Download postpartum depression

POSTPARTUM
DEPRESSION
Shanna M. Combs, MD, FACOG
“I can hear the breathing of my sleeping newborn
son in his bassinet next to the bed….I feel like I am
playing hide-and-seek from my own life, except that I
just want to hide and never be found. I want to
escape my body. I don’t recognize it anymore. I have
lost my resemblance to my former self. I can’t laugh,
enjoy food, sleep, concentrate on work, or even carry
on a conversation. I don’t know how to go on feeling
like this: the emptiness, the endless loneliness. Who
am I? I can’t go on.”
-Marie Osmond, Behind the Smile: My Journey out of
Postpartum Depression
Postpartum Depression
■ Approximately 15% of women will
experience clinically significant depression
during the postpartum period
■ Postpartum depression and anxiety
disorders can begin immediately after birth
and up to a year after delivery
Postpartum Depression
■ Despite multiple contacts with health care
professionals, postpartum depression most often is
undiagnosed and therefore untreated
–
People who interact with postpartum women have an
opportunity to try and identify these women
–
Delay in diagnosis is the biggest contributing factor in the
length of the postpartum depression
Postpartum Depression
■ Untreated postpartum depression poses serious
and long term health risks to mother and child
■ Suicide risk of postpartum depression
–
Suicide rate is increased 70 fold
–
Need to assess suicidality
■ Children of mothers with postpartum depression
are at risk for poor growth as well as attachment,
cognitive, and behavioral disturbances
Postpartum Depression as a
Public Health Problem
■ Depression is the leading cause of disease-related
disability among women
■ Over 400,000 women suffer from perinatal
depression every year
■ Depression is a communicable disease between
mother and child
■ Serious and lasting effects on child health and
family functioning
Postpartum Depression
■The most common
complication of childbirth
is depression
BABY BLUES
Baby Blues
■ Usually develops 3-5 days after delivery
■ Hallmark is emotional reactivity
■ Occurs in 70-80% of all new mothers
■ Normal reaction to hormonal changes, stress of
having a baby, and lack of sleep
■ Does not require treatment
■ Resolves within 1-2 weeks
POSTPARTUM DEPRESSION
Postpartum Depression
■ Prevalence
–
15% of postpartum women = 1 out of 7 mew mothers
■ Higher risk groups
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–
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Young
Low socioeconomic status
Poor social support
Family history of mood disorders
Personal past history of depression
■ 25-40% risk of postpartum depression
Prior postpartum depression
■ 30-50% recurrence risk
Risk Factors for Postpartum
Depression
■ Depression during pregnancy is the best predictor
of postpartum depression
■ History of depression
■ Prenatal anxiety
■ Family history of depression
■ Obstetrical complications at delivery
■ Complicated pregnancy
■ Neonatal loss or illness
■ Difficult infant temperament
Risk Factors for Postpartum
Depression
■ Ambivalence about pregnancy
■ Marital conflict
■ Lack of social support
■ Number of children
■ Recent loss
■ History of sexual abuse
■ Low self esteem
■ Recent stressful life events
■ Breastfeeding difficulties
Presentation of Postpartum
Depression
■
Usually develops slowly over the first 3 months, most often beginning
within the first 4 weeks, though some women have a more acute onset
■
More persistent than baby blues, and may affect mom’s ability to care
for the baby
■
Signs and symptoms are the same for major depression
– Depressed mood
– Irritability
– Loss of interest and appetite
– Fatigue
– Insomnia
■
Often complain of being physically and emotionally exhausted, but
unable to sleep
Presentation of Postpartum
Depression
■ Classic symptoms of depression with some
typical features
– Often express concerns about her ability to care for her
baby or anxiety about the baby’s well-being
– Anxiety symptoms are common
– Women are often unable to sleep even when given the
opportunity
Presentation of Postpartum
Depression
■ Frequently have intrusive, obsessive
ruminations, usually focused on the baby,
often violent in nature
– One study showed 50% of women with postpartum
depression had these thoughts
– These thoughts do not increase harm to the baby, but
must be distinguished from actual psychosis
Duration of Postpartum
Depression
■ Untreated depression often persists for months to
years after childbirth, with lingering effects on
physical and psychological functioning following
recovery
–
25-50% of women have episodes lasting 7 months
–
The most significant factor in the duration of postpartum
depression is delay in receiving treatment
Risks of Untreated Postpartum
Depression
■ To mother:
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Diminished capacity to care for self and baby
Substance abuse
Increased healthcare costs
Stressful impact on relationship between woman and her
partner
Suicidal thoughts more likely to be accompanied by homicidal
thoughts
Kindling phenomenon:
■ Development of a chronic low grade depression with more
susceptibility to repeated episodes of major depressive
disorder
Risks of Untreated Postpartum
Depression
■ To Child:
–
Poor attachment, bonding, and less nurturing maternal interaction
–
Poor weight gain
–
Sleep problems
–
Less likely to breastfeed
–
Less likely to receive preventative healthcare and child safety practices
–
Poor cognitive, language, and motor development
–
Behavioral problems
