 3 weeks Prevalence: 50 – 80% Etiology Hormones Adjustment period Subsides in time with support Possible risk factor for PPD Symptoms Crying, tearfulness Fatigue Mood swings Anxiety Baby Blues

  15. Onset: Anytime in the first year Prevalence: 10 %– 21.9% **Twice the rate of gestational diabetes and gestational hypertension- of which universal screening for both of these illnesses occurs routinely with ALL pregnancies Etiology: A biologic and life stressors illness Prognosis: Favorable with appropriate treatment Treatment: Meds, psychotherapy, support, self help Postpartum Depression

  16. Depressive mood Sadness/crying Anxiety / insecurity Sleep disturbances Appetite changes Poor concentration Confusion Irritability Unable to take care of self /family Numerous Losses, ie: self, spontaneity, body image, sexual, etc. Isolation Worthlessness Shame Guilt Anger PMD Symptoms

  17. Onset: first month Prevalence: 10-15% Etiology: unknown Treatment: meds, therapy, support Symptoms: Panic attacks Anxiety Agitation Insomnia Self doubts Extreme worries Postpartum Panic/Anxiety Disorder

  18. Chest pain Muscle tension Shortness of breath Hot and cold flashes Tingling hands and feet Extreme worries and fears Fear of dying Fear of going crazy Fear of being alone Faintness Irritability- anger and rage Feeling trapped Racing heartbeat Hyperventilating/ Difficulty breathing Nausea /Vomiting Dizziness Symptoms of Anxiety/Panic Attacks

  19. Onset: first month Prevalence: unknown Etiology: unknown Treatment: meds, therapy, thought stopping techniques, support Intrusive thoughts, fears, images Person cannot control thoughts The person understands that to act on these thoughts would be wrong Often misdiagnosed as psychosis Postpartum Obsessive Compulsive Disorder

  20. Intrusive Thoughts: Recurring, persistent and disturbing thoughts, ideas or images (scary images of accidents, abuse, harm to self or baby) Hyper vigilant (i.e. can’t sleep for fear that something awful will happen to baby, constantly checking on baby) Ritual behaviors done to avoid harming baby ( put away knives) or to create protection for baby ( will not leave the house) OCD

  21. Onset: soon after birth Prevalence: 1.5%-6% Etiology: birth trauma, recent or past trauma Treatment: meds, counseling-debriefing, support Re-experiencing over and over in one’s mind (sensations of “being in the trauma” now) Nightmares/Flashbacks Increased arousal/anxiety/anger Emotional numbing/detachment/isolation Post Traumatic Stress Disorder (PTSD) Due to Childbirth

  22. After Birth • Ask mother soon after birth if there is anything they want to know or talk about regarding their birthing experience. • Allowing expression of their perceptions and experiences of their birth and the care they received. • Websites and organizations: www.tabs.org.nz www.solaceformothers.org www.ptsdafterchildbirth.org

  23. Often presents with Mania first: Feels great High energy Irritability Decreased need for sleep Feeling “speedy” Easily distracted Mind racing Fast speech 85% of bipolar women who go off their medications during pregnancy will have a relapse before the end of their pregnancy . Increased potential for development of psychotic symptoms. Bipolar Disorder

  24. Onset: first 1 – 3 weeks ( months) Prevalence: 1 – 2 per 1000 births or 4,000 per year nationally Etiology: unknown – 70% have significant history of mental illness 5% commit suicide 4% infanticide Treatment: Inpatient hospitalization for close observation - a true psychiatric emergency Spinelli MG. Am J Psychiatry. 2004;161:1548–1557 SpinelliMG. Am J Psychiatry. 2009;166(4):405-408. Symptoms: Delusions Hallucinations Paranoia Loss of reality Agitation Irrational statements Mania Insomnia NonacsR, Cohen LS. J Clin Psychiatry. 1998;59(Suppl 2):34-40 Jones I, Craddock N. Ann Med. 2001;33(4):248-256. Postpartum Psychosis

  25. Differentiating between OCD and Psychotic Thoughts Postpartum OCD • Thoughts are ego-dystonic • Disturbed by thoughts • Avoid objects or being with baby • Very common disorder • Low risk of harm to baby Postpartum Psychosis • Thoughts are ego-syntonic • Rarely distressed by thoughts • Do not have avoidant behaviors • Not common disorder • High risk of harm to baby

  26. All normal physical changes of pregnancy and childbirth Hormone changes Brain chemical changes Thyroid imbalance ( 5-10% during first postpartum year) Multiple Births (25%) Infertility Hx Family Hx of Mental Illness Hx PMS- PMDD (premenstrual dysphoric disorder) Personal history of mental illness (3-4 times the risk) Hx prenatal depression (33%) Hx PPD (50-70%) Complicated pregnancy or deliveryincluding PTSD Biological Risk Factors

