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Home , Postpartum blues, Postpartum depression

10/31/2016

Postpartum

Learning for Babies

Michael Caucci MD Assistant Professor of Clinical and Obstetrics and Gynecology Vanderbilt University Medical Center 11/3/2016

Disclosure Statement

• I have no drug company-sponsored grants, am not on any drug company advisory committees, or involved in other engagements that would incur financial bias to this presentation. • Some information presented is antecdotal and designated as such.

Presentation Objectives

• To be able to assess for and differentiate between postpartum low mood and • To predict risk associated with postpartum depression and other postpartum disorders • To formulate a safe, evidence-based postpartum treatment plan

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Identification and Treatment

• Distinguishing what is psychologically normal for each stage of and postpartum vs psychiatric disease • Risks, effects, and course of untreated disease during and after pregnancy • Triage, management and treatment options • Medication and its effect on pregnancy, , neonate, and

Normative Perinatal Symptoms Versus Symptoms of Mood Disorders

Perinatal Symptoms Psychiatric Illness • Feeling “slow” or “less active”, low- • Suicidal, homicidal thoughts / thoughts of energy / violent behavior • Extreme, emotional lability out of • Mild emotional lability character for the person • Crying during commercials, being • , apathy, or grandiosity out of easily frustrated character for the person Disturbed sleep • Overwhelming hopelessness / • helplessness • Situational low mood or • • Poor concentration • Worthlessness, inappropriate guilt, burdensomeness, or • Change in appetite

Major Depressive Episode (1)

• ≥ 5 during the same two-week period and deviates from baseline function present nearly every day. (S) - Change in sleep (I) - Either depressed mood or diminished interest / pleasure (G) - Feelings of worthlessness or excessive / inappropriate guilt (E) - Change in energy level: / loss of energy (C) - Diminished ability to think / concentrate or indecisiveness (A) - Unintentional change in weight or appetite (P) - Change in psychomotor activity: agitation / retardation (S) - Recurrent thoughts of death ( suicide)

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Defining an Illness “Postpartum Depression”

• DSM-IV TR: (what all data, screens, recommendations, etc. are based on) • With Postpartum onset = Onset of episode within 4 weeks postpartum • DSM-5: (Official in 2013, but not commonly used) • With Peripartum Onset - Applied to current or most recent episode with symptom onset during pregnancy or within 4 weeks postpartum • Other terms • Perinatal, antepartum, antenatal, puerpartum, postnatal …

Screening for Depression (2-4, 53)

• ACOG Recommendations • Screen at least once during the perinatal period. • Women with psychiatric risk factors or history warrant particularly attention. • Screening must be coupled with appropriate follow-up and treatment. • Ob/Gyn should be prepared to initiate medical therapy and or refer for care. • Systems should be in place to ensure follow-up for diagnosis and treatment.

Identification and Treatment

• Distinguishing what is psychologically normal for each stage of pregnancy and postpartum vs psychiatric disease • Risks , effects, and course of untreated disease during and after pregnancy • Triage, management and treatment options • Medication and its effect on pregnancy, fetus, neonate, and breastfeeding

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Postpartum Risks of Untreated Depression

• Postpartum Syndromes (5, 6) • Postpartum Depression: ~ 25% - 50% • : 1-2/1000 live births • ~15 % in bipolar patients • Postpartum Suicide: exact incidence unknown. (51, 52) • Postpartum OCD • Neonatal effects (15, 20, 21) • No studies show a link to malformation. • Low birth weight • Parenting • Disrupted mother- bonding. (15, 20, 21) • Potential harm to or neglect of the infant by depressed mother (15, 20, 21) • Neurodevelopmental • Long-term effects on offspring (15, 20, 21) • Sudden Infant Death Syndrome (22)

Postpartum Syndromes

• Postpartum “Baby” Blues • Postpartum Depression • Postpartum / Hypomania • Postpartum Psychosis • Postpartum OCD

Postpartum Blues (5, 6)

• Most common • 50-85% of adult females within the 2 weeks • Transient and technically not a disorder • Symptoms • Reactivity of mood / irritability • Tearfulness • Mild depression, anxiety • and forgetfulness • Headaches, fatigue • Up to 20%  within the first year postpartum. (7, 8)

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Postpartum Depression (5, 6)

• Overall incidence: 10-15% • About 2/3 of patients will have their first symptoms within the first six weeks postpartum. • Significant depression as well as anxiety and or obsessive symptoms.

