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A Primer on Cams for Peripartum Depression

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A Primer on Cams for Peripartum Depression DIAGNOSIS AND TREATMENT OF POSTPARTUM DEPRESSION Learning Objectives •Improve the recognition of postpartum depression •Optimize treatment for patients with postpartum depression Epidemiology of Postpartum Depression (PPD) •Worldwide incidence and prevalence of PPD is approximately 12% and 17%, respectively •Prevalence is 6.9–12.9% in high-income countries and >20% in low-income countries •Highest prevalence in Middle Eastern countries (26%) •Lowest prevalence in European countries (8%) Gelaye B et al. Lancet Psychiatry 2016;3(10):973-82; Shorey S et al. J Psychiatr Res 2018;104:235-48; Stewart DE, Vigod SN. Annu Rev Med 2019;70:183-96. Suicide in the Postpartum •Suicide deaths and attempts are lower during postpartum than in the general population of women •Suicide is the second leading cause of mortality in postpartum women •Postpartum suicide is characterized by violent and lethal means Lindahl V et al. Arch Womens Ment Health 2005;8(2):77-87. PPD in Adolescence •Higher prevalence of PPD among adolescents (~25%) than adults (~17%) •Suicidal behavior in postpartum adolescents is higher than the general population of adolescent girls and women •Adolescent mothers face more psychosocial challenges (e.g., lower social support and socioeconomic status) that increase risk for PPD Dinwiddie KJ et al. J Psychosom Obstet Gynaecol 2018;39(3):168-75; Lindahl V et al. Arch Womens Ment Health 2005;8(2):77-87. “Major Depressive Disorder, With Peripartum Onset” DSM-5 Diagnostic Criteria Major Depression Diagnostic Criteria • Diagnostic criteria are the same Five or more symptoms present ≥2 as major depression weeks; change from previous functioning; causing clinically significant distress • Peripartum specifier stipulates symptom onset within 4 weeks • Depressed mood of delivery • Anhedonia • Sleep and appetite disturbance • In clinical practice and research, • Impaired concentration symptom onset within 12 • Psychomotor disturbance months of delivery may be • Fatigue considered PPD • Feelings of guilt or worthlessness • Suicidal thoughts Stewart DE, Vigod SN. Annu Rev Med 2019;70:183-96. Additional Symptoms Common to PPD Irritability Mood lability Anxiety Feeling Thoughts of harming child overwhelmed Obsessional worries or preoccupations with baby Stewart DE, Vigod SN. Annu Rev Med 2019;70:183-96. PPD Detection Ask all postpartum women about feelings in past month: Feeling down, depressed, or Bothered by little interest or hopeless? pleasure in doing things? The American College of Obstetrics and If positive answer to either question: Gynecology (ACOG) Administer Edinburgh Postnatal Depression Scale (EPDS) or recommends all other screening questionnaire mothers be screened for PPD within 3 weeks of giving birth Score indicating PPD in a screening tool Clinical interview to confirm diagnosis Stewart DE, Vigod SN. Annu Rev Med 2019;70:183-96; ACOG Committee Opinion No. 736. Obstet Gynecol 2018;131(5):e140-50. Edinburgh Postnatal Depression Scale (EPDS) •Easy to administer, 10-item questionnaire about feelings in the past 7 days •Items scored 0–3 depending on severity of symptoms •Total score is sum of all 10 items (max score 30) •A score ≥10 or a positive response to item 10 (i.e., self-harm ideation) indicate possible depression and require clinical evaluation Cox JL et al. Br J Psychiatry 1987;150:782-6; Wisner KL et al. JAMA Psychiatry 2013;70(5):490-8. Differential Diagnosis Condition Distinguishing Features From PPD • Less severe and persistent symptoms Postpartum blues • Onset of symptoms always during postpartum • Typically no severe obsessional preoccupations or suicidality • Fewer and less severe symptoms Adjustment disorders • Improvement after mitigating stressors Posttraumatic stress • Remote or recent traumatic events associated with nightmares, disorder (PTSD) flashbacks, or other symptoms of PTSD Bipolar disorder • Manic or hypomanic symptoms Postpartum psychosis • Delusions, grandiosity, hallucinations, confusion, bizarre behavior, (PPP) or disorganized thoughts, accompanied by depression or mania Depressive symptoms secondary to untreated medical conditions (e.g., thyroid dysfunction, anemia) or alcohol or other substance abuse must also be ruled out Stewart DE, Vigod SN. Annu Rev Med 2019;70:183-96. Strongest Risk Factors for PPD Domestic Negative life Low partner Migration violence, events, low support, marital status* previous abuse social support difficulties Depression or Anxiety in History of unhappiness in pregnancy* depression pregnancy *Only in high-income countries The strongest risk factor is a history of mood or anxiety disorder, especially if symptomatic during pregnancy Howard LM et al. Lancet 2014;384(9956):1775-88; Wisner KL