Learning Objectives

4/4/2019

Perinatal Mood & Anxiety Disorders: From Recognition to Recovery HILARY WALLER, MS, LPC Director of Programming [email protected]

The Postpartum Stress Center • postpartumstress.com

©The Postpartum Stress Center, LLC

Who are you? What do you bring to this work? Why is training important?

Trigger Disclaimer & We’re only scratching the surface

©The Postpartum Stress Center, LLC 2

Learning Objectives

Recognize & describe how and why mood disorders in the perinatal period are unique.

Differentiate between “normal” perinatal experiences and clinically relevant symptoms.

Identify best practices for screening, evidence-based therapeutic interventions, self help/ social supports, and interview strategies that optimally position patient for recovery.

Discuss impact of special circumstances on therapeutic process and treatment planning.

©The Postpartum Stress Center, LLC 3

1 4/4/2019

“SOUNDS LIKE IT’S TIME FOR SOME FORMULA”

©The Postpartum Stress Center, LLC 4

What was missed?

• Psychoeducation • Medical Evaluation • Psychosocial

Consequences for a healthy mother: Termination of psychotherapy

©The Postpartum Stress Center, LLC

Consequences of missed DX • Pregnancy: Poor prenatal self care, Increased risk for Postpartum mood and anxiety disorders • Long-term effects on child development. (Peindl, Wisner, & Hanusa, 2004; Weissman, Wickramaratne, Nomura, Warner, Pilowsky, Verdeli, 2006) • Chronicity • Increased risk for recurrence of PMAD • Impaired maternal attachment • Marital and social distress

©The Postpartum Stress Center, LLC

2 4/4/2019

MASQUERADE Women with postpartum depression who told everyone they were “fine” while struggling with thoughts of self- harm

©The Postpartum Stress Center, LLC 7

1 in 7 women are suffering from a PMAD in the postpartum period

©The Postpartum Stress Center, LLC 8

If you do not ask every single pregnant and postpartum woman if she is having thoughts of hurting herself, you have no idea whether she is suicidal or not.

©The Postpartum Stress Center, LLC

3 4/4/2019

Women who died by suicide during a postpartum depressive episode

©The Postpartum Stress Center, LLC 10

NUANCED PERINATAL PERIOD And this is why we need perinatal specialists

BIOLOGICAL/ PSYCHOLOGICAL MEDICAL

SOCIAL

©The Postpartum Stress Center, LLC 11

Why? It’s Not Just Hormones some examples… PHYSICAL: EMOTIONAL: Bodily Changes Self Esteem Discomfort, pain Loss of Self Sleep Deprivation Fatigue Recovery from Birth Isolation Delivery/Pregnancy Unexpected Outcomes Nutritional Needs No Time For Myself Lactation Failure ©The Postpartum Stress Center, LLC 12

4 4/4/2019

Signs & Symptoms PHYSICAL EMOTIONAL Headaches Feelings of inadequacy Overwhelming sadness Difficulty breathing Guilt/ Shame Palpitations Isolation Fatigue Anger/ Overwhelm Stomach ache or nausea Depletion Extreme agitation Lack of confidence or self esteem Insomnia/ Excessive sleeping Overall irritability or over sensitivity Helplessness, hopelessness, worthlessness Shakiness Scary fantasies Loss of appetite/ Overeating Thoughts of suicide or self harm Poor concentration Thoughts of infanticide or harm to baby

©The PostpartumNightmares Stress Center, LLC 13

Risk Factors

BIOLOGICAL PSYCHOLOGICAL SOCIAL Baby Blues Prenatal anxiety S.E.S. Severe PMS/ PMDD Prenatal mood/anxiety disorders Child care stress Prenatal complications/ bedrest History of mood/anxiety disorders Work stress/ new job History of thyroid dysfunction Family history of mood/anxiety Poor social support Bereavement Poor marital relationship History of loss Poor family of origin relationships (pregnancy/infant/child) Difficult infant temperament Bipolar Disorder Single parent Unplanned pregnancy * Plus Unexpected Outcomes History of violence/ abuse

©The Postpartum Stress Center, LLC 14

Perinatal definition

Medically: Pregnant or within 12 months of delivery

Clinically: Pregnant or within two years of delivery

Consider overlapping perinatal periods as well.