Postpartum Depression Risk Factors 120%

~100% History of depression (6, 9) 100%

Depressive episode during pregnancy (6, 9) 80% History of postpartum depression (6, 9) Especially 3 rd trimester Especially PMDD (10) Active or history of an (10) (10) 60% ~50% History of premenstrual dysphoric disorder (10) 40% ~35% Percent Incidence Percent Family history of perinatal depression? (55) ~25% ~25% Heritability estimated at 44-54% vs 32% in 20% non-perinatal depression ~2% 0% No History History of History of Major History of History of of Major Bipolar Depression Postpartum Postpartum Depression Depression Disorder during Depression Bipolar Pregnancy Depression

Postpartum

• Postpartum hypomania (12) • Present in 9-20% of those with • Onset within the first 24 hours postpartum • Often mistaken for the “normal joy of delivery" • Postpartum mania

• Limited data, but cumulative incidence theorized to be 0.03% (13)

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Postpartum Psychosis

• Incidence is 0.07-0.2% in the general population (6, 11, 13). • 70% of cases have an underlying affective disorder such as bipolar or major depression. • This can develop in those with no history of psychiatric illness as well. (14) • Onset (6, 11) • 26.3 years of age; occurs within the first 2-4 weeks postpartum (as early as 2-3 days postpartum). • Symptoms: • Severe mood swings, confusion, having of “the changeling”, , decreased need for sleep (11). • Prognosis is very good with treatment: • With treatment relapse risk is 23% vs 66% without treatment. (14) • 75-86% will remain symptom-free after treatment. (11)

Postpartum Psychosis Risk Factors

35% • History of bipolar affective disorder 30-70% 30% • History of postpartum psychosis • Family history of bipolar affective disorder 25% History of postpartum psychosis • 20% • History of poor sleep ~15% 15% Percent Percent Incidence 10%

5% ? ~0.07-0.2% ??? 0% No History General History of History of Mood History of History of population Major Bipolar episodes Postpartum Postpartum Depression Disorder during Depression Psychosis Pregnancy

Postpartum OCD

• In general ~ 90% of postpartum women have mild, transient intrusive thoughts similar to postpartum OCD • Incidence • 2.7-3.9% at 6 weeks postpartum • Rapid onset: • Mean onset postpartum 2–4 weeks • Commonly comorbid with postpartum depression • 57% with postpartum depression (intrusive or infanticidal thoughts) vs. 39% with no postpartum depression (obsessional thoughts or OCD like symptoms) • Symptoms can persist after resolution of depression. • 50% of women with standard OCD reported: • was the precipitant of the illness • Worsening of symptoms in the

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Postpartum OCD

Obsessions Compulsions • Contamination = 75% • Ritualistic behaviors (156) • Symmetry / Exactness = 33.3% • Cleaning / Washing = 66.7% (156) • Aggressive Thoughts = 33.3% • Checking = 58.3% (156) • Higher incidence than standard OCD • Severity of symptoms does not differ Avoidant behavior between both types of OCD (postpartum • vs. standard). • Avoidance of the feared situation • Symptoms are highly distressing or seen as foreign. • Asking others to care for the baby • There is no elevated risk of aggressive • Avoiding behaviors or objects harm to infant if mother has: associated with obsessions • No psychosis • No severe • Removing the objects from the room

Identification and Treatment

• Distinguishing what is psychologically normal for each stage of pregnancy and postpartum vs psychiatric disease • Risks, effects, and course of untreated disease during and after pregnancy • Triage, management, and treatment options - The treatment of postpartum disorders starts during pregnancy • Medication and its effect on pregnancy, fetus, neonate, and breastfeeding

Triage (3)

Outpatient Treatment Emergent Care / Inpatient • Current mild-moderate mood, anxiety, • Current symptoms of severe or disorder psychiatric illness • No current symptoms, but has a history of severe psychiatric illness • Danger to self or others • or postpartum psychosis • Psychosis, mania, or severe • Postpartum depression depression, anxiety or stress • Bipolar disorder, mania or hypomania. disorder. • A recent episode of severe depression or • Severe eating disorder anxiety • No response to pharmacotherapy or • Moderate-severe addiction with in the past potentially dangerous intoxication • Coexisting anxiety, eating disorder, or and or withdrawal.

