Perinatal Depression, Anxiety, and Trauma: What they are, Why they don't get treated, How to move fo

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Peri-natal Depression, Anxiety, and Trauma
What they are, Why they don't
get treated, How to move
forward.

• Brian Stafford, MD, MPH
• Assistant Professor of Psychiatry and Pediatrics,
  UCHSC
• Medical Director, Postpartum Depression
  Intervention Program
• The Kempe Center and Childrens Hospital

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Colorado Perinatal Council Meeting

• Denver Childrens Hospital
• Tammen Hall, Nov 17, 2006

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The Caregiving System

• Mothers express intense feelings of pleasure
  when they are able to provide protection for
  their children they experience heightened anger,
  sadness, anxiety, and despair when they are
  separated from their children or when their
  ability to protect their children is threatened
  or blocked!
• C George and J Solomon, Attachment and
  the Caregiving System,
• Handbook of Attachment, p 652

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My Experience in this Landscape

• A case or two

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Outline

• Brief History
• Multiple Lenses
• The Nature of the Problems
• Outcomes of Distress
• Predicting Problematic Outcomes
• Barriers to Intervention
• Interventions
• Moving Forward

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History

• Pediatric Lens
• Vulnerable Child Syndrome
• Developmental Psychology
• Risk, Resilience and Longitudinal Outcome
• Psychiatric Lens
• Postpartum Depression
• Maternal Outcomes
• Infant Outcomes
• Relationship Outcomes
• Medical Post Traumatic Stress
• Infant Mental Health
• Treatment Strategies

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Vulnerable Child Syndrome(Green and Solnit,
REACTIONS TO THE THREATENED LOSS OF A CHILD A
VULNERABLE CHILD SYNDROME.
PEDIATRIC MANAGEMENT OF THE DYING CHILD, PART
III. Pediatrics. 1964 Jul3458-66. )

• Parents thought or told child would/might die
• Anticipatory grief (Lindemann, )
• Parents perceive child is on tenuous loan to
  them

• Paths to VCS
• Serious illness in the child
• Representation of a another figure whose loss is
  not resolved
• Pregnancy complications and fears that she might
  die

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VCS Behavioral Outcomes

• Pathological Separation difficulties
• Sleep problems
• Inability to set age-appropriate limits
• Over-protectiveness

• Aggression by child toward the parent
• Hyperactive child in presence of the caregiver
• School underachievement
• Excessive health concerns, frequent health care
  use

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Parental Perception of Child Vulnerability

• Contributing Factors
• Low social support
• Parental Anxiety
• Cong. Heart Disease
• Jaundice
• Non-illness
• Marital Satisfaction
• Prematurity
• sickness

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Developmental Risk

• Child competence is not related to current SES
  but the number of years the family had spent in
  poverty( Brooks-Gunn, 1993)
• Duncan GJ, Brooks-Gunn J, Klebanov PK.
  Economic deprivation and early childhood
  development. Child Dev. 1994 Apr65(2 Spec
  No)296-318.
• Child psychopathology is related to the number of
  risk factors as well (Rutter, 1979)
• Marital distress Low SES
• Large family Maternal Psychiatric
• Foster Care placement

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Rochester Longitudinal Study (Sameroff,
1998) To examine the effects of the environment
on early emotional behavior and later mental
healthSameroff AJ. Environmental risk factors
in infancy.Pediatrics. 1998 Nov102(5 Suppl
E)1287-92.

• An investigation of the development of a group of
  children from the prenatal period through
  adolescence living in a socially heterogeneous
  set of family circumstances.
• Evaluated risk factors
• Childs cognitive ability
• Socialemotional competence.
• Early childhood phase of the RLS,
• Assessed children and their families at
• Birth, 4, 12, 30, and 48 months of age
• In the home and in the laboratory.
• During adolescence
• Assessment at age 13 and 18.

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TABLE 1. Summary of Risk VariablesRisk Variables
RLS Low Risk High Risk

• Mental illness
• 01 Psychiatric contact
• More than 1 contact
• Anxiety
• 75 Least
• 25 Most
• Parental perspectives
• 75 Highest
• 25 Lowest
• Spontaneous interaction
• 75 Most
• 25 Least
• Occupation
• Skilled
• Semi- or unskilled

• Education
• High school
• No high school
• Minority status
• No
• Yes
• Family support
• Father present
• Father absent
• Stressful life events
• 75 Fewest
• 25 Most
• Family size
• 13 Children
• Four or more children

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Additive Risk
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RLS Findings

• On intelligence test,
• children with 0 environmental risks scored 30
  points higher than did children with eight or
  nine risk factors.
• On average, each risk factor reduced the childs
  IQ score by 4 points.

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Resiliency (Werner) Kauai LSPediatrics. 2004
Aug114(2)492. Werner EE. Journeys from
childhood to midlife risk, resilience, and
recovery.

