* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Document
Separation anxiety disorder wikipedia , lookup
Mental status examination wikipedia , lookup
Moral treatment wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Abnormal psychology wikipedia , lookup
Narcissistic personality disorder wikipedia , lookup
Mental disorder wikipedia , lookup
Conversion disorder wikipedia , lookup
Classification of mental disorders wikipedia , lookup
Antipsychotic wikipedia , lookup
Cases of political abuse of psychiatry in the Soviet Union wikipedia , lookup
Spectrum disorder wikipedia , lookup
Anti-psychiatry wikipedia , lookup
History of mental disorders wikipedia , lookup
Political abuse of psychiatry in Russia wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
Political abuse of psychiatry wikipedia , lookup
Schizoaffective disorder wikipedia , lookup
Bipolar disorder wikipedia , lookup
Emergency psychiatry wikipedia , lookup
Child psychopathology wikipedia , lookup
Critical Psychiatry Network wikipedia , lookup
Behavioral theories of depression wikipedia , lookup
Biology of depression wikipedia , lookup
Major depressive disorder wikipedia , lookup
Pyotr Gannushkin wikipedia , lookup
History of psychiatry wikipedia , lookup
Bipolar II disorder wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
1 Postpartum Psychiatric Illness: Early Detection, Treatment, and Prevention Lee S. Cohen, M.D. 2 Admissions Per Month Risk of Psychiatric Illness During Pregnancy and Postpartum Period 60 50 40 30 20 10 -2 Years Pregnancy -1 Year Childbirth +1 Year +2 Years Kendell et al. Br J Psychiatry. 1987;150:662 3 Spectrum of Postpartum Mood Disorders Postpartum Psychosis Postpartum Symptom Severity Postpartum Depression (10-15%) Postpartum Blues (50-85%) None 4 Postpartum Blues • 50-85% of women • Within first two weeks after delivery • Mood lability, tearfulness, anxiety and sleep disturbance • Minimal or no impairment of functioning • Time limited • No specific treatment required 5 Postpartum Depression • Major and minor depression occurs in approximately 10% of women after live childbirth; range 5% to 15%14 • May have acute early onset (within days) but symptoms typically emerge over time (within 3 months postpartum)5 • Often underdiagnosed and undertreated5 • Significant risks to mother and child if left untreated6 1. 2. 3. 5. O’Hara MW, et al. J Abnorm Psychol. 1984;93:158-171. O’Hara MW, et al. J Abnorm Psychol. 1991;100:63-73. Kumar R, Robson RM. Br J Psychiatry. 1984;144:35-47. 4. Kendall K, et al. Br J Psychiatry. 1987;150:662-673. Nonacs R, et al. J Clin Psychiatry. 1998;59(suppl 2):34-40. 6. Lyons-Ruth. Harv Rev Psychiatry. 2000;8:148-153. 7. Cogill SR, et al. Br Med J. 1986;292:1165-1167. 8. Murray L, et al. Child Dev. 1996;67:2512-2526. 6 Puerperala Depression as a Distinct Diagnostic Entity ? • Prevalence of PPD is similar to non-puerperal MDD • Similar clinical presentation • Vulnerability to recurrent non-puerperal and puerperal depression • Similar response to antidepressant treatment 7 Psychiatric History Predicts Risk of Depression in the Postpartum Period 60 Incidence (%) 50 40 30 20 10 0 Risk in general population 1 History of major depression 2 1. 2. History of postpartum depression 2 O’Hara MW, et al. J Abnorm Psychol. 1984;93:158-171. O’Hara MW, et al. Postpartum Depression: Causes and Consequences. New York, NY: Springer-Verlag; 1995. 8 Postpartum Anxiety Disorders • Postpartum panic disorder • Postpartum OCD : can be seen in the absence of PPD • Comorbid depression and anxiety commo 9 PPD: Obsessions and Compulsions • Intrusive obsessional thoughts common • Thoughts of doing harm to infant • Obsessions more common in PPD (57%) than in nonpuerperal MDD (36%) Wisner et al, 1999 10 Postpartum Psychosis • Rare, occurs in 1 to 2 per 1000 pregnancies • Rapid, dramatic onset within first 2 weeks • Resembles an affective (manic) psychosis • Early signs: sleep disturbance, restlessness • Depressed or elated mood, agitation, delusions, depersonalization • Risk of self-harm and harm to infant 11 What is the relationship between PPD and Bipolar Disorder ? 