Mothers outside these periods can still struggle.

©The Postpartum Stress Center, LLC 15

5 4/4/2019

Spectrum of PPD

mod mild severe . | | || | | BB AD PPD PPP

Transient Serious Disability Medical Emergency non pathological

Kleiman, K. 2006. Postpartum mood disorders: Identification and screening

©The Postpartum Stress Center, LLC

Baby Blues- Typical Experience

• Occur within 2 weeks of baby’s birth and resolves in a few days • Weepiness, fatigue, anxiety, difficulty sleeping, “hormonal feeling” • Requires good self care, does not require professional intervention

©The Postpartum Stress Center, LLC

If a woman complains of symptoms that bear a resemblance to Baby Blues and she is BEYOND the 2-3 week post-delivery time-frame It is NOT the BLUES.

©The Postpartum Stress Center, LLC

6 4/4/2019

Postpartum Psychosis- Rare Experience

• Occurs in 0.1% of women • Onset within first 2 postpartum weeks • Risk Factors: family history, previous bipolar dx • Symptoms: Confusion, disorientation, delusions, mood swings, hallucinations, paranoia, ego syntonic thoughts of harm to baby

©The Postpartum Stress Center, LLC

Postpartum Depression- A Clinical Depression •Serious, sometimes life-threatening •Onset often within first 3 mos pp, may occur anytime during the first year •During the first month after delivery, childbearing women have 3x greater risk for depression compared to non-childbearing women. •An agitated depression

©The Postpartum Stress Center, LLC

Postpartum Anxiety- Common! •Often co-morbid with PPD, dx according to dominant symptoms •Marked by excessive worry, somatic symptoms of panic Postpartum Panic Postpartum OCD ©The Postpartum Stress Center, LLC

7 4/4/2019

PPOCD

• Distressing, UNWANTED, intrusive, ego dystonic thoughts • Thoughts/ images often relate to harm coming to baby, sometimes involving mother bringing harm to baby • Compulsive rituals often include checking and cleaning. • Compulsive behaviors are often AVOIDANT, aiming to prevent harm.

©The Postpartum Stress Center, LLC

PPOCD/ Scary Thoughts

• To date, there is NO evidence that women who report unwanted, intrusive thoughts of intentional infant-related harm are more likely to report increased aggression toward their infant. - Fairbrother, 2018

• http://postpartumstress.com/get-help-2/are-you-having-scary- thoughts/10060-2/

©The Postpartum Stress Center, LLC

When mom and baby need space…

8 4/4/2019

Can YOU Relate/ How do clients differ from you?

Tolerance levels vary

Suffering is subjective

frequency+duration+intensity = Distress level Degree of interference

©The Postpartum Stress Center, LLC

SCREENING TREATMENT RECOVERY

SCREENING with the EPDS

• http://postpartumstress.com/wp-content/uploads/2012/02/EPDS.pdf

9 4/4/2019

What’s the problem?

©The Postpartum Stress Center, LLC

Recommended screening for pregnancy and postpartum period

• 1st prenatal visit 26-28 wks Birth 2 wks pp 6 wks pp

Administer EPDS Administer EPDS for high-risk patients ©The Postpartum Stress Center, LLC 29 Adapted from MCPAP Massachusetts Child Psychiatry Access Project

TREATMENT • Medical Underlying: Thyroid, Vitamin, Anemia

• Alternative Treatments: Exercise, Acupuncture, Hypnosis, Essential Oils, Relaxation, EMDR

