Download Perinatal Depression, Anxiety, and Trauma: What they

Peri-natal Depression, Anxiety,
and Trauma:
What they are,
Why they don't get treated,
How to move forward.
Brian Stafford, MD, MPH
Assistant Professor of Psychiatry and Pediatrics, UCHSC
Medical Director, Postpartum Depression Intervention Program
The Kempe Center and Children’s Hospital
Colorado Perinatal
Council Meeting
Denver Children’s Hospital
Tammen Hall, Nov 17, 2006
The Caregiving System
 “Mothers express intense feelings of
pleasure when they are able to provide
protection for their children; they
experience heightened anger, sadness,
anxiety, and despair when they are
separated from their children or when
their ability to protect their children is
threatened or blocked!”
C George and J Solomon, Attachment and the Caregiving System,
Handbook of Attachment, p 652
My Experience in this
Landscape
 A case or two
Outline
 Brief History:

Multiple Lenses
 The Nature of the Problems
 Outcomes of Distress
 Predicting Problematic Outcomes
 Barriers to Intervention
 Interventions
 Moving Forward
History
 Pediatric Lens
 Vulnerable Child Syndrome:
 Developmental Psychology
 Risk, Resilience and Longitudinal Outcome:
 Psychiatric Lens
 Postpartum Depression:
 Maternal Outcomes:
 Infant Outcomes:
 Relationship Outcomes:
 Medical Post Traumatic Stress:
 Infant Mental Health
 Treatment Strategies
Vulnerable Child Syndrome
(Green and Solnit, REACTIONS TO THE THREATENED LOSS OF A CHILD: A VULNERABLE
CHILD SYNDROME. PEDIATRIC MANAGEMENT OF THE DYING CHILD, PART III.
Pediatrics. 1964 Jul;34:58-66. )
 Parent’s thought or
told child
would/might die
 Anticipatory grief
(Lindemann, )
 Parent’s perceive
child is “on tenuous
loan” to them
 Paths to VCS



Serious illness in the
child
Representation of a
another figure whose
loss is not resolved
Pregnancy
complications and
fears that she might
die
VCS Behavioral Outcomes
 Pathological
 Aggression by child
Separation difficulties
 Sleep problems
 Inability to set ageappropriate limits
 Over-protectiveness
toward the parent
 Hyperactive child in
presence of the
caregiver
 School
underachievement
 Excessive health
concerns, frequent
health care use
Parental Perception of Child
Vulnerability
 Contributing Factors:







Low social support
Parental Anxiety
Cong. Heart Disease
Jaundice
Non-illness
Marital Satisfaction
Prematurity
+
sickness
Developmental Risk
 Child competence is not related to current SES
but the number of years the family had spent in
poverty( Brooks-Gunn, 1993)
Duncan GJ, Brooks-Gunn J, Klebanov PK. Economic deprivation and early
childhood development. Child Dev. 1994 Apr;65(2 Spec No):296-318.
 Child psychopathology is related to the number
of risk factors as well (Rutter, 1979):



Marital distress Low SES
Large family
Maternal Psychiatric
Foster Care placement
Rochester Longitudinal Study: (Sameroff, 1998)
To examine the effects of the environment on early
emotional behavior and later mental health
Sameroff AJ. Environmental risk factors in infancy.
Pediatrics. 1998 Nov;102(5 Suppl E):1287-92.

An investigation of the development of a group of
children from the prenatal period through adolescence
living in a socially heterogeneous set of family
circumstances.

Evaluated risk factors:
 Child’s cognitive ability


Social–emotional competence.
Early childhood phase of the RLS,

Assessed children and their families at:



Birth, 4, 12, 30, and 48 months of age
In the home and in the laboratory.
During adolescence:

Assessment at age 13 and 18.
TABLE 1. Summary of Risk Variables
Risk Variables :
RLS Low Risk
High Risk
 Mental illness


0–1 Psychiatric contact
More than 1 contact
 Anxiety


75% Least
25% Most
 Parental perspectives


75% Highest
25% Lowest
 Spontaneous interaction


75% Most
25% Least
 Occupation


Skilled
Semi- or unskilled
 Education


High school
No high school
 Minority status


No
Yes
 Family support


Father present
Father absent
 Stressful life events


75% Fewest
25% Most
 Family size


1–3 Children
Four or more children
Additive Risk
RLS Findings
 On intelligence test,

children with 0 environmental risks scored
30 points higher than did children with
eight or nine risk factors.

On average, each risk factor reduced the
child’s IQ score by 4 points.
Resiliency (Werner): Kauai LS
Pediatrics. 2004 Aug;114(2):492. Werner EE. Journeys from childhood to
midlife: risk, resilience, and recovery.

