Postpartum Maternal Psychiatric Illness: Impact on the infant and role of the pediatrician

1. Postpartum Maternal Psychiatric Illness: Impact on the infant and role of the pediatrician

2. Goals of this Presentation: • Understand the potential impact of untreated perinatal maternal psychiatric illness on the infant • Be familiar with the presentation of postpartum maternal psychiatric illness • Elucidate the potential role of the pediatrician in identifying postpartum maternal psychiatric illness • Understand the importance and impact of treatment of perinatal maternal psychiatric illness

3. We need to start at the beginning….

4. Between 10-20% of women will experience significant depression during pregnancy • Routine screening for depression during pregnancy is uncommon • Typically depression during pregnancy is untreated or incompletely treated • Anxiety disorders (OCD, GAD) generally worsen during pregnancy

5. Prenatal anxiety, depression, and high stress lead to increased maternal cortisol transmitted to the fetus via the placenta • Fetal exposure to prenatal anxiety and depression play a role in programming the fetal HPA axis • High cortisol results in lowered cognitive development (measured by the Bailey at 16 months)

6. 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

7. Antidepressant Exposure and the Neonate: Poor Neonatal Adaptation • Consistent data: Late trimester exposure to SSRIs is associated with transient irritability, agitation, jitteriness, and tachypnea • 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

8. 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 This phenomenon may represent transient neonatal serotinergic dysfunction rather than medication withdrawal

9. 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 by Andrade.et al., 2009 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**

10. 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

11. Pediatricians play an important role in supporting strong infant mother relationships and identifying the need for intervention when maternal perinatal psychiatric illness puts infants at risk for negative outcomes

13. Spectrum of Postpartum Mood Disorders Postpartum Psychosis (0.1-0.2 %) Postpartum Depression (Approx 15%) Postpartum Symptom Severity Postpartum Blues(50-85%) None

14. PPD: EARLY RECOGNITION PPD is most often missed despite multiple contacts with health care providers The most significant factor in the duration of PPD is delay in receiving treatment Depression often persists for months to years after childbirth, with lingering effects on physical and psychological functioning following recovery from depressive episodes

15. PRESENTATION OF PPD • Usually develops slowly over the first three months, often beginning within the first 4 weeks, though some women have a more acute onset • May affect ability to care for the baby • Signs and symptoms are those of Major Depression---depressed mood, irritability, loss of interest and appetite, fatigue insomnia. • Often complain of being physically and emotionally exhausted

16. PRESENTATION OF PPD Some common features: • Often express concerns about her ability to care for her baby or anxiety about the baby’s well being • Anxiety symptoms are common including frank panic disorder, hypochondriasis, and most common, generalized anxiety disorder • Women are often unable to sleep even when given the opportunity

17. PRESENTATION OF PPD • Frequently have intrusive, obsessional ruminations • Usually focused on the baby, often violent in nature • Egodystonic , VERY troubling to mothers • NO problem with reality testing i.e. non-psychotic. • One study showed 50% of women with PPD had these obsessional thoughts

18. VERY IMPORTANT TO DISTINGUISH OBSESSIONAL THOUGHTS FROM PSYCHOSIS • NOT associated with psychotic symptoms • Experienced as inside the head • May be experienced dramatically as images in the mind, e.g. as knives or bloody babies, etc • Are often accompanied by protective or avoidant behaviors, e.g. hiding all the knives, refusing to bathe the baby, similar to the hand washing used to neutralize the anxiety of fears that accompany OCD • DO NOT increase the risk of harm to the baby • DO NOT necessitate separating mother and baby

19. Treatment of Postpartum Depression • Mild to moderate– psychotherapy • Other modalities: bright light therapy, exercise, omega 3 FA • More severe may warrant medication • SSRI’s are first line • Benzodizepines in low dose may be needed transiently as adjunctive treatment