–
Future depression and anxiety disorders
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Risk of future medical illnesses:
■
Maternal depression is an “Adverse Childhood Experience”
Impact of Postpartum
Depression
■ Diminished maternal ability to function in many
roles particularly the core parenting role has long
lasting adverse effects on child’s health, cognitive
and emotional development, and ongoing risk to
mother’s emotional physical and social well-being
■ Treatment for mother is early intervention for the
child
POSTPARTUM PSYCHOSIS
Postpartum Psychosis
■ Typical onset is within 2 weeks after delivery, first
symptoms often within 48-72 hours
■ Earliest signs are restlessness, irritability, and
insomnia
■ Often very labile in presentation
■ Often looks “organic” with a lot of confusion and
disorientation
■ Most often consistent with mania or a mixed state
Postpartum Psychosis
■ Includes agitation, paranoia, delusions,
disorganized thinking and impulsivity
■ Thoughts of harming the baby are frequently driven
by delusions
–
Child must be saved from harm
–
Child is malevolent, dangerous, has special powers, is Satan or
God
■ Rates of infanticide associated with untreated
postpartum psychosis have been estimated to be
as high as 4 %
Postpartum Psychosis
■ Warrants emergency level care and usually
requires inpatient hospitalization
■ Medication treatment is necessary
SUICIDE IN THE POSTPARTUM
PERIOD
Suicide in the Postpartum
Period
■ Any indication of self-harm or suicidal
ideation should be taken seriously
■ Suicide risk in the first postnatal year is
estimated to be increased by 70 fold
SCREENING AND
TREATMENT
Despite multiple contacts
with medical professionals
following the birth of a child,
postpartum depression most
often goes undiagnosed.
All women should be
considered at risk for
postpartum depression.
Implement Universal
Screening.
Screening
■ Edinburgh Postnatal Depression Scale
– 10 question survey
– Available in multiple languages
– Score 0-30
– >10: possible depression
– Question 10 addresses suicidality
■
Always evaluate
Edinburgh Postnatal
Depression Scale
■ In the past 7 days:
1. I have been able to laugh and see the funny side of
things
2. I have looked forward with enjoyment to things
3. I have blamed myself unnecessarily when things went
wrong
4. I have been anxious or worried for no good reason
5. I have felt scared or panicky for no very good reason
Edinburgh Postnatal
Depression Scale
■ In the past 7 days:
6. Things have been getting on top of me
7. I have been so unhappy that I have had difficulty
sleeping
8. I have felt sad or miserable
9. I have been so unhappy that I have been crying
10. The thought of harming myself has occurred to me
Treatment Options
■ Medications
– Anti-depressants, usually SSRI
■ Sertraline preferred due to minimal reported side
effects in infants, especially for breast-feeding
mothers
■ Therapy
– Interpersonal psychotherapy
– Cognitive behavioral therapy
– Behavioral Activation
PATIENT EDUCATION
Need for Patient Education
■ Lack of knowledge about postpartum depression, treatment
options, and community resources is common in postpartum
women and their families, and frequently leads to a delay in
seeking treatment
■ Delay in treatment for postpartum depression results in a
longer illness
■ Information about postpartum depression should be provided
to women in the prenatal period, soon after delivery, and
further encounters with healthcare providers in the first
postpartum year
What do women need to talk
about?
■ Negative childbirth experiences-especially with
trauma
■ Concerns about their infants-their temperaments,
health issues
■ Interactions with their babies and caring for them
■ How this time differs from their expectations
■ Feelings of isolation
What do women need to talk
about?
■ Loss–
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Prior employment role
Closeness with spouse or older child
■ Feelings of frustration, inadequacy in mothering
■ Breastfeeding difficulties
■ Loss of care and attention received during
pregnancy
■ Ambivalence about returning to work and sense of
loss when that is a necessity
Patient Resources
■ Postpartum Support International
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www.postpartum.net
1-800-944-4773
■ Mental Health America of Greater Tarrant County
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http://www.mhatc.org
■ JPS 10th floor
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817-927-4156
■ MHMR Crisis Line
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817-335-3022
References
■
Screening for perinatal depression. Committee Opinion No. 630. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2015;125:1268–71.
■
Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ. Homicide and suicide during the
perinatal period: findings from the National Violent Death Reporting System. Obstet
Gynecol 2011;118:1056–63.
■
Siu AL and the U.S. Preventive Services Task Force (USPSTF). Screening for Depression
in Adults: US Preventive Services Task Force Recommendation Statement. JAMA.
2016;315(4):380-387.
■
Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal
depression: a systematic review of prevalence and incidence. Obstet Gynecol
2005;106:1071–83.
■
Williams Obstetrics, 22nd edition
■
Roy-Byrne, PP. Postpartum blues and unipolar depression: Epidemiology, clinical
features, assessment, and diagnosis. www.uptodate.com
■
Rob-Byrne, PP. Postpartum blues and unipolar depression: Prevention and treatment.
www.uptodate.com