Postpartum Depression

1. Postpartum Depression April Wilson MD PGY1 OB/Gyn Rotation Family and Social Medicine

2. Case DP is a 19yo G1P1 female who presented to clinic with her newborn for a newborn visit and f/u visit for herself. DP has a healthy 1 wk old baby girl. DP is no longer in a relationship with the FOB. DP recently went to ED due to perineal pain. Today DP has no complaints.

3. DP • PMH: Strabismus, Congenital deformity of Left hand, Depression (suicidal ideation) at age 14 • Social Hx: Lives with mom(recovering drug addict) and baby, dropped out of high school during pregnancy, at home school lessons about 2x week, plans to start job corp in the Spring, no cigs, no ETOH, no drugs; not currently sexually active • When asked about feeling down, DP admitted to having moments of feeling depressed due to her circumstances but tries not to dwell on such feelings. She remains hopeful for her future and looks forward to the job corp program.

4. What is postpartum depression? • Postpartum depression: a major depressive episode that is temporally associated with childbirth • Postpartum blues: “baby blues”, heightened emotions, peaks in 3-5 days after delivery, may last up until 14 days (tearfulness, anxiety, irritability, fatigue, mood lability) • Postpartum psychosis: severe postpartum depression associated with delusions

5. Who is most likely to be affected? • Estimated that 10-20% of mothers have postpartum depression • Postpartum blues occurs in about 50-80% of mothers • 2/3 women have onset within 6 weeks of delivery • African-American and Hispanic mothers more likely than Caucasian mothers to have early symptoms

6. Causes of Postpartum Depression • Possibly related to hormonal changes • ??????????????????????????????????????????????????????????????????????????????????????????????????????????

7. Underlying psychiatric disorder Lack of social support Anxiety and depression during pregnancy Hx of depression Moms with preterm infants(<32 wks) “baby blues” Stressful life events Hx of postpartum depression Bipolar (risk for postpartum psychosis) Catastrophizing labor pain Risk Factors *Multiparity and breastfeeding associated with reduced risk; no association b/w C-sec and postpartum depression

8. Factors that may delay or prevent women from seeking help • Being a first-time mom • Pressures of society to be a “good mom” • Fear of being sent to jail or baby being taken away if disclose thoughts to PCP • Confusion about which doctor to see about their concerns **Also, remember that physicians my delay detection by minimizing a woman’s distress in an effort to be reassuring.

9. Making the diagnosis-usually presents up to 4-6 months postpartum • Symptoms: depressed mood, lack of pleasure or interest, sleep disturbance, weight loss, loss of energy, agitation, feelings of worthlessness or inappropriate guilt, diminished concentration, thoughts of death or suicide • Social Hx: depressed mood during pregnancy, life stress, postpartum anxiety, poor marital adjustment, infant sleep problems • Physical: poor eye contact, tearfulness, blunt affect, inattention to personal appearance • Diagnosis: DSM-IV criteria for major depression SIGECAPS **symptoms which may be considered normal experiences after childbirth

10. Diagnosis Continued…. • Screening: Edinburgh Scale • Tests: CBC, TFTs • Rule Out: postpartum blues, postpartum psychosis, anemia, postpartum thyroid dysfunction • NOTE: Postpartum Psychosis (hallucinations or delusions, manic) is a MEDICAL EMERGENCY!!!! Patient must be hospitalized immediately. -usually presents within first two weeks, incidence rate is 0.1-0.2 percent

11. Screening: Edinburgh Scale AAFP recommends universal screening at 6-wk postpartum visit A score higher than 12 is 100% sensitive and 95.5% specific in detecting major depression One study showed that postpartum women residing in the inner city had a prevalence rate of 22% when screened with EPDS

12. Edinburgh Scale In the past 7 days: 1. I have been able to laugh and see the funny side of things *6. Things have been getting on top of me As much as I always could Yes, most of the time I haven’t been able Not quite so much now to cope at all Definitely not so much now Yes, sometimes I haven’t been coping as well Not at all as usual No, most of the time I have copied quite well 2. I have looked forward with enjoyment to things No, I have been coping as well as ever As much as I ever did Rather less than I used to *7 I have been so unhappy that I have had difficulty sleeping Definitely less than I used to Yes, most of the time Hardly at all Yes, sometimes Not very often *3. I have blamed myself unnecessarily when things 1 No, not at all went wrong Yes, most of the time *8 I have felt sad or miserable Yes, some of the time Yes, most of the time Not very often Yes, quite often No, never Not very often No, not at all 4. I have been anxious or worried for no good reason No, not at all *9 I have been so unhappy that I have been crying Hardly ever Yes, most of the time Yes, sometimes Yes, quite often Yes, very often Only occasionally No, never *5 I have felt scared or panicky for no very good reason Yes, quite a lot *10 The thought of harming myself has occurred to me 1  Yes, sometimes Yes, quite often No, not much Sometimes No, not at all Hardly ever Never Administered/Reviewed by ________________________________ Date ______________________________ Response categories are scored 0,1,2,3 to increased severity. Items marked with * are reversed scored 3,2,1,0. Total score is adding all scores. Scores above 12 likely have depression

