Maternal Depression

15th Annual CityMatCH Urban Maternal and Child Health Leadership Conference

September 12, 2005

Diana Cheng, M.D.

Medical Director, Women’s Health

Maryland Department of Health and Mental Hygiene

Depression Rates by GenderUnited States

6.6

12

0

2

4

6

8

10

12

14

Male Female

Dep

ress

ion

Rat

e pe

r ye

ar

Incidence of Depression

• Lifetime - 20% of women (10% of men) will experience depression

• Annual - 12 % of women (6% men) will experience a depressive disorder during a one year period

Genes vs. Environment

Genetics39%

Environment61%

Kessler KS, Prescott CA. Arch Gen Psychiatry. 1999;56:39-44

Causes of Depression in Women

• Genetics

• Hormones

• Environment

Depression Across the Female Lifespan

Birth DeathMenarche Menopause

Premenstrual

Pregnancy/Postpartum

Peri-menopause

Postpartum Depression

DepressionDuring Pregnancy

“In Cyzius a woman gave birth with difficult labor to twin daughters,…Sixth day Much wandering at night; no sleep. About the eleventh day she went out of her mind and then was rational again.”

From Hippocrates’ Epidemics, fifth century B.C.

Postpartum Psychosis

• Affects 0.1-0.2% of postpartum women• Usually begins within first month after delivery• Bipolar disorder, schizophrenia, unipolar depression• Symptoms

– Agitation, confusion

– Hallucination

– Delusions and thought disorders

• Risk for infanticide 4%

Treatment for Psychosis

A medical emergency (life-threatening!)

• Medication

• Hospitalization

• Electroconvulsive therapy (ECT)

Baby Blues

• Affects 70% of postpartum women

• Begins 1-5 days after delivery

• Disappears by 14 days postpartum

• Mild symptoms– Tearfulness, fatigue, insomnia, irritability, poor

concentration, sadness, mood changes

Postpartum Depression

• Affects 10-15% of postpartum women• Begins 2 weeks – 1 year postpartum• Symptoms

– Strong feelings of depression, irritability, anger– Emotional stress, helplessness– Inability to do normal everyday tasks– Appetite changes, sleeping too much/ too little– Overly intense worries about baby– Lack of interest or fear of harming baby (as high as 40%)– Thoughts of self-harm or suicide

Psychiatric Hospitalizations for Women During Perinatal Years

From Kendall RE et al. Br J Psychiatry, 1987; 150:662-673

"I was sitting on the kitchen floor, heaving in sobs, and all I could think was: 'This can't possibly be me.”

“I thought I might try to escape or wouldn’t be able to stop myself from swallowing a bottle of pills. I even thought I’d welcome being kidnapped. I wanted to disappear and retreat so far. ..I didn’t want to be living life with my child”

Depression During Pregnancy

• Pregnancy is not protective against depression• Affects 10-15% of pregnant women• Begins any trimester• Symptoms

– Strong feelings of depression, irritability, anger– Emotional stress, helplessness– Loss of interest in activities– Inability to do normal everyday tasks– Appetite changes, sleeping too much/ too little– Thoughts of self-harm or suicide

Criteria For Major Depression(including depression during pregnancy and postpartum)

• Symptoms should be present:– most days– most of the day– for at least 2 weeks

DSM-IV* Criteria for Depression

Symptoms present for at least 2 weeks, most of the day and nearly everyday

1) Depressed mood, and/or

2) Loss of interest or pleasure in most activities

Plus 3 or more of the following symptoms

APA.DSM-N: Diagnostic and Statistical Manual of Mental Disorders, 4th ed.1994

Diagnostic Criteria for Depression(Continued)

At least 3 more symptoms, nearly everyday for 2 weeks:

1) Weight loss or weight gain/change in appetite

2) Insomnia or hypersomnia

3) Psychomotor agitation or retardation

4) Fatigue or loss of energy

5) Feelings of worthlessness or excessive guilt

6) Diminished concentration or indecisiveness

7) Thoughts of death or suicide

Screening for Maternal DepressionEdinburgh Postnatal Depression Scale

• Created for postpartum women– Less emphasis on physical symptoms– Can also be used during pregnancy

• Rates intensity of depressive symptoms – 10 questions, each worth 0-3 points– Score >12 (out of 30) indicates likely depression

• Takes < 5 minutes to complete• Self-administered• Validated screening tool

Risk Factors for Maternal Depression

• Prior depression (30%)• Prior postpartum depression (50%) or psychosis (70%)• Depression during pregnancy• Prior PMDD (premenstrual dysphoric disorder)• Family history of depression or bipolar disorder• ?Younger age, single, high parity, multiple gestation• Recent stressful events

– marital/partner discord, loss of loved one, family illness

Maternal DepressionGetting Help

No referral65%

Referred35%

Untreated Depression During Pregnancy

• Maternal– Longer persistence of symptoms

– Increased risk of postpartum depression

– Increased risk of recurrence

– Poor prenatal behaviors

• Infant– Poor pregnancy outcomes

– Irritable, lethargic, poor sleep, need for neonatal care, lower apgars, future behavioral development