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Immediate Postpartum Management (24)

• Outline the treatment plan • Give copy of plan to all involved (team, family, parent) • List all pharmacological and other treatments. • Recommendations • Plan for lactation • Support and rest in early postpartum period • Minimize • Mobilize support for the mother, partner, mother/infant relationship • Initiate early parenting skills • Provide regular assessments and monitoring for relapse • Length of stay should be longer if monitoring maternal mental state and or pharmacological exposure effect on the infant.

Weighing the Risks and Benefits of Medication

Degree of Effect of psychiatric impairment caused medication on by active psychiatric pregnancy, fetus, disease breastfeeding

Workup and Required Information

• Chief complaint / current symptoms • Substance use history • Stage of pregnancy • Rule out substance induced disorder • Prevailing symptoms • Medical history Symptom Severity • • Rule out psychiatric disorder secondary to a • Current treatment ? general medical condition. • Effective ? • Form of contraception - (pre-pregnancy and • Further questions postpartum only) • Risk factors and elements of history to address • Do they plan on breastfeeding? with specific psychiatric illnesses and other issues that would support initiation of • Past symptoms medication • History of psych illness • Patient Choice: • Symptom Severity • “When you think about how impairing your • Past treatment ? disorder was at its worst do you feel you would • Effective ? be able to tolerate those same symptoms throughout your pregnancy with potential worsening after delivery and still be able to function and care for yourself and your child?”

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Calculating Treatment Risk Severity Flow Chart

Scoring: - Mild = (0-3) Are symptoms present? - Moderate = (4-5) - Severe = (6-12) Yes No: 0

Eating Psychosis Mania Depression / Anxiety Disorders Any past symptoms?

6 6 Mild: 1 Yes No: 0

Eating See Eating Psychosis Mania Depression / Anxiety disorders Moderate: 3 Disorders

Severe: 6 See Eating Mild: 1 disorders 6 Mild: 2

Subtotal Current (0-6) + Subtotal Past (0-6) = Total (0-12) Moderate: 4 Moderate: 3

Severe: 6 Severe: 5 Once complete, proceed to “Determining Treatment Direction”

Direction of Treatment

Treatment Risk Category* Start / Restart Mild Moderate Severe Maintenance Maximize / Transition 1. Effective Current D. Taper medication once in B. Continue medication and encourage counseling. Treatment counseling. Discontinue 2. Ineffective Current C. Counseling first. Treatment; Effective Past If limited effect from counseling, maximize dosage. Treatment If intolerant of medication, transition to the effective / Counseling only another treatment. 3. Ineffective Current Treatment; No / Ineffective Past Treatment. * Risk category after application of “Tie 4. No Current Treatment; E. Counseling only A1. If limited effect from A2. Encourage counseling Breakers” Ineffective Past Treatment. counseling, then start / and - Always consider the patient’s choice. restart the effective / start / restart the effective / 5. No Current Treatment; another / a treatment. another / a treatment. Effective Past Treatment Once complete, proceed to “Treatment Options by Disorder” 6. No Current or Past Treatment

Direction of Treatment

Types Of Treatment Factors That Support Use Of Medication • Counseling is always recommended if feasible • Patient prefers a medication (9) • Short-term Cognitive Behavioral Therapy (15, 25) • No access to counseling (9) • Interpersonal Psychotherapy (15, 25) • Antidepressants • Poor response to therapy in the past (9) • Rule out bipolar disorder • Unable to tolerate medication taper in • Discontinuation of medication the past. • On medication • Start / Restart • Postpartum illness • Maintenance • Current Psychotic or manic symptoms • Maximize / Transition • ECT • Severe illness currently • History of severe illness • Placentophagia / Placentotherapy (54) • replacement ? • History of psychotic disorder

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A Stepwise Progression Of Treatment

Avoid multiple trials of different agents or polypharmacy, if possible. Supportive counseling x 2 weeks

If effective: If ineffective: Continue supportive therapy Start formal psychotherapy (≥ 8 sessions)

If effective: If ineffective: Continue Psychotherapy Initiation of medication in addition to counseling (≥ 2 months on a stable dose)

If ultimately ineffective: If effective: ECT: only if symptoms are mood related and are severe, treatment Continue treatment resistant

If effective: If ineffective: Continue treatment Reassess

Identification and Treatment

• Distinguishing what is psychologically normal for each stage of pregnancy and postpartum vs psychiatric disease • Risks, effects, and course of untreated disease during and after pregnancy • Triage, management and treatment options • Medication and its effect on pregnancy, fetus, neonate, and breastfeeding

Pregnancy Risks of Antenatal Antidepressant Exposure • The rate of malformations does not seem to be any more common than at random (~3%). • Within this rate exposure to SSRI appears skewed toward cardiac anomalies • There are conflicting data on fetal malformations, pregnancy complications, and fetal growth. • The bottom line : Safe to use antidepressants in pregnancy in appropriate patients.

