Perinatal Mood Disorder

1. Perinatal Mood Disorder California Parenting Institute Santa Rosa, CA Grace Harris, MFT

2. Why?

3. Why “Perinatal Mood Disorder” vs. “Postpartum Depression”? PMD includes other Mental Health diagnoses: Depression / Anxiety / OCD / Panic Disorders, Agoraphobia / Bi- Polar Disorder / Psychosis / PTSD PMD occurs before, during & up to 12 months postpartum. (Also PMAD – Peri Natal Mood & Anxiety Disorders)

4. Why is this important? • Postpartum Depression is highly prevalent • Postpartum Depression is not time-limited • Postpartum Depression is a major risk factor for an infant’s development • Postpartum Depression IS HIGHLY TREATABLE • Postpartum Depression does not get treated

5. Prevalence

6. Prevalence of Depression* * No data available on Perinatal Mood Disorder Data collected from 17 states through the Pregnancy Risk Assessment Monitoring System (PRAMS) revealed that 11-20% of women experienced postpartum depression. The Agency for Healthcare Research and Quality reports the prevalence for depression during pregnancy as 14-23%.

7. Prevalence • Major depression during pregnancy: • 9 -13 % of U.S. Women • (Gaynes et al. 2005, AHRQ) • Major depression postpartum: • 7 % of U.S. women in the first 3 months • 22 % of U.S. women in the first 12 months • 10% of fathers develop depression within the first year after the birth of a child • (Gaynes et al. 2005, AHRQ)

8. Kaiser Small Test of Change Started with small group of pediatricians – voluntary participation (Sonoma County – Santa Rosa facility) Used PHQ-9 Rate of depression first trial 19% Now screening is routine (pediatrics, gynecology and other departments) Rate is close to 20%

9. Major and Minor Depression in Pregnancy ACOG VOL. 113, NO. 6, JUNE 2009

10. Prevalence maternal depression and related symptoms

11. Prevalence maternal depression and related symptoms

12. Prevalence maternal depression and related symptoms

13. Prevalence of other high risk conditions routinely screened: Gestational Diabetes 4.6% Hypertension 5%

14. Detection of ante natal depression withoutformal screening: 6% with standard care 34% with Edinburgh Postnatal Depression Scale

15. Paternal Peri-Natal Depression Research at Easton Virginia Medical School 28,000 male and female subjects Women 24 % Men 10.4% (compared to typical rate of 4.8%)

16. RISK FACTORS Amanda is 24 years old. She has a history substance abuse. Both she and her partner entered treatment when she learned she was pregnant. She has a 3 month old girl. She has a history of bipolar disorder which was previously controlled well with medication. However, she really wants to breast feed her baby and is worried about the medication’s effects so she is not taking it right now. She is trying hard to be a good mom but is very worried that she “will do the wrong thing.” She is feeling isolated because she can’t talk to old friends who are still using and her partner spends a lot of time going to NA meetings because he seriously is trying to stay clean. She is willing to talk to a doctor about resuming medication and accepted a referral to a baby gym class. She also put her name on a list to receive subsidized housing so hopes she and her partner can move in 6 months to a year.

17. RISK FACTORS Maricela is a 29 year old monolingual Latina living with her partner and her 5 year old son from a previous relationship and her new baby girl. Her father recently died in Mexico. She was unable to attend the funeral due to finances. She reported being depressed after her last delivery and scored 16 on the EPDS which is in the clinical range. She has difficulty sleeping and worries about the baby. Recently she told her partner she had been sexually abused as a child and her mother told her she just had to live with it. There was IPV in her previous relationship.

18. Risk Factors Biological Vulnerability Psychological Factors Life Stressors

19. Biology Rule out other medical problems – anemia, thyroid deficiency Hormone fluctuations including stress hormones Fatigue Prior history of depression

20. Psychology / Life Stressors

21. Biology / Psychology • Women who have never been depressed: • 10% develop PPD • Women who have been depressed: • 25% develop PPD • Women with previous PPD: • 50% develop PPD

25. Effects Mother – Child – Family

26. Mother Suffering Lack of joy in child Lack of confidence in parenting ability Missed work Social withdrawal Somatic symptoms Guilt Suicidality

27. Father Increased anger/conflict with others Increased use of alcohol/drugs – misuse of Rx Isolated from family Feeling discouraged Impulsive – reckless driving, extra-marital relationship Physical problems – headaches, indigestion Work constantly or worry about performance at work Conflict between how he thinks he should be as a man and how he actually is

28. Family Marital discord Withdrawal from other family members Challenging relationship with other children

29. PMD affects pregnancy outcomes ↑ preterm birth ↑ low birth weight ↑ miscarriage ↑ preeclampsia Research suggests maternal depression leads to an alteration in the mother’s neuroendocrine axis and uterine blood flow which may contribute to premature delivery, LBW etc. Babies of mothers who suffered from depression during pregnancy have elevated cortisol and catecholamine levels at birth. They cry more often and are more difficult to console. Marcus, S., & Heringhausen, J. (2009). Depression in Childbearing Women: When Depression Complicates Pregnancy. National Institute of Health. Primary Care, March 2009.

30. PMD & BIRTHWEIGHT Wright State University School of Medicine Study Boonshoft School of Medicine 2009 (Kohake, Paton and Heis) Maternal age and trimester entry into prenatal care not statistically significant relative to infant birth weight. EPDS score and maternal race was statistically significant relative to EPDS score. Future studies should quantify if antenatal depression existed with low birth weight infants.

