Download The Reproductive Health Implications of Depression: Postpartum

The Reproductive Health
Implications of Depression:
Postpartum Depression
Association of Reproductive Health
Professionals
www.arhp.org
Expert Medical Advisory Committee
• Norma Jo Waxman, MD
• Ellen Haller, MD
• Ann Hutton, PhD, APRN
• Kathy Besinque, PharmD
Polling Question A
Learning Objectives
At the end of this session participants should
be able to:
• Recognize symptoms, risk factors and
presentations of depression in women, including
pre-menstrual and post partum mood disorders.
• Screen women for depression throughout their
reproductive years
• Prescribe medications for depression in women
and know when to refer
Postpartum Depression (PPD)
A sad story…
• 35 year old man, named, Moki, is a
Japanese immigrant, and member of suicide
survivors grief support group
• His wife committed suicide two months prior
to starting group
• She was four months postpartum with third
child; two older children 5 and 8 years old
Question 1
D. 80% of women who are pregnant and have
symptoms of depression remain untreated.
Significance of Postpartum
Depression
• During postpartum period up to 85% of
women experience some type of mood
disturbance, usually transient, “baby blues.”
• Depression in postpartum period not distinct
from major depressive disorders in general
Question 2
B. Symptom resolution within several days
to 2 weeks following birth.
“Baby Blues”
• Occurs in 70-85% of women
• Onset within the first few days (4-5 days)
after delivery
• Resolves by 2 weeks
• Symptoms include: mild depression,
irritability, tearfulness, fatigue, anxiety
• May have increased risk of post-partum
major depression later on
Beck CT. Am J Nurs. 2006. Hirst KP, Moutier CY. Am Fam Physician. 2010. Pearlstein T, et al.
Am J Obstet Gynecol. 2009.
Question 3
A. Up to 15% of women are estimated to be
affected by postpartum depression.
Postpartum Depression
• Similar symptoms but
longer duration and more
severe than “baby blues”
• Affects 7% to 15% of
women
• 0.1% to 2% have
postpartum psychosis
Beck CT. Am J Nurs. 2006. Hirst KP, Moutier CY. Am Fam Physician. 2010. Pearlstein T, et al.
Am J Obstet Gynecol. 2009.
Postpartum Depression
• Most frequent in first 4
months following birth
• Significant impact on both
mother and child
• Under diagnosed, universal
screening needed
Beck CT. Am J Nurs. 2006. Hirst KP, Moutier CY. Am Fam Physician. 2010. Pearlstein T, et al.
Am J Obstet Gynecol. 2009.
Question 4
C. Older age at first birth is not a factor
associated with increased risk of postpartum
depression.
Risk Factors for Depression:
Pregnancy and Postpartum
• History of prior depressive episodes, family
history of depression
• History of childhood abuse, neglect
• Single parent; low SES
• Absence of emotional, social support
• Unplanned pregnancy
• Domestic conflict, violence, abuse
Risk Factors for Depression:
Pregnancy and Postpartum
• Susceptibility to hormonal changes, PMS,
PMDD
• Recent loss, death, stressful life events
• Any infant health problems (ex: colic)
Postpartum Mood Disorders
Prevalence
Blues
Onset
Duration
Treatment
50-80%
1-5 days
<2 weeks
Reassurance
Depression
10%-15%
2wk - 1 year
3-14 mo
Medication or
psychotherapy
Psychosis
0.1-0.2%
2 days to 1
month
Variable
Medication,
hospitalization
Polling Question B
Screening for Depression
• Inquire about mood history before delivery
• Alert patient to note mood changes on
continuum
• Severity guides treatment
• Tools for screening
Two Question Screen for Depression
During the past month, have you been bothered
by little interest or pleasure in doing things?
During the past months, have you often been
feeling down, depressed, or hopeless?
Validated screening tool with
97% sensitivity, 67% specificity
Arroll B. BMJ 2003.