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Postpartum Risks of Antenatal Antidepressant Exposure • Neonatal abstinence / discontinuation syndrome • Occurs in 15-30% of cases (22, 28, 29) • Especially when exposed in late pregnancy. • Symptoms are mild and transient (22, 28) • Onset within the first day of life. (30) • Resolution in 75% of cases within 3-5 days (30) • Risk factors: • Antidepressants + benzodiazepines, third trimester exposure, and increased doses of medication. (31, 32) • Other postpartum risks of antenatal exposure • Neonatal respiratory distress (34) • Jaundice (34) • Feeding problems (34) • Convulsions (33) • Neurodevelopmental Abnormalities (24, 35-37) • No consistent evidence

Dosing of Medication and Metabolism during Perinatal Period (26) • There is an increase in metabolism of medication > 20 weeks EGA. • May require dosage increase, divided dosing.

• There is a decrease in metabolism 2 – 4 weeks postpartum(26, 27) • If side effects do occur, taper dosage. (27) • If there are no side effects, continue pregnancy dose for ≥ 6 weeks postpartum before tapering or discontinuing. (27)

• Normal metabolism returns by ~ 12 weeks postpartum. (26)

Perinatal Psychotropic Medication Treatment Approach • Address breast-feeding early on. • Have access to home ovulation predictor kits or home pregnancy tests. • Allow at least two months of stability on new medicine or off medicine and tolerance of any side effects before attempting pregnancy. • Starting medications: be sure the patient: • Has established psychotherapy • Is in the severe risk category • Has chosen medication management • Has failed to respond to eight or more sessions of psychotherapy • Discontinuing medications: be sure the patient: • Has established psychotherapy • Is in a mild risk category • Is having significant side effects • You are planning on switching to a different agent • Never discontinue a medication abruptly

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Breastfeeding

• General considerations (38) • All psychotropic medications are secreted into . • Breast milk concentrations of medication will vary. • Peak concentrations occur 6 to 8 hours after dosing. • On-demand breast-feeding disrupts sleep  relapse during the postpartum period.

• Neonatal Metabolic Considerations (39, 40) • In full term • 0 - 4 weeks postpartum: ~ 1/3 to 1/5 of the adult hepatic drug metabolism capacity. • 2 - 3 months postpartum: will surpass adult metabolism. • In preterm infants or infants with impaired hepatic metabolism • Defer breast-feeding if on medication.

Breastfeeding on Antidepressants (5, 15, 41-50)

Percentage Dose Drug Compatibility Reported Side Effects Exposure (%) SSRI

Citalopram Caution 1.0-10.9% (Avg. ~10%) Colic, poor suckle, drowsiness, irritability; irregular breathing, sleep disturbances, hypotonia/ hypertonia

Escitalopram Caution 2.9-8.3% (Avg ~8%) Necrotizing enterocolitis Transient irritability, sleep disturbances, colic; hypotonia, sedation, poor suckle, fever; hyperglycemia, glucosuria; peripheral Caution 0.8-16.3% (Avg. >10%) Fluoxetine cyanosis and unresponsiveness to stimuli Fluvoxamine Yes 0.1-1.6% –

Paroxetine Yes 0.1-5.5% (Avg <4%) Irritability, agitation, feeding problems, nervousness Hypotonia, drowsiness, ear problems, body growth problems; withdrawal syndrome after cessation of breast-feeding (agitation, Yes <0.1-3.6% (Avg <2%) Sertraline poor suckle, high-pitched crying, ) SNRI