1) What are the long-term effects of adverse perinatal and early childrearing conditions on individuals’ physical, cognitive, and psychosocial
development at midlife?
 2) Which protective factors allow most individuals who are exposed to
multiple childhood risk factors to make a successful adaptation in
adulthood?
 The KLS has monitored the impact of a wide array of biological,
psychological, and social risk factors:



The follow-up at midlife was able to track 80% of the "high-risk" children who
had been exposed to





Multiracial cohort of 698 individuals who were born in 1955 on the Hawaiian island of
Kauai,
From the perinatal period to ages 1, 2, 10, 18, 31/32, and 40.
chronic poverty,
birth complications,
parental psychopathology,
and family discord
as well as comparison groups of men and women who had not
experienced significant childhood adversities.
KLS
 “With the exception of serious central nervous
system damage, the impact of peri-natal
complications on adult adaptation diminished
with time, whereas the outcomes of biological
risk conditions depended, increasingly, on the


1)quality of the child-rearing environment and
2) the emotional support provided by family
members, friends, teachers, and adult mentors”.
 Poorest outcomes at age 40 were associated
with prolonged exposure to parental alcoholism
and/or mental illness—especially for the men.
KLS

Quality of the individual’s adaptation at age 40 correlated significantly
with
 Health status in the first decade of life (based on a pediatric
assessment of all organ systems at age 2 and number of health
problems, including serious illnesses and accidents, between birth
and age 10)
 The mother’s caregiving competence and the emotional
support provided by the family in childhood.

This study demonstrates the need for early attention to the health status
of our nation’s children—especially those who are exposed to poverty,
serious perinatal complications, and parental psychopathology.

The social policy implications are clear: early access to good preventive
and ameliorative health services and proper attention to the quality of
early child care can pay ample dividends in an improved quality of life in
adulthood.
Other Contextual Factors
Neurobiology
Infant
Family
Culture
Social
Historical
Postpartum Depression
 Definitions:



Postpartum Blues
Postpartum Psychosis
Postpartum Depression
Postpartum/ Baby Blues
 Mild and Transient Mood
Disturbance
 Begins 1st Week
Postpartum
 Lasts from a Few Hours
to a Few Days
 Prevalence:


Up to 80%,
My Work 25-40%
 Few Negative Sequelae
 High EPDS Score
 Symptoms






􀁺 Low Mood
􀁺 Mood Lability
Insomnia
􀁺 Anxiety
Crying
􀁺 Irritability
Baby Blues Case:
 Melinda:







20 yo Hispanic female
Baby hospitalized for jaundice
Anxious
Didn’t sleep for 4 days
Wants to go home
Irritable with nurses, neonatal staff
Not yet prepared at home
Postpartum Psychosis
 􀁺 Unipolar or Bipolar
Affective Disorder
 Primiparity
 Cesarean Delivery
 Previous Psychosis
 Schizophrenia
 Previous
Postpartum
Psychosis
 Family History of
Psychosis
PPP
 Immediate treatment/hospitalization
 Usually Begins Within 90 Days
Postpartum
 Length is Quite Variable
 Prevalence: 1/500 to 1/1000
 Sequelae: Future Postpartum Psychosis
 A Yates, et al.
Post partum depression
 􀁺 Not as mild or transient as the blues
 􀁺 Not as severely disorienting as

psychosis
Range of severity
PPD symptoms (DSM-IV-TR)
 1) Depressed Mood
 6) Fatigue
 2) Diminished
 7) Worthlessness or
pleasure
=================
 3) Change in
appetite
 4) Change in sleep
 5) Psychomotor
agitation/retardation
guilt
 8) Poor
concentration
 9) Recurrent
thoughts of death, SI,
plan, attempt
Prevalence of PPD
 1/8 : average of numerous studies
 Higher in lower SES and other high-risk
groups: Up to 25%
 Nationally:
 Colorado:
Front Range Counties
(Colorado Vital Statistics, 2003)
County
Live Births 2004
Estimated
Depressed (12%)
Adams
7,483
900
Boulder
3,548
420
Denver
10,438
1300
Jefferson
6,251
750
Colorado
68,000
8160
PRAMS DATA
Variable
Premature
Not
premature
36.72 %
45.35
Depression=A little depressed
34.35
36.68
Depression=Moderately depressed
15.54
12.06
Depression=Very depressed
7.47
3.62
Depression=Very depressed and had to
get help
5.92
2.30
Depression=Not depressed at all
Risk Factors for PPD
 Social Support
(Beck and O’Hara)
 Unplanned /
 Prenatal depression
 Life Stress

 Marital relationship

 Depression History

 Child Care Stress

Unwanted
Self-Esteem
Prenatal anxiety
Infant Temperament
Unexpected change
A Mother’s Fault Line
PPD Etiology
 Hormonal
 Stress
 Loss
 Role transition
 Support
 Expectation
 Own receipt of care
Consequences of Perinatal
Depression
 􀁺 Maternal
Consequences






Suffering
Lack of joy in child
Missed work,
Suicide attempts
Social Impairment
Marital discord
 Child Consequences






Cognitive delay
Speech delay
Disruptive behavior
Less frequent HSV
More Urgent Care
/ER
Ineffective
Anticipatory
Guidance
Other consequences
 Relationship Consequences

