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Mood And Anxiety Disorders in NICU Families

Mood And Anxiety Disorders in NICU Families. By Pec Indman EdD, MFT. The Field of Neonatology Has Expanded beyond the Primary Aim of Saving Infant’s Lives to Minimizing Survivor’s Long-term Complications, and thus Extending Clinicians’ Responsibilities beyond the Baby to the Broader Family.

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Mood And Anxiety Disorders in NICU Families

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  1. Mood And AnxietyDisorders in NICU Families By Pec Indman EdD, MFT

  2. The Field of Neonatology Has Expanded beyond the Primary Aim of Saving Infant’s Lives to Minimizing Survivor’s Long-term Complications, and thus Extending Clinicians’ Responsibilities beyond the Baby to the Broader Family. Meyer EC, Brodsky D, Hansen AR, et al. An interdisciplinary, family-focused approach to relational learning in neonatal intensive care. J Perinatol 2011; 31: 212- 219.

  3. MYTHS ABOUT PERINATALMOOD DISORDERS

  4. HISTORICAL INFORMATION • Psychiatric history • History of sexual abuse or trauma • Fertility problems • Perinatal loss • Previous pregnancy, birth, or postpartum difficulties

  5. DEPRESSION IN PREGNANCY • About 15-21% of women experience depression in pregnancy up to 38% in low SES (Alfonso DD, et al. Birth 1990;17:121-130) • 50-75% relapse after discontinuing medication when pregnant (Cohen LS, et al. Psychother Psychosom. 2004 Jul-Aug;73(4):255-8) • Over 40% resume medication during pregnancy (Cohen LS, et al.. Psychother Psychosom. 2004 Jul-Aug;73(4):255-8) • Most are undetected and under treated (Marcus, S.,Depression during Prengnancy:Rates, Risks, and Consequences. Can J Clin Pharmacol Winter 2009 Vol 16 (1)

  6. DEPRESSION/ANXIETY IN PREGNANCY Depression in pregnancy associated with: • Low birth weight (under 2500 grams) • Preterm delivery (less than 37 weeks) up to 2X risk (Li D, Liu L, Odouli R, Hum Repod.2009 Jan;24(1):146-53. Epub 2008 Oct 23, Straub H, Adams M, Kim JJ, et al. Am J Obstet Gynecol 2012;207) • Small-for-gestational age/IUGR(Grote, N, et al. ARCH GEN PSYCHIATRY/VOL 67 (NO. 10), OCT 2010) Severe anxiety in pregnancy associated with: • Constriction in placental blood supply • Heightened startle response in newborn • Newborns more inconsolable, poor sleep (Bennett HA, Einarson, A. et al. Clin Drug Invest 2004;24 (3)

  7. POSTPARTUM “BLUES” • Occurs in 50-80% of postpartum women • Onset usually in first week postpartum • Symptoms may persist from several days to a few weeks NORMAL

  8. BLUES OR BEYOND? • Severity • Timing • Duration

  9. POSTPARTUM DEPRESSION-NICU • PPD rates 40% if premature infant • Sustained (up to 52 wks) depression associated with: • earlier gestational age • lower birth weight • ongoing infant illness/disability • perceived lack of social support. • most studies failed to consider depression in pregnancy as a confounding variable (Vigod SN, Villegas L, Dennis CL, Ross LE. Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: a systematic review. BJOG. 2010 Apr;117(5):540-50)

  10. SYMPTOMS OF POSTPARTUMDEPRESSION/ANXIETY: • Sad mood, guilt, irritability, excessive worry, anxiety, or feelings of being overwhelmed • Sleep problems (often insomnia), fatigue • Symptoms or complaints in excess of, or without physical cause • Discomfort around baby, or lack of feelings towards baby • Loss of focus and concentration (may miss appointments) • Loss of interest or pleasure • Appetite changes-poor appetite or weight gain

  11. NICU MOMS and PPD • A mom’s perception of of nursing support and depressive symptoms were found to be directly related. • As the perception of nursing support decreased by one point, the risk of depression increased by 6% (Kyle Mounts, Screening for Maternal Depression in the Neonatal ICU, Clin Perinatol, 2009;36: 137-152)

  12. NICU MOMS AT 1 year • 39%-63% depressed at 1 year pp

  13. RISK FACTORS FOR PPD • 50-80% risk if previous postpartum depression • 50% risk if depression or anxiety during pregnancy • Personal and/or family history of depression or other psychiatric disorder • History of severe PMS or PMDD • Social isolation/poor support system/teens (Suri R and Burt VK. The Assessment and treatment of Postpartum Psychiatric Disorders. Jrnl Prac Psych and Behav Hlth. March 1997)

  14. TREATMENT FOR POSTPARTUMDEPRESSION/ANXIETY • Individual/couples therapy, group • CBT or Interpersonal Therapy (IPT) • Antidepressant and/or antianxiety medication, Sleep meds (Wisner KL, et al., N Engl J Med. July 2002;347(3):194-199) • Treat thyroiditis • ECT INADEQUATE TREATMENT CAN LEAD TO CHRONIC DEPRESSION OR RELAPSE

  15. POSTPARTUM OBSESSIVE-COMPULSIVE DISORDER (OCD) • 3% to 9% of new mothers may develop obsessive symptoms (Abramowitz JS, et al. Anxiety Disorders 2003. 17:461-478, Chaudron, LH and Neha Nirodi. The obsessive–compulsive spectrum in the perinatal period: a prospective pilot study. Arch Womens Ment Health, March, 2010;1434-1816.)

