breaking the ice: post- partum depression · breaking the ice: post-partum depression marina...
TRANSCRIPT
10/2/17
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Breaking The Ice: Post-Partum Depression Marina Delazari Miller, MD Clinical Assistant Professor
Department of Obstetrics & Gynecology
University of Iowa Hospitals and Clinics
Objectives
� Identify risk factors for post-partum depression
� Understand screening strategies for post-partum depression
� Understand how to establish the diagnosis of post-partum depression
� Understand approaches to treatment of post-partum depression
Background
� In 700 BC Hippocrates wrote about women suffering from emotional difficulties during their post-partum period
� “Trotula of Salerno” – series of three books written in honor of 12th century female MD Trota makes mention of post-partum depression � “If the womb is too moist,
the brain is filled with water, and the moisture running over the eyes, compels them to shed involuntary tears."
Background
� 18-19th century: � Women did not talk about or report their
symptoms – fear of institutionalization and being labeled neurotic or insane, punished for behaving in ways that male society did not agree.
� During this time, women were subjected to various peculiar treatments.
� “Rest cure” in which patient was not allowed to read, write, feed herself, or talk to others.
� 1892 early feminist Charlotte Perkins Gilman published in The Yellow Wallpaper a short story recounting her post-partum depression after the birth of her daughter.
� After 2 years she sought help from a famous neurosurgeon who prescribed complete confinement.
� "Live as domestic a life as possible. Have your child with you all the time... Lie down an hour after each meal. Have but two hours' intellectual life a day. And never touch pen, brush or pencil as long as you live."
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Background
� During the 1950s electroshock therapy was often the recommended treatment for a “neurotic" woman or they were occasional prescribed valium.
� Louis Victor Marce - French psychiatrist wrote the first treatise entirely devoted to postpartum mental illness in 1958
� 1980s DSM-III first recognized post-partum depression as a condition.
Background
� Recent celebrities have helped to establish that postpartum depression is no longer a "dirty little secret" for women to be ashamed of.
� Marie Osmond “Behind The Smile”
� Brooke Shields “Down Dame The Rain”
Background
� Only 5% of pregnant women with psychiatric disorders receive treatment.
� Suicide is the 5th leading cause of death among perinatal women in the US.
� 10-20% of women develop post-partum depressive disorder within 6 months of delivery.
� If untreated, 25% will have persistence of depression at 1 year.
� Up to 70% will have recurrence.
Background
� Psychiatric disorder in pregnancy is associated with � Scant prenatal care
� Substance abuse
� Poor obstetrical and neonatal outcomes � Preterm birth, low birthweight, perinatal mortality
� Higher risk of post-partum psychiatric illness
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Background
� Pregnancy is a major life stressor and can precipitate or exacerbate depressive tendencies
� Estrogen has been implicated in increased serotonin synthesis, decreased breakdown, and receptor modulation.
� Women who experience postpartum depression have higher pre-delivery estrogen/progesterone.
Risk Factors � The following have been shown to be risk factors for post-partum depression
� Pre-existing:
� Personal or family history of psychiatric illness
� History of sexual, physical, or verbal abuse
� Substance abuse
� Personality disorders
� Smoking/drinking
� During pregnancy:
� Young maternal age
� Unintended pregnancy
� Unmarried status, low social support
� Hyperemesis gravidarum
� Fetus with malformation
� Preterm labor/delivery
� Medical/obstetrical complications in pregnancy
� Post-partum:
� Difficulties with breastfeeding
� Prolonged separation from the neonate
Screening
� Perinatal depression often goes undiagnosed because changes in sleep, appetite, and libido may be attributed to normal pregnancy/post-partum changes.
� Less than 20% of women report symptoms to their healthcare provider.
� In patients with risk factors, consider scheduling post-partum visit sooner than 6 weeks.
Screening
� Ask open-ended questions: � How do you feel things are going?
� How are things with the baby?
� Are you feeling how you expected to feel?
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Screening
� ACOG: � Insufficient evidence for firm screening recommendations
� Limited evidence that screening improves outcomes � Can you diagnose and treat?