20. POST PARTUM PSYCHOSIS • A PSYCHIATRIC EMERGENCY WHICH REQUIRES IMMEDIATE INTERVENTION • Typical onset is within 2 weeks after delivery, first symptoms often within 48-72 hours • Earliest signs are restlessness, irritability and insomnia • Often very labile in presentation • Often looks “organic” with a lot of confusion and disorientation • Most often consistent with mania or a mixed state

21. POST PARTUM PSYCHOSIS • Includes agitation, paranoia, delusions, disorganized thinking and impulsivity • 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 • Auditory hallucinations instructing the mother to harm herself or the child are common • Rates of infanticide associated with untreated postpartum psychosis have been estimated to be as high as 4% and suicide as high as 5%

22. Treatment of Postpartum Psychosis • A psychiatric emergency • Requires hospitalization • Treated as affective psychosis (i.e. bipolar disorder) with antipsychotics and mood stabilizers (+/- antidepressants) Typical regimen might be zyprexa and lamictal

23. Other Considerations • The onset or worsening of OCD, PTSD and panic disorder can also occur postpartum. There can be considerable overlap with PPD. • PTSD can develop in response to a traumatic birth experience or pregnancy loss • PTSD can emerge in pregnancy when past physical or sexual trauma is reexpereinced • Often are intermingled with symptoms of PPD

24. Impact of Untreated Postpartum Maternal Depression on the Infant • Poor weight gain • Sleep problems • Less breastfeeding-depressed mothers more likely to discontinue breastfeeding • Impaired maternal health and safety practices • Increased risk of child abuse and neglect

25. Disruption in the attuned infant-caregiver interactions which promote brain neurological “wiring”: • Future , hyperactivity, conduct disorders and school behavior problems • Delays in language and social development • Increased risk of depression and anxiety disorders • Maternal depression is an “Adverse childhood experience” ACE, often it is not the only adversity • MATERNAL POST PARTUM MOOD IS ONE OF THE STRONGEST PREDICTORS OF NEUROCOGNITIVE DEVELOPMENT IN CHILDREN MEASURED UP TO AGE SIX

26. Public Health Issue • Over four million live births in the US each year. About 15% will have postpartum depression • About 10% are teen mothers About 30% will have PPD • 660,000 Babies at risk for being affected by PPD alone each year

27. Need for Patient Education • The greatest barrier to treatment for PPD in women is lack of knowledge • 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 • 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. Postpartum Depression Screening • There is tremendous societal pressure for women to present as happy and well functioning during these times. • Despite contact with multiple healthcare providers PPD is usually not diagnosed • Postpartum depression is often not recognized– when formal screening methods are not utilized detection rates are as low as 2% • Despite the availability of validated screening tools, routine screening for PPD is not widespread • Lack of recognition often means untreated depression and poor outcomes for the mother, her infant, and family

29. Postpartum Depression Screening • American Academy of Pediatrics (AAP) released a recent report which recommends that pediatricians screen mothers for postpartum depression at baby’s one-, two-, and four-month visits. • Recommends screening with either the EPDS or a 2 question screener • EPDS: • 10 question self administered screening test • Well validated Cut-off point of 10 as an indicator of risk for depression

30. Postpartum Depression Screening • Two-question Screener (PHQ-2) 1.    Over the past two weeks have you ever felt down, depressed or hopeless? 2.    Over the past two weeks have you felt little interest or pleasure in doing things? Considered positive if answered yes to either question • A score above 20 on the EPDS or any indication of suicidality or psychosis warrants consideration for crisis intervention services.

31. If not using screening tools, be specific: • “Are you been unable to sleep even when your baby is sleeping?” (“Or do worries and anxiety keep you awake?”) • “Have you found yourself crying a lot?” • “Have you had any thoughts that have been worrisome or frightening to you?” • “Have you had any thoughts of harming yourself or your baby?” • The suicide rate is increased 70 fold with postpartum depression necessitating assessment of suicidality as part of every screening for postpartum depression.