12 Bipolarity in Postpartum Depression • Increased risk for PPD in women with bipolar disorder • Early age at illness onset • Recurrent depressive episodes (>3) • Brief episodes of MDD (<3 months) • Hyperthymic personality • Antidepressant-induced hypomania/mania • Non-response to 3 or more antidepressants Ghaemi et al, 2002 13 High Risk for Postpartum Psychosis Among Women With Bipolar Disorder • forme fruste of bipolar disorder • Symptoms usually appear acutely within 48 hours to 2 weeks after delivery • Psychiatric emergency • Estimated risk for bipolar patients is 20%–30% (baseline risk in general population is 0.1%–0.2%) Chaudron LH, et al. J Clin Psychiatry. 2003;64:1284-1292. Jones I, Craddock N. Am J Psychiatry. 2001;158:913-917. 14 Postpartum Psychosis: Further Evidence for a Bipolar Connection • Family studies: postpartum psychosis – Clusters in families multiply affected with bipolar disorder – Clusters in families multiply affected with postpartum psychosis • Genetic studies: – Postpartum psychosis susceptibility linked to variation at the serotonin transporter Jones I, Craddock N. Am J Psychiatry. 2001;158:913-917. Coyle N, et al. Lancet. 2000;356:1490-1491. 15 Longitudinal Course of Postpartum Psychosis • 95 % affective psychosis (bipolar disorder or schizoaffective disorder) • 5 % schizophrenia • Recurrence of affective episodes is the rule though circumscribed illness may be seen Terp et al, 1999 16 Postpartum Psychiatric Illness: Implications for Early Detection • Symptoms of postpartum depression may be difficult to distinguish from normative postpartum symptoms (sleep & appetite disturbance, loss of libido) • Multiple contacts with health care providers • PPD is frequently missed: role of obstetrician, pediatrician 17 The MOTHERS Act (S. 1375) Mom’s Opportunity to Access Help, Education, Research and Support for Postpartum Depression Act • “To ensure that new mothers and their families are educated about postpartum depression (PPD), screened for symptoms, and provided with essential services, and to increase research at the National Institutes of Health on postpartum depression.” • Proposes to institute a program of grants to establish, operate, and coordinate educational programs and health care services • Current status: Bill has been referred to the Committee on Health, Education, Labor, and Pensions 18 Edinburgh Postnatal Depression Scale (EPDS) • Screening tool for postpartum depression • Validated in diverse populations • 10-item self-rated questionnaire • Score of > 12 suggestive of depression • Suicidal ideation requires further evaluation Cox et al, Br J Psychiatry 150:782-786. 19 Screening for PPD • Screening and early intervention – Most women not identified – Goal is to screen women at highest risk – Late identification increases risk – What is the ideal screening tool? Nonacs R, Cohen, L. Postpartum Psychiatric Syndromes. In: Sadock B, Sadock A, ed. Comprehensive Textbook of Psychiatry. Philadelphia: Lippincott Williams and Wilkins; 2000:1276-1283. 20 Postpartum Depression Predictors Inventory Stronger Predictors: • History of depression • Depression in pregnancy • Anxiety in pregnancy • Stressful life events • Marital dissatisfaction • Child care stress • Inadequate social supports • Difficult infant temperament • Low self-esteem Weaker Predictors: • Unwanted or unplanned pregnancy • Lower socioeconomic status • Being single • Postpartum blues 21 Postpartum Mood Disorders: Etiology 22 Psychosocial Variables PPD Genetic Vulnerability Hormonal Factors 23 Risk for PPD: Hormonal Factors • Inconsistent findings • Thyroid dysfunction is common in PPD • No correlation with absolute concentrations of gonadal steroid • Behavioral sensitivity to gonadal steroids in women with PPD Bloch 2000 24 Postpartum Mood Disorders: Treatment 25 Treatment of Depression in the Postpartum Period: Psychotherapy Treatment Design Results RCT • 12-wk IPT > wait-list controls 6 Open • Significant in depressive symptoms from baseline CBT3 (and fluoxetine) 87 RCT • 6 sessions CBT >1 session CBT • No significant advantage for combination with fluoxetine Counseling4 41 RCT • 6 health nurse visits > controls IPT1,2 n 120 IPT=interpersonal psychotherapy; CBT=cognitive behavioral therapy; 1. O'Hara MW, et al. Arch Gen Psych. 