Perinatal Mental Health: We Can Prevent a Crisis

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Perinatal Mental HealthWe Can Prevent a Crisis
Wendy N. Davis, PhD Perinatal Mental Health ?
Oregon State Symposium Skill Building
Workshop March 5, 2009
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Worldwide Perinatal Support

• Postpartum Support International
• www.postpartum.net
• 1-800-944-4PPD

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The Role of the Provider

• Prenatal Education
• Screening for Risk
• Screening for Occurrence
• Education and Support
• Referrals, Resources, and Follow-Up
• Compassionate Care

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Reliable and Informed Medical Care for Perinatal
Mood Disorders

• Intervenes before a crisis
• Lowers risk of neglect, abuse, or assault
• Prevents overuse of healthcare systems
• Improves birth outcomes
• Keeps families intact, healthy, and productive

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Social Structures that Protect New Mothers

• A distinct postpartum period
• Protective measures reflecting the new mothers
  vulnerability
• Social seclusion and mandated rest
• Functional assistance
• Social recognition of her new role and status

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Supporting the Mother-Infant Relationship

• Adequate rest nutrition
• Positive or resolved birth experience
• Accurate/timely info
• Emotional support
• Practical assistance

• Respite from infant care
• Maternal self-efficacy/self-esteem
• Realistic expectations of self and infant
• Understanding of temperament
• Positive feeding experience

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Screening and AssessmentBest Practice Guidelines

• Inform Mom and Partner Prenatally
• Screen For Risk Factors
• Compassionate Care
• Screen for Present Symptoms
• Assess Severity, Lethality, and Support
• Educate and Validate
• Provide Resources and Referrals
• Follow Up

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Strongest Predictive Factors

• Antenatal depression and anxiety
• Personal and family history of depression
• Life stress and the lack of social support
• Socially disadvantaged women

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Not Risk Factors

• Ethnicity
• Level of education
• Parity
• Gender of child (within Western societies)
• Age (except for hormonal sensitivities)

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Screening Hints

• Missing appointments
• Needing frequent reassurance
• This is harder than I thought
• Repetitive fears and anxieties
• Frequent pain not explained by illness
• Intensity of anger and irritability
• Social Isolation

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Screening Indicators

• sleep disturbance
• marked change in eating habits or weight
• prolonged or unusual fatigue or energy
• extended or severely depressed mood or continued
  mood swings

• Anger, irritability, outbursts
• unusual thoughts, images, or dreams
• feeling disconnected from baby or other children
• inability to rest or relax

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Drawing Them Out

• Let them know that it is your policy to talk to
  all families about their moods and emotions
• Reassure first
• Having a baby is a big change. How are you doing?

• Do you have any questions about your emotions?
• Have you found a good way to eat?
• Many people feel _____. How is it for you?
• Do you have any questions about depression or
  anxiety?

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Assessment The MAP

• Mood Intensity, Duration, Volatility
• Appetite
• Pains
• Sleep
• Support System
• Self-Harm

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EPDS

• Free
• Can be used prenatally or postpartum
• Validated for use in non-postpartum women as well
  as parents of toddlers
• Can be used with adoptive parents
• Translated to 23 languages
• Scoring
• Major depressive disorder cutoff score 12 or 13
• Positive score on item 10 indicates suicidal
  thought

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Sample Lead In Statement

• Please be as open and honest as possible when
  answering these questions.
• It is not easy being a new mother and it is OK to
  feel unhappy at times. As you have recently had a
  new baby, we would like to know how you are
  feeling.
• Please state the answer which comes closest to
  how you have felt during the past several days,
  not just how you are feeling today.

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EPDS InterpretationNursing Best Practice
Guidelines

• Consider score along with the assessment of the
  health care provider.
• Score of 12 or greater indicates the presence of
  depressive symptoms.
• Use caution when interpreting the score of
  mothers who are non-English speaking and/or use
  English as a second language or are multicultural.

• Registered Nurses Association of Ontario (RNAO).
  Interventions for postpartum depression. Toronto
  (ON) Registered Nurses Association of Ontario,
  2005

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EPDS Interpretation ( continued)Nursing Best
Practice Guidelines

• If score is positive (1, 2 or 3) on self-harm
  item number 10, further assessment should be done
  immediately for self-harm ideation
• Follow agency/institution protocol regarding
  scores.
• Remember that the EPDS is only a tool. If your
  clinical judgment indicates differently than the
  EPDS continue with the follow up as the
  assessment indicates.

