1. Postpartum Depression Bradley K. Harrison, M.D.

2. Case Presentation A woman visits the doctor for her six- week postpartum evaluation. She reports that she cannot sleep even if her baby sleeps. She cries daily and worries constantly. She does not feel hungry and is not eating regularly. Making decisions is overwhelming. She says she is not herself. –How should this new mother be evaluated and treated?

3. Epidemiology The most common complication of childbearing –10-20% in the US within 6 months of delivery –Nearly 4 million births annually = 400- 800,000 women have this each year Rate may be 25% or higher in women with a history of PPD Over half of all women who develop PPD still suffer symptoms a year later Patients are more likely to seek their PCM than mental health providers

4. Diagnostic Criteria Clinical term referring to a major depressive episode that is temporally associated with childbirth APA DSM-IV: an episode of depression is considered to have postpartum onset if it begins within 4 weeks after delivery –Onset within 3 months after delivery is the time frame commonly used for epidemiologic studies –Episodes at any time within the 1 st year can be considered as being postpartum in onset

5. Diagnostic Criteria (cont.) DSM-IV: uses the term “postpartum” in reference to symptoms of: –Major depressive disorder –Bipolar disorder –Brief psychotic disorder Beginning within 4 weeks of delivery Does not apply “postpartum” modifier to all other psychiatric illnesses –Anxiety disorders: panic disorder, obsessive-compulsive disorder, and phobias

6. Symptoms of Major Depression Defined by 5 of the following: –Depressed mood, often with anxiety* –Markedly diminished interest or pleasure* –Appetite disturbance, usually loss –Sleep disturbance, most often insomnia –Physical agitation or psychomotor slowing –Fatigue, decreased energy –Feelings of worthlessness or guilt –Decreased concentration –Recurrent thoughts of death or suicide Symptoms must be present for most of the day, nearly every day, for two weeks Requires a decline from the woman’s previous level of functioning and substantial impairment

7. Causes Rapid decline in the levels of reproductive hormones that occurs after delivery is believed to contribute Women with a history of postpartum depression appear differentially sensitive to the effects on mood of the withdrawal of gonadal steroids No consistent relationship has been identified Other factors may predispose: –Stressful life events (marital discord, inadequate social support), past episodes of depression (not necessarily related to childbearing), and a family history of mood disorders are all predictors

8. What is not a predictor… Likelihood of postpartum depression does NOT appear to be related to a woman’s education level, the sex of her infant, whether or not she breast- feeds, the mode of delivery, or whether or not the pregnancy was planned.

9. Barriers to Detection Women may expect a period of adjustment; may not recognize ab- normal May be reluctant to admit her feelings May have seen multiple providers for prenatal care May not identify their baby’s pediatrician as a source of help Physicians must evaluate in a shorter amount of time Physician uncertainty

10. Screening Texas Senate Bill (S.B.) 826, directs the Health and Human Services Commission (HHSC) to conduct a study to determine the feasibility and effects of providing 12 months of Medicaid health services to women who are diagnosed with postpartum depression and who are eligible for Medicaid at the time of diagnosis April 13, 2006: Health care providers in New Jersey will be required to screen new mothers for postpartum depression and teach the women and their families about the disorder under a bill signed into law New Jersey, Illinois, Montana, Ohio, and Oklahoma Medicaid agencies are the only programs that reimburse for screening USPSTF: Grade B, “recommends that clinicians routinely provide screening for depression to eligible patients”

11. Screening (cont.) Edinburg Postnatal Depression Scale –10-item questionnaire, self-rated (0,1,2,3) –Used throughout Europe, New Zealand, and Australia primary care offices –Excludes symptoms that may suggest merely physical discomfort –May be filled out by patients in the waiting area prior to examination –Studied extensively and shown to be highly effective at detecting PPD –Threshold score of 12/30 to detect major depression: 100% sensitive, 95.5% specific Routine use of a screening tool results in the dramatic increase in the rate of identification of PPD

