POSTPARTUM DEPRESSION BEYOND THE BLUES

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POSTPARTUM DEPRESSION BEYOND THE BLUES

• Debby Carapezza, R.N., M..S.N.
• Nurse Consultant, Reproductive Health Program
• Utah Department of Health

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INCIDENCE OF DEPRESSION

• Each year, 15 to 20 of adults in the United
  States experience a major depression
• The incidence among women is twice that of men
  and peaks between 18 to 44 years of age - the
  childbearing years

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DEPRESSION IN WOMEN

• Women are at increased risk of mood disorders
  during periods of hormonal fluctuation-
• premenstrual
• postpartum
• perimenopausal

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THE RANGE OF POST-DELIVERY MOOD DISORDERS

• 50 to 80 of women experience transient baby
  blues within the first two weeks following
  delivery
• 0.1 to 0.2 of women experience postpartum
  psychosis usually within the first 4 weeks
  following delivery

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POSTPARTUM DEPRESSION

• 6.8 to 16.5 of women experience postpartum
  depression (PPD) also known as postpartum major
  depression (PMD)
• Onset can be as early as 24 hours or as late as
  several months following delivery

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SYMPTOMS OF POSTPARTUM DEPRESSION
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RANGE OF SYMPTOMS

• Symptoms range-
• from mild dysphoria
• to suicidal ideation
• to psychotic depression

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DURATION OF SYMPTOMS

• Untreated, symptoms can last
• several months
• into the second year postpartum

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THE ETIOLOGY OF POSTPARTUM DEPRESSION

• Various theories based in physiological changes
  have been postulated
• hormonal excesses or deficiencies of estrogen,
  progesterone, prolactin, thyroxine, tryptophan,
  among others

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ETIOLOGY OF POSTPARTUM DEPRESSION

• Other theories cite numerous psychosocial factors
  associated with PMD
• marital conflict
• child-care difficulties (feeding, sleeping,
  health problems)
• perception by mother of an infant with a
  difficult temperament
• history of family or personal depression

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POSTPARTUM DEPRESSION IN UTAH

• What can PRAMS data tell us?

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INDICDENCE OF POSTPARTUM DEPRESSION AMONG 2000
UTAH PRAMS RESPONDENTS

• 24.1 of PRAMS respondents indicated that in the
  months after delivery they were moderately to
  very depressed

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• When the results of the survey are weighted to
  represent all 47,331 Utah women who had a live
  birth in 2000, this means an estimated 11,416
  women reported being moderately or very
  depressed.

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Higher rates of depression were noted among women
who
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THE IMPACT OF POSTPARTUM DEPRESSION
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LONG TERM CONSEQUENCES OF PMD

• Negative impact on the infant s social,
  emotional and cognitive development
• 2 month old infants of mothers with PMD had
  decreased cognitive ability and expressed more
  negative emotions during testing

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LONG TERM CONSEQUENCES OF PMD

• Babies of mothers with PMD were perceived by
  their mothers as more difficult to care for and
  more bothersome.

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POSTPARTUM DEPRESSION MATERNAL MORTALITY IN UTAH

• In recent years, there have been two maternal
  deaths due to suicide by women within one year of
  giving birth.
• Neither woman had been screened for postpartum
  depression

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RISK FACTORS FOR PMD
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INTERVENTIONS

• SCREENING FOR PMD

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SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A
WOMAN MAY

• Be unable to recognize she is depressed

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SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A
WOMAN MAY

• Believe her symptoms are normal for new moms

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SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A
WOMAN MAY

• Fear being labeled a bad mother if she admits
  her maternal experience does not meet societys
  picture of bliss

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SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A
WOMAN MAY

• Feel she is going crazy and fears her baby will
  be taken from her

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WHEN TO SCREEN FOR PMD

• At preconception visit
• During prenatal intake subsequent visits
• During postpartum exams
• During infants WCC WIC visits
• When infant is seen for sick care or in ER
• At early intervention home visits
• At family planning visits during the first year
  postpartum
• At mothers visits for routine episodic care

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SCREENING TOOLS

• There are several tools available
• Edinburgh Postnatal Depression Scale (EPDS)
• The Mills Depression Anxiety Checklist
• The Center for Epidemiological Studies Depression
  Scale (CES-D)
• Others, often on various websites for mental
  health

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A WORD ABOUT SCREENING TOOLS!