Untreated Postpartum Depression

• Maternal– Longer persistence of symptoms– Increased risk of recurrence, postpartum and non

• Infant– Decreased cognitive skills– Delay in language development– Poor attention span

Postpartum DepressionGetting Help

No referral65%

Referred35%

Treatment for Depression

• Support

• Counseling

• Other treatments

• Medication

Helping Yourself• Do not set difficult goals for yourself. • Do not take on new responsibilities. • Do what you can when you can.• Try to be with other people.• Force yourself to participate in activities.• Try engaging in mild exercise.• Eat healthy.• Avoid tranquilizers and alcohol.• Do not make major life decisions.• Get help from a professional.

Helping the Depressed Person

• Help her get treatment.

• Offer emotional support.

• Invite her for activities.

• Don’t expect her to “snap out of it”.

• Reassure her that things will get better.

Mood Regulation Neurotransmitters

Antidepressants - SSRIs

• Fluoxetine (Prozac)

• Paroxetine (Paxil)

• Sertraline (Zoloft)

• Citalopram (Celexa)

• Fluvoxamine (Luvox)

Safety of SSRIs during PregnancyRisk vs. Benefit

• Lack of large prospective randomized studies

• Limited data show no teratogenic effects

• Little data of long-term neurobehavioral effects

• Recent report of neonatal syndrome with SSRIs

• Conflicting reports, other findings

• Need for further studies

• Risk of untreated depression and relapse

Safety of SSRIs during BreastfeedingRisk vs. Benefit

• Psychotropic medications secreted in breast milk

• Limited data show no adverse effects on infants

• Little data of long-term effects on offspring

• Undetectable serum levels in infants

• All antidepressants same safety profile

• Need for further studies

• Risk of untreated depression and relapse

Getting Help: Reality vs. Myth

Myth• “I am an unfit and

uncaring mother.”

Reality• “I am a responsible

mother and am looking out for the welfare of my family and myself”.

Maryland Depression Programs

• Committees– Maternal Depression– New Mother Information

• Educational Presentations– Providers, Organizations, Businesses, Women

• Educational Materials– Brochures, articles, website, interviews

• Public Awareness– SaferMaternity.org– Legislators

• Direct Services

Data Sources

Perinatal population• Depression

– HSCRC

– PRAMS

• Suicides– Vital Records

– Medical Examiner charts

Female population• Depression

– HSCRC

– BRFSS

• Suicides– Vital records

PRAMS Survey

“In the months after your delivery, would you say that you were

Not depressed at all

A little depressed

Moderately depressed

Very depressed

Very depressed and had to get help”

Postpartum Depression 2003

Needed help3%

Very depressed5%

Moderately depressed

14%

Not depressed39%

Slightly depressed

39%

Not depressed

78%Depressed

22%

Presentations

• Grand rounds– Ob/gyn

– Pediatrics

– Family practice

• Medical conferences• Local health depts• Annual meetings

– WIC, MCOs, DV, WH

• Daycare providers• Schools• Health Fairs• Women’s groups• Businesses

Maternal Depression Team

• Maternal Mortality Review– Maryland State Medical Society (MedChi)

• Provider awareness– Education– Screening– Treatment– Referral

• Multi-disciplinary

Maryland Maternal Depression Team

• Maryland State Medical Society• Maryland Department of Health and

Mental Hygiene– MCH– Mental Health– Medicaid

• Maryland Health Partners• Hospitals

– University of Maryland– Johns Hopkins– Sinai Hospital– Franklin Square Hospital

• Mental Health Assn of MD• Family Mental Health Fdn• ACOG• Friends of the Family• Baltimore City Health Dept• Healthy Start• Amerigroup Corp• Healthcare Providers

– Obs, Peds, CNMs, Psychs, nurses, SW,

Maternal Depression Team

• Survey of state practitioners

• Resource library

• Provider Referral list

• Patient and provider education

• Provider toolkit

Maryland House Bill 844

• Introduced 2004 General Assembly– Distribute information about postpartum depression to

new mothers in the hospital

• Not passed

Educational Materials for New Mothers

• Hospital discharge packets after delivery – Maryland Hospital Association New Mother

Information Workgroup• Established July 2004

• Stakeholders to decide on content

– Maryland Department of Health and Mental Hygiene Committee

• Established September 2004

Maryland Department of Health and Mental Hygiene

November 2004

Depression in WomenFrom Data to Action

DATA Depression

Suicide

Awareness

Education

Advocacy

Community groups

Access

Screening, Treatment, Referral

Maternal Depression

Common disorder

Frequently unrecognized

Under-treated

Effective treatments

Medication/therapy

Risk vs. benefit of treatment

Risk vs benefit of untreated depression

Need for Education and Awareness