10/31/2016 Postpartum Depression Learning for Babies Michael Caucci MD Assistant Professor of Clinical Psychiatry 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 postpartum depression • To predict risk associated with postpartum depression and other postpartum disorders • To formulate a safe, evidence-based postpartum treatment plan 1 10/31/2016 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 Normative Perinatal Symptoms Versus Symptoms of Mood Disorders Perinatal Symptoms Psychiatric Illness • Feeling “slow” or “less active”, low- • Suicidal, homicidal thoughts / thoughts of energy infanticide / violent behavior • Extreme, emotional lability out of • Mild emotional lability character for the person • Crying during commercials, being • Anhedonia, apathy, or grandiosity out of easily frustrated character for the person Disturbed sleep • Overwhelming hopelessness / • helplessness • Situational low mood or anxiety • Psychosis • Poor concentration • Worthlessness, inappropriate guilt, burdensomeness, or loneliness • 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: fatigue / 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) 2 10/31/2016 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 mental health 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 3 10/31/2016 Postpartum Risks of Untreated Depression • Postpartum Syndromes (5, 6) • Postpartum Depression: ~ 25% - 50% • Postpartum Psychosis: 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-infant 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 Mania / 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 • Confusion and forgetfulness • Headaches, fatigue • Up to 20% postpartum blues Major Depressive Episode within the first year postpartum. (7, 8) 4 10/31/2016 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 eating disorder (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 Manias • Postpartum hypomania (12) • Present in 9-20% of those with bipolar disorder • 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) 5 10/31/2016 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 delusions of “the changeling”, hallucinations, 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: • Childbirth was the precipitant of the illness • Worsening of symptoms in the postpartum period 6 10/31/2016 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 personality disorder • 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 stress disorder psychiatric illness • No current symptoms, but has a history of severe psychiatric illness • Danger to self or others • Schizophrenia 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 psychotherapy in the past potentially dangerous intoxication • Coexisting anxiety, eating disorder, or and or withdrawal. substance use disorder 7 10/31/2016 Immediate Postpartum Management (24) • Outline the treatment plan • Give copy of plan to all involved (team, family, parent) • List all pharmacological and