Psychiatric Complications of Pregnancy and the Postpartum

1. Psychiatric Complications of Pregnancy and the Postpartum Joseph Breuner, MD Swedish Family Practice Residency

2. Objectives • Appreciate the postpartum period as a time of increased vulnerability to psychiatric illness • Recognize and diagnose psychiatric illness during pregnancy and the postpartum • Understand risks to the fetus of psychiatric medications • Prevent and treat psychiatric illness in pregnancy and the postpartum

3. Outline • Psychiatric illness during pregnancy • incidence equal to nonpregnant • review medication risks and safety • Psychiatric illness in the postpartum • increased incidence • clinical features of • bipolar/depression/panic/OCD/psychosis • prophylaxis and treatment

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5. But first, a review • The following slides contain DSM-IV criteria for various episodes. Please SHOUT OUT what you think they are, first three correct answers for each slide get a prize.

6. DSM-IV Definition of... • For at least one week (or less, if hospitalized) the patient's mood is • abnormally and persistently high, irritable or expansive. • To a material degree during this time, the patient has persistently had 3 or • more of these symptoms (4 if the only abnormality of mood is irritability): • -Grandiosity or exaggerated self-esteem • -Reduced need for sleep • -Increased talkativeness • -Flight of ideas or racing thoughts • -Easy distractibility • -Psychomotor agitation or increased goal-directed activity (social, sexual, • work or school) • -Poor judgment (as shown by spending sprees, sexual adventures, foolish • investments)

7. DSM-IV definition of... • In the same 2 weeks, the patient has had 5 or more of the following symptoms, • which are a definite change from usual functioning. Either depressed mood or • decreased interest or pleasure must be one of the five. • -Mood. For most of nearly every day, the patient reports depressed mood or • appears depressed to others. • -Interests. For most of nearly every day, interest or pleasure is markedly • decreased in nearly all activities (noted by the patient or by others). • -Eating and weight. Although not dieting, there is a marked loss or gain of • weight (such as five percent in one month) or appetite is markedly decreased • or increased nearly every day. • -Sleep. Nearly every day the patient sleeps excessively or not enough. • -Motor activity. Nearly every day others can see that the patient's activity • is agitated or retarded. • -Fatigue. Nearly every day there is fatigue or loss of energy. • -Self-worth. Nearly every day the patient feels worthless or inappropriately • guilty. These feelings are not just about being sick; they may be delusional. • -Concentration. Noted by the patient or by others, nearly every day the • patient is indecisive or has trouble thinking or concentrating. • -Death. The patient has had repeated thoughts about death (other than the fear • of dying), suicide (with or without a plan) or has made a suicide attempt.

8. DSM-IV definition of... • For at least 4 days the patient has a distinct, sustained mood that is • elevated, expansive or irritable. This is different from the patient's usual • nondepressed mood. • During this time, the patient has persistently had 3 or more of the following • symptoms (4 if the only abnormality of mood is irritability). They have been • present to an important degree. • -Grandiosity or exaggerated self-esteem • -Reduced need for sleep • -Increased talkativeness • -Flight of ideas or racing thoughts • -Easy distractibility • -Psychomotor agitation or increased goal-directed activity (social, sexual, • work or school) • -Poor judgment (as shown by spending sprees, sexual adventures, foolish • investments)

9. DSM-IV definition of... • The patient suddenly develops a severe fear or discomfort that peaks within 10 • minutes. • During this discrete episode, 4 or more of the following symptoms occur: • -Chest pain or other chest discomfort • -Chills or hot flashes • -Choking sensation • -Derealization (feeling unreal) or depersonalization (feeling detached from • self) • -Dizzy, lightheaded, faint or unsteady • -Fear of dying • -Fears of loss of control or becoming insane • -Heart pounds, races or skips beats • -Nausea or other abdominal discomfort • -Numbness or tingling • -Sweating • -Shortness of breath or smothering sensation • -Trembling

10. DSM-IV definition of... • The patient must have all of: • 1 Recurring, persisting thoughts, impulses or images inappropriately intrude • into awareness and cause marked distress or anxiety. • 2 These ideas are not just excessive worries about ordinary problems. • 3 The patient tries to ignore or suppress these ideas or to neutralize them by • thoughts or behavior. • 4 There is insight that these ideas are a product of the patient's own mind.