  27. Normal psychological changes that always occur with childbirth Unplanned pregnancy: ambivalence Expectations of motherhood Personality characteristics : “the perfectionist” Significant Lifestyle changes first time mothers Adoptive mothers not excluded Unresolved losses: especially reproductive in nature: miscarriage, abortion,infertility, PP sterilization. Recent stresses: illness, divorce, move, job change, death, finances Negative childhood experiences : Hx abuse, neglect, PTSD Psychological Risk Factors

  28. Relationship with the significant other/partner/husband The “Quality “of the partnership Mothers social support system Single mothers at higher risk Quality of relationship with BABY High Need infant: ill, colic, NNICU Mothers relationship with OTHER children Relationship Risk Factors

  29. Screening Recommendations: US Preventive Services Task Force • 2 Question Screener: (PHQ-2) • 1. “During the past month have you been bothered by feeling down, depressed or hopeless?” • 2. “During the past month, have you often been bothered by having little interest or pleasure in doing things that you previously enjoyed?” • *A window of opportunity exists for screening because this is the time of life when women are under the care of a healthcare provider and entering medical systems.

  30. ACOG: Screening for PMD • May 2015 • ACOG (The American College of Obstetricians and Gynecologists) • New Committee Opinion Report Published! • Finally! • http://m.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression?IsMobileSet=true • Replaces the Feb 2010 report

  31. PMD Screening Tools • Edinburgh Postnatal Questionnaire (EPDS) by Cox • Postpartum Depression Screening Tool (PDSS) by Cheryl Beck Western Psychological Services 310-478-2061 www.wpspublish.com • Patient Health Questionnaire (PHQ-9) by Spitzer Linked to DSM- www.pfizer.com/phq-9 • Postpartum Depression Checklist (PDC) by C. Beck – Identifies 11 symptoms • Beck Depression Inventory (BDI) by A. Beck - 21 items, self report, 3 versions • Others for clinical depression: CES-D Center for Epidemiologic Studies/Depression MHI-5 Mental Health Inventory

  32. Edinburgh Postnatal Depression Scale EPDS • Brief - 10 questions • Easily read and understandable - 6th grade reading level • Self administered : 2-4 minutes to complete • Published in 20 languages and used internationally • No cost - unless for electronic documentation • Can be used both prenatal or postpartum • Validated by research –Reliable Sensitivity: 78% Specificity 99% • In use since 1987 • Explores mood symptoms in PP period and less physical and somatic symptoms

  33. Edinburgh Postnatal Depression Scale

  34. Interpretation of the EPDS score • A score of 12 or more suggests further assessment for intervention to take place • Confirmation requires 2 consecutive scores of 12 or more separated by 2 weeks plus a professional interview/assessment. • Always intervene with #10 question if marked positive • Other Languages at: http://bit.ly/1xb0N4o

  35. Diagnostics: DSM-V Criteria Uses same criteria as for non-pregnant. PPD is not listed as a separate diagnosis, however the DSM-V has a postpartum onset specifier within 4 weeks of delivery. (Although studies show onset can occur much later in the PP period) Five (or more) symptoms present in the same 2 week period: 1. Depressed mood most of the day 2. Diminished interest or pleasure in activities 3. Significant weight loss or weight gain 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive guilt 8. Diminished ability to think or concentrate 9. Recurrent thoughts of death or suicidal ideation

  36. Performed at many hospitals in Michigan using the Spectrum Health Postpartum Depression Risk Questionnaire. The self administered PMD Risk Questionnaire AND Edinburgh is completed by mother within first 12 hours after birth If High Risk - The staff/RN/MSW provides education, creates a PMD plan with patient and family, and initiates follow up screening and /or phone call. 35% Screen at High Risk at Spectrum Health. Other hospitals report similar findings. Risk Assessment Screening

  37. Postpartum Depression Risk Questionnaire

  38. Key Questions to ask • “How are things a home?” • “Are you sleeping OK when the baby sleeps?” • “Any changes in your appetite?” • “Are you experiencing anxiety or panic?” • “Are you afraid to be alone with your baby?” • “Do you feel more irritable or angry than usual?” • “Are you afraid you might lose control?” • “Are you worried about the way you feel right now” • “Are you afraid of any thoughts you are having?” • “Does your partner know how you are feeling?” • “Do you ever have thoughts about hurting yourself or the baby?” • “Is there anything you are afraid to tell me but think I should know?