Edinburgh Postnatal Depression
Scale
British Journal of Psychiatry 150:782-786
Edinburgh Postnatal Depression
Scale
• A 10-item screening tool
• Woman self-reports how she has been
feeling during the previous week for a
number of affect states
• Maximum score is 30
• Possible depression score: ≥ 10
• Includes item to assess risk of suicide
Cox JL et al. Br J Psychiatry. 1987. Hirst KP, Moulter CY. Am Fam Physician. 2010.
Brief Patient Health Questionnaire
(PHQ-9)
MacArthur Initiative on Depression and Primary Care. 2009
PHQ-9
• 9 Questions based on DSM-IV criteria for
major depression
• Scores between 10 and 27 = moderate to
severe depression
• Used by CNMs to make referrals
Assessment of Suicide Risk
• Screen every patient suspected of
depression
• Asking does not insult patient or
initiate thought
• Ask direct questions:
• "Have you had thoughts of hurting
yourself?"
• "Do you sometimes wish your life was
over?"
• "Have you had thoughts of ending your life?"
Hackley et al 2010. MacArthur Initiative on Depression and Primary Care. 2009
Assessment of Suicide Risk
• If yes, assess immediate risk:
"Do you feel that way now?”
"Do you have a plan?"
"Do you have the means to carry out your plan?”
• Contracting not to harm has not been shown
to be a preventive strategy.
• Call 911 or the police, to have patient
transported for evaluation (5150) if high risk
Hackley et al 2010. MacArthur Initiative on Depression and Primary Care. 2009
Common Symptoms of Postpartum
Depression
Worry about the baby’s health, wellbeing and safety
Intrusive thoughts about harming the
baby
Feelings of inadequacy or detachment
from infant
Beck CT. Am J Nurs. 2006. Hirst KP, Moutier CY. Am Fam Physician. 2010. Pearlstein T, et al.
Am J Obstet Gynecol. 2009.
Postpartum Depression with Atypical
Features
• Common in young women with depression,
Two of the following symptoms:
• Hypersomnia
• Either increased appetite or weight gain
• Leaden paralysis
• Interpersonal rejection sensitivity and
irritability
Comorbidities
• Anxiety Disorders
• Eating Disorders
• Substance related disorders
• Personality Disorders:
▪
▪
▪
Avoidant
Borderline
Histrionic
Question 5
C. Individual or group psychotherapy can
effectively manage mild to moderate
depression.
Postpartum Depression: Treatment
Assess
TSH,
CBC
Psychotherapy
Medication
(if prior)
SSRIs
(moderate to
severe
)
*Include the patient in decision-making
Beck CT. Am J Nurs. 2006. Dennis CL, Hodnett E. Cochrane Database Syst Rev. 2007.
Hirst KP, Moutier CY. Am Fam Physician. 2010. Pearlstein T, et al. Am J Obstet Gynecol. 2009.
Selective Serotonin Reuptake
Inhibitors (SSRIs)
Medication
Dose
Range
Advantages
Disadvantages
Citalopram
Celexa
20-40 mg
•
Few drug interactions
•
Short half-life
Escitalopram
Lexapro
10-30 mg
•
•
Greater potency
Indicated for anxiety
•
•
No generic yet
Short half-life
Fluoxetine
Prozac
10-80 mg
•
•
Long half-life
Less frequent symptoms
with discontinuation
Reduces PTSD symptoms
•
•
•
Can be over-stimulating
Inhibitor of P450 2D6 and
3A4
Use with caution with elderly
patients and those on other
meds
Higher rates of GI side effects
•
•
Paroxetine
Paxil
10-50 mg
•
•
Relieves anxiety
Reduces PTSD symptoms
•
•
•
Sedation, sweating, wt gain
Anticholinergic effects
Inhibitor of CYP2D6
Sertraline
Zoloft
25-200 mg
•
Indicated for anxiety
disorders, PTSD
•
•
Weak inhibitor of CYP2D6
Diarrhea
Lam RW. J Affect Disord. 2009. Papakostas GI. J Clin Psychiatry. 2010. The MacArthur
Initiative on Depression and Primary Care. 2009.
