POSTPARTUM MOOD DISORDERS Identification and Treatment Cheryl Carroll CNM, PMHNP 2017 Psych Retreat Greensboro, NC Postpartum Depression • DSM – 5 • Major Depressive Disorder Diagnostic Criteria specifer: with peripartum onset • Peripartum - Mood Disorder with most recent episode occurring during pregnancy or 4 weeks* following delivery • WHO International Classification of Diseases – 10th Revision requires onset of episode within 6 weeks of delivery. • Various definition of timing found were from 4 weeks to 12 months postpartum • Fifty percent of these women will experience symptoms during the pregnancy NCNA 2017 Psych Retreat Early Assessment Prevalence • 1 in 7 women experience peripartum depression (approximately 650, 000) or 10-15%. Some sources site 25% • Syphilis 74,702 • Chlamydia 1,536,658 • Gonorrhea 395,216 • HIV 8,500 • Hepatitis B 0.6 – 6% • Hepatitis C 1-4% • Gestational Diabetes 8.7 – 9.2% • Proteinuria 3.8 – 10.6% • Pre-Eclampsia 2-8% Etiology • Unknown specified cause, rather likely combination of contributing factors • Hormonal Changes (progesterone, estrogen, TSH, oxytocin, cortisol) • Genetic Factors • Slow Recovery from Birth Injury • Traumatic or Disappointing Birth Experience • Conditioned Response Risk Factors • Financial Difficulty • Poor social support • Unemployment • Single • Separation, Deployment, Divorce, Death of Partner • Restriction of Activity • History of a Mood Disorder Risk Factors • Young women < 20 years and Primiparas >35 • White and Native women are more likely to report symptoms • Latinas and women of African descent are more likely to experience multiple adversities and less likely to receive services • Postpartum mood disorders may not differ by race or ethnicity • Disparity recognized with initiation and continuation of treatment Clinical Manifestations • Unrelenting sadness or irritability • Insomnia or hypersomnia • Little or no interest in the baby’s activities • Unable to engage with baby • Inappropriate guilt • Decreased self worth • Frequent crying • Recurrent thoughts about death of self and/or infant • Marked change in appetite • Relationship discord Screening Tools EPDS Edinburgh Postnatal Depression Scale SCORING This is a screening tool not a diagnostic test. To Physicians and Other Healthcare Practitioners: If you are not asking these questions of each postpartum patient, you do not know how she is feeling. · Have you had PPD before? · Do you have a history of depression? · Are you sleeping okay when your baby sleeps? · Any changes in your appetite? · Are you experiencing anxiety or panic? · Are you afraid to be alone with your baby? · Do you feel more irritable or angry than usual? · Are you worried about the way you feel right now? · What worries you the most about the way you feel? · Are you afraid you might lose control? · Are you afraid of the thoughts you are having? · Do you wonder if you're a bad mother? · If you are breastfeeding, how important is that to you? · Do you ever have thoughts about hurting yourself? · Do you find it hard to make decisions? · Does your husband know how you are feeling? · How do you feel about taking medication if it helps you feel better? · Are there other stressful events that are impacting the way you feel? · Is there anything you are afraid to tell me, but think I should know? Tips For Professional and Family Support: · Do not assume that if she looks good, she is fine. · Do not tell her it's normal to feel this way after having a baby. · Do not assume this will get better on its own. · Do encourage her to get a comprehensive evaluation. · Do take her concerns seriously. · Do let her know you are there if she needs you. Postpartum Stress Center Questions to Consider For Physicians | © 2014 The Postpartum Stress Center, LLC Page 1 Disclaimer: These materials are made available for personal use provided there is proper attribution, no changes are made, and no fee is charged. Differential Diagnosis • Normal Physiologic Changes • Baby Blues • Minor Depression • BiPolar Depression • Postpartum Psychosis Labs • CBC • Thyroid Panel: TSH, thyroxine (free T4), tri- iodothyronine (T3), anti-thyroid peroxidase antibody • Vitamin D • Vitamin B 12 Considerations • Who is at home? • What and who are her support options? • What is her feeding method? • What is her birth control method? • What medications and supplements does she take? • What recreational drugs is she using? • Is her baby preterm, full term, sick or well Essentials of Wellbeing for the Postpartum Woman • Rest • Adequate Nutrition • Physical Activity • Hygiene • Positive Human Contact with Other Adults Treatment Modalities • Psychotherapy – Individual and/or Couples • Medication • Combination Delayed or Inadequate Treatment • Risk for chronic mood disorder • Increased risk for suicide • Interferes with maternal infant bonding • Interferes with breastfeeding • Dysfunctional