• 1) What are the long-term effects of adverse
  perinatal and early child-rearing conditions on
  individuals physical, cognitive, and
  psychosocial development at midlife?
• 2) Which protective factors allow most
  individuals who are exposed to multiple childhood
  risk factors to make a successful adaptation in
  adulthood?
• The KLS has monitored the impact of a wide array
  of biological, psychological, and social risk
  factors
• Multiracial cohort of 698 individuals who were
  born in 1955 on the Hawaiian island of Kauai,
• From the perinatal period to ages 1, 2, 10, 18,
  31/32, and 40.
• The follow-up at midlife was able to track 80
  of the "high-risk" children who had been exposed
  to
• chronic poverty,
• birth complications,
• parental psychopathology,
• and family discord
• as well as comparison groups of men and women who
  had not experienced significant childhood
  adversities.

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KLS

• With the exception of serious central nervous
  system damage, the impact of peri-natal
  complications on adult adaptation diminished with
  time, whereas the outcomes of biological risk
  conditions depended, increasingly, on the
• 1)quality of the child-rearing environment and
• 2) the emotional support provided by family
  members, friends, teachers, and adult mentors.
• Poorest outcomes at age 40 were associated with
  prolonged exposure to parental alcoholism and/or
  mental illnessespecially for the men.

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KLS

• Quality of the individuals adaptation at age 40
  correlated significantly with
• Health status in the first decade of life (based
  on a pediatric assessment of all organ systems at
  age 2 and number of health problems, including
  serious illnesses and accidents, between birth
  and age 10)
• The mothers caregiving competence and the
  emotional support provided by the family in
  childhood.
• This study demonstrates the need for early
  attention to the health status of our nations
  childrenespecially those who are exposed to
  poverty, serious perinatal complications, and
  parental psychopathology.
• The social policy implications are clear early
  access to good preventive and ameliorative health
  services and proper attention to the quality of
  early child care can pay ample dividends in an
  improved quality of life in adulthood.

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Other Contextual Factors
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Postpartum Depression

• Definitions
• Postpartum Blues
• Postpartum Psychosis
• Postpartum Depression

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Postpartum/ Baby Blues

• Mild and Transient Mood Disturbance
• Begins 1st Week Postpartum
• Lasts from a Few Hours to a Few Days
• Prevalence
• Up to 80,
• My Work 25-40
• Few Negative Sequelae
• High EPDS Score

• Symptoms
• ?? Low Mood
• ?? Mood Lability
• Insomnia
• ?? Anxiety
• Crying
• ?? Irritability

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Baby Blues Case

• Melinda
• 20 yo Hispanic female
• Baby hospitalized for jaundice
• Anxious
• Didnt sleep for 4 days
• Wants to go home
• Irritable with nurses, neonatal staff
• Not yet prepared at home

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Postpartum Psychosis

• ?? Unipolar or Bipolar Affective Disorder
• Schizophrenia

• Primiparity
• Cesarean Delivery
• Previous Psychosis
• Previous Postpartum Psychosis
• Family History of Psychosis

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PPP

• Immediate treatment/hospitalization
• Usually Begins Within 90 Days Postpartum
• Length is Quite Variable
• Prevalence 1/500 to 1/1000
• Sequelae Future Postpartum Psychosis
• A Yates, et al.

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Post partum depression

• ?? Not as mild or transient as the blues
• ?? Not as severely disorienting as psychosis
• Range of severity

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PPD symptoms (DSM-IV-TR)

• 1) Depressed Mood
• 2) Diminished pleasure
• 3) Change in appetite
• 4) Change in sleep
• 5) Psychomotor agitation/retardation

• 6) Fatigue
• 7) Worthlessness or guilt
• 8) Poor concentration
• 9) Recurrent thoughts of death, SI, plan, attempt

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Prevalence of PPD

• 1/8 average of numerous studies
• Higher in lower SES and other high-risk groups
  Up to 25
• Nationally
• Colorado

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Front Range Counties (Colorado Vital Statistics,
2003)
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PRAMS DATA
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Risk Factors for PPD (Beck and OHara)

• Social Support
• Prenatal depression
• Life Stress
• Marital relationship
• Depression History
• Child Care Stress

• Unplanned / Unwanted
• Self-Esteem
• Prenatal anxiety
• Infant Temperament
• Unexpected change

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A Mothers Fault Line
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PPD Etiology

• Hormonal
• Stress
• Loss
• Role transition
• Support
• Expectation
• Own receipt of care

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Consequences of Perinatal Depression

• ?? Maternal Consequences
• Suffering
• Lack of joy in child
• Missed work,
• Suicide attempts
• Social Impairment
• Marital discord

• Child Consequences
• Cognitive delay
• Speech delay
• Disruptive behavior
• Less frequent HSV
• More Urgent Care /ER
• Ineffective Anticipatory Guidance

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Other consequences

• Relationship Consequences
• Less sensitive caregiving
• Insecure attachments
• Trauma and the Caregiving System

