The Pediatrician and maternal depression

1
The Pediatrician and maternal depression

• Martin Maldonado MD

2
Why is maternal depression important?

• Frequency of the problem, i.e. Epidemiology
• Impact of depression on
• The mother
• The baby
• The father
• The family

3
Why is maternal depression important?

• Transactional aspects of depression
• Impact on the mother-infant relationship
• Manifestations of distress in the baby i.e.
  calls to the pediatrician
• Long Term effects of maternal depression on child
  and adolescent

4
Why is maternal depression important?

• Treatability of depression
• Preventability of negative effects on the mother,
  infant and family

5
Role of Pediatrician

• Detection
• Referral
• Provide support and containment

6
Pregnancy and Postpartum period

• Normal tensions during pregnancy
• Fear of loss of the baby
• Fear of outcome of pregnancy
• Fear of delivery itself
• Tension about how to be a mother/ father
• Somatic symptoms and emotionality

7
Excessive stress during pregnancy

• ASSOCIATED WITH
• Increased risk for the pregnancy
• Higher rate of premature delivery (Raufus and
  Gauger, 2003)
• Higher risk of preeclampsia (Glynn et al, 2001)
• Higher rate of miscarriage
• Higher possibility of dysmorphic conditions?

8
Excessive stress during pregnancy

• Higher risk of miscarriage i.e. premature
  spontaneous termination of pregnancy
• Eg. If victim of a crime
• If stress at work place
• If death of a relative

9
Excessive stress during pregnancy

• Lower perfusion by uterine artery (Contraction of
  uterine artery. (Glover et al.)
• Higher level of cortisol in serum in mother and
  fetus
• Higher level of epinephrine in mother and
  negative effect on fetus
• Risks of higher fetal suffering
• Placenta more likely insufficient

10
Excessive stress during pregnancy

• Copper et al. 1996. Multicenter study
• 2593 women in ten centers
• Ages 25-29
• Higher psychosocial stress is associated with
• HIGHER INCIDENCE OF PREMATURITIY
• LOWER GESTATIONAL WEIGHT
• Growth restriction of fetus

11
Excessive stress during pregnancy

• Rauchfus and Gauger, 2003
• Study with 508 women
• Higher rates of stress are associated with higher
  risk of prematurity
• Higher risk if Lower access to female network
• Lower support from Partner
• Higher preoccupation with somatic problems

12
Excessive stress during pregnancy

• Higher incidence of low birth weight, even if at
  term
• Chronic lower perfussion toward placenta and
  fetus? ( Xiao et al, 2003)
• Associated with daily hassles in womans life
• Particularly if stress occurs during the first
  trimester of pregnancy (e.g. earthquake)

13
Long term effects of anxiety in pregnancy

• Prematurity is known to be associated with
  emotional and behavioralP disturbances later on
• Learning difficulties
• Attention deficit hyperactivity disorder
• Disruptive behavior
• Increased aggression

14
Long term effect of in utero stress for child

• Higher risk of self-regulation difficulties
• Higher risk of attention deficit hyperactivity
  disorder ( Linnet et al, 2003. Laucht et al,
  2000. War time stress , Meijer 1985)
• More temperamental difficulties, more difficult
  children at age 4 (OConnor, 2002)

15
Long term effect of in utero stress for child

• Avon Longitudinal Study ( OConnor et al, 2003)
• High anxiety during pregnancy
• PROGRAMMING EFFECT on fetus
• Higher rate of behavioral and emotional problems
  at ages 47 months and 81 months

16
Long term effect of in utero stress for child

• Huizink et al, 2003
• Higher anxiety during pregnancy
• Follow up 170 women
• LOWER performance in developmental scores in the
  babies at 8 months (cognitive and motor
  performance)

17
Need to reduce stress for future mother

• Awareness of negative effects
• Avoidance of stressful situations
• Creating a protective of buffering environment
• Mothering of the mother
• Need for peace of mind, absence of daily hassles
  and a supportive network.

18
Depression during pregnancy and postpartum

• Many women who are depressed postpartum are known
  to have been depressed during the pregnancy
  already
• The husband of a depressed woman is more often
  (than the general population) depressed also

19
Postpartum blues

• Awareness of negative effects
• Avoidance of stressful situations
• Creating a protective of buffering environment
• Mothering of the mother
• Need for peace of mind, absence of daily hassles
  and a supportive network.

