1. Taking Care of the Tree Chris Raines MSN APRN-BC Associate Director, Obstetrical Liaison and Community Outreach UNC Perinatal Psychiatry Program

2. Take Care of the Tree Trunk and the Branches will survive

3. Care of the Tree How do you take care of a Tree WaterNutrientsFertilizer Protect the Roots Sunlight

4. Care of the Tree How do we take care of Ourselves

5. Mood Disorders in Women in the General Population Depressive disorders are very common Depressive disorders are very common Lifetime prevalence rates range from 4.9-17.1 percent Lifetime prevalence rates range from 4.9-17.1 percent Women report a history of major depression at nearly twice the rate of men Women report a history of major depression at nearly twice the rate of men Depression is now considered the leading cause of disease-related disability among women in the world. Depression is now considered the leading cause of disease-related disability among women in the world. Women of childbearing age are at high risk for major depression Women of childbearing age are at high risk for major depression

6. Perinatal Mood Disorder COMMON COMMON 1 in 7 women…15% prevalence rate 1 in 7 women…15% prevalence rate 4 million women give birth annually in U.S.; ½ million with PPD 4 million women give birth annually in U.S.; ½ million with PPD Most common, complication of perinatal and postpartum period Most common, complication of perinatal and postpartum period Compare to prevalence rate of gestational diabetes at 2-5% Compare to prevalence rate of gestational diabetes at 2-5% MORBID MORBID Devastating consequences for patient and family Devastating consequences for patient and family low maternal weight gain, preterm birth low maternal weight gain, preterm birth Impaired bonding between mother and infant Impaired bonding between mother and infant Increased risk of suicide and infanticide Increased risk of suicide and infanticide

7. Risk of Relapse of Major Depression in Pregnancy High risk of depressive relapse following antidepressant discontinuation during pregnancy ( Cohen et al, JAMA, 2006). High risk of depressive relapse following antidepressant discontinuation during pregnancy ( Cohen et al, JAMA, 2006). Of 201 women in the sample, 86 (43%) experienced a relapse of major depression during pregnancy. Of 201 women in the sample, 86 (43%) experienced a relapse of major depression during pregnancy. Women who discontinued medication relapsed more frequently (68% vs 26%) compared to women who maintained medication (hazard ratio, 5.0; 95% confidence interval, 2.8-9.1; P<.001). Women who discontinued medication relapsed more frequently (68% vs 26%) compared to women who maintained medication (hazard ratio, 5.0; 95% confidence interval, 2.8-9.1; P<.001). Pregnancy is not "protective" with respect to risk of relapse of major depression Pregnancy is not "protective" with respect to risk of relapse of major depression

8. Care of the Tree Why do women stop their medications FEAR of harm to the unborn child Pressure from Family Medical Provider tells them to stop I can handle my depression for 9 months GUILTSTIGMA

9. Risks of Untreated Antenatal Depression Associated with low maternal weight gain, increased rates of preterm birth, low birth wt, increased smoking, ETOH and other substances Associated with low maternal weight gain, increased rates of preterm birth, low birth wt, increased smoking, ETOH and other substances Increased ambivalence about the pregnancy and overall worse health status. Increased ambivalence about the pregnancy and overall worse health status. Prenatal exposure to maternal stress has consequences for the development of infant temperament. Prenatal exposure to maternal stress has consequences for the development of infant temperament. Children exposed to perinatal maternal depression have higher cortisol levels than infants of mothers who were not depressed, and this continues through adolescence. Children exposed to perinatal maternal depression have higher cortisol levels than infants of mothers who were not depressed, and this continues through adolescence. Maternal treatment of depression during pregnancy appears to help normalize infant cortisol levels. Maternal treatment of depression during pregnancy appears to help normalize infant cortisol levels.

10. Care of the Tree How do we take care of Ourselves Guilt “Guilt is a cognitive or an emotional experience that occurs when a person realizes or believes-accurately or not- that he or she has compromised his or her own standards of conduct or has violated a moral standard” Wikipedia Wikipedia

12. Care of the Tree How do we take care of Ourselves Stigma “ a set of negative and often unfair beliefs that a society or group of people have about something” Merriam-Webster

13. Documentary Dark Side of the Full Moon Jennifer Silliman Maureen Fura http://www.youtube.com/watch?v=DyYXhgEhcXg www.youtube.com