12. Screening (cont.)

13. “Have you had depressed mood or decreased interest or pleasure in activities most of the day nearly every day for the past two weeks?” “Has the depression made it hard for you to do your work, take care of things at home, or get along with people?” Postpartum Depression Checklist, Beck Depression Inventory, Center for Epidemiologic Studies Depression Scale

14. Differential Diagnosis “Baby blues” Postpartum Depression Postpartum Psychosis Other psychiatric diagnoses –Anxiety –Panic –Obsessive compulsive Hypo/Hyper-thyroidism Anemia

15. Baby Blues Majority of women (40-85%) experience May last hours to days Symptoms (often for no discernable reason) such as weeping, sadness, irritability, anxiety, and confusion occur Peaks around the 4 th day following delivery, and resolves by 10 th day Transient mood disturbance does not affect the woman’s ability to function

16. Postpartum Psychosis Psychiatric emergency that requires immediate intervention because of the risk of infanticide and suicide 0.2% of childbearing women –Infanticide rate of ~4% in untreated women Usually within the first 2-4 weeks of delivery Differs from other psychotic episodes because it usually involves extreme disorganization of thought, bizarre behavior, unusual hallucinations (visual, olfactory, or tactile), and delusions

17. Postpartum Psychosis (cont.) Psychosis is typically manic in nature –Usually a manifestation of bipolar disorder Warning signs include: insomnia for several nights, agitation, an expansive or irritable mood, and infant avoidance All patients with postpartum depression should be screened: –“Have you ever had 4 continuous days when you were feeling so good, high, excited, or ‘hyper’ that other people thought that you were not your normal self or you go into trouble?” –“Have you experienced 4 continuous days when you were so irritable that you found yourself shouting at people or starting fights or arguments?”

18. Treatment Pharmacologic: SSRI, TCA, SNRI –SSRI: equally effective, once daily dosing, first- line therapy for MDD and PPD, low risk of toxic effects Sensitivity to side effects may indicate initiation of medication at half-dosage –Slow increases are helpful with side effects Remain on starting dosage for ~2 weeks before dosage increased No improvement, or symptoms worsen, initial dosage should be increased –Further increases approximately every week Uncomplicated PPD should have clinical improvement If previous positive response to a specific drug, that agent should be considered

19. Treatment (cont.) SSRI (cont.) –Response to initial medication lasting 6 to 8 weeks, same dose should be continued for a minimum of 6 months –If no improvement after 6 weeks, or if relapse, referral to psychiatrist considered –50-85% with a single episode of major depression will have at least one more episode after discontinuation of medication Risk increases with number of previous episodes Psychotherapy (marital counseling, interpersonal therapy) –Effective for the relief of depressive symptoms and improvement in psychosocial functioning Electroconvulsive

21. Treatment (cont.) Prophylaxis –Should be considered for those at high risk for developing PPD: History of PPD/postpartum psychosis Severe recurrent MDD Onset of depression during pregnancy –Begins with prenatal risk assessment and education –Counseling, social support, and increased education are likely to benefit these women –Prophylactic antidepressant therapy during the 3 rd trimester reduces relapse

22. Breastfeeding All antidepressants are excreted in breast milk; serum levels in infants in multiple studies –Clinical management dictates the use of the lowest effective dose in lactating mothers No reports of adverse effects in breast-fed infants whose mothers were treated with sertraline, paroxetine, or fluvoxamine (Luvox) have been published –Breast-fed fluoxetine-treated gained significantly less weight, no unusual behaviors Colic has been reported in 3 infants who were breast-fed by mothers taking fluoxetine (Prozac) All studies in full-term infants, no preterm No data on long-term neurodevelopment

23. Male Postpartum Depression More women than men had past histories of depression but their rates of depression did not differ significantly during pregnancy In the first 3 months postnatally, nearly 25% of the women at risk were found to have become depressed in contrast with less than 5% of the men In the next 9 months men were more prone to become depressed than previously Prevention and early treatment of depression in fathers may benefit not only themselves but also their spouses and their children