• Registered Nurses Association of Ontario (RNAO).
  Interventions for postpartum depression. Toronto
  (ON) Registered Nurses Association of Ontario
  (RNAO) 2005

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3 Question EPDS

• I have blamed myself unnecessarily when things
  went wrong.
• I have felt scared or panicky for not very good
  reason.
• I have been anxious or worried for no good
  reason.
• Kabir, Sheeder and Kelly

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PDSS Postpartum Depression Screening Scaleby
Cheryl Beck

• Written at a third-grade level
• Long Form is 35-item Response Scale, Short Form
  is 7 questions
• PDSS has been validated in English and Spanish
• Scores
• Major depressive disorder cutoff 80
• minor depression cutoff 60

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Ruling Out Other Causes

• PTSD
• Birthing Trauma
• Undisclosed trauma or abuse
• Thyroid or pituitary imbalance
• Anemia
• Side effects of other medicines
• Alcohol or drug use

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Referral and Treatment Options

• Medical Assessment to rule out other causes
• Social Support Phonelines and Groups for PMDs
• Individual, family, or group therapy
• Psychiatric medication evaluation
• Endocrinology
• Supportive Treatments
• Spiritual support

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9 Steps to Wellness

• Education
• Rest
• Nutrition
• Exercise and Time for Myself
• Sharing with Non-Judgmental Listeners

• Emotional Support
• Practical Support
• Professional Resources
• Plan of Action

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Acute Stage Difficulties

• Insomnia
• Panic Attacks and Fear of Being Alone
• Intrusive Thoughts
• Discouragement and Despair
• Suicidal Ideation and Escape Fantasies
• Guilt and Poor Self-Nurturing

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Research on Rates of Depression in High Risk
Pregnancy and Postpartum

• High-Risk Pregnancies
• Bed-Rest, Hyperemesis
• Pre-term Infants and Maternal Mental Health Risks
• Unique risks and stressors
• Moms of Multiples
• Depression and anxiety disorders over 25 more
  prevalent in mothers of multiples during prenatal
  and postpartum periods (Leonard L., 1998)
• Neonatal/Perinatal Loss

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Panic

• Episodes of extreme anxiety
• Shortness of breath, chest pain, sensations of
  choking or smothering, dizziness
• Hot or cold flashes, trembling, rapid heart rate,
  numbness or tingling sensations
• Restlessness, agitation, or irritability
• Excessive worry or fear
• Panic may wake her up
• Beyond the Blues by Indman and Bennett

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PTSD

• Symptoms
• Intrusive re-experiencing of a past traumatic
  event
• Isolation from family friends
• Emotional Numbing
• Hyperarousal, Hypervigilant
• Visions, flashbacks, nightmares
• Avoidance
• Lack of concentration
• Anger/ Irritability/ Mood Swings
• Websites
• tabs.org.nz

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OCD Symptoms

• Intrusive, repetitive thoughtsusually of harm
  coming to baby (ego-dystonic thoughts)
• Tremendous guilt and shame
• Horrified by these thoughts
• Hypervigilence
• Moms engage in behaviors to avoid harm or
  minimize triggers
• Educate mom that thought does not equal action

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OCD Behavioral Symptoms

• Cleaning
• Checking
• Counting
• Ordering
• Obsession with germs, cleanliness
• Checking on baby
• Hypervigilence

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OCD Things to Note

• Often occurs along with Depression
• Because women with OCD will not discuss thoughts,
  providers MUST ask about scary thoughts
• Afraid Im Andrea Yates

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Peripartum OCD

• High risk time for onset exacerbation
• Antepartum onset in 13 - 59 of mothers with OCD
• Exacerbation in women with pre-existing OCD 17
  - 43 during pregnancy 29 postpartum
• Clinical presentation
• Higher rate of aggressive obsessions - e.g.
  obsessional fears of harming infant
• Fear of contaminating fetus or infant
• Compulsive washing of items belong to infant