  39. Red Flags: Mothers may reply… • “I have not slept at all in 48 hours or more” • “I have lost a lot of weight without trying to “ • “I do not feel loving towards my baby and can’t even go through the motions to take care of him/her” • “I feel like such a bad mother” • “I am afraid I might harm myself in order to escape this pain” • “I am afraid I might actually do something to hurt the baby” • “I hear sounds or voices when no one is around” • “I feel that my thoughts are not my own or that they are totally out of my control’ • “Maybe I should have never become a mother, I think I may have made a mistake” • Always use Clinical Judgement

  40. Tips for Professional and Family • Do not assume that if she looks good, she is fine. • Do not assume this will get better on its own. • Do encourage her to get a comprehensive evaluation if you are concerned. • Do take her concerns seriously. • Do let her know you are available if she needs you and inform her of support resources for PPD.

  41. Why don’t mothers seek treatment? “I never let others know how bad I felt. I was so afraid people would think I was crazy and take my baby away.”

  42. PMD and Treatment • PMD Education • Family support • Social support / Support Groups • Self Help • Counseling / Therapy - Cognitive behavioral and Interpersonal therapy • Medications

  43. Education: Books, Journals, Videos, Websites, Resources Exercise “Activity or Movement” ( Yoga, Tai Chi, Stroller Exercises, etc) Sleep / Rest Nutrition (High protein, Limit sugar and caffeine) Vitamins (Prenatals, Vit. B Complex, Vit. D3, Omega 3 Fatty Acids) Social and Family Support Journaling Keep expectations realistic Postpone major life changes Prayer and Spiritual Healing Self-Care Treatment Options

  44. Hormonal replacement – Controversial - Estrogen/Progesterone creams, injections, etc Complementary Alternative Medicine (CAM) Treatment: Light Therapy, Massage Therapy, Infant massage, Hypnosis, Acupuncture, etc Mindfulness, Meditation, Relaxation, Stress Reduction Herbal -St Johns Wort ,SamE, etc Homeopathy, Naturopathy Placenta Ingestion TMS – Transcranial Magnetic Stimulation ECT – Electro Convulsive Therapy Barnes PM et al. Natl Health Stat Report. 2008;(12):1-23; Eisenberg DM et al.JAMA. 1998;280(18): 1569-1575; NahinRL et al. Natl Health Stat Report. 2009;(18):1-14. Other Treatment Options

  45. Psychotherapy Approaches Cognitive Behavioral Therapy (CBT) Thought or symptom based methods Interpersonal Psychotherapy (IPT) Grief, Role Transitions, Interpersonal Disputes, Interpersonal Deficits Couples Therapy Group Therapy EEG Biofeedback / EMDR Aaron Beck, Founder of CBT O’Hara, Interpersonal Psychotherapy Manual for PPD, 1993

  46. Two Choices: Risk/Benefit Analysis • Expose the baby/fetus to medication during pregnancy or lactation • Expose the baby/fetus to the adverse effects of untreated depression in the mother

  47. Medication • Use the medication that Mom has taken in past with good results (if possible) • Start on lowest dosage and increase gradually every 5-7 days (if possible) • Use the safest medications possible (review the research and categories) • A plan of action needs discussion between patient and provider during the pregnancy for the upcoming year. • Most advise to continue meds 6-12 months after patient begins to feel better, then discontinue slowly as provider monitors.

  48. Assessment of the mothers perception of the breastfeeding experience and her own expectations It may be the ONLY thing that she feels good about Do not tell her to automatically discontinue breastfeeding if taking meds Give her permission to follow her instincts Support the mother whatever her decision, to avoid guilt and shame If SHE chooses to wean, do NOT let her wean abruptly (slowly over 2-3 weeks) Breastfeeding and PMD

  49. Considerations • Balance the benefits of breastfeeding with the risks of the drug • The risk/ benefit assessment is case-specific • Observe the infants behavior. Inform the Pediatrician. American Academy of Pediatrics Policy Statement

  50. Medication Resources • Zachary Stowe, MD- Women's Mental Health Program, Emory University www.emorywomensprogram.org • Lee Cohen, MD-Center for Women’s Health, Massachusetts General Hospital www.womensmentalhealth.org • Thomas Hale, PhD. - “Medication and Mother’s Milk” www.iberastfeeding.comwww.neonatal.ttuhsc.edu/lact • www.ibreastfeeding.com An online pharmacy subscription • www.motherrisk.orgValuable info about meds during pregnancy and lactation • Mother To Baby: Medications and More During Pregnancy and Breastfeeding OTIS: Organization of Teratology Information Specialists www.mothertobaby.org LactMed - www.toxnet.nim.nih.gov www.bmj.com/content/351/bmj.h3190 - SSRI safety study

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