• Pharmacology: Referral to MD

• Non-pharmacologic: Social Support, Self Care

• Therapy Nearly 60% of women with depressive symptoms do not receive appropriate clinical diagnosis, and 50% of women with a diagnosis

©The Postpartum Stress Center, LLC do not receive any treatment 30

10 4/4/2019

Barriers to Treatment

• Practitioner resources are lacking • Stigma • Unsupportive/ Fear of unsupportive spouse • Desire for quick fix • Social/family pressure and expectations • Cost • Geographic isolation

©The Postpartum Stress Center, LLC 15 31

• Failure to recognize symptoms/ symptoms resembling normal postpartum changes • Difficult to discern abnormal degrees of normal perinatal experience • Typical symptoms of depression interfere with help-seeking behavior • Lack of prenatal education for both partners • Lack of focus on self-care or mental health issues during this stage

Worst of all: • Fear being labeled a “bad mother” • Worry that her baby will be taken away

©The Postpartum Stress Center, LLC 32

How is PMAD different?

When symptoms onset with motherhood, she misinterprets symptoms as motherhood’s fault:

Motherhood ruined me… I am a terrible mother… A terrible mother is a terrible person

©The Postpartum Stress Center, LLC

11 4/4/2019

SOCIAL SUPPORT • Support Groups

• Social Media Interactions • www.postpartum.net • www.postpartumstress.com

• Find Opportunities

• Create Opportunities

©The Postpartum Stress Center, LLC 34

SELF CARE • Messaging at postpartum follow up appointment

• Consider expectations for a mother’s self care

• Assess perception of gains & losses r/t self care

• Psycho-educate & adjust expectations to fit “new normal” • Exercise • Nutrition • Sleep • Social/ Intimate ©The Postpartum Stress Center, LLC 35

THERAPY https://postpartumstress.com/for-professionals/assessments/

• PMAD Interview Questions • How are you feeding your baby? • Are you sleeping at night when the baby sleeps? • When did your symptoms start? During pregnancy? Before? • Are you having thoughts that are scaring you? • Do you ever have thoughts about hurting yourself? • Is there anything you are afraid to tell me but you think I should know? • Evidence Based: CBT, IPT

©The Postpartum Stress Center, LLC 36

12 4/4/2019

THERAPY •Evidence Based Treatment •Interpersonal Psychotherapy •Cognitive Behavioral Therapy

• Supportive Psychotherapy

©The Postpartum Stress Center, LLC 37

ACCESSING AUTHENTIC SUFFERING

A place for tools.

©The Postpartum Stress Center, LLC

13 4/4/2019

RECOVERY: PPD Impact Statement

http://postpartumstress.com/get-help-2/what-next-ppd-impact-statement/

SPECIAL CONSIDERATIONS

• Does breastfeeding contribute to problem or solution? • Changing relationship dynamics • Depression in non-pp partner • Impact of trauma history or trauma related perinatal period • Unexpected outcomes • Perinatal loss

14 4/4/2019

CASE STUDIES

Case Study: Molly G2, P1, A1; 31 years old; Upper Middle Class; Caucasian; Female; 4 weeks postpartum, Married 3 years to husband

• Referred to PPSC following 1 week inpatient admission to local behavioral health hospital.

• Current daily symptoms of severe depression, history of anxiety, highly distressed about intrusive thoughts focused on self.

• Difficulty bonding with baby, unable to care for baby alone due to symptoms.

• Husband & parents are main support, no history of trauma or mental illness.

Case Study: Molly Major Depressive Disorder • Treatment Goals/Objectives

• Establish Therapeutic Alliance • CRITICAL in PMAD treatment • Compliance with psychiatry treatment/ safety planning/ level of care • Decrease level of distress about symptoms • Psycho-educate/ Distress Tolerance • Utilize therapeutic interventions aimed at reduction of frequency, intensity, and duration of symptoms • Support return to full level of functioning

* Molly continues to attend sessions monthly at 4 years postpartum. She is 4 months postpartum with her second child and had no recurrence of PMAD

15 4/4/2019

Case Study: Emily G1, P1; 34 years old; Upper Middle Class; Caucasian; Female; 7 weeks postpartum, Married 8 years to husband

• Self referred to PPSC via internet following diagnosis of pelvic organ prolapse.