13. Complications of Postpartum Depression • May affect the mother’s ability to care for the infant • Disturbs the bond b/w mother and infant • Increases the child’s and entire family’s risk of psychiatric disorders • Higher incidence of SIDS in children of mothers with postpartum depression

14. Treatment • Prognosis- may last 6-12 months; women at risk for postpartum depression and depression in the future • Professional and/or social support • Counseling • Antidepressants • Transdermal estrogen

15. Counseling • Psychosocial and psychological interventions may reduce depressive symptoms (ex. Group therapy) • Interpersonal psychotherapy-focuses on patient’s interpersonal relationships and changing roles • Multi-component intervention associated with improved short-term improvements for low-income women • Partner participation

16. Antidepressants • Fluoxetine: only drug proven as effective as cognitive-behavioral counseling and more effective than placebo; transmits through breast milk • Nortriptyline • Sertraline • Fluvoxamine ---may have to use for 9-12 months, data lacking in regards to optimal duration

17. Hormonal Therapy • Transdermal estrogen: effective in severe postpartum depression - women treated for 6 months - estrogen patch more effective than placebo for treating postpartum depression, effect occurred by 1st month and remained statistically significant - for last 3 months, women given progesterone 12days/month to reduce risks of unopposed estrogen • Sublingual 17-beta estradiol - effective in 2 case reports and uncontrolled series of 23 cases

18. Alternative options • Enhanced professional and social support • Massage therapy (reduced anxiety) • Behavioral sleep intervention • Electroconvulsive therapy

19. Prevention • Group psychotherapy may reduce risk of depression for up to 3 months postpartum • Insufficient evidence regarding prophylactic antidepressants postpartum • Music therapy may reduce prenatal stress, anxiety, and postpartum depression

20. Educational Materials for Patients • Postpartum Support International: Helpline: 1-800-944-4PPD Website: http://postpartum.net NEW YORK STATE CO-COORDINATOR: LAUREN SAFRAN, LCSW WESTCHESTER, THE BRONX, THE HUDSON VALLEY, QUEENS and LONG ISLAND Telephone: 917.658.0624

21. Plan for DP • Risk Factors: hx of depression, lack of social support • Post-partum visit plan: physical exam, Edinburgh scale, further discuss support system, f/u in regards to topics discussed at visit with social worker

22. References Blenning, Carol and Paladine, Heather. An Approach to the Postpartum Office Visit. American Family Physician 2005; 72: 2491-6, 2497-8) Dennis, C-L; Hodnett, E; Cindy-Lee. Psychosocial and psychological interventions for treating postpartum depression (Cochrane Review). In: The Cochrane Library 2008 Issue 2. Chichester, UK: John Wiley and Sons, Ltd. Epperson, CN. Postpartum Major Depression: Detection and Treatment. American Family Physician 1999; April 15, 1999. Ferber SG, Granot M, Zimmer EZ. Catastrophizing labor pain compromises later maternity adjustments. Am J Obstet Gynecol 2005; 192: 826-31. Hoffbrand S, Howard L, Crawley H. Antidepressant treatment for post-natal depression. Cochrane Database Syst Rev. 2001;(2):CD002018. Miller L. Postpartum depression. JAMA 2002; 287: 762-5. Morris-Rush JK, Freda MC, Bernstein PS. Screening for postpartum depression in an inner-city population. Am J Obstet Gynecol 2003; 188: 1217-9. Adolescence 1996 Winter; 31(124): 903 Am J Obstet Gynecol 2005 Feb; 192(2): 522 Am J Psychiatry 2006 Aug; 163(8): 1435, 1443 Arch Womens Ment Health 2007; 10(6): 259) Arch Womens Ment Health 2006 Sep; 9(5): 273 BMJ 2002 May 4; 324(7345): 1062 Can J Psychiatry 2000 Aug; 45(6): 554 Cochrane Library 2007 Issue 4: CD006116 Early Hum Dev 2003 Aug; 73(1-2): 61 Lancet 1996 Apr 6; 347(9006): 930 Lancet 1998 Jan 10; 351(9096: 109 Lancet 2007 Nov 10; 370(9599): 1629 J Clin Nurs 2008 Feb 19 early online J Clin Psychiatry 2001 May; 62(5): 332 Obstet Gynecol 2005 Jun; 105(6): 1442 Obstet Gynecol 2005 Nov; 106(5): 1071 Obstet Gynecol 2007 Nov; 110(5): 1102 Psychosom Med 2006 Mar-Apr; 68(2): 321