11. DSM-IV definition of... • The patient must have all of: • 1 The patient feels the need to repeat physical behaviors (checking the stove • to be sure it is off ,handwashing) or mental behaviors (counting things, • silently repeating words). • 2 These behaviors occur as a response to an obsession or in accordance with • strictly applied rules. • 3 The aim of these behaviors is to reduce or eliminate distress or to prevent • something that is dreaded. • 4 These behaviors are either not realistically related to the events they are • supposed to counteract or they are clearly excessive for that purpose.

12. DSM-IV definition of... • For more than half the days in at least 6 months, the patient experiences • excessive anxiety and worry about several events or activities. • The patient has trouble controlling these feelings. • Associated with this anxiety and worry, the patient has 3 or more of the • following symptoms, some of which are present for over half the days in the • past 6 months:* • -Feels restless, edgy, keyed up • -Tires easily • -Trouble concentrating • -Irritability • -Increased muscle tension • -Trouble sleeping (initial insomnia or restless, unrefreshing sleep)

13. First Case • Your patient veronica is the director of entertainment on a cruise ship. She wants to have a baby but her boyfriend is worried that pregnancy will make her crazy, or at least make her more likely to have a mental illness. Is psychiatric illness more common in pregnancy?

14. Pregnancy and Psychiatric Morbidity • In general population, pregnancy confers no risk or benefit of developing a psych diagnosis, except that 25% of new OCD cases start in pregnancy • In patients with prior psych history, relapse risk is unaffected by pregnancy, except that • panic disorder may improve

15. Veronica • It turns out that veronica has had two episodes of major depression. Will pregnancy increase her relapse risk?

16. First Case, Again • Three months later, Veronica is pregnant.She would like to know which classes of psych meds are dangerous for her baby, so that when she sails to Asia on her next cruise she can obtain treatment with confidence. • Extra credit question: in which trimester?

17. Teratogenic Risk from Tricyclic Exposure • 689 exposed cases • 414 first-trimester exposed cases • 13 malformations (3.14% incidence, within baseline incidence of 2-4%) • McElhatton PR Reprod Toxicol 10(4): 285-294, 1996

18. Teratogenic Risk of SSRI exposure • Paxil 0 of 63 first-trimester exposures • SSRI monotherapy 2 of 92 exposures • Prozac N=1700 first-trimester exposures: no increased incidence of malformations

19. Teratogenicity of Lithium • Lithium and Ebstein’s anomaly • base rate is 1/20,000 • lithium in first trimester is 1/1000 • screen with 16-20 week ultrasound • consider genetic counselling

20. Teratogenicity of Depakote and Tegretol • Carbamazepine first-trimester risk for spina bifida is 0.5%-1% • Valproic acid risk for neural tube defects is 3-5% • Lithium is probably safer first trimester • Depakote/Tegretol are better during breastfeeding

21. Teratogenic Risks of Benzodiazepines • Oral cleft rates • general population 6/10,000 • first trimester BZD exposure 7/1,000 • altshuler ll Am J Psychiatry 153:592-606, l996

22. Why take Paxil? • Veronica is now three months pregnant and clinically depressed. She can’t sleep, can’t tap dance, hates her life. She’s reluctant to take medication because it may hurt the baby and, though she may feel better, it won’t help the baby. • Is she right?

23. Neonatal Risks of Untreated Depression and Anxiety • During Pregnancy: • N=500 • Lower birth weight • Preterm delivery • Steer RA epidemiology 45:1093-1099, l992

24. Neonatal risks of untreated depression/anxiety • Elevated maternal glucocorticoid levels adversely affect fetal brain development • Meaney MJ Developmental Neuroscience 18:49-72, l996

25. Postpartum Psychiatric Morbidity

26. Neurophysiology of post partum period • Because of normal vigilance in new parents, the nervous system is “naked” or unprotected • Locus ceruleus threshold is lowered • Innocuous stimuli may be perceived as threatening

27. First Case, revisited • Veronica now has a lovely boy named Bart. Her boyfriend’s upset because the baby gets all the attention. • If she has no history of depression, what’s her risk of post partum depression? How about if she does?

28. Postpartum depression incidence is • 10 to 15% with no prior psych history

29. Postpartum relapse rates are increased

30. Veronica, otra vez • Veronica and her boyfriend get very little sleep and argue a lot. Does their marital conflict increase her risk of depression?

