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Mood And Anxiety Disorders in NICU Families By Pec Indman EdD, MFT The Field of Neonatology Has Expanded beyond the Primary Aim of Saving Infant’s Lives to Minimizing Survivor’s Long-term Complications, and thus Extending Clinicians’ Responsibilities beyond the Baby to the Broader Family. Meyer EC, Brodsky D, Hansen AR, et al. An interdisciplinary, family-focused approach to relational learning in neonatal intensive care. J Perinatol 2011; 31: 212- 219. MYTHS ABOUT PERINATAL MOOD DISORDERS © 2012 Pec Indman EdD, MFT HISTORICAL INFORMATION • • • • • Psychiatric history History of sexual abuse or trauma Fertility problems Perinatal loss Previous pregnancy, birth, or postpartum difficulties © 2012 Pec Indman EdD, MFT DEPRESSION IN PREGNANCY • About 15-21% of women experience depression in pregnancy up to 38% in low SES (Alfonso DD, et al. Birth 1990;17:121-130) • 50-75% relapse after discontinuing medication when pregnant (Cohen LS, et al. Psychother Psychosom. 2004 JulAug;73(4):255-8) • Over 40% resume medication during pregnancy (Cohen LS, et al.. Psychother Psychosom. 2004 Jul-Aug;73(4):255-8) • Most are undetected and under treated (Marcus, S., Depression during Prengnancy:Rates, Risks, and Consequences. Can J Clin Pharmacol Winter 2009 Vol 16 (1) © 2012 Pec Indman EdD, MFT DEPRESSION/ANXIETY IN PREGNANCY Depression in pregnancy associated with: • Low birth weight (under 2500 grams) • Preterm delivery (less than 37 weeks) up to 2X risk (Li D, Liu L, Odouli R, Hum Repod. 2009 Jan;24(1):146-53. Epub 2008 Oct 23, Straub H, Adams M, Kim JJ, et al. Am J Obstet Gynecol 2012;207) • Small-for-gestational age/IUGR (Grote, N, et al. ARCH GEN PSYCHIATRY/VOL 67 (NO. 10), OCT 2010) Severe anxiety in pregnancy associated with: • Constriction in placental blood supply • Heightened startle response in newborn • Newborns more inconsolable, poor sleep (Bennett HA, Einarson, A. et al. Clin Drug Invest 2004;24 (3) © 2012 Pec Indman EdD, MFT POSTPARTUM “BLUES” • • • Occurs in 50-80% of postpartum women Onset usually in first week postpartum Symptoms may persist from several days to a few weeks NORMAL © 2012 Pec Indman EdD, MFT BLUES OR BEYOND? • Severity • Timing • Duration © 2012 Pec Indman EdD, MFT POSTPARTUM DEPRESSION-NICU • • PPD rates 40% if premature infant Sustained (up to 52 wks) depression associated with: • earlier gestational age • lower birth weight • ongoing infant illness/disability • perceived lack of social support. • most studies failed to consider depression in pregnancy as a confounding variable (Vigod SN, Villegas L, Dennis CL, Ross LE. Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: a systematic review. BJOG. 2010 Apr;117(5):540-50) © 2012 Pec Indman EdD, MFT SYMPTOMS OF POSTPARTUM DEPRESSION/ANXIETY: • • • • • • • Sad mood, guilt, irritability, excessive worry, anxiety, or feelings of being overwhelmed Sleep problems (often insomnia), fatigue Symptoms or complaints in excess of, or without physical cause Discomfort around baby, or lack of feelings towards baby Loss of focus and concentration (may miss appointments) Loss of interest or pleasure Appetite changes-poor appetite or weight gain © 2012 Pec Indman EdD, MFT NICU MOMS and PPD • • A mom’s perception of of nursing support and depressive symptoms were found to be directly related. As the perception