� Consider screening if risk factors identified
� Screening tools: � Edinburgh Postnatal Depression Scale (EPDS)
� Patient Health Questionnaire 9 (PHQ9)
Screening Tools
EPDS EPDS
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Diagnosis
� Post-partum blues: � Experienced by 50-70% of women within the first week
after delivery
� A time-limited period of heightened emotional reactivity
� Generally peaks on post-partum day 4-5 and normalizes by day 10
� If lasting more than 2 weeks -> evaluate for depression
� Patients feel predominantly happy, but may experience: labile mood, insomnia, weepiness, depression, anxiety, poor concentration, irritability.
Diagnosis
� Post-partum depression � Sad, anxious, or “empty” feelings
� Hopelessness or pessimism � Feelings of guilt, worthlessness, or helplessness
� Irritability, restlessness
� Loss of interest (anhedonia)
� Fatigue/decreased energy
� Difficulty concentrating � Insomnia or excessive sleeping
� Change in appetite
� Suicidal ideation/attempt
� Persistent aches/pains
Diagnosis
� Occurs in 8-20% of pregnancies within 12 months after delivery � Peaks between 2 and 4 months
� SIG E CAPS � Sleep, Interest, Guilt, Energy,
Cognition/Concentration, Appetite, Psychomotor, Suicide
� At least 5 symptoms
� Must include low mood/anhedonia
� Last at least 2 weeks
Post-partum Psychosis
� Post-partum psychosis: � Usually with pre-existing bipolar disorder, but may occur
due to major depression
� Incidence 1:1000 deliveries
� More common in primiparas
� Manifests within 2 weeks of delivery
� 50% recurrence risk; often develop chronic psychotic manic depression.
� Requires hospitalization, pharmacological treatment, and long-term psychiatric care
� More likely to commit infanticide
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Post-partum Psychosis
� Symptoms: � Physical or mental slowing
� Agitation
� Poor concentration
� Delusions
� Hallucinations
� Disorganized behavior
� Flat affect
Treatment
� Post-partum blues: � Supportive
� Provide reassurance
� Monitor for depression or other psychiatric disturbance
� Post-partum depression: � SSRI is first line
� If improvement within 6 weeks, should be continued for at least 6 months
� Psychotherapy
� In high risk patients, consider starting SSRI immediately after delivery.
Treatment in Pregnancy
� Paroxetine � 1:200 risk of ventricular septal defect
� Should be avoided
� SSRIs: � 2:1000 risk of pulmonary hypertension (marginal increase
above baseline)
� 30% of neonates will experience withdrawal symptoms
� Use with caution, when risks outweigh benefits
Treatment While Breastfeeding
� First line: � SSRI: sertraline, paroxetine
� TCA: nortriptyline
� All have been studied and found at very low levels in breast milk and infant serum.
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Treatment in Pregnancy
� No-No’s: � Lithium
� Cardiac malformations - Ebstein anomaly
� Growth restriction, lithium toxicity
� Valproic acid
� Neural tube defects
� Heart valve defects, cleft palate, hypospadias, polydactyly, growth restriction, withdrawal, hypofibrinogenemia
� Carbamazepine � Neural tube defects
� Craniofacial defects, fingernail hypoplasia, developmental delay, growth restriction, microcephaly
Conclusions
� Perinatal depression is common
� It often goes unrecognized/untreated
� Screening should take place at least once during the perinatal period using a standardized validated tool
� Providers should be prepared to initiate treatment and refer patients as needed
� Have a system in place to ensure follow up for diagnosis and treatment
References
� Williams Obstetrics � Obstetrics: Normal and Problem
Pregnancies � Creasy and Resnik � Committee on Obstetric Practice.
Committee Opinion no. 630: Screening for perinatal depression. Obstetrics and Gynecology. 2015 May; 125(5): 1269-71.
� https://en.wikipedia.org/wiki/Trotula
� https://en.wikipedia.org/wiki/Charlotte_Perkins_Gilman
� https://en.wikipedia.org/wiki/The_Yellow_Wallpaper
� http://www.healthguideinfo.com/postpartum-depression/p99788/
Thank you!