31. Risk factors for postpartum psychiatric illness • Personal history of psychiatric illness • First degree relative with psychiatric illness • Marital conflict • Poor emotional and physical support to the mother

32. Risk factors for postpartum psychiatric illness • Excessive sleep disruption • Medical complications during pregnancy • Child-care stress: feeding problems, difficult infant, infant illness • Stressful life events: moves, job loss, financial stress • Adolescent mother

33. Psych Syndromes in the Postpartum: Bipolar • 50% of first manic episodes in women who have ever had a baby occur in the first six months postpartum • Manic episodes usually emerge in the first 3 postpartum weeks

34. Psych Syndromes in the Postpartum: Bipolar • Manic episodes are particularly difficult to control once well established • Mania is usually followed by a depression

35. Psych Syndromes in the Postpartum:Depression Diagnoses • Baby Blues: begin within three days postpartum, resolve by 2 weeks untreated. Prevalence 30-70% • Postpartum Depression: Can begin up to 6 mo postpartum, but typical is within 6 weeks. Meets DSM-IV criteria. 10-20% incidence is fourfold increase over nonpregnant population

36. Psych Syndromes in the Postpartum:Depression • Frequent variability in the severity of symptoms • “scary thought about the baby” are common • Prominent somatic symptoms

37. Psych Syndromes in the Postpartum:Depression • “Feeling overwhelmed” about parenting • Difficulty sleeping even when the baby sleeps • Marked guilt/disbelief in inability to bond

38. Screening Questions for Postpartum Depression • Can you sleep when the baby is sleeping • Do you feel overwhelmed • Are you comfortable in your relationship with the baby (over or under protective) • Do your symptoms come and go rapidly • Are you having headache/backache/abdominal pain • A validated screening instrument for postpartum depression is the Edinburgh Postnatal Depression Scale

39. Psych Syndromes in the Postpartum:Panic • Panic Attacks and Generalized Anxiety are frequently comorbid with depression • Panic is markedly heightened during periods of solo care of the baby • Fear of diminished level of functioning is accompanied by profoundly lowered self-esteem

40. Psych Syndromes in the Postpartum:Obsessive Compulsive Disorder • Features of OCD are nearly always present as frightening thoughts related to the safety of the baby. These thoughts are intrusive and ego-dystonic, but are typically concealed for fear of negative societal reaction. Marked anxiety is comorbid • As a result, an apparent under or over concern about the baby frequently develops

41. Psych syndromes in the postpartum: psychosis • Postpartum Psychosis: most likely a manic episode with psychotic features. • 1/1000 • Hospitalize • role plays

42. First case, still • Veronica is now quite depressed. She read on the web that her baby will do more poorly in school if her postpartum depression goes untreated. Is this true?

43. Long term effects on children of mothers with untreated postpartum depression • Compared controls, treated moms and untreated moms • Blinded observers rated 5 and 9 year olds • Boys disruptive • Girls withdrawn

44. Veronica and Bart • What medications are safe for treating veronica’s depression?

45. Breastfeeding and Tricyclics • Infant dose is approximately 0.5% of the maternal dose • infant serum assays are nearly always negative with assay sensitivities below 1 ng/ml • an exception is doxepin, with a case report of 3 ng/ml

46. SSRI’s and Breastfeeding • Prozac has been detected in an infant’s serum (340 ng/ml fluoxetine, 208 ng/ml norfluoxetine) and colic was attributed to it • Zoloft was detected in 3 of 12 nursing infants, but serum levels did not exceed 1 ng/ml • Paxil was not detected

47. Breastfeeding and Mood Stabilizers • Depakote and Tegritol are generally considered safe • no need to check levels in baby • Lithium has been associated in case report with electrolyte abnormalities and “floppy baby”

48. Breastfeeding and Benzodiazepines • Limited data support safety • No significant impact on neurobehavioral function • Cohen LS etal. J.Clin Psych 1998:59(suppl 2)

49. Some years later • Bart is now 7.He has collected key chains from every time zone. Veronica is about to have their second baby. She wonders what could be done to prevent post partum depression this time around.

50. Prophylaxis of Postpartum Depression • Indicated in moms with prior hx of PPD or two or more episodes of MDD • Depression recurrence in moms with prior hx PPD reduced by meds from 70 to 7%