2000;57:1039-1045. =decrease; RCT=randomized, controlled trial. 2. Stuart S, et al. J Psychother Pract Res. 1995;4:18-29. 3. Appleby L, et al. BMJ. 1997;314:932-936. 4. Wickberg B, Hwang CP. J Affect Disord. 1996;39:209-216. 26 Postpartum Depression: Pharmacologic Treatment Fluoxetine Appleby, 1997 Paroxetine Misri, 2004 Sertraline Wisner, 2006 Nortriptyline Wisner, 2006 Double-Blind Double-Blind Double-Blind Double-Blind Sertraline Stowe, 1995 Fluvoxamine Suri, 2002 Venlafaxine Cohen, 2001 Open Open Open Bupropion Nonacs, 2004 Open 27 Venlafaxine for PPD: Treatment Response 5 25 25 20 20 4 15 15 3 ** 10 10 * 5 5 0 0 Base Week 4 End Ham-D * = p<.0001 ** = p<.0001 ** 2 ** * * 1 0 Base Week 4 End Kellner Anxiety * = p<.0001 ** = p<.0001 Base Week 4 End CGI * = p<.0001 ** = p<.0001 Cohen LS et al, 2001. J Clin Psychiatry 62:592-596. 28 Postpartum Depression: Comparing Treatment Response • Most studies on 100 • SSRIs and TCAs have similar efficacy • Bupropion may be less effective % of Patients serotonergic agents Response Remission 80 60 40 20 0 SERT OPEN VEN OPEN BUP OPEN Stowe ZN, et al. Depression. 1995;3(49):55. Cohen LS, et al. J Clin Psychiatry. 2001;62(8):592-596. Nonacs RM, Unpublished data. 29 Postpartum Depression: Pharmacologic Strategies • Data to support use of serotonergic agents (sertraline, fluoxetine, venlafaxine, fluvoxamine) and TCAs (nortriptyline) • Other antidepressants may be effective • Adequate dosage • Adequate duration of treatment (>6 months) • Adjunctive anxiolytic agents (lorazepam, clonazepam) 30 Treatment of Bipolar Depression During the Postpartum Period • No treatment studies in literature • Mood stabilizers (lithium, lamotrigine) • Atypical anti-psychotics may be helpful • Antidepressants may exacerbate mood and should be used with caution 31 Postpartum Depression: Is there a Role for Hormonal Treatment ? • Progesterone: Inconsistent findings • Progesterone may exacerbate mood symptoms ? • Estrogen: Beneficial alone or as adjunct to antidepressant Gregoire 1996, Ahokas 2001 32 Estrogen for Postpartum Depression • 61 women with PPD (37 active, 24 placebo) • Transdermal 17 -estradiol • 47% on antidepressants at study entry • Treatment effect within 1st month, estrogen decreased EPDS by 4.38 points at 12 wks • At 12 wks, 80% on estrogen no longer depressed (<14 on EPDS) vs. 31% in placebo group • No evidence of uterine hyperplasia Gregoire, 1996 33 Estrogen for Postpartum Depression • 23 women with PPD (mean MDRS 40.7) • All women with low serum estradiol (mean 79.8 pmol/L) • Sublingual 17 -estradiol • After 2 wks, 19/23 (83%) with clinical recovery (mean MDRS 11.0) Ahokas, 2001 34 Postpartum Psychosis: Treatment • Psychiatric /Obstetric emergency • Treat as an affective psychosis (antipsychotic ( atypical/typical), mood stabilizer, benzodiazepines) • ECT is rapid and effective • Duration of treatment not well established • Need for maintenance treatment in patients with recurrent affective disorder 35 Psychotropic Medications in Breast-Feeding Mothers 36 Psychotropic Medications and Breast-Feeding • About 50% of women nurse their infants • Benefits: nutrition, immunity, cognitive development • All medications are secreted in breast milk • Concentrations in breast milk vary • Adverse events in infant are rare • Decisions made on a case by case basis 37 Which Antidepressant is the Best ? The one that is likely to work the best • Continue antidepressant used during pregnancy • Use agent to which patient has responded to in the past • Sertraline, paroxetine, nortriptyline well-characterized, no adverse events 38 Prevention of Postpartum Illness 39 Identification of women at high risk for postpartum psychiatric illness Is this disorder preventable? 