Serotonin-Norepinephrine Reuptake
Inhibitors (SNRIs)
Medication
Duloxetine
Cymbalta
Venlafaxine
Effexor and generic
Desvenlafaxime
Pristiq
Dose
Range
Advantages
Disadvantages
40-60 mg
•
Also indicated for GAD,
diabetic neuropathy,
fibromyalgia
•
•
Nausea and vomiting
Sexual dysfunction
75-375
mg
•
Relieves anxiety
disorders, neuropathic
pain, and
perimenopausal
vasomotor symptoms
•
•
•
•
Higher doses may increase risk
of hypertension
Drug interactions
Sexual dysfunction less common
Nausea and vomiting
Relieves anxiety
disorders, neuropathic
pain, and vasomotor
symptoms
Can be started without
titration at effective
dose
•
No generic
50-100
mg
•
•
Lam RW. J Affect Disord. 2009. Papakostas GI. J Clin Psychiatry. 2010. The MacArthur
Initiative on Depression and Primary Care. 2009.
Additional Classes of
Antidepressants
Medication
Mirtazapine
(serotonin and
norepinephrine
antagonist)
Dose
Range
15-45 mg
Advantages
•
•
•
Bupropion
(norepinephrine/
dopamine reuptake
inhibitor- NDRI)
Wellbutrin, Zyban
200-450 mg
Nortriptyline
(tricyclic - TCA)
25-100 mg
•
•
•
•
•
Disadvantages
Few drug interactions
Low rate of sexual
dysfunction
May stimulate appetite
•
Can be stimulating
Low rate of sexual
dysfunction
May decrease appetite
•
•
Less likely to cause
orthostatic hypotension
than other tricyclics
Helpful for pain,
migraine and insomnia
•
•
•
•
Increased risk of sedation at
doses ≤ 15 mg
Weight gain due to appetite
stimulation
Higher doses can cause seizures
Contraindicated for patients with
seizures or eating disorders
Can increase anxiety or insomnia
Anticholinergic, cardiac, and
hypotensive effects
Use cautiously for patients with
cardiac conduction disorder
Lam RW. J Affect Disord. 2009. Papakostas GI. J Clin Psychiatry. 2010. The MacArthur
Initiative on Depression and Primary Care. 2009.
Safety Of Drugs: Lactation
• All antidepressants found in breast milk


Limited data on newborn impact
No findings of effect on growth or development
•
Milk-to-plasma ratio of meds in breast milk varies,
but usually < 0.1, decreasing concern about harm
• Sertraline, then Paroxetine, then Nortriptyline
recommended for the least relative infant dose and
the most studied
• Avoid Fluoxetine (Prozac) due to long half life- and
increased accumulation in the infant
Lanza di Scalea. 2009.
Safety of SSRIs
• May delay developmental milestones
• Cost-benefit of SSRIs during pregnancy and
postpartum
• GlaxoSmithKline paid $2.5 million to settle
lawsuit relating to Paxil (paroxetine) that
included birth defects.
SSRIs in Treatment
• Use of standard dosages
• Start with low dosage and check for
response
▪
Ex: Zoloft (sertraline) 50 mg
• Some women are rapid responders, others 2
to 4 weeks, but full remission may take
several months, and dose may need to be
increased
• May need additional meds for anxiety and
sleep
SSRIs in Treatment
• Remain on SSRI 6 to 12 months to avoid
relapse
• Monitoring and tracking with mood diary
• Refer for evaluation to mental health provider
for complex cases, comorbid conditions, or
failure to achieve remission
Complementary and Alternative Medicine
Therapy for Depression
• Commonly used and often not revealed
• St. John’s Wort for mild-moderate depression
▪
▪
▪
Studies conflicting
Drug-drug interactions including hormonal
contraception, SSRIs and Coumadin
Most guidelines discourage use
• Exercise and mindfulness based stress reduction
• Light therapy for seasonal affective disorder
• No benefit in RCTs
▪
Accupuncture and Omega-3 fatty acids
Ravindran AV, et al. J Affect Disord. 2009. Cochrane Review, 2009. Freeman, M P et al. 2010.