of nursing support decreased by one point, the risk of depression increased by 6% (Kyle Mounts, Screening for Maternal Depression in the Neonatal ICU, Clin Perinatol, 2009;36: 137-152) © 2012 Pec Indman EdD, MFT NICU MOMS AT 1 year • 39%-63% depressed at 1 year pp © 2012 Pec Indman EdD, MFT RISK FACTORS FOR PPD • • • • • 50-80% risk if previous postpartum depression 50% risk if depression or anxiety during pregnancy Personal and/or family history of depression or other psychiatric disorder History of severe PMS or PMDD Social isolation/poor support system/teens (Suri R and Burt VK. The Assessment and treatment of Postpartum Psychiatric Disorders. Jrnl Prac Psych and Behav Hlth. March 1997) © 2012 Pec Indman EdD, MFT • • TREATMENT FOR POSTPARTUM DEPRESSION/ANXIETY Individual/couples therapy, group • CBT or Interpersonal Therapy (IPT) Antidepressant and/or antianxiety medication, Sleep meds (Wisner KL, et al., N Engl J Med. July 2002;347(3):194-199) • • Treat thyroiditis ECT INADEQUATE TREATMENT CAN LEAD TO CHRONIC DEPRESSION OR RELAPSE © 2012 Pec Indman EdD, MFT POSTPARTUM OBSESSIVECOMPULSIVE DISORDER (OCD) • 3% to 9% of new mothers may develop obsessive symptoms (Abramowitz JS, et al. Anxiety Disorders 2003. 17:461-478, Chaudron, LH and Neha Nirodi. The obsessive–compulsive spectrum in the perinatal period: a prospective pilot study. Arch Womens Ment Health, March, 2010;1434-1816.) © 2012 Pec Indman EdD, MFT SYMPTOMS OF POSTPARTUM OCD • • • • • Intrusive, repetitive, and persistent thoughts or mental picture – different that PTSD flashback Thoughts often are about hurting or killing the baby Tremendous sense of horror and disgust about these thoughts (ego alien) Thoughts may be accompanied by behaviors to reduce the anxiety (such as hiding knives) Repetitive counting (diapers in the bag), checking (baby’s breathing), cleaning (The obsessive–compulsive spectrum in the perinatal period: a prospective pilot study. Arch Womens Ment Health, March, 2010;1434-1816. Sichel D and Driscoll JW. Women’s Moods, 1999) © 2012 Pec Indman EdD, MFT TREATMENT FOR OCD • • Psychotherapy and psychoeducation Medication (SSRIs) © 2012 Pec Indman EdD, MFT POSTPARTUM PANIC DISORDER • May occur in about 10% of postpartum women © 2012 Pec Indman EdD, MFT SYMPTOMS OF PANIC DISORDER • • • • • • • Episodes of extreme anxiety: excessive or obsessive worry or fears Shortness of breath, chest pain, sensations of choking or smothering, dizziness Hot or cold flashes, trembling, palpitations, numbness or tingling sensations Restlessness, agitation, or irritability During attack may fear she is going crazy, dying, or losing control Attack may awaken her from sleep Often no identifiable trigger for panic (Sichel D and Driscoll JW. Women’s Moods, 1999) © 2012 Pec Indman EdD, MFT TREATMENT FOR PANIC DISORDER • • • Psychotherapy SSRIs Antianxiety medication © 2012 Pec Indman EdD, MFT BIPOLAR DISORDER • • • • In women with BD rates range up to 82% Time of increased vulnerability for relapse Most present with depression Closely associated with postpartum psychosis (Sharma, V. et al. Bipolar II Postpartum Depression: Detection, Diagnosis, and Treatment. Am J Psychiatry 2009; 166:1217–1221.)Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy and Postpartum. American Psychiatric Publishing, Inc., 2005) © 2012 Pec Indman EdD, MFT SYMPTOMS OF BIPOLAR • • • Mania or hypomania Depression Rapid and severe mood swings © 2012 Pec Indman EdD, MFT TREATMENT OF BD • • Careful observation for symptoms High Risk postpartum mania/psychosis (Cohen LS and Nonacs RM eds. Mood and Anxiety Disorders During Pregnancy and Postpartum. American Psychiatric Publishing, Inc., 2005) © 2012 Pec Indman EdD, MFT POSTTRAUMATIC STRESS DISORDER (PTSD) • May occur in 1-6% (Beck CT. Nursing Research. July/Aug 2004; 53(4):216-224) • Up to 38% report traumatic birth (Beck C & Watson S, Impact of Birth Trauma on Nursing, Nursing Research 2008(57);4:228-236) © 2012 Pec Indman EdD, MFT PTSD in NICU Families • • Up to 70% Common to experience PTSD, PMADs (Lefkowitz DS, Chiara Baxt C, Evans JR.. J Clin Psychol Med Settings 2010; 17: 230–237) © 2012 Pec Indman EdD, MFT SYMPTOMS OF PTSD • • • Recurrent nightmares Extreme anxiety Reliving past traumatic events • sexual • physical • emotional • childbirth © 2012 Pec Indman EdD, MFT TREATMENT FOR PTSD • • • • Psychotherapy SSRIs and/or antianxiety medication May require sleep medication Social support © 2012 Pec Indman EdD, MFT POSTPARTUM PSYCHOSIS • • Occurs in 1-2/1000 5% suicide and 4% infanticide rate (Doucet, S. et al. Differentiation and Clinical Implications of Postpartum Depression and Postpartum Psychosis. JOGNN, 2009. 38, 269-279. Sit, D. et al. A Review of Postpartum Psychosis, Journal of Women’s Health. 2006:15(4) © 2012 Pec Indman EdD, MFT SYMPTOMS OF POSTPARTUM PSYCHOSIS Usually begins 48-72 hours postpartum • • • • • Most develop symptoms within 2-4 weeks Visual or auditory hallucinations Early symptoms restlessness, agitation, irritability Confusion, paranoia, extreme moodswings Delusional thinking (infant death, denial of birth, need to kill baby) (Sit, D. et al. A Review of Postpartum Psychosis, Journal of Women’s Health. 2006:15(4)., Suri R and Burt VK., Jrnl Prac Psych and Behav Hlth. March 1997) © 2012 Pec Indman EdD, MFT RISK FACTORS FOR POSTPARTUM PSYCHOSIS • • • Personal (20-50% risk) and/or family history of psychosis or bipolar disorder 80% risk if previous postpartum psychotic or bipolar episode First baby (Sit, D. et al., A Review of Postpartum Psyhosis, Journal of Women’s Health 2006, (15)4. Suri R and Burt VK., Jrnl Prac Psych and Behav Hlth. March 1997) © 2012 Pec Indman EdD, MFT TREATMENT FOR POSTPARTUM PSYCHOSIS • IMMEDIATE HOSPITALIZATION • Antipsychotics Mood stabilizers (antidepressants as needed) Psychotherapy ECT • • • (Yonkers KA, et al.. Am J Psychiatry. 2004;161:608-620) © 2012 Pec Indman EdD, MFT WHY TREAT PARENTS? • • • Potential for child abuse and neglect Negative impact on marital/family relationships Increased risk chronic depression and relapse (Field T. et al., Infant Behavior & Development 2004;(27) 216-229, Hart S. et al., Infant Behavior & Development 1998; 21(3):519-525, Murray L and Cooper PJ.,. Psychological Medicine 1997;27(2):253-260) © 2012 Pec Indman EdD, MFT OUTCOMES OF UNTREATED PARENTAL ILLNESS • • • Increased incidence of childhood psychiatric disturbances Impaired cognitive and language development in children Negative influence on preterm children's later cognitive function (McManus BM and Poehlmann J. Infant Behav Dev. 2012 Jun;35(3):489-98 Muzik, M and S. Borovska, Mental Health in Family Medicine 2010;7:239–47) © 2012 Pec Indman EdD, MFT BREASTFEEDING AND ANTIDEPRESSANTS • • AAP now recommends 1 year of breastfeeding. Depression preceeds weaning. “Paxil and Zoloft usually produce undetectable infant levels.” (Weissman AM. et al. Am J Psychiatry 2004;161:1066-1078) • Studies of exposed infants show no differences in IQ or neurobehavioral development (Yoshida K, et al. Br J Clin Pharmacol. 