pospartum depression

POSTPARTUM DEPRESSION

Adriano Lercara | João Augusto Ribeiro | João Sousa Soares

CU Gynecology and Obstetrics, 4th yearNOVA Medical School

Postpartum depression

Blues

Postpartum psychosis

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1. Biological Factors

2. Obstetric Factors

3. Clinical and Pshychological Factors

4. Socials and Psycho-Social Factors


RISK FACTORS

1. Biological Factors

Hormonal variations during pregnancy and puerperium

2. Obstetric Factors

C-section

Unplanned pregnancies


RISK FACTORS

3. Clinical and Psychological Factors

History of previous depression

Prenatal anxiety and/or depression


RISK FACTORS

Stress pré-natal

Falta de suporte social

Falta de suporte conjugal

Expectativa/Realidade de ser mãe

Exigências do cuidado

do bebé

Temperamento do bebé


RISK FACTORS – SOCIAL AND PSYCHO-SOCIAL FACTORS


RISK FACTORS – SOCIAL AND PSYCHO-SOCIAL FACTORS

Sintomas

• Perda de prazer, energia e motivação

• Ansiedade

• Irritabilidade, agitação

• Alteração dos hábitos alimentares e de sono

• Medo de não ser uma boa mãe – culpa

• Pensamentos em magoar o bebé ou a si própria

Trying to mitigate the serious adverse outcomes of PPD already mentioned → EARLY DETECTION!

Screening: at 1st postnatal obstetrical visit (usually 4-6 weeks after delivery), FP or pediatric setting

Most common: EPDS (Edinburgh Postnatal Depression Scale) (Sensitivity 80-82%, Specificity 78-82%)

Other: PDSS (Postpartum Depression Screening Scale) and PHQ-9 (9-item Physician’s Health Questionnaire)

Antepartum: APQ (Antepartum Questionnaire) (Sensitivity 80-82%, Specificity 78-82%)


SCREENING

PPD frequently missed by the primary care team (clinical signs not apparent unless screened for)

DSM-IV Criteria for MDE (Major Depressive Episode) ↔ PPD

Antepartum education on PPD!

Postpartum onset of MDE → 4 weeks after delivery … but… 3 months? ≥1 year?

Differential psychiatric diagnosis: Postpartum Blues (up to 75% of mothers in the 10 days following delivery)

Differential psychiatric diagnosis: Postpartum Psychosis (psychiatric emergency requiring hospitalization)

Differential non-psychiatric diagnosis: Transient hypothyroidism, hyperthyroidism, anemia, infection


DIAGNOSIS

Treatment

1st line therapy: non-pharmacological therapy!

Psychotherapy → IPT (Interpersonal Therapy) and CBT (Cognitive Behavioral Therapy)

IPT – time-limited interpersonally-oriented psychotherapy (depression as a medical illness occurring in a social context)

Effectiveness supported by several studies (O’Hara and colleagues, Clark et al)

CBT – well studied and effective treatment for MDE (modification of distorted patterns of negative thinkingand making behavioral changes that enhance coping and reduce distress)

Several trials assessing CBT alone or with other interventions for the treatment of PPD → support CBT interventionsas helpful in the treatment of PPD (Appleby et al, Misri et al)

1. Postpartum blues: generally self-limited and resolve between 2 weeks and 3 months. Supportive reassurance is sufficient.

2. Postpartum depression:• psychotherapy

• pharmacotherapy

• diet

3. Postpartum Psychosis, add:

• electroconvulsive therapy

• hospitalization


TREATMENT OPTIONS

• IPT (InterPersonal Therapy): time-limited (12-20 weeks) treatment based onaddressing connection between interpersonal problems and mood.

• CBT (Cognitive Behavior Therapy): to help the depressed patient tomodify negative thinking and to make behavioral changes in order to reducedistress.

• Non-Directive Counseling: with a health visitor to empathically andnonjudgementally listen and support.

• Peer and Partner Support: practical and emotional support from partner andfriends are essential to recovery for most women.


PSYCHOTHERAPY – 1ST LINE TREATMENT

• Doses and time are similar to the ones for major depression.

• Must be continued for 6 to 12 months after childbirth.

• If the mother had responded to a specific psychodrug in the past, thatmedication must be the first one to consider.


PHARMACOTHERAPY – 2ND LINE TREATMENT

• SSRI (Selective Serotonin Recaption Inhibitors): I choice

• Sertraline

• Paroxetine

• Fluoxetine (Prozac®)

• TCA (Tricyclic Antidepressant): II choice

- Nortriptyline

- Imipramine


PHARMACOTHERAPY – ANTIDEPRESSANTS

• Transdermal Estrogen• neural growth

• neurotransmitters activity

• oxidative stress

• Must be avoided if risk of tromboembolism is present

• Progesterone (norethisterone nitrate)

• Very few studies

• No role for synthetic progesterone in treatment

• Increases risk of depression

After childbirth, we assist to a dramatic drop of maternal levels of estrogen and progesterone thatcould be the trigger to PPD.


PHARMACOTHERAPY – HORMONAL THERAPY

• Few studies on the effects on infants of exposure to antidepressantsthrough breast milk.

• Adverse effects include: sleep changes, gastrointestinal problems,respiratory problems, seizure.

• Mostly resolved by interruption of treatment or breastfeeding

• SSRI (sertraline, fluoxetine) and TCA (nortriptyilne) have the mostdata supporting safety during breastfeeding


PHARMACOTHERAPY – BREASTFEEDING CONSIDERATIONS

• Diet• Ω3 fatty acids (3-4 g/die): depletion during pregnancy to build the fetus’s CNS

• Proteins

• vit. B6

• carbohydrates, caffeine, sugar

• Electroconvulsant therapy (ECT)- psychotic symptoms

- for non-respondent to antidepressants women

• Hospitalization- suicide risk


OTHER TREATMENTS

pospartum depression

Healthcare