• Current daily symptoms of depression related to physical limitations. Significant negative self talk and shame. Successfully treated for OCD 5 years prior, no symptoms at time of referral.

• Husband is main support, pt. refuses to discuss prolapse with others.

Case Study: Emily Major Depressive Disorder • Treatment Goals/Objectives

• Establish Therapeutic Alliance • CRITICAL in PMAD treatment • Compliance with medical treatment/ level of care • Decrease level of distress about symptoms • Psycho-educate/ Distress Tolerance • Utilize therapeutic interventions aimed at reduction of frequency, intensity, and duration of symptoms • Support return to full level of functioning

* Emily continues to attend sessions weekly at 1.5 years postpartum. Therapy is related to family of origin dynamics and low esteem as a parent. Emily remains highly guarded about POP.

CULTURAL DISCLAIMER • Chose two similar cases to illustrate best case scenario

• Consider additional complicating factors • Race: Rates of PPD up to 38% in Black mothers • Age: PPD twice as prevalent in mothers 15- 19 y.o. • SES: Prioritizing needs • Gender & Sexuality Stereotyping/ Transferrence • Cultural stigma varies across communities

16 4/4/2019

PRO TIPS

Addl. Recommendations for Counselors:

• Screen every postpartum woman for PMAD and suicidal ideation • Integrate family & partner work • Seek additional training • Seek out ongoing supervision- triggering work • Find a peer supervisory resource

Addl. Recommendations for Docs, Midwives, Nurse Practitioners, & Nurses: • Ask for your patient’s mental health history at her initial prenatal appt./provide psycho-ed • Giving birth is not routine • Acknowledge that prescriptions feel like they compromise breastfeeding • Women are most willing to confide in OB • Pediatricians- these recs. apply to you too! • Provide weaning support if needed

17 4/4/2019

Additional Q & A

RESOURCES

• The Postpartum Stress Center • Postpartum Support International

• 20/20 Mom

• Massachusetts Child Psychiatry Access Project

• Seleni Institute

REFERENCES

1. Fairbrother, N. and Abramowitz, J., (2007). New parenthood as a risk factor for the development of obsessional problems, 2155-2163. Behavior Research and Therapy (45). 2. Keefe, R.H., Brownstein-Evans, C. & Rouland Polmanteer, R.S. (2015). Having our say: African-American and Latina mothers provide recommendations to health and mental health providers working with new mothers living with postpartum depression. Social Work in Mental Health, 1 -11. 3. Kleiman, K., (2009). Therapy and the postpartum woman: Notes on healing postpartum depression for clinicians and the women who seek their help. New York, NY: Routledge. 4. Kleiman, K., (2017). The art of holding in therapy: An essential intervention for postpartum depression and anxiety. New York, NY: Routledge. 5. Ko JY, Farr SL, Dietz PM, Robbins CL. (2012). Depression and treatment among U.S. pregnant and nonpregnant women of reproductive age, 2005–2009. J Womens Health, 21:830–6. 6. Lindahl, V., Pearson, J.L., & Colpe, L. (2005). Prevalence of suicidality during pregnancy and the postpartum. Archives of Women’s Mental Health; 8(2):77-87. 7. Zauderer, C. (2009) Postpartum depression: How childbirth educators can help break the silence. The Journal of Perinatal Education, 18(2):23-31/

18 4/4/2019

Hilary Paige Waller, LPC Director of Programming/ Psychotherapist The Postpartum Stress Center Postpartumstress.com [email protected] 610-525-7527

Facebook: @postpartumstresscenter2 Twitter: @ppstresscenter Instagram: postpartum stress LinkedIn: The Postpartum Stress Center, LLC