  16. SYMPTOMS OF POSTPARTUM OCD • Intrusive, repetitive, and persistent thoughts or mental picture – different that PTSD flashback • Thoughts often are about hurting or killing the baby • Tremendous sense of horror and disgust about these thoughts (ego alien) • Thoughts may be accompanied by behaviors to reduce the anxiety (such as hiding knives) • Repetitive counting (diapers in the bag), checking (baby’s breathing), cleaning (The obsessive–compulsive spectrum in the perinatal period: a prospective pilot study. Arch Womens Ment Health, March, 2010;1434-1816. Sichel D and Driscoll JW. Women’s Moods, 1999)

  17. TREATMENT FOR OCD • Psychotherapy and psychoeducation • Medication (SSRIs)

  18. POSTPARTUM PANIC DISORDER • May occur in about 10% of postpartum women

  19. SYMPTOMS OF PANIC DISORDER • Episodes of extreme anxiety: excessive or obsessive worry or fears • Shortness of breath, chest pain, sensations of choking or smothering, dizziness • Hot or cold flashes, trembling, palpitations, numbness or tingling sensations • Restlessness, agitation, or irritability • During attack may fear she is going crazy, dying, or losing control • Attack may awaken her from sleep • Often no identifiable trigger for panic (Sichel D and Driscoll JW. Women’s Moods, 1999)

  20. TREATMENT FOR PANIC DISORDER • Psychotherapy • SSRIs • Antianxiety medication

  21. BIPOLAR DISORDER • In women with BD rates range up to 82% • Time of increased vulnerability for relapse • Most present with depression • Closely associated with postpartum psychosis (Sharma, V. et al. Bipolar II Postpartum Depression: Detection, Diagnosis, and Treatment. Am J Psychiatry 2009; 166:1217–1221.)Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy and Postpartum. American Psychiatric Publishing, Inc., 2005)

  22. SYMPTOMS OF BIPOLAR • Mania or hypomania • Depression • Rapid and severe mood swings

  23. TREATMENT OF BD • Careful observation for symptoms • High Risk postpartum mania/psychosis (Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy and Postpartum. American Psychiatric Publishing, Inc., 2005)

  24. POSTTRAUMATIC STRESS DISORDER (PTSD) • May occur in 1-6% (Beck CT. Nursing Research. July/Aug 2004; 53(4):216-224) • Up to 38% report traumatic birth(Beck C & Watson S, Impact of Birth Trauma on Nursing, Nursing Research 2008(57);4:228-236)

  25. PTSD in NICU Families • Up to 70% • Common to experience PTSD, PMADs (Lefkowitz DS, Chiara Baxt C, Evans JR.. J Clin Psychol Med Settings 2010; 17: 230–237)

  26. SYMPTOMS OF PTSD • Recurrent nightmares • Extreme anxiety • Reliving past traumatic events • sexual • physical • emotional • childbirth

  27. TREATMENT FOR PTSD • Psychotherapy • SSRIs and/or antianxiety medication • May require sleep medication • Social support

  28. POSTPARTUM PSYCHOSIS • Occurs in 1-2/1000 • 5% suicide and 4% infanticide rate (Doucet, S. et al. Differentiation and Clinical Implications of Postpartum Depression and Postpartum Psychosis. JOGNN, 2009. 38, 269-279. Sit, D. et al. A Review of Postpartum Psychosis, Journal of Women’s Health. 2006:15(4)

  29. SYMPTOMS OF POSTPARTUM PSYCHOSIS Usually begins 48-72 hours postpartum • Most develop symptoms within 2-4 weeks • Visual or auditory hallucinations • Early symptoms restlessness, agitation, irritability • Confusion, paranoia, extreme moodswings • Delusional thinking (infant death, denial of birth, need to kill baby) (Sit, D. et al. A Review of Postpartum Psychosis, Journal of Women’s Health. 2006:15(4)., Suri R and Burt VK., Jrnl Prac Psych and Behav Hlth. March 1997)

  30. RISK FACTORS FOR POSTPARTUM PSYCHOSIS • Personal (20-50%risk) and/or family history of psychosis or bipolar disorder • 80% risk if previous postpartum psychotic or bipolar episode • First baby (Sit, D. et al., A Review of Postpartum Psyhosis, Journal of Women’s Health 2006, (15)4. Suri R and Burt VK., Jrnl Prac Psych and Behav Hlth. March 1997)