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Attachment and Caregiving

• Attachment
• Secure
• Avoidant
• Resistant
• Disorganized

• Caregiving
• Flexible
• Distant
• Close
• Disabled

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Disabled Caregiving

• Unresolved Loss
• Grief
• Diagnosis
• Trauma
• Depression

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Comorbidity

• Anxiety
• Worry , cant control
• Fatigued
• Poor concentration
• Irritability
• Sleep
• Muscle tension
• OCD
• Obsessions
• Compulsions

• Panic
• Attacks
• Acute Stress Disorder and
• Post Traumatic Stress Disorder
• Substance Abuse

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Medical Traumatic Stress

• Informing lens
• Ongoing possible trauma
• Threatened delivery and consequences
• NICU environment
• Complication
• IVH, NEC
• Long-term consequences CP, other

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Acute Stress Disorder (DSM-IV-TR)

• A) Trauma exposure
• 1) Confronted
• 2) Fear, helplessness, horror
• B) Dissociation
• Numbing
• Daze
• De-realization
• De-personalization
• Amnesia

• C) Re-experiencing
• D) Avoidance of reminders
• E) Increased anxiety and arousal
• F) Impairment in Functioning

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Importance of Acute Stress Disorder!

• Unable to process information
• Difficulty sleeping
• Edginess
• Predictor of PTSD?

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PTSD (DSM-IV)

• A) Trauma exposure
• 1) confronted
• 2) Fear, helplessness, horror
• B) Re-experiencing
• Distressing recollections
• Dreams
• Flashbacks
• Distress at cues
• Physiological reactivity to cues

• C) Avoidance of stimuli
• Thoughts and feelings
• Activities, places, people
• Inability to recall aspects
• Decreased interest/participation
• Detachment
• Restricted affect
• Foreshortened sense of future
• D) Symptoms of arousal
• Insomnia
• Irritability
• Concentrating
• Hypervigilance
• Startle

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Caregiver PTSD

• Of parents completing follow-up 3 months later
  -
• (21) met symptom criteria for PTSD.
• PTSD symptoms at follow-up were associated with
• ASD symptoms assessed in the PICU,
• Unexpected admission,
• Parent's degree of worry that the child might
  die,
• The occurrence of another hospital admission or
  other traumatic event subsequent to the first
  admission.
• Neither ASD nor PTSD responses were associated
  with objective measures of a child's severity of
  illness

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NICU

• ASD symptoms assessed in the NICU
• Unexpected admission
• Parent's degree of worry that the child might die
• The occurrence of another hospital admission or
  other traumatic event subsequent to the first
  admission NEC, ICH, etc

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Screening

• EPDS 10 item Likert 12/13
• CES-D 20 question
• BDI-II 15 question
• PPDS 25 question
• Acute Stress Disorder Scale (ASDS)

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Assessment

• Empathic
• Education
• Safety
• Screening
• Assessment of Other Pathology
• All women are different

• Subjective experience is the key!
• Assessment as Intervention

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Treatment of PPD and Its Co-morbidities

• Biological
• Medication
• Antidepressants
• Anti-anxiety
• Sleep
• Massage
• Exercise
• Sunlight
• Alternative
• Narrative Journaling
• Meditation
• Art
• Music

• Social
• Family
• Friends
• Church
• Nurse Visitors
• Psychological
• Psychotherapies
• Cognitive Behavioral
• Group
• Individual
• Family
• EMDR

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Psychopharmacology

• Antidepressants
• Breast Milk
• SSRIs
• Time to Work

• Anti-anxiety/Somnolents
• Klonopin

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Psychotherapies

• Cognitive Behavioral Therapy
• Inter Personal Therapy
• Mother Infant Therapy Group

• Limitations
• Cost
• Logistics
• Training
• Doesnt address trauma specifically
• No change in relationship with infant

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Who gets treated

• Mental Health Centers
• Nurse Home Visiting
• Kaiser study
• 2.8 of women received medication for depression
  or anxiety in 1 yr past delivery

• In Colorado?
• Mostly mid and high SES with support and
  resources
• Individual Psychotherapy
• Psychotropics
• Group

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Barriers

• Lack of Awareness
• Lack of Formal Screening
• Lack of Resources
• Lack of Training

• Public Awareness
• Professional Training
• Satellite Support Groups
• Mandatory Screening
• Linking IMH and MH
• Conference

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KEMPE PPDIP

• Psychiatric Evaluation
• MITGGroup Therapy
• Infant
• Mothers Group
• Dyadic
• Open Groups
• Conference
• Professionals
• Families

• Strategic Initiative
• Public Awareness
• Screening
• Primary Care
• Public Health
• Improved Education
• Improved mental health services
• 1-800
• Community Network
• Linking MMH to IMH

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Neonatal

• Nursery
• Mandatory Screening and Education
• Consultation
• Availability of Support
• Availability of Medication
• Connection to Local Resources

• NICU
• Mandatory Screening and Education
• Consultation
• Availability of Support
• Availability of Medication
• On-site therapy

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Who gets what?Step wise approach
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Collaboration!

• Thank You