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OCD vs. Psychosis

• Postpartum OCD
• More gradual onset
• Women recognize thoughts/images are unhealthy
• Extreme anxiety related to thoughts/images
• Overly concerned about becoming crazy
• Postpartum Psychosis
• Acute onset sudden noticeable change from
  normal functioning
• Women do not recognize actions/thoughts are
  unhealthy
• May seem to have less anxiety when indulging in
  thoughts/behaviors

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Thoughts of Harming Baby Low Risk

• Mother doesnt want to harm baby
• The thought is obsessive in nature and
  odd/frightening to mother
• Mother has taken steps to protect baby
• Mother has no delusions or hallucinations related
  to harming baby

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Interventions

• Educate that thought does not equal action
• Cognitive-behavioral techniques
• Connect with others who have recovered
• Educate and Teach about Anxiety Reduction

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Thoughts of Harming Baby High Risk

• Mother has delusional beliefs about the baby
  e.g. that the baby is a demon
• Thoughts of harming baby are ego-syntonic (mother
  thinks they are reasonable and/or feels tempted
  to act on them)
• Mother has a history of violence
• Mother has a labile mood and/or impulsive behavior

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Postpartum Psychosis

• Risk Factors
• Pre-existing bipolar disorder
• Family hx of PP Psychosis
• Chance of Recurrence is 20 - 25
• Higher if it was mania
• Higher if it has happened more than once

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Bipolar Disorders Manic/Depressive

• 60 of bipolar women present initially as
  depressed (if prescribed antidepressant alone,
  might induce cycling into mania)
• 50 of women with bipolar are 1st diagnosed in
  the postpartum period
• 85 of bipolar women who go off their medications
  during pregnancy will have a bipolar relapse
  before the end of their pregnancy

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The "Highs" of Bipolar Disorder Symptoms of Mania

• Racing speech, racing thoughts, flight of ideas
• Impulsiveness, poor judgment, distractibility
• Reckless behavior
• Grandiose thoughts, inflated sense of
  self-importance
• In the most severe cases, delusions and
  hallucinations

• Increased physical and mental activity and energy
• Heightened mood, exaggerated optimism and
  self-confidence
• Excessive irritability, aggressive behavior
• Decreased need for sleep without experiencing
  fatigue

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The Lows of Bipolar Disorder

• Prolonged sadness or unexplained crying spells
• Significant changes in appetite and sleep
  patterns
• Irritability, anger, worry, agitation, anxiety
• Pessimism, indifference
• Loss of energy, persistent lethargy

• Feelings of guilt, worthlessness
• Inability to concentrate, indecisiveness
• Inability to take pleasure in former interests,
  social withdrawal
• Unexplained aches and pains
• Recurring thoughts of death or suicide

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The Medication Decision

• Not every depressed mother needs medication, but
  some can really benefit from it
• Ask about her current level of functioning and
  her feelings about medication
• Discuss risks of breastfeeding with medications
  vs. risks of not breastfeeding
• If mother is unsure or negative about
  medications, ask if she would be willing to give
  non-medication choices a try

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Safety of Medications

• Factors to consider
• Peak. Time from administration to highest level
  in mothers plasma. Mother can avoid
  breastfeeding during peak. Choose meds with short
  peak intervals
• Protein binding. The higher percentage of protein
  binding, the less likely the drug is to enter the
  milk. Good protein binding is gt90
• Nature of the metabolites. The baby gets
  significantly less exposure with inert
  metabolites
• Hale (2002) Lawrence Lawrence (1999)

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Resources for Breastfeeding and Medications

• www.breastfeedingonline.com
• www.kellymom.com
• www.womensmentalhealth.org
• Mass General's Center for Women 
•   
• www.motherisk.org
• Canadian organization provides evidence-based
  research
• www.psych.uic.edu/clinical/HRSA
• www.pregnancyanddepression.com

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Omega 3s and Infant Sleep

• Mothers who were high in DHA during pregnancy had
  
• Infants with a significantly lower ratio of
  active sleep to quiet sleep
• And less active sleep than infants of mothers low
  in DHA
• These were indications that infants of high-DHA
  mothers had greater CNS maturity because DHA is
  essential for the babys developing central
  nervous system (Cheruku et al., 2002)