1997 Aug;44(2):210-1) © 2012 Pec Indman EdD, MFT BREASTFEEDING • • Depressed moms breastfed for shorter durations Experienced breastfeeding more negatively than non-depressed (Individual and Combined Effects of Postpartum Depression in Mothers and Fathers on Parenting Behavior. Paulson, Dauber, and Leiferman. Pediatrics, 118(2), Aug 2006:659-668) • • Decreased levels of breastfeeding selfefficacy Increased breastfeeding difficulties (Dennis CL & McQueen K. The Relationship Between Infant-Feeding Outcomes and Postpartum Depression. Pediatrics 2009;123:e736-e751) © 2012 Pec Indman EdD, MFT WHAT ABOUT DADS/PARTNERS? © 2012 Pec Indman EdD, MFT NICU DADS • • • Fathers of premature infants in a medical NICU demonstrated elevated levels of stress that persisted. Paternal self-reported stress and depressive symptomatology was independent of infant illness. 30% of NICU dads screened positive for depression (Mackley AB, et al. Forgotten parent: NICU paternal emotional response. Adv Neonatal Care. 2010 Aug;10(4):200-3) © 2012 Pec Indman EdD, MFT ROLE OF NICU MENTAL HEALTH PROVIDERS • • • • • Providing emotional support and therapy to families in the NICU Overcome barriers to treatment Integrated family care NICU psychologists in OK, Miami, Pittsburgh, Columbia/Pres in NY, Kansas City National Perinatal Association (www.nationalperinatal.org) © 2012 Pec Indman EdD, MFT POSTPARTUM SCREENING • Edinburgh Postnatal Depression Scale (EPDS), 1987 by Cox, et. al. • Score of > 10 refer for evaluation • PHQ9 and PHQ2-not well studied for perinatal use, frequently used in practice • Postpartum Depression Screening Scale (PDSS), 2002 by Cheryl Beck D.N.Sc. (Gjerdingen, D, and Yawn, B. Postpartum Depression Screening, J Am • Board Fam Med 2007;20:280 –288. ACOG Committee Opinion, Screening for Depression During and After Pregnancy, No.453, 2/2010) © 2012 Pec Indman EdD, MFT TREATMENT GUIDELINES • • • • Always r/o bipolar spectrum before starting SSRI’s. http://www.psycheducation.org/depression /MDQ.htm F/U and treat to remission! Meds work best with therapy Find therapists with expertise in perinatal moods and loss (www.postpartum.net and www.mededppd.org). © 2012 Pec Indman EdD, MFT PROFESSIONAL RESOURCES • Resources for information about perinatal psychopharmacology • UIC Perinatal Mental Health Project • • (800)573-6121 (free for providers) www.psych.uic.edu/research/perinatalm entalhealth • Other online resources • • • • www.mededppd.org www.toxnet.nlm.nih.gov/ www.reprotox.org www.motherisk.org © 2012 Pec Indman EdD, MFT RESOURCES • Postpartum Support International www.postpartum.net • • • North American Society for Psychosocial OB/GYN www.naspog.org www.mededppd.org Regrouptherapy.com (online web video support) © 2012 Pec Indman EdD, MFT Other Resources • • • • https://www.marchofdimes.com/pdf/california/Bernard_ -_Medical_PTSD_in_the_NICU.pdf http://jpepsy.oxfordjournals.org/content/30/8/667.full.pd f http://www.kan.or.kr/new/kor/sub3/filedata_anr/200703 /199.pdf http://fn.bmj.com/content/90/2/F109.full © 2012 Pec Indman EdD, MFT