Venlafaxine Yes 3.5-9.2% -

Duloxetine Caution 0.1-0.81% -

Other

Bupropion Yes ~2 % -

Mirtazapine Yes 0.5-4.4% (Avg 1.5%) -

Trazodone Yes 0.65% -

Citations

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. 2. Muzik, M: Psychiatric illness during pregnancy: Early detection, individualized care can promote health for mother and infant. Current Psychiatry 2012; 11(2): 23-32 3. Stewart, DE: Depression during pregnancy. N Engl J Med 2011; 365: 1605-11 4. Matthey, S, et. al.: Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale: Implications for clinical and research practice. Arch Womens Ment Health 2006; 9(6): 309-315 5. Marchand, WR, et al: Psychopharmacologic management of depression in pregnant women and breastfeeding mothers. HospPhys 2008; Aug: 8-16. 6. Tam, WH and Chung, T: Psychosomatic disorders in pregnancy. Curr OpinOb/Gyn2007; 19: 126-132. 7. Leigh, B and Milgrom, J.: Risk factors for , postnatal depression and parenting stress. BMC Psychiatry 2008; 8: 1471-1482 8. Newport, DJ, et. Al.: The treatment of postpartum depression: Minimizing infant exposures. Journal of Clinical Psychiatry 2002; 63 [suppl 7]: 31-44 9. O’Hara, MW, et al.: Controlled prospective study of postpartum mood disorders: Psychological, environmental, and hormonal variables. J Abnorm Psychol1991; 100: 63-73 10. Bloch, M et al, Risk factors for early postpartum depressive symptoms. General Hospital Psychiatry 2006; 28: 3– 8 11. Sit, D, et. Al.: A review of postpartum psychosis. J Women’s Health 2006; 15: 352-368 12. Sharma, v, et al. Bipolar II Postpartum Depression: Detection, Diagnosis, and Treatment. Am J Psychiatry 2009; 166:1217–1221 13. Harlow, BL, et al. Incidence of Hospitalization for Postpartum Psychotic and Bipolar Episodes in Women With and Without Prior Prepregnancy or Prenatal Psychiatric Hospitalizations. Arch Gen Psychiatry 2007;64:42-48 14. Wesseloo, R, et al: Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A and Meta-Analysis: Am J Psychiatry 2016; 173:117–127 15. Levey, L, et al.: Psychiatric disorders in pregnancy. NeurolClin 2004; 22:863-893. 16. Raphael, D, et al.: Treating anxiety during pregnancy: Just how safe are SSRIs? Clin Psychiatry 2008; 7: 38-52. 17. Ross, L and mclean, L.: Anxiety disorders in the peripartum and postpartum period: A systemic review. J Clinical Psych 2006; 67: 1285-98 18. Uguz, F, et al.: Postpartum-onset obsessive-compulsive disorder: Incidence, clinical features, and related factors. J lin Psychiatry2007; 68: 132-137.

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Citations

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20. Hasser, C, et al.: SSRI use during pregnancy: Do antidepressants’ benefits outweigh the risks? Curr Psych 2006; 5: 31-40

21. Wise, DD, et al.: Tailoring treatment of depression for women across the reproductive lifecycle: The importance of pregnancy, vasomotor symptoms, and other -related events in psychopharmacology. CNS Spectr 2008; 13: 647-662

22. Howard LM et al.: Sudden infant death syndrome and maternal depression. J Clin Psychiatry 2007; 68: 1279-1283

23. Knopps, G.: Postpartum mood disorders: A startling contrast to the joy of birth. Postgraduate Medicine 1993; 93: 103-116

24. Galbally, M, et al.: A review of the use of psychotropic medication in pregnancy. Current Opinion in Obstetrics and Gynecology 2011; 23: 408–414

25. Yonkers, KA, et al: The management of depression during pregnancy: A report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114(3): 703–713

26. Sit, D, et. Al.: Change in antidepressant metabolism and dosing across pregnancy and early postpartum. J Clin Psychiatry 2008; 69: 652-658.

27. Deligiannidis, K. Therapeutic drug monitoring and pregnant and postpartum women: Recommendations for ssris, lamotrigine, and lithium. Journal of Clinical Psychiatry 2010; 71(5): 649-650

28. Levinson-Castiel, R, et al. Neonatal abstinence syndrome after in utero exposure to selective serotonin reuptake inhibitors in term infants. Arch Pediatr Adolesc Med 2006; 160: 173-176

29. Occhiogrosso, et la: Persistent pulmonary hypertension of the newborn and selective serotonin reuptake inhibitors: Lessons from clinical and translational studies. Am J Psychiatry 2012; 169: 134-140