et al. JAMA Psychiatry 2013;70(5):490-8; English S et al. Sci Rep 2018;8(1):12799. Postpartum Anxiety Is More Common Than You Think • An estimated 8.5% of postpartum women are diagnosed with one or more anxiety disorders • Approximately two-thirds of women with PPD have a comorbid anxiety disorder or symptoms • Women with postpartum depression and anxiety diagnoses display poorer quality of life and their illness is slower to remit than women with postpartum depression only • DSM-5 specifies no diagnosis of postpartum anxiety disorder and no standardized diagnostic criteria exist Goodman JH et al. J Affect Disord 2016;203:292-331; Farr SL et al. J Womens Health (Larchmt) 2014;23(2):120-8; Wisner KL et al. JAMA Psychiatry 2013;70(5):490-8; Misri S, Swift E. J Obstet Gynecol Can 2015;37(9):798-803; Jordan V, Minikel M. J Fam Pract 2019;68(3):165-74. Course of PPD Illness • 33% of women experience depression during pregnancy (i.e., antepartum depression) • With treatment, most cases resolve within a few months • 24% are depressed 1 year after giving birth despite receiving treatment • 13% are depressed 2 years after giving birth despite receiving treatment • 40% will relapse during subsequent pregnancy or unrelated to pregnancy Stewart DE, Vigod SN. Annu Rev Med 2019;70:183-96. PPD Outcomes ↓ Physical health ↓ Quality of sleep ↓ Bonding and ↓ Psychological health ↓ Cognitive development attachment ↓ Quality of life ↓ Language ↓ Maternal care development ↑ Relationship problems ↑ Breastfeeding ↑ Risky behavior ↑ Health concerns problems ↑ Behavioral problems Mother-Infant Mother Infant Interactions Slomian J et al. Womens Health (Lond) 2019;15:1745506519844044. Reduction in Rate of Subsequent Live Births Following Postpartum Psychiatric Illness • Women with postpartum psychiatric illness after their first birth demonstrate a decline in subsequent live births • The reduction in subsequent live births is • 33% for women with any postpartum psychiatric illness; • 39% for women with postpartum depression; and • 47% for women with any postpartum psychiatric illness with hospitalization (indicating greater severity) • In women with postpartum psychiatric illness whose first child died, there is no reduction in subsequent births, suggesting that the reduction in subsequent live births in this population is at least, in part, voluntary Liu X et al. Hum Reprod 2020;35(4):958-67. Pathophysiological Mechanisms Implicated in PPD Neuroinflammation (IL-6, IL-1ꞵ, IL-8, TNF- Neuroendocrine α, IFN-γ) Changes Neurocircuit (allopregnanolone, Dysfunction progesterone, (amygdala, prefrontal 5-HTT:serotonin transporter estrogen, oxytocin, cortex, cingulate ACTH:adrenocorticotropic hormone prolactin, cortisol, cortex, insula) ACTH, CRH) COMT:catechol-O-methyltransferase CRH:corticotropin releasing hormone ESR1:estrogen receptor alpha gene GABA:gamma aminobutyric acid HMNC1:Hemicentin 1 gene Genetics/ HPA:hypothalamic-pituitary-adrenal Neurotransmitter Epigenetics IFN:interferon Alterations Postpartum (ESR1, 5-HTT, IL:interleukin MOAO, COMT, MOAO:monoamine oxidase A (GABA, glutamate, Depression TPH2, OXT/OXTR, serotonin, dopamine) OXT:oxytocin HMNC1, HPA OXTR:oxytocin receptor pathways) TNF:tumor necrosis factor TPH2:tryptophan hydroxylase 2 Payne LJ, Maguire J. Front Neuroendocrinol 2019;52:165-80. Evidence-Based Treatment Recommendations All PPD Self-care Moderate PPD Sleep protection Psychological treatments, Severe PPD Exercise including cognitive Psychosocial support behavioral therapy and SSRI alone or with strategies interpersonal therapy psychological intervention Add selective serotonin Consider antidepressant switch and augmentation Investigate and manage reuptake inhibitor (SSRI) if insufficient response strategies if no response to social stressors, medical and SSRI alone psychiatric comorbidities Brexanolone Brexanolone Consider electroconvulsive therapy with severe suicidality or treatment resistance Stewart DE, Vigod SN. Annu Rev Med 2019;70:183-96; Zheng W et al. Psychiatry Res 2019;279:83-9. Psychological Interventions Reduce Depression Symptoms in Women With PPD Data from meta-analysis of 10 studies with randomized controlled design (N=1,324) examining change in depressive symptoms following psychological interventions for PPD in primary care Change in Depression Symptoms Intervention Immediately Post-intervention, Psychological SMD (95% CI) interventions also Cognitive behavioral significantly reduced -0.36 (-0.52 to -0.21) * therapy depressive symptoms 6 months post-intervention Interpersonal therapy -0.93 (-1.27 to -0.59) * (SMD = -0.21) and were Counseling -0.29 (-0.53 to -0.05) * significantly better than Other psychological control conditions for -0.23 (-0.46 to 0.01) # interventions reducing symptoms Total -0.38 (-0.49 to -0.27) * below threshold (odds ratio [OR] = 2.24) SMD=standardized
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