14. Treatment

15. Perinatal Mood Disorders Treatment One size does not fit all!! One size does not fit all!! Critical for the well being of the woman,baby and family Critical for the well being of the woman,baby and family Effective treatments are readily available Effective treatments are readily available Psychotherapy Psychotherapy Medication Management Medication Management Other, alternative Other, alternative Skilled assessment and treatment by mental health professionals in perinatal psychiatry makes a difference in outcomes Skilled assessment and treatment by mental health professionals in perinatal psychiatry makes a difference in outcomes

16. Screening Instruments Edinburgh Postnatal Depression Scale (EPDS) Edinburgh Postnatal Depression Scale (EPDS) Most commonly employed screening tool Most commonly employed screening tool Beck Depression Inventory (BDI) Beck Depression Inventory (BDI) Montgomery-Asberg Depression Rating Scale (MADRS) Montgomery-Asberg Depression Rating Scale (MADRS) Hamilton rating Scale for Depression (HRSD) Hamilton rating Scale for Depression (HRSD) Nine Symptom Depression Checklist of the Patient Health Questionnaire (PHQ) Nine Symptom Depression Checklist of the Patient Health Questionnaire (PHQ)

17. Edinburgh Postnatal Depression Scale (EPDS) 1,2 Ask patient how they have been feeling OVER THE LAST 7 DAYS, not just today To use calculator, click on appropriate answer and score appears in box when all questions completed 1,2 1. I have been able to laugh and see the funny side of things * 2. I have looked forward with enjoyment to things * 3. I have blamed myself unnecessarily when things went wrong 4. I have been anxious or worried for no good reason * 5. I have felt scared or panicky for no very good reason 6. Things have been getting on top of me 7. I have been so unhappy, I have had difficulty sleeping 8. I have felt sad and miserable 9. I have been so unhappy that I have been crying 10. The thought of harming myself has occurred to me * Questions 1, 2, and 4 are scored in reverse order (0-3) Edinburgh Postnatal Depression Score = /30

18. UNC Center for Women’s Mood Disorders: Perinatal Psychiatry Program Clinical and Research Program that provides assessment, treatment and support for women in the perinatal period Collaboration of doctors, nurses, midwives, therapists, & social workers www.womensmooddisorders.org www.womensmooddisorders.org

19. UNC Center for Women’s Mood Disorders: Perinatal Psychiatry Inpatient Unit 1st free-standing Perinatal Inpatient Unit in the US— renovated summer 2011 1st free-standing Perinatal Inpatient Unit in the US— renovated summer 2011 Provides specialized comprehensive assessment and treatment Provides specialized comprehensive assessment and treatment Medication stabilization Medication stabilization Individual and group counseling and behavioral therapy Individual and group counseling and behavioral therapy Partner assisted therapy, maternal-infant interaction, spirituality, biofeedback, yoga, psycho-education for both patients and spouses Partner assisted therapy, maternal-infant interaction, spirituality, biofeedback, yoga, psycho-education for both patients and spouses Family therapy Family therapy

21. UNC Center for Women’s Mood Disorders: Perinatal Psychiatry Inpatient Unit Protected sleep times Protected sleep times Gliders and hospital grade pumps, supplies, and refrigerator for milk storage Gliders and hospital grade pumps, supplies, and refrigerator for milk storage Specialty perinatal nursing staff Specialty perinatal nursing staff State-of-the art treatment State-of-the art treatment Extended visiting hours to maximize Extended visiting hours to maximize positive mother-baby interaction

22. UNC Center for Women’s Mood Disorders: Outpatient Services: Evaluation, Medication Management, and Therapy Outpatient Services: Evaluation, Medication Management, and Therapy NP embedded in OB High Risk NP embedded in OB High Risk NP embedded in Peds Clinic NP embedded in Peds Clinic Satellite Clinic at Rex Hospital Satellite Clinic at Rex Hospital Tele med Psychiatry for outlying rural Clinics Tele med Psychiatry for outlying rural Clinics Support group Support group 2 nd and 4 th Tuesday of each month 6:30-8p-free 2 nd and 4 th Tuesday of each month 6:30-8p-free