Family Dynamics Breastfeeding A beautiful experience – for the most part Breastfeeding Benefits • Economic Savings • Accelerates Uterine Involution • Reduces Maternal Stress by increasing oxytocin, prolactin, neuroendorphin peptides • Enhances Weight Loss • Prolongs postpartum anovulation • Decreases the risk of CVD cumulative effect • Decreases the risk of DM II • Decreases the risk of breast and ovarian cancer • Decreases the risk of infant mortality • Sense of Accomplishment Negatives Effects of Breastfeeding • Physically Uncomfortable • Intrusive • Demanding • Unshared Responsibility • Burdensome • Guilt Inducing • Lack of Privacy • Lack of Flexibility • Disempowering Family Affair Household Impact Family Affair • 10 – 25% of partners experience a mood disorder during the postpartum period • Impaired maternal – infant bonding • Altered or delayed infant development • Child Psychopathology • Cognition delay • Increased risk of infanticide Postpartum Medication Use • Successful in pregnancy, typically stay with it • Use what has been efficacious in the past • Start low • Avoid polypharmacy if possible SSRIs Low Infant Serum Concentration Higher Infant Serum <10% Concentration • Paroxetine • Citalopram • Sertraline • Fluxoetine • Fluvoxamine • Venlafxine • Desvenlafaxine SSRIs cont • Escitalopram – less studied but likely compatible • Duloxetine – little data but may be compatible • Minacipran – very little data Atypical Antidepressants • Bupropion – likely compatible, but consider alternative use in mothers of premature infants or infants with seizures • Mirtazapine – likely compatible • Agomelatine – very little data • Vertioxetine – very little data Serotonin Modulators • Trazodone – may be compatible, however data is limited • Nefazodone – Data is limited, Generally not recommended secondary to riks of hepatotoxicity • Vilazodone – too little data Tricyclics Considered Compatible Not Recommended • Nortriptyline • Doxepin (30 hour half life) • Amitriptyline • Clomipromine • Desipramine • Imipramine MAOIs • Not Recommended • Very little information • High SE Profile • Multiple Food Interactions Benzodiazapines • Short Term Medication • Choose a low dose with a short half life and no metabolite • Lorazepam – Short half life, no metablite • Clonazepam – No active metabolite, but long half life • Diazepam - Avoid Hypnotics • Zolpidem – Considered compatible with breastfeeding • Zaleplon – Considered compatible with breastfeeding Antihistamines • Used for sleeplessness and anxiety • Hydroxyzine, Diphenhydramine, Doxylamine, Levocitirizine, Citirizine are drying to breast milk Stimulants • Seem compatible with breastfeeding • Low concentrations in breast milk and infant serum level • Less available information on atomoxetine AntiPsychotic 1st Generation Likely Compatible Very Little Data • Haloperidol • Perphenazine • Chlopromazine • Trifluoperazine • Zuclopenthixol AntiPsychotic 2nd Generation Likely Compatible Very Little Data • Olanzapine – most studied • Ariprazole suggests compatibility • Asenapine • Quetiapine suggested • Ziprasidone compatibility • Paliperidone • Lurasidone – likely compatible at low dosage but needs more study Antipsychotic cont • Clozapine is not recommended secondary to increased risk of hematologic toxicity • Lithium – Mixed reviews. Requires drug levels at same schedule as adult. Requires more mature kidney function, so possibly a cumulative effect. Anti Epileptics Likely Compatible with Breastfeeding Incompatible with breastfeeding • Topiramate (Low) • Phenobarbital • Gabapentin (Low) • Primidone • Levitiracetam (Low) • Diazepam • Carbamazepine • Lamotrigine (High serum concentration – 90% of maternal serum) • Phenytoin • Valproate Substance Use Inhibitors • Buprenorphine – likely compatible • Disulfiram Very little available data. May alter the taste of breast milk • Methadone – likely compatible, low milk and infant serum concentration • Naltrexone – likely compatible, however too little data available • Varenicline – Too little data available Patient Resources You are the diagnostic tool most effective for these women Patient Resources • www.postpartum.net • www.mombaby.org • www.mothertobaby.org • www.nih.gov • www.mayoclinic.org • Postpartum Support International • Postpartum Stress Center • County Health Department • Private and Public Health Care Facilities Professional Reources • Maternal Mental Health Now – online training • Postpartum Action Institute – 2 day training course Santa Barbara, California • Postpartum Stress Center – 12 hour Training course Rosemont, Pennsylvania • Postpartum Support International – 2 day course Portland, Oregon • The Seleni Institute, Perinatal Mood Anxiety Disorders – 2 day course New York, New York CONTACT INFO, REFERENCES, ETC. Cheryl Carroll CNM, PMHNP Women’s Health Alliance 919-471-2273 [email protected] 2017 Psych Retreat – GREENSBORO, NC .