40 Stratification of Risk LOW No history Routine Hx of MDD Consider Prophylaxis Hx of PPD OR Antidepressant Recurrent Severe MDD Prophylaxis Hx of Bipolar Disorder Intense Monitoring OR PP Psychosis HIGH AND Li Prophylaxis 41 Risk of Relapse Following Lithium Discontinuation Postpartum (Weeks 41–64) % Remaining Stable Pregnancy (Weeks 1–40) 100 90 80 70 60 50 40 30 20 10 0 (n=25) (n=42) (n=59) (n=20) Nonpregnant Pregnant Nonpregnant Postpartum 0 4 8 12 16 20 24 28 32 36 40 44 48 Weeks at Risk Off Lithium 52 56 60 64 Viguera AC. Am J Psychiatry. 2000;157:179-184. 42 Non-Pharmacologic Prophylaxis • Positive effect of IPT during pregnancy – 13 women with depression during pregnancy – IPT induced remission in all – No women developed PP Spinelli 1997 43 Pharmacologic Prophylaxis: Postpartum Major Depression • Antidepressant treatment in women with history of PPD: equivocal results – Open study with TCAs and SSRIs showed reduction in risk (Wisner 1994) – Placebo-controlled study with NTP negative (Wisner 1999) – Placebo-controlled study with sertraline positive (Wisner 2004) 44 Depression in Women Treated with Postpartum Sertraline or Placebo • Non-depressed women with hx of PPD (n=22) • Randomized to sertraline (up to 75mg) or placebo • Drug started after delivery • Drug tapered at week 17 Wisner KL et al, 2004. Am J Psychiatry 161:1290-1292. 45 Postpartum Prophylaxis for Women with Bipolar Disorder 46 Postpartum Lithium Prophylaxis for Bipolar Women Subjects (Dx) Lithium benefit Austin, 1992 Puerperal psychosis/ Bipolar disorder + Van Gent, 1992 Bipolar disorder + Abou-Saleh, 1983 Bipolar disorder Unipolar depression + Stewart et al, 1991 Mixed diagnoses + Cohen et al, 1995 Bipolar disorder + 47 Postpartum Prophylaxis with Mood Stabilizers other than lithium Wisner, 2004 Sharma , 2006 Subjects (Dx) Benefit Bipolar disorder Valproate +/- Puerperal psychosis/Bipolar disorder olanzapine + Wisner KL et al Biol Psychiatry 2004;56:592-596; Sharma V et al. Bipolar Disord 2006;8:400-4 48 Cumulative Survival Postpartum Prophylaxis in Bipolar Women Prophylaxis (N=14) No Prophylaxis (N=13) Time (Weeks) Significant difference between groups (Peto-Peto-Wilcoxen 2=6.966, df=1,p<0.01) Cohen LS, Sichel DA, et al. Am J Psychiatry. 1995. 49 Postpartum Mood Disorders: Long Term Impact 50 Impact of Maternal Depression on Child Well-Being • Delays in cognitive development • Increased risk of behavioral problems – Infants: sleep problems – Toddlers: temper tantrums – School age: anxiety, inattention, hyperactivity, aggression, poor school performance • Insecure attachment, emotional dysregulation • Risk for child abuse and neglect Atkinson L et al. Clin Psychol Rev. 2000;20:1019-1040. Murray L, Cooper PJ. Arch Dis Child. 1997;77:99-101. 51 Impact of Postpartum Depression (PPD) on Cognitive Functioning • Cohort of mothers recruited at 2 months postpartum (Cambridge, England) • At 18 months, children of mothers with PPD more likely than children of well mothers to have cognitive delays • At 5 years, no differences between 2 groups • Other studies in disadvantaged populations show persistence of cognitive deficits, especially in boys Murray L. J Child Psychol Psychiatry. 1992;33:543-561. Cogill SR et al. BMJ. 1986;292:1165-1167. Sharp D et al. J Child Psychol Psychiatry. 1995;36:1315-1336. 52 PPD: Long-Term Effects on IQ and Cognitive Function • 148 women enrolled at 3 months postpartum • Children (n = 132) assessed at 11 years • Lower IQ • Attention, mathematical reasoning deficits • Conduct problems • Outcomes worse in children exposed to recurrent MDD (although exposure to one episode of MDD had negative effects) Hay DF et al. J Child Psychol Psychiatry. 2001;42:871-889. 53 Summary • Postpartum psychiatric illness is common • Untreated illness has significant impact on child development and well-being • Effective non-pharmacologic and pharmacologic treatments • Early treatment is associated with better prognosis 54 www.womensmentalhealth.org