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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