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DHA in Food

• Mothers who
• Consumed high amounts of seafood during pregnancy
  
• And had high levels of DHA (docosahexaenic acid)
  in their milk
• Had lower levels of postpartum depression
• Hibblen, 2002

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Social Support

• The Empowerment of Peer Support

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Telephone Support

• Warmline one to one
• Nonjudgmental
• Confidential

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Therapeutic Interventions

• Put out the fire before you rewire the house.
• Therapy or Counseling
• Individual
• Couples
• Family
• Group
• Evidence Based Treatment
• Cognitive Behavioral
• Interpersonal
• Family Systems

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Cognitive-Behavioral Therapy

• Highly effective therapy for the treatment of
  depression, anxiety, OCD, and pain
• Based on the premise that depression is caused by
  distortions in thinking
• The goal is to help clients identify these
  distorted thoughts and replace them with more
  rational ones

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Meta-Synthesis of 18 Qualitative Studies

• Incongruity between expectations and reality of
  motherhood
• Spiraling downward
• Pervasive loss

Mauther, 1999
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Downward Spiral

• Shattered Expectations
• labor and delivery
• life with their infants
• self as mother
• relationship with partners
• support from family and friends
• life events
• physical changes
• Berggren-Clive, 1998

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Pervasive Loss

• Loss of control was identified as a central theme
  in 15 out of the 18 studies
• Loss of autonomy and time were precursors to
  feeling out of control
• Lack of time to consider themselves or process
  their daily experiences.
• Loss of self-identify, loss of former sense of
  self.
• Loss of relationships with their partners,
  children, and family members
• Morgan, Matthey, Barnett Richardson, 1997
• McIntosh, 1993

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Alienation and Rejection

• Wanted their partners to be able to read their
  minds and take some initiative in helping them
• Felt that admitting their feelings was a sign of
  personal inadequacy and failure as a mother
• Risked being misunderstood, rejected, or
  stigmatized
• Expressed feelings of being different and
  abnormal compared to other mothers

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Alienation and Rejection

• Profound sense of isolation, loneliness,
  discomfort being around others
• Believed that no one really understood what they
  were experiencing
• Socially withdrew to escape a potentially
  critical world

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Depressive Symptoms in Dads

• Initial high after birth may give way to
  depression
• Rather than sadness, men may be more likely to be
  irritable, aggressive, and sometimes hostile when
  depressed
• Distancing Checking Out
• Distractions and Habits
• James F. Paulson, et.al, Pediatrics, Aug 2006

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How do we support partners?

• ASK how they are doing
• Online Support
• Family Groups and Meetings
• Use Inclusive Language
• Encourage more research
• Remember Family Diversity
• Ask for their stories

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Resources for Fathers

• www.postpartumdads.org
• www.postpartummen.com
• PSI Free Phone Forums - www.postpartum.net
• www.bcnd.org
• www.brandnewdad.com
• www.postpartumdadsproject.org
• www.fathersforum.com

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Effects on Toddlers

• Higher risk for affective disorders
• Poor peer relationships, poor self-control
• Neurological delays, attention problems
• Symptoms mimic moms depressed behavior

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Post - Adoptive Depression

• Little research
• some evidence shows depression post adoption
• Resources developed in last 5 years
• Melges, F.T. (1968).Postpartum psychiatric
  syndromes. Psychosomatic Medicine. 30, 95-108.

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Cultural Practices and Values

• Gender Roles
• Assumptions about Mental Illness or Distress
• Medicine
• Faith and Religious Practice
• Role of Friendship, Role of Family
• What is a Good Mother? A Strong Woman?

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Depression in Latin American Mothers

• Three samples of mothers from Costa Rica and
  Chile
• All mothers were low-income
• 35 to 50 had at least one episode of MDD or
  were severely dysphoric at time of assessment
• One third of Chilean moms were dysphoric after
  childbirth (Wolf et al.,2002)

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Mamás y BebésMothers and Babies course

• Aimed at preventing depression among pregnant,
  predominantly Latina women
• Addressed cultural differences in the role of
  mothers in the U.S. versus Latin America
• Strategies for empowering clients include how to
  attain greater agency by selecting positive
  cultural values and practices both from ones
  culture of origin and the majority culture

(Munoz Mendelson, 2005)