Perinatal Mood Disorders Presented By: Heidi Haensel, MD, FRCPC March 20, 2019 Perinatal Mood Disorders

Disclosure: I have not had in the past 3 years, a financial interest, arrangement or affiliation with one or more organizations that could be perceived as a direct or indirect conflict of interest in the content of this presentation.

Objectives: To review the presentation of mood disorders (Depression and Bipolar Disorders) in pregnancy and postpartum To discuss the impact of mood disorders in pregnancy and postpartum on the mother and infant To discuss screening and management of mood disorders in pregnancy and postpartum

Depression in Pregnancy and Postpartum- a Common Problem Between 5 and 16% of women will experience major depression at some point during their pregnancy Between 4.2%–9.6% will experience a major depressive disorder between birth and 3 months postpartum Estimates vary between 9.3% and 31% for the first year postpartum

Baby Blues – Even More Common occur in 50-85% of women Peak symptoms 3rd to 7th day after delivery; usually completely gone 3 weeks after delivery Thought to be reaction to hormone changes post-pregnancy Main feature is mood lability - “crying at the drop of a hat”; “moodiness” Also anxiety, insomnia, poor appetite and irritability Not as severe, persistent or pervasive as postpartum depression

Depression in Pregnancy and Postpartum – How to Recognize Those with a history of depression carry the greatest risk However, for 50-70% it is the first presentation of depression in their lifetime If discontinuation of antidepressants near conception,75% relapse (often 1st trimester) With abrupt discontinuation antidepressants during pregnancy, 70% have adverse effects, suicidality, hospitalization

Depression in Pregnancy and Postpartum – How to Recognize Symptoms: Sad mood Crying frequently Changes in sleep: in post-partum, often not able to sleep when baby is sleeping Appetite: diminished appetite in breastfeeding a concern Decreased energy and motivation: not keeping up with baby or self care Anhedonia: don’t enjoy, feel bonded to the baby High anxiety frequently seen May have thoughts of harm to self or to the baby: e.g. “They are better off without me”; smothering baby, leaving baby in a snow bank

Risks for Developing Perinatal Depression Personal history of depression, depression in pregnancy – up to 50% develop postpartum depression Previous postpartum depression Family history of depression

Risks for Developing Perinatal Depression Excessive anxiety during pregnancy; Lack of confidence in parenting skills/excess anxiety about baby Poor social support – social isolation, recent move, poverty, cultural or language issues Relationship or family conflict; Life/financial stress Recent adverse life events (e.g., loss of close relative or friend); previous pregnancy loss Intimate partner violence Unintended pregnancy/ambivalence towards pregnancy Infants with health problems or perceived difficult temperaments Chronic/acute maternal health problems

Perinatal Depression - Impact Impacts of untreated perinatal depression are much greater and farther-reaching than risks associated with antidepressant treatment Impacts on pregnancy outcomes and child development derive from poorer prenatal care, more substance use in pregnancy, poorer nutrition and self-care, epigenetic effects of chronic stress Postnatal impacts on relationships with family and spouse; attachment security of infant; confidence in parenting; sustaining breastfeeding; substance use In turn, these impact the motor, language and social development of infants and children Suicide and infanticide risks

Perinatal Depression - Impact Impacts for mother poor self care, inadequate nutrition & weight gain, sleep disturbance, illicit drug use, smoking , alcohol abuse emotional deterioration, increased anxiety interpersonal/family conflict increased risk pre-eclampsia, operative delivery, epidural, NICU Suicide, attempted suicide, infant harm and infanticide Impacts for infant preterm birth lower birth weight smaller head circumference lower APGAR scores Significant behavioural problems more likely Sleep and eating disorders Difficulties in regulating emotions and behaviour eg. temper tantrums Delayed language development Lower rates of secure attachment

Bipolar Disorder in the Perinatal Period Rates the same as general population (2.1%) Pregnancy confers risk for exacerbation of symptoms (45-50% report this) Many women discontinue medications abruptly in pregnancy; 50% will relapse Postpartum period conveys increased risk for onset of Bipolar Disorder or relapse 25%–30% recurrence rate in the immediate postpartum and relapse rates at 3-6 months postpartum of 67%–82%. Rate of postpartum psychosis is 10–20% among women with bipolar disorder. In Bipolar Type 2, hypomanic symptoms in pregnancy can be misattributed as “nesting behavior”, and in postpartum they can be attributed to elation about the baby Diagnosis often missed until mood swings into depression