23. References Andrade SE, McPhillips H, Loren D, Raebel MA, et al. Antidepressant medication use and risk of persistent pulmonary hypertension of the newborn. Pharmacoepidemiol Drug Saf. 2009 Mar;18(3):246-52 Andrade SE, McPhillips H, Loren D, Raebel MA, et al. Antidepressant medication use and risk of persistent pulmonary hypertension of the newborn. Pharmacoepidemiol Drug Saf. 2009 Mar;18(3):246-52 Andrade SEMcPhillips HLoren DRaebel MA Andrade SEMcPhillips HLoren DRaebel MA Gavin N, Gaynes B, Lohr K, Meltzer-Brody S. et al. 2005 Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 106:1071-83 Gavin N, Gaynes B, Lohr K, Meltzer-Brody S. et al. 2005 Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 106:1071-83 Cohen L, Altshuler L, Harlow B, Nonacs R. 2006. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 295(5):499-507 Cohen L, Altshuler L, Harlow B, Nonacs R. 2006. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 295(5):499-507 Chambers C, Hernandez-Diaz S, VanMarter L, Werler M. 2006. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med. 354(6):579-87. Chambers C, Hernandez-Diaz S, VanMarter L, Werler M. 2006. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med. 354(6):579-87. Delatte R, Meltzer-Brody S, Cao H, Menard K. 2009 “Universal Screening for Postpartum Depression: An Inquiry into Provider Attitudes and Practice American Journal of Obstetrics and Gynecology, 200(5):e63-4. Delatte R, Meltzer-Brody S, Cao H, Menard K. 2009 “Universal Screening for Postpartum Depression: An Inquiry into Provider Attitudes and Practice American Journal of Obstetrics and Gynecology, 200(5):e63-4. Einarson A, Choi J, Koren G 2009 Incidence of major malformations in infants following antidepressant exposure in pregnancy: results of a large prospective cohort study. Canadian Journal of Psych, 54(4):242-6. Einarson A, Choi J, Koren G 2009 Incidence of major malformations in infants following antidepressant exposure in pregnancy: results of a large prospective cohort study. Canadian Journal of Psych, 54(4):242-6. McKenna K, Koren G, Tetelbaum M, Wilton L et al. 2005 Pregnancy outcome of women using atypical antipsychotic drugs: A prospective comparative study. J Clin Psychiatry: 66:444-449. McKenna K, Koren G, Tetelbaum M, Wilton L et al. 2005 Pregnancy outcome of women using atypical antipsychotic drugs: A prospective comparative study. J Clin Psychiatry: 66:444-449.

24. References Meltzer-Brody S, Payne J, Rubinow D. 2008 Postpartum Depression: Evolving Etiology & Treatment Considerations, Current Psych, 7(5):87-95. Meltzer-Brody S, Payne J, Rubinow D. 2008 Postpartum Depression: Evolving Etiology & Treatment Considerations, Current Psych, 7(5):87-95. Meltzer-Brody S, Hartmann K, Miller W, Scott J. 2004 A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecology. Obstet Gynecol.104(4):770-776. Meltzer-Brody S, Hartmann K, Miller W, Scott J. 2004 A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecology. Obstet Gynecol.104(4):770-776. Oberlander TF, Warburton W, Misri S et al. 2006 Neonatal Outcomes After Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants and Maternal Depression Using Population-Based Linked Health Data. Arch General Psychiatry :63:898-906. Oberlander TF, Warburton W, Misri S et al. 2006 Neonatal Outcomes After Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants and Maternal Depression Using Population-Based Linked Health Data. Arch General Psychiatry :63:898-906. Sit D, Rothschild A, Wisner K. 2006 A Review of Postpartum Psychosis, Journal of Women’s Health: 15(4):352-368. Sit D, Rothschild A, Wisner K. 2006 A Review of Postpartum Psychosis, Journal of Women’s Health: 15(4):352-368. Viguera A & Cohen L. 1998. The course and management of bipolar disorder during pregnancy. Psychopharmacology Bulletin 34:339-353. Viguera A & Cohen L. 1998. The course and management of bipolar disorder during pregnancy. Psychopharmacology Bulletin 34:339-353. Viguera A, Cohen L et al. 2002 Managing bipolar disorder during pregnancy: weighing the risks and benefits. Can J Psychiatry. 2002 Jun;47(5):426-436. Viguera A, Cohen L et al. 2002 Managing bipolar disorder during pregnancy: weighing the risks and benefits. Can J Psychiatry. 2002 Jun;47(5):426-436. Webb R, Abel K, et al. 2005 Mortality in Offspring of Parents with Psychotic Disorders: A Critical Review and Meta-Analysis, Am J Psych:162:1045-1056 Webb R, Abel K, et al. 2005 Mortality in Offspring of Parents with Psychotic Disorders: A Critical Review and Meta-Analysis, Am J Psych:162:1045-1056 Yonkers K, Wisner K, Stowe Z, et al. 2004. Management of Bipolar Disorder during pregnancy and the postpartum period. Am J Psychiatry:161:608-620 Yonkers K, Wisner K, Stowe Z, et al. 2004. Management of Bipolar Disorder during pregnancy and the postpartum period. Am J Psychiatry:161:608-620