1. Dr:Eman Elsheshtawy Ass. Prof. Psychiatry

3. Transient Heightened emotional reactivity 50-85% women experience baby blues Peaks 3-5 days after delivery Lasts up to 10-14 days

4. Considered normal experience of childbirth Symptoms can be distressing Usually don’t affect mother’s ability to function and care for child

5. Characteristics: Mild mood swings Irritability Anxiety Decreased concentration Insomnia Tearfulness Crying spells

6. Two leading hypothesis: Abrupt hormone withdrawal Ovarian steroid receptors in CNS are heavily concentrated in the limbic system The magnitude of the postpartum drop in estrogens and progesterone correlates with presence of “blues”; absolute levels don’t Neuroactive steroids (pregnanolone, allopregnanolone) decrease postpartum, affecting GABA

7.  Neurobiological systems foster attachment between mammalian mothers & infants  Oxytocin activates limbic structures (e.g. the ACG) that mediate the interface between attention & emotion  Postpartum reactivity may stem from this  With stressors, depression may result

9. About 10% of women after delivery Average duration 7 months ¼ still affected at child’s first birthday Overlooked and under diagnosed

10. Female is a 27 year old mother brought into my office as an urgent care appointment. She just had a baby 4 weeks ago after much anticipation. Her husband is an only child and her in-laws filled the nursery with toys and clothes for the baby and are very excited. She is unable to sleep and eat, extremely doubtful of her ability to do anything. She is preoccupied with the fear that she will harm the baby and intense guilt of her inability to meet the expectations of the family. She has been thinking that how easy it is kill herself than to be this worthless

11. Depression negatively effects:  Mother’s ability to mother  Mother—infant relationship  Emotional and cognitive development of the child

12.  Infants perceived to be more bothersome  Make harsh judgments of their infants  Feelings of guilt, resentment, and ambivalence toward child  Loss of affection toward child

13.  Gaze less at their infants  Take longer to respond to infant’s utterances  Show fewer positive facial expressions  Lack awareness of their infants

14. Negative interactive patterns with infant Children exposed to maternal psychiatric illness have:  Higher incidence of conduct disorders  Inappropriate aggression  Cognitive and attention deficits

15.  London study 2001 demonstrated lower IQ’s in 11 year olds whose mothers were depressed at 3 months age  Increased behavior concerns and ADHD (sp. in boys)  Shorter duration of breastfeeding in PPD  Continued breastfeeding in PPD was protective

16.  Patient, society, and physicians dismiss or minimize patients experiences as “normal”  Patient without a primary care physician don’t know who to turn to  Women’s fear and shame about not being a “good mother”  Patients don’t present with CC of depression

17.  Noted in medical history since Hippo crates Recognized in DSM-IV in 1994  Major depression that occurs within 4 weeks of delivery  Definition used by researchers usually allows up to 6 months  5 symptoms, every day, at least 2 weeks AND functional impairment

18. Depressed mood Lack of pleasure or interest Appetite disturbance or weight loss* Sleep disturbance* Physical agitation or psychomotor slowing Fatigue, loss of energy* Feelings of worthlessness or excessive guilt Diminished concentration, or indecisiveness* Thoughts of death or suicidal ideation, Thoughts of harming infant

19. Severe Symptoms:  Thoughts of dying  Thoughts of suicide  Wanting to flee or get away  Being unable to feel love for the baby  Thoughts of harming the baby  Thoughts of not being able to protect the infant  Hopelessnes

20.  Cause unclear  Rapid decline in reproductive hormones  Several factors increase risk

21.  Prior episodes depression, anxiety, OCD, bipolar d/o, eating d/o  Prior depression = 25% risk PPD  Prior PPD = 50% risk recurrent PPD  Stressful life events  FHx mood disorders  Hx of PMDD  Inadequate social support

22.  Education level  Sex of infant  Breastfeeding  Mode of delivery  Planned or unplanned pregnancy

23. During Pregnancy A young and single mother H/O Mental illness or substance abuse Financial or relationship difficulties Previous Pregnancy or postpartum depression After Birth Labor/Birth Complications Low confidence as a parent Problems with Baby’s Health Lack of supports Major Life change at the same time as birth of the baby

25. 2:1,000 births Psychiatric emergency Usually within 3 weeks Usually manifestation of bipolar d/o 70% women experience recurrence in PPP

26.  Severe disturbances  Rapidly evolving manic episodes  Dramatic presentation  Initial signs are restlessness, irritability, insomnia  Infanticide: 4% of untreated PPP  Suicide: 5% of untreated PPP

27. Confusion/disorientatio n Extreme disorganization of thought Bizarre behavior Unusual hallucinations Visual, olfactory, or tactile Delusions (often centered on the infant) Hyperactivity Not feeling need to sleep Rapid speech Loss of touch with reality

28. Inform the public Depression screening in public health settings Provide appropriate referrals Partnership with mental health, social service agencies Follow up care (home visits, support services

29. “Behind the Smile: My Journey Out of Postpartum Depression”, Marie Osmond “Down Came the Rain”, Brooke Shields Anne Lamott, “