Postpartum Psychosis Rare; 1 to 2 per 1000 births If first onset psychosis, usually is a first presentation of bipolar disorder Symptoms develop typically 2 to 3 days after delivery, but may develop up to 4 weeks after Prodrome of worsening insomnia and agitation Symptoms of lability, disorganized thoughts and behaviour, bewilderment, poor memory Progresses rapidly Bizarre thoughts often involve the baby; e.g. the baby is an alien, dead, replaced Infanticide: 1-3 per 50,000 births; suicide also a risk Postpartum psychosis is an emergency, and requires hospitalization and psychiatric management

Perinatal Mood Disorders - Screening Bipolar Disorder – no validated tool for perinatal period; rely on diagnostic interview Depression – Edinburgh Postnatal Depression Scale See the “new” Ontario Antenatal Record for screening tools and schedule Screening in pregnancy recommended, as well as 6 weeks postpartum

Edinburgh Postnatal Depression Scale Validated for use in postpartum and pregnancy; self-report Can be used for partners and adoptive parents as well Puts less emphasis on sleep and appetite as symptoms, as these are commonly disrupted in pregnancy and postpartum; more emphasis on anxiety symptoms and cognitive symptoms of depression Is not the “gold standard” – this is still the diagnostic interview

EPDS Score Interpretation Action Less than 8 Depression not likely Continue support 9–11 Depression possible Support, re-screen in 2–4 weeks. Consider referral to primary care provider (PCP). 12–13 Fairly high possibility of depression Monitor, support and offer education. Refer to PCP. 14 and higher (positive screen) Probable depression Diagnostic assessment and treatment by PCP and/or specialist. Positive score (1, 2 or 3) on question 10 (suicidality risk) Immediate discussion required. Refer to PCP ± mental health specialist or emergency resource for further assessment and intervention as appropriate. Urgency of referral will depend on several factors including: whether the suicidal ideation is accompanied by a plan, whether there has been a history of suicide attempts, whether symptoms of a psychotic disorder are present and/or there is concern about harm to the baby.

Also Consider: Anxiety disorders Adjustment disorder with depressive symptoms Grief Personality disorders, especially Borderline Personality Disorder Domestic violence Stressful life circumstances Substance misuse

Perinatal Mood Disorders - Treatment

Bipolar Disorder in the Perinatal Period Ideally, consultation with a psychiatrist prior to conception to discuss relapse risks and risks of medication Generally psychiatric management recommended throughout pregnancy; requires close monitoring for emergence of relapse Consult regarding medications: Mother Risk or FRAME Clinic at Victoria Hospital 519-685-8500 ext. 58293 Need high support in immediate postpartum; extended hospital stay (3 to 5 days) recommended Promote medication adherence and good self-care, especially sleep

Perinatal Bipolar Disorder - Medications Atypical antipsychotics, lamotrigine are safest in pregnancy Lithium – risks of neonatal toxicity at birth and through breast milk; cardiac risk is less than original estimates Valproic acid – confers greatest risk of neural tube defects; only use if no other medications work; use 5 mg folic acid daily Detailed second trimester ultrasound recommended for women on lithium or antiepileptic medications

Depression in the Perinatal Period Treatment should take into account history of symptoms, preferences of woman Mild to moderate depression – psychotherapeutic interventions first line Moderate to severe depression – indication for medications

Psychotherapy in Perinatal Depression Psychoeducation Lifestyle interventions – promoting sleep, nutrition, exercise, social support Healthy Babies, Healthy Children referral Strong research evidence on benefit of friendly home visitor

Psychotherapy in Perinatal Depression Evidence-based psychotherapies: Supportive Psychotherapy Cognitive-Behaviour Therapy Interpersonal Therapy Remember to screen for Employee Assistance Program or Benefits to access community psychotherapy Postpartum Mood Disorders Support Groups Elgin PPMD Support Group Vesta Parenting Centre

Medications in Perinatal Depression Most antidepressant medications in pregnancy have not been shown to confer risks above the baseline risk of malformations Exception is: Wellbutrin – increased risk of left ventricular outflow obstruction; paroxetine in first trimester – increased cardiac and limb defects Most antidepressant medications are very compatible with breastfeeding Fluvoxamine, Effexor and Wellbutrin have increased exposure through breastmilk and require more monitoring

Perinatal depression – when to refer Complex, treatment resistant depression Very severe symptomatology Depression with psychosis

QUESTIONS? Heidi.Haensel@lhsc.on.ca 519-685-8500 ext 76673