31. INFANT CARE Health Care Consequences - Less frequent HSV - More urgent care/ER - Ineffective Anticipatory Guidance - Behind on Immunizations

32. Video

33. Do babies have mental health?

34. Infant Mental Health Relationships are central to infant mental health Social-emotional capacities depend on love and care Trusting and caring by the primary caregiver is the foundation for later development. Social development includes ability to form relationships and knowledge of social rules and standards Emotional development includes experience of feelings about self and others.

35. Impact of maternal depression on developing child When compared to non-depressed mothers, depressed mothers demonstrate:                 *Less affectionate behaviors                 *Less responsive to infant cues                 *More flat affect or withdrawal Infants display more sleep problems which further exacerbates mother’s difficulties As studies continue - effects on child may extend well into early teen years and have continued repercussions Paternal depression has shown a strong link to future mental health problems in children

36. Impact of maternal depression on developing child • PMD directly impacts the infant’s experience and current studies indicate negative consequences on development • Social • Emotional • Cognitive • Language • Attention • Mother/Father-Infant Relationship/ Interaction

37. Maternal Depression and the Developing Child Studies of children of depressed mothers show patterns of brain activity (in EEG) that is similar to what is found in adults with depression. The patterns are more pervasive with the mother is both depressed and withdrawn from her infant “Children who experience maternal depression early in life may suffer lasting effects on their brain architecture and persistent disruptions of their stress response systems”. Maternal Depression Can Undermine the Development of Young Children (2009). Working paper 8, Center on the Developing Child Harvard University. December 2009.

38. Screening

39. Why use a validated screening tool? • to increases diagnostic reliability EPDS increased the detection of PPD from 6.3% to 35.4% (Evins et.al, 2000) Why screen universally? • to identify women who would otherwise go undiagnosed - including those with suicidal ideation In a sample of women 6 wks PP, the diagnosis of PPD increased from 3.7% to 10.7% with routine screening. (Georgiopoulous et. al. 2001)

40. Who Knew? Among women who were screened and identified as depressed, less than half report that they recognized their depression.

41. Who should screen? Every health care provider that interacts with women of childbearing age …. Mental Health Providers Family Practice OB/Gyn Pediatricians Internists Community Health Workers Others including social service providers

42. Validated Screening Tools Edinburgh (EPDS) 10 questions – available in Spanish and 20 other languages. Patient Health Questionnaire (PHQ) 9 questions Postpartum Depression Screening Scale (PDSS) 35 questions 2-question screen: • During the past month, have you often been bothered by feeling down, depressed, or hopeless? • During the past month, have you often been bothered by little Interest or pleasure in doing things?

43. DID YOU KNOW? The American Academy of Obstetrics and Gynecology recommends the screening of pregnant women for depression at least once per trimester, using a simple two question screening tool Two question screen: • During the past month, have you often been bothered by feeling down, depressed or hopeless? • During the past month, have you often been bothered by little interest or pleasure in doing things?

44. Treatment

45. Protective Factors Blanca is a 27 year old Latina who following the birth of her fourth child became very anxious and wasn’t able to sit still. She was referred by WIC. She scored 22 on the EPDS with many responses indicating anxiety or worry. She also mentioned thoughts to harm herself, but agreed to contract for safety. Her family is supportive and she says she feels comfortable in her mom’s home. When the symptoms became too much for her she accepted a referral to the county Psychiatric Emergency Services and received a prescription for an antidepressant. She had been offered medication before, but felt that the doctor hadn’t really listened to her and simply gave medication. She felt that the county doctor paid attention to her before he prescribed so she was willing to try medication. She began to feel better and began to sleep. She then disclosed that she was having problems with her partner who began seeing another woman when Blanca was pregnant. He also had a problem with alcohol which affected his ability to hold a job. Her family supported her decision to leave him and she is grieving the loss of the 10 year relationship. At the same time she is thinking to a future where she might get some training at the local community college and get a job in the medical field. Blanca has 4 sisters and they spend time with her and her children or invite her to their homes during the day. Her mother read the brochure we gave Blanca about peri-natal depression and she has also become more understanding.

46. Support – Increased Protective Factors 1. Parental Resilience 2. Social Connections 3. Knowledge of Parenting & Child Development 4. Concrete Support in Times of Need 5. Social and Emotional Competence of Children www.strengtheningfamilies.net

47. Counseling *Interpersonal Therapy Cognitive Behavioral Therapy *Couples Therapy *focus on quality of relationships

48. Medication Antidepressants “The research suggests safest choices for breastfeeding mothers include the SSRI sertialine and the tri-cyclic antidepressant nortiptyline” www.womenshealth.org

49. University of Illinois at Chicago (UIC)Perinatal Consultation Service • 1-800-573-6121 • The UIC Perinatal Consultation Service assists health professionals by answering questions they have concerning screening, assessing and treating women with mental health issues during pregnancy and postpartum. • Detailed information about effects of antidepressant medications during pregnancy and breastfeeding • Perinatal anxiety disorders • The impact of perinatal mental health issues on the mother-infant relationship. The service is sponsored by a grant from the Illinois Department of Healthcare and Family Services. • HANDOUT ON PERINATAL ANTIDEPRESSANTS

50. Electroconvulsive Therapy Effective and works faster than drugs Severe depression Postpartum psychosis