20
Postpartum blues

• Appears most often in the 4th or 5th day
  postpartum
• Does not require treatment
• Requires psychosocial support, reassurance
• mothering the mother
• Role of sudden suppression of progesterone?
• Improves spontaneously over weeks

21
Postpartum depression

• The problem is frequent
• 15 to 20 of women suffer depression in the
  post-partum period
• In some groups, the figure is higher
• It is largely a psychosocial problem
• To a lesser extent a biological problem

22
Postpartum depression

• First described 1551 by Amatus Lusitanus
  (Rodrigues de Castelo Branco)
• Schultz Melancholia ex utero
• Then, recurrent puerperal melancholia
• Tuke, 155 cases of pregnancy-related insanity

23
Diagnostic suspicion

• Clinicians working with infants must take into
  account the possibility of depression
• Think of risk factors and protective factors
• Think of psycho-somatic manifestations of
  depression
• Observe the mothers demeanor, mood and level of
  energy

24
Risk factors for depression

• CURRENT LIFE CIRCUMSTANCES
• Small children at home
• Poverty and stress associated with it
• Unsupportive partner or husband
• Single mother or abandoned
• Other sources of stress ( multiplying effect of
  stressors)

25
Risk factors for depression

• PREVIOUS EXPERIENCES
• History of physical or emotional maltreatment
• History of losses before age 10
• Poor school history
• More separations from parents during childhood

26
Risk factors for depression

• Main factors are psychosocial
• Biological factors
• Sudden decrease in hormones after delivery, e.g.
  decrease in progesterone
• Possible role of anti-thyroid antibodies (10 of
  women)
• Possible role of thyroiditis after delivery
• Role of increased levels of cortisol?

27
Depression phenomenology

• Sadness, anxiety, irritability, tension
• Self-reproach, pessimism
• Reclusion , loss of vitality, role-failure,
  self-neglect
• Somatic features, insomnia, sloness in thinking,
  hyporexia
• Suicidal ideation?
• Feeling overwhelmed and incapable

28
Effects of depression

• Duration of depression, I.e. whether several
  months or throughout the first year of babys
  life
• Clinical features of depression e.g. withdrawal
  socially , isolation, unresponsiveness vs
• Irritability, less patience, agitation

29
Effects on mother

• Mother may feel overwhelmed by her baby
• Mother may feel inadequate, too uncertain
• Mother may worry about physical status of baby,
  excessively
• Frequent calls to health care personnel in order
  to establish contact, to talk, to be supported
• Multiple questions

30
Effects on infant

• First few months
• Infant may appear depressed (Field et al.)
• Less emotional availability, conversations,
  animation
• Less stimulation and less responsiveness
• Baby may become flat or dejected

31
Effects on infant

• Young infant ( Lynne Murray et al.)
• More infant crying,
• More inconsolable crying
• More sleeping difficulties
• More difficult child
• More irritability in infant

32
Mother infant relationship

• If withdrawal and less energy in the mother
• More distance maneuvers
• More coercive techniques
• Child perceived as more demanding, difficult and
  as work.
• Little joy in the relationship

33
Mother infant relationship

• If mother is more irritable and has mood shifts
• More parent child conflict
• More possibility of negative interactions, anger
  in the relationship
• More perception of childs negative attributes

34
Long term effects

• More negative effects on boys as a whole, but
  also on girls ( L. Murray)
• More possibility of negative and angry behaviors
  in the child at 7 years of age
• More hyperactivity and restlessness in the child
• More difficulties academically, attention,
  reading, learning in general

35
Other effects

• Possibly affects nutritional status of infant
• Higher rate of growth retardation
• Higher rate of growth stunting
• (Cohort of 160 infants of depressed mothers
  compared with control group in Pakistan,
• Rahman et al, 2004
• (Higher rate of diarrhea)

36
Duration

• May experience remission after 3 months
• More likely to persist the more it occurred
  before childbirth
• More likely to persist the more risk factors are
  present

37
Interventions

• Early identification
• Early Intervention
• Role of the primary health care staff
• Role of lactation consultant, pediatrician,
  visiting nurse, home visitor
• Asking questions and observing actual
  interactions

38
Early identification

• Edinburgh Postnatal Depression Scale
• 10 items. Rated according to severity of
  symptoms 0,1,2, and 3
• Items 3,5,6,7,8.9, 10 are reverse-scored (3,2,1,
  0)
• Add up points , cut off varies After threshold
  of 10 sensitivity falls
• Score of 13, picks up 81 major depression
• High specificity and sensitivity

39
Interventions

• Psychosocial interventions are primary
• Emotional support
• Normalization
• Understanding
• Providing information about depression
• Seeking supplementation of what is missing

40
Interventions

• Supportive relationships
• Confiding feelings, losses, previous experiences
• Role of containing and listening to stories
• Role of being emotionally available
• Role of giving practical help

41
Interventions

• Maternal need for mothering
• I.e. support, understanding, care, etc.
• Eliciting participation from extended family and
  companion, spouse, etc.
• Role of interpersonal relationships eg.
• Interpersonal psychotherapy

42
Interventions

• Unloading of emotions, empathic exploration of
  experiences
• Shameful feelings about the baby
• No censure, conveying hope
• Much psychotherapy is provided by friends,
  mother, spouse (Brockington, 1996)
• Involving the father, day hospital, etc.

43
Interventions

• Cognitive and behavioral interventions
• Psychodynamic interventions
• Role of group of peers
• Other adults, other mothers.
• Help coping with infant needs and problem-solving
• Alleviation of stressors

44
Interventions

• Role of medications
• Selective Serotonin Reuptake Inhibitors (SSRI)
• Indications for medication. Severity, absence of
  support, important neurovegetative symptoms.
• Suicidal ideation