  31. TREATMENT FOR POSTPARTUM PSYCHOSIS • IMMEDIATE HOSPITALIZATION • Antipsychotics • Mood stabilizers (antidepressants as needed) • Psychotherapy • ECT (Yonkers KA, et al.. Am J Psychiatry. 2004;161:608-620)

  32. WHY TREAT PARENTS? • Potential for child abuse and neglect • Negative impact on marital/family relationships • Increased risk chronic depression and relapse (Field T. et al., Infant Behavior & Development 2004;(27) 216-229, Hart S. et al., Infant Behavior & Development 1998; 21(3):519-525, Murray L and Cooper PJ.,. Psychological Medicine 1997;27(2):253-260)

  33. OUTCOMES OF UNTREATED PARENTAL ILLNESS • Increased incidence of childhood psychiatric disturbances • Impaired cognitive and language development in children • Negative influence on preterm children's later cognitive function (McManus BM and Poehlmann J. Infant Behav Dev. 2012 Jun;35(3):489-98 Muzik, M and S. Borovska, Mental Health in Family Medicine 2010;7:239–47)

  34. BREASTFEEDING AND ANTIDEPRESSANTS • AAP now recommends 1 year of breastfeeding. Depression preceeds weaning. • “Paxil and Zoloft usually produce undetectable infant levels.” (Weissman AM. et al. Am J Psychiatry 2004;161:1066-1078) • Studies of exposed infants show no differences in IQ or neurobehavioral development(Yoshida K, et al. Br J Clin Pharmacol. 1997 Aug;44(2):210-1)

  35. BREASTFEEDING • Depressed moms breastfed for shorter durations • Experienced breastfeeding more negatively than non-depressed (Individual and Combined Effects of Postpartum Depression in Mothers and Fathers on Parenting Behavior. Paulson, Dauber, and Leiferman. Pediatrics, 118(2), Aug 2006:659-668) • Decreased levels of breastfeeding self-efficacy • Increased breastfeeding difficulties (Dennis CL & McQueen K. The Relationship Between Infant-Feeding Outcomes and Postpartum Depression. Pediatrics 2009;123:e736-e751)

  36. WHAT ABOUT DADS/PARTNERS?

  37. NICU DADS • Fathers of premature infants in a medical NICU demonstrated elevated levels of stress that persisted. • Paternal self-reported stress and depressive symptomatology was independent of infant illness. • 30% of NICU dads screened positive for depression (Mackley AB, et al. Forgotten parent: NICU paternal emotional response. Adv Neonatal Care. 2010 Aug;10(4):200-3)

  38. ROLE OF NICU MENTAL HEALTH PROVIDERS • Providing emotional support and therapy to families in the NICU • Overcome barriers to treatment • Integrated family care • NICU psychologists in OK, Miami, Pittsburgh, Columbia/Pres in NY, Kansas City • National Perinatal Association (www.nationalperinatal.org)

  39. POSTPARTUMSCREENING • Edinburgh Postnatal Depression Scale (EPDS), 1987 by Cox, et. al. • Score of > 10  refer for evaluation • PHQ9 and PHQ2-not well studied for perinatal use, frequently used in practice • Postpartum Depression Screening Scale (PDSS), 2002 by Cheryl Beck D.N.Sc. (Gjerdingen, D, and Yawn, B. Postpartum Depression Screening, J Am • Board Fam Med 2007;20:280 –288. ACOG Committee Opinion, Screening for Depression During and After Pregnancy, No.453, 2/2010)

  40. TREATMENT GUIDELINES • Always r/o bipolar spectrum before starting SSRI’s. http://www.psycheducation.org/depression/MDQ.htm • F/U and treat to remission! • Meds work best with therapy • Find therapists with expertise in perinatal moods and loss (www.postpartum.net and www.mededppd.org).

  41. PROFESSIONAL RESOURCES • Resources for information about perinatal psychopharmacology • UIC Perinatal Mental Health Project • (800)573-6121 (free for providers) • www.psych.uic.edu/research/perinatalmentalhealth • Other online resources • www.mededppd.org • www.toxnet.nlm.nih.gov/ • www.reprotox.org • www.motherisk.org

  42. RESOURCES • Postpartum Support International www.postpartum.net • North American Society for Psychosocial OB/GYNwww.naspog.org • www.mededppd.org • Regrouptherapy.com (online web video support)

  43. Other Resources • https://www.marchofdimes.com/pdf/california/Bernard_-_Medical_PTSD_in_the_NICU.pdf • http://jpepsy.oxfordjournals.org/content/30/8/667.full.pdf • http://www.kan.or.kr/new/kor/sub3/filedata_anr/200703/199.pdf • http://fn.bmj.com/content/90/2/F109.full

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