Complementary and alternative medicine in MDD: APA Task Force Report. J Clin Psy 2010.
Psychotherapy
• Psychotherapy is important part of treatment
for women who have past history of
depression, developmental abuse, marital
conflict, lack of support, or comorbid mental
health conditions
• Cognitive Behavior Therapy (CBT),
Interpersonal Therapy (IPT) and
Psychodynamic Therapy are all effective
and may be cost-effective in improving long
term outcomes
Joan
•
•
•
•
•
•
•
•
34 yo, 3 weeks postpartum
Moody, irritable, exhausted
Seems disconnected from her baby
Tearful and difficult to focus during the
visit
Having a hard time caring for the baby and gave up
nursing, feels very guilty
No local family support, partner works “all the time”
Prior history of depression
Emergency C-section
Joan
• Treatment:
▪
▪
▪
Sertraline 50 mg increased to 100 mg
Individual psychotherapy
Encourage mothers club involvement
• Follow Up:
▪
▪
▪
Sertraline reduced irritability, stabilized mood
Therapy promoted insight
Meeting other new moms gave her support and
outside of the house activities
Question 6
D. All of the above care consequences of
depression during pregnancy which can
affect the infant.
Treat Prophylactically for Additional
Pregnancies
• Increased likelihood of PPD after first
episode of depression
• Case example:
▪
▪
▪
first pregnancy, possible “baby blues”;
second pregnancy, psychotic depression,
hallucinated;
third pregnancy covered with Zoloft prior to
delivery
Hormones and CNS
• Effect of estrogen and progesterone on
affective states are probably not linear or
dose-dependent
• Estrogen and progesterone modulate each
others effects on CNS and that complicates
understanding of their individual effects
Hormones and the Gender
Difference
• Gender difference emerges at puberty
• Some women more vulnerable, sensitive to
estrogen precipitous change from birth to 48 hours
• Women more likely than men to become depressed
in response to stressful events
• Sleep deprivation with motherhood may play a role
• Need for further studies of treatment with
transdermal estradiol in treatment of PPD
Neuroimaging Studies of Women
with PPD
• Dorsomedial prefrontal cortex less active in
women with PPD than healthy new mothers
• DMPFC involved in voluntary and automatic
control and reappraisal of emotional
responses in social cognition (interpret
emotional responses of others)
• Diminished HPA Axis drive DMPC
connectivity with amygdala
Am J Psych, Sept. 2010
“SHAPED BY LIFE IN THE WOMB”
Comment on Perinatal Depression
• Babies with mothers with untreated
depression (Perinatal) show
neurobehavioral changes, born at earlier
gestational age, and have elevated stress
hormones
• Epigenetic changes and neurobiological
models of emotion-behavior regulation are
implicated; attention regulation capacities
that call on brain stem and limbic system
networks
Improved Outcome with Integrated
Care
• Integrating primary care with mental health
services has shown to improve overall
medical care and reduces costs
• Collaborate with Certified Nurse Midwives
and others who refer patients with
depression and other mental health
diagnoses
• Screen using the Patient Health
Questionnaire (PHQ-9)
Provider Resources
• MacArthur Initiative on Depression in Primary
Care
▪
http://www.depression-primarycare.org/
• American Psychiatric Association
▪
http://www.healthyminds.org/
• Cox, J.L., Holden, J.M., and Sagovsky, R.
1987. Detection of postnatal depression:
Development of the 10-item Edinburgh
Postnatal Depression Scale.
Provider and Patient Resources
• National Institute of Mental Health
▪
http://www.nimh.nih.gov/health/publications/wome
n-and-depression-discovering-hope/index.shtml
• WomensHealth.gov
•
http://www.womenshealth.gov/faq/depressionpregnancy.cfm
• Mayo Clinic
•
http://www.mayoclinic.com/health/depression/MH
00035
Provider and Patient Resources
• Healthy Place
▪
http://www.healthyplace.com/depression/women/d
epression-in-women/menu-id-68/.
• Massachusetts General Hospital Center for
Women’s Mental Health
▪
http://www.womensmentalhealth.org/.