• Be familiar with the tool - its validity and
  limitations
• Have a referral network available for women
  screening positive
• Document the screening and any referrals made
• Follow-up with your client to assure that she
  received needed assistance

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EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS)

• Designed for home or outpatient use
• Consists of 10 questions
• Can be completed in approx. 5 minutes
• Reviews feelings the previous 7 days
• Scored 0-3 depending on symptom severity
• Depending on study, cut off is 13 - 9 points

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SAMPLE EPDS QUESTIONS

• 1. I have been able to laugh see the funny
  side of things
• As much as I always could
• Not quite so much now
• Definitely not so much not
• Not at all

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SAMPLE EPDS QUESITONS (Cont.)

• 3. I have blamed myself unnecessarily when
  things went wrong
• Yes, most of the time
• Yes, some of the time
• Not very often
• No never

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SAMPLE EPDS QUESTIONS (Cont.)

• 6. Things have been getting on top of me
• Yes, most of the time I havent been able to cope
  at all
• Yes, sometimes I havent been coping as well as
  usual
• No, most of the time I have coped as well as ever
• No, I have been coping as well as ever

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TREATMENT

• 1. Educate the woman and her support system
  regarding the diagnosis of postpartum
  depression.

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TREATMENT OPTIONS

• Pharmacological intervention
• Counseling, individual and/or group
• Support groups

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PHARMACOLOGICAL INTERVENTION

• Use of tricyclic antidepressants and selective
  serotonin reuptake inhibitors (SSRIs) may be
  indicated for both non-nursing and nursing
  mothers
• Have low incidence of infant toxicity and adverse
  effects during breastfeeding
• Decisions regarding use while breastfeeding must
  be on a case by case basis

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OTHER CONSIDERATIONS

• Provider must be familiar with agents and the
  hepatic function of mother and infant
• Client must be informed of risks/benefits of
  treatment Vs. no treatment for herself and her
  infant
• unknown impact of long-term use of medications on
  neurodevelopment of infant

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Other Considerations - Cont.

• If the woman chooses to breastfeed while on
  psychotropics, she should work collaboratively
  with a psychiatrist and her pediatrician
• If the infant experiences insomnia or other
  behavior changes, his serum should be assayed for
  the presence of medication
• Document all discussions regarding treatment in
  the clients chart

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TREATMENT OF DEPRESSIONPATIENT ASSISTANCE
PROGRAMS

• Pharmacological treatment of depression can be
  effective. Unfortunately, it can also be
  expensive. Costs of antidepressants vary
  depending on the drug, dose and pharmacy.
• Paxil 20mg qd X 30 Days 85.39
• Prozac 20mg qd X 30 Days 67.79 (generic)
• Zoloft 50mg qd X 30 days 75.00
• Elavil, at approximately 75mg qd X 30 days
  11.39 (generic) or 37.89 (brand).

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COUNSELING

• Know referral sources in your locale, especially
  those that
• accept Medicaid
• utilize a sliding fee
• will develop a payment plan with the client
• offer free counseling
• Be familiar with indigent drug programs available
  through various pharmaceutical manufacturers

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Counseling - Cont.

• Any woman with symptoms of psychosis or with
  serious suicidal/homicidal ideation should be
  referred for emergency psychiatric evaluation

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SUPPORT GROUPS

• Numerous postpartum support groups are available.
  Contact
• Local mental health agencies
• Hospitals
• Websites

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WEBSITE INFO SUPPORT

• Depression After Delivery - http//www.depressiona
  fterdelivery.com
• Postpartum Support International
  -http//www.postpartum.net/
• The Postpartum Stress Center -http//www.postpartu
  mstress.com/
• Postpartum Education for Parents
  -http//www.sbpep.org
• Office on Womens Health -http//www.4women.gov-pr
  egnancy-after the baby is born-PPD

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Websites and Other Resources

• Mental Health Association in Utah
• http//www.xmission.com/mhaut/
• For information on medication while
  breastfeeding, call Pregnancy RiskLine
• In Salt Lake City 328-BABY (2229)
• Outside Salt Lake 1-800-822-BABY (2229)

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SUMMARY

• Postpartum depression
• is relatively common
• may have long-term consequences for mother,
  infant family
• is easily missed
• should be screened for
• can be treated successfully