30. Ferreira, E, et al: Effects of selective serotonin reuptake inhibitors and venlafaxine during pregnancy in term and preterm neonates. Pediatrics 2007; 119: 52-59

31. Oberlander, TF, et al.: Pharmacologic factors associated with transient neonatal symptoms following prenatal psychotropic medication exposure. Journal of Clinical Psychiatry 2004; 65: 230-237

32. Galbally, M, et al.: Serotonin discontinuation syndrome following in utero exposure to antidepressant medication: Prospective controlled study. Australian and New Zealand Journal of Psychiatry; 43(9): 846—854

33. Hayes, RM, et. al.: Maternal antidepressant use and adverse outcomes: A cohort study of 228,876 . Am J Obstet Gynecol 2012; 207(49): e1-9

34. Oberlander, TF, et al.: Neonatal outcomes after prenatal exposure to selective serotonin reuptake inhibitor antidepressants and maternal depression using population-based linked health data. Arch Gen Psychiatry 2006; 63: 898-906

35. Croen, LA, et. al.: Antidepressant use during pregnancy and childhood spectrum disorders. Arch Gen Psychiatry 2011; 68(11):1104-1112

36. Galbally, M, et. al: Developmental outcomes of children exposed to antidepressants in pregnancy. Australian and New Zealand Journal of Psychiatry 2011; 45:393 – 399

Citations

37. Casper, RC, et. al.: Length of prenatal exposure to selective serotonin reuptake inhibitor (SSRI) antidepressants: Effects on neonatal adaptation and psychomotor development. Psychopharmacology 2011; 217: 211–219 38. Stowe, ZN: The use of mood stabilizers during breastfeeding. J Clin Psychiatry 2007; 68 (suppl 9): 22-28 39. Loughhead, AM, et al: Antidepressants in : Another route of fetal exposure. Am J Psychiatry 2006; 163: 145–147 40. Stowe, ZN, et al.: The pharmacokinetics of excretion into human breast milk: Determinants of infant serum concentrations. J Clin Psychiatry 2003; 64: 73-80 41. FortinguerraF, et. Al.: Psychotropic drug use during breastfeeding: A review of the evidence. Pediatrics. 2009; 124: e547–e556. 42. Boyce, PM, et al.: Duloxetine transfer across the placenta during pregnancy and into milk during lactation. Arch Womens Ment Health 2011 14:169–172 43. Di Scalea, TL and Wisner, KL. Antidepressant medication use during breastfeeding. Clinical Obstetrics and Gynecology 2009; 52(3): 483–497 44. Kristensen, JH, et al: Transfer of the antidepressant mirtazapine into breast milk. British Journal of Clinical Pharmacology 2007; 63(3): 322–327 45. Verbeeck, RK, et al.: Excretion of trazodone in breast milk. Br J Clin Pharmac1986; 22: 367-370 46. Malone, K, et al. Antidepressants, , benzodiazepines, and the breastfeeding dyad. Perspectives in Psychiatric Care 2004; 40(2): 73-85 47. Newport, DJ, et. Al.: Venlafaxine in human breast milk and nursing infant plasma: Determination of exposure. J Clin Psychiatry 2009; 70(9): 1304-10. 48. Briggs, GG, et al: Use of duloxetine in pregnancy and lactation. Ann Pharmacother 2009; 43(11): 1898-1902 49. Briggs, GG, et al: Excretion of bupropion in breast milk. Ann Pharmacother 1993; 27: 431-3 50. Tonn, P, et al: High mirtazapine plasma levels in infant after breast feeding: Case report and review of the literature. J Clin Psychopharmacol 2009; 29(2): 191-2 51. Comtois, KA, et. Al.: Psychiatric risk factors associated with postpartum suicide attempt in Washington state, 1992 to 2001. Am J Obstet Gynecol 2008; 199: 120.e1-120.e5 52. Marzuk, PM, et al.: Lower risk of suicide during pregnancy. Am J Psychiatry 1997; 154: 122–123 53. Committee Opinion number 630. Screening for perinatal depression. Obstetrics & Gynecology 2015; 125:5 54. Coyle, C.W. et al. Placentophagy: therapeutic miracle or myth? Arch Womens Ment Health 2015; 18:673–680 55. Viktorin, M. et al. Heritability of perinatal depression and genetic overlap with nonperinatal depression. Am J Psychiatry 2016; 173:158–165

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