Less sensitive caregiving
Insecure attachments

Trauma and the Caregiving System

Attachment and Caregiving
 Attachment




Secure
Avoidant
Resistant
Disorganized
 Caregiving




Flexible
Distant
Close
Disabled
Disabled Caregiving
 Unresolved Loss
 Grief
 Diagnosis
 Trauma
 Depression
Comorbidity
 Anxiety






Worry , can’t control
Fatigued
Poor concentration
Irritability
Sleep
Muscle tension
 OCD


Obsessions
Compulsions
 Panic

Attacks
 Acute Stress
Disorder and
 Post Traumatic
Stress Disorder
 Substance Abuse
Medical Traumatic Stress
 Informing lens
 Ongoing possible trauma
 Threatened delivery and consequences
 NICU environment
 Complication


IVH, NEC
Long-term consequences: CP, other
Acute Stress Disorder
(DSM-IV-TR)
 A) Trauma exposure
 1) Confronted
 2) Fear,
helplessness, horror
 B) Dissociation:
 Numbing
 Daze
 De-realization
 De-personalization
 Amnesia
 C) Re-experiencing:
 D) Avoidance of
reminders
 E) Increased anxiety
and arousal
 F) Impairment in
Functioning
Importance of Acute Stress
Disorder!
 Unable to process information
 Difficulty sleeping
 Edginess
 Predictor of PTSD?
PTSD (DSM-IV)

A) Trauma exposure



1) confronted
2) Fear, helplessness, horror
C) Avoidance of stimuli





B) Re-experiencing





Distressing recollections
Dreams
Flashbacks
Distress at cues
Physiological reactivity to
cues




Thoughts and feelings
Activities, places, people
Inability to recall aspects
Decreased
interest/participation
Detachment
Restricted affect
Foreshortened sense of
future
D) Symptoms of arousal





Insomnia
Irritability
Concentrating
Hypervigilance
Startle
Caregiver PTSD
Of parents completing follow-up – 3 months later (21%) met symptom criteria for PTSD.
 PTSD symptoms at follow-up were associated with:




ASD symptoms assessed in the PICU,
Unexpected admission,
Parent's degree of worry that the child might die,
The occurrence of another hospital admission or other
traumatic event subsequent to the first admission.
 Neither ASD nor PTSD responses were associated with
objective measures of a child's severity of illness
NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parent's degree of worry that the child might die

The occurrence of another hospital admission or
other traumatic event subsequent to the first
admission: NEC, ICH, etc
Screening
 EPDS: 10 item Likert; 12/13
 CES-D: 20 question
 BDI-II: 15 question
 PPDS: 25 question
 Acute Stress Disorder Scale (ASDS)
Assessment
 Empathic
 Subjective
 Education
experience is the
key!
 Assessment as
Intervention
 Safety
 Screening
 Assessment of Other
Pathology
 All women are
different
Treatment of PPD and Its Comorbidities
 Biological:

Medication






Antidepressants
Anti-anxiety
Sleep
Massage
Exercise
Sunlight
 Alternative




Narrative Journaling
Meditation
Art
Music
 Social:




Family
Friends
Church
Nurse Visitors
 Psychological

Psychotherapies:





Cognitive Behavioral
Group
Individual
Family
EMDR
Psychopharmacology
 Antidepressants:



Breast Milk
SSRIs
Time to Work
 Anti-
anxiety/Somnolents:

Klonopin
Psychotherapies:
 Cognitive Behavioral
Therapy
 Limitations:


 Inter Personal
Therapy


Cost
Logistics
Training
Doesn’t address
trauma specifically
 Mother Infant
Therapy Group

No change in
relationship with
infant
Who gets treated
 Mental Health
 In Colorado?
Centers
 Nurse Home Visiting
 Kaiser study:
 Mostly mid and high

2.8% of women
received medication
for depression or
anxiety in 1 yr past
delivery
SES with support
and resources



Individual
Psychotherapy
Psychotropics
Group
Barriers
 Lack of Awareness
 Public Awareness
 Professional Training
 Lack of Formal
Screening
 Lack of Resources
 Lack of Training
 Satellite Support
Groups
 Mandatory Screening
 Linking IMH and MH
 Conference
KEMPE PPDIP
 Psychiatric
Evaluation
 MITG:Group Therapy



Infant
Mother’s Group
Dyadic
 Open Groups
 Conference
 Professionals
 Families
 Strategic Initiative
 Public Awareness
 Screening
 Primary Care
 Public Health
 Improved Education
 Improved mental
health services
 1-800
 Community Network
 Linking MMH to IMH
Neonatal
 Nursery





Mandatory
Screening and
Education
Consultation
Availability of
Support
Availability of
Medication
Connection to Local
Resources
 NICU





Mandatory
Screening and
Education
Consultation
Availability of
Support
Availability of
Medication
On-site therapy
Who gets what?
Step –wise approach
Collaboration!
 Thank You