Prenatal

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Prenatal Postpartum Depression

• Bev Young,
• MD, FRCP(C)
• Head,
• Perinatal Mental
• Health Program,
• Mt. Sinai Hospital,
• Toronto, Ontario

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Disclosure

• Speakers Bureau
• GSK, Wyeth, Lundbeck, Astra Zeneca
• Advisory Boards
• GSK, Wyeth, Janssen Ortho

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Pregnancy Postpartum Depression
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Screening for PPD

• Up to 50 of PPD cases go undetected.
• Guilt, shame, and fear of negative consequences
  may prevent women from disclosing their emotional
  distress during what is supposed to be a happy
  time.

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Depression During Pregnancy

• Prevalence similar to nonpregnant women
• Symptoms different from usual pregnancy
• anxiety, irritability, insomnia
• anhedonia
• guilt, worthlessness
• suicidality
• Confounded by medical illness

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Depression During Pregnancy

• Risk Factors
• personal / family history of depression
• marital discord
• adverse life events
• unwanted pregnancy
• Treatment
• Psychotherapy- IPT, CBT
• pharmacologic
• ECT

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Medication in Pregnancy

• First Trimester Exposure
• Organogenesis
• Third Trimester Exposure
• Neonatal Adaptation Syndrome
• Longterm Effects
• Behavioural Teratogenicity

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Antidepressants in PregnancyHealth Canada
Advisory

• When treating depression in pregnant women,
  physicians and patients should carefully consider
  the potential risks and benefits for both the
  mother and the unborn baby
• It is very important that patients do NOT stop
  taking these medications without first consulting
  with their doctor

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First Trimester Exposure

• -Paroxetine and cardiac anomalies
• -increased risk (2 vs. 1)
• -cardiac malformations were not described
• Motherisk study (2005)
• outcomes of almost 3000 infants exposed to
  antidepressants in utero
• no increased risk in any major malformations
  including cardiac defects

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Long term effects

• Fluoxetine and tricyclics
• First trimester use only
• Exposed throughout pregnancy
• 4 year follow-up by neurologist, psychologist,
  pediatrician
• No differences between exposed and non-exposed
  babies
• Nulman I et al N Engl J Med 1997
• Nulman I et al Am J Psychiatry 2002

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Third Trimester Exposureneonatal adaptation
syndrome

• 30 of newborns exhibited symptoms, most were
  self- limiting
• 60 neonates exposed in utero
• 10 showed mild symptoms
• 8 showed severe symptoms tremor, high pitched
  cry, hypertonicity, GI problems, respiratory
  difficulties and occasional seizures
• Costei et al Arch Pediatr Adolesc Med. 2002
• Levinson-Castiel et al Arch Ped Adolesc Med 2006
• Sanz et al Lancet 2005

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Untreated depression physiological effects

• Adverse effects have been linked to increased
  risk for spontaneous abortion, bleeding during
  gestation, growth retardation, pre-eclampsia,
  premature labour and delivery
• Untreated depression in pregnancy is the biggest
  predictor of postpartum depression
• Bonari et al Can J Psychiatry 2004

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Untreated Depressionpsychological effects

• Women suffering from depression are less likely
  to get appropriate prenatal care, more likely to
  smoke and use alcohol
• Women who are depressed are less likely to bond
  well with their baby
• Buist. Aust Fam Physician 2000

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Postpartum Mood Disorders

• Definition
• Begin after delivery
• DSM IV postpartum onset modifier
• symptoms onset within 4 wks pp
• Range in severity
• Postpartum Blues
• Postpartum Depression
• Postpartum Psychosis

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Postpartum Blues

• Prevalence 50 - 85
• Mild and transient
• Symptoms low mood, crying, mood
  lability, irritability, anxiety, insomnia,
  memory concentration problems
• Course begins 3-4 days after delivery peaks
  at day 5-6 back to normal in 2-3 weeks

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Postpartum Psychosis

• Incidence 1-2/1000 births
• Onset mean is 2-3 wks pp, usually within 8
  wks of delivery
• Symptoms
• Early - insomnia, mood lability, restless
• Later - marked mem conc impairment, incoherence
  , suspiciousness, irrational/obsessive
  concerns, delusions and hallucinations

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Postpartum Psychosis

• Suicidal, homicidal ideation
• High rates of maternal and infant morbidity and
  mortality - 4 infanticide
• ? A variant of Bipolar Disorder
• 86 of PPP go on to develop Bipolar Disoder
• Bipolar women have a hundredfold higher risk of
  developing PPP

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Postpartum Psychosis

• Treatment mood stabilizer, antipsychotic,
  benzodiazepine, ECT
• Prevention
• Lithium prophylaxis 24 hrs. pp
• Avoid antidepressants
• Minimize sleep deprivation

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Postpartum Depression

• Prevalence 10-22 of women 26 of
  adolescent mothers
• 60 have their first episode of depression in pp
  period
• Onset within 6 weeks after delivery 85
  reported having PP Blues
• Duration a few wks to many months
• Risk of future PPD 50-65

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Postpartum Depression

• Symptoms depressed mood, anxiety, fatigue,
  changes in sleep and appetite, anhedonia, guilt,
  suicidalilty
• Risk factors pers/fam hx of depression hx
  of PDD stressful life events marital
  discord few social supports preg/delivery
  complications

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Postpartum Anxiety Disorders

• Panic Disorder
• OCD
• PTSD

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Postpartum Depression

• Etiology
• Psychodynamic theories - reactivation of
  mother-daughter conflicts
• Psychosocial theories - role adaptation
• Neuroendocrine theories
• hormonal withdrawal
• ?pp autoimmune thyroiditis

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Postpartum Depression

• Treatment
• Interpersonal psychotherapy
• Psychosocial interventions
• SNRI/SSRIs, TCAs
• Estrogen
• ECT
• Prophylaxis start antidepressant pp week 1

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Medications in Breastfeeding

• Many benefits of breastfeeding
• All medications are excreted in breast milk
• Look at benefits vs. risks
• All antidepressants considered safe
• Guilt of not breastfeeding

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Untreated Postpartum Depression

• PPD may be associated with
• increased rates of depression in husband
• insecure attachment of infant to mother
• negative infant cognitive and social adjustment

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Take-home Messages

• If you ask it, they will respond
• Screen for depressive symptoms routinely
• Pregnancy is not protective for depression
• Treat like past depressive episodes
  
• Postpartum Blues common, normal
• Postpartum Depression anxiety/ irritability/
  guilt, treat ASAP
• Postpartum Psychosis psychiatric emergency,
  think bipolar disorder

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Take-home Messages

• Perinatal depression / anxiety is very treatable
• Consider prophylactic meds if high risk
• Rule-out medical problem- check TSH
• Medications in pregnancy and breastfeeding weigh
  the risks and benefits of each case
• Treatment decisions should be collaborated among
  patient, partner, obstetrician, family doctor,
  midwife, pediatrician and psychiatrist
• Look for available community supports

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For more information

• MGH Womens Mental Health Pgm
• www.womensmentalhealth.com
• B.C. Reproductive Mental Health Pgm
• www.bcrmh.com
• Motherisk 416-813-6780
• www.motherisk.ca
• Postpartum Support International
• www.postpartum.net
• Perinatal Bereavement Services of Ontario
• www.pbso.ca