32. Other considerations Suspect PPD if: • Frequent calls with concerns about the infant seem to reflect maternal anxiety • Infant fails to gain weight and there isn’t an explanation

33. Impact of Treatment on the Infant: Exposure to Medications via Breastfeeding • Antidepressants have more published data in breast feeding than any other class of medications • All antidepressants are secreted into breast milk • Nursing infant serum concentrations are not detectable by the usual laboratory assays • Literature review revealed 11 publications of 40 infants (5 % of published breast feeding cases)with purported adverse effects from antidepressant exposure during breastfeeding—majority of symptoms were GI distress and sleep problems some of which resolved with discontinuation

34. Impact of Treatment on the Infant: Exposure to Medications via Breastfeeding Minimize infant exposure by: • Using a medication of prior response • Using a medication of prior infant exposure (i.e. in utero) • Monotherapy is preferable • Infant serum monitoring is not recommended

35. Choice of Antidepressant • Antidepressant used during pregnancy should be continued • Use agent to which patient has responded to in the past • Caution may be needed with exposure in premature infants with hepatic immaturity • Onset of action requires 2-4 weeks • Exposure for the infant is lowest for sertraline (Zoloft) and fluvoxamine (Luvox), somewhat higher for paroxetine (Paxil), higher with citalopram (Celexa) and fluoxetine (Prozac) • With the current knowledge there is no strong evidence to recommend one drug over another or rationale to switch from one SSRI to another to promote safety during breastfeeding

36. Use of Benzodiazepines During Lactation • Data is somewhat limited • When measured, exposure through breast milk is extremely low • Some anecdotal reports of sedation, poor feeding, respiratory distress; pooled data show low incidence of adverse effects • Diazepam more likely to accumulate in breast feeding baby • Less likely to accumulate—lorazepam (Ativan) clonazepam (Klonopin) • Benzodiazepines may be needed transiently whne maternal anxiety is high and SSRI’s have not yet begun to work

37. Mood Stabilizers and Lactation • Lamictal present in breast milk at variable levels; infant serum levels 20-50 % of maternal . Only one adverse event reported with daily maternal Lamictal dose of 850 mg. • Tegretol and Depakote are approved by the AAP for use in lactating infants. Need close monitoring for drug levels and liver function • Lithium is excreted into breast milk at high levels • Breastfeeding generally avoided • Possible as monotherapy with close supervision at lowest possible dose with close clinical monitoring for signs of toxicity and checking Li levels, TSH, BUN, Cr Women with history of moderate to severe bipolar disorder need to preserve their sleep and should pump and have someone else do night time feedings if possible

38. Neurodevelopmental Effects of Antiepileptic Drugs Study Effects of breastfeeding during AED therapy cognitive outcomes in 199 children at age 3 No difference in IQ’s in breastfed (exposed) vs. non breastfed Limitations: All had exposure to AEDs in utero, No control of women not taking AED’s Meador KJ, Baker GA, et al Neurology. 2010 Nov 30;75(22):1954-60. Epub 2010 Nov 24

39. Antipsychotics and Lactation • Typical Antipsychotics • Medium to high potency typical antipsychotics rarely have adverse effects • Thorazine associated with sedation and developmental delay • Clozapine may be concentrated in breast milk– requires infant blood monitoring • Atypicals Antipsychotics • olanzapine, risperidone, and quetiapine-excretion into breast milk is low • adverse effects appear to be rare

40. Role of the Pediatrician • Have a high awareness of incidence of postpartum psychiatric illness and the consequences of lack of treatment • Play a role in educating mothers (MAPP has materials) • Play a role in identifying postpartum illness, especially depression (routine screening, if possible) • Be prepared to refer identified mothers to treatment • Provide support to mothers who are in need • Collaborate as part of a team in treating maternal postpartum illness bearing in mind the child’s wellbeing

41. TREATMENT OF POSTPARTUM PSYCHIATRIC ILLNESS FOR A MOTHER IS AN EARLY INTERVENTION FOR A CHILD

44. Maine Association of Psychiatric Physician’s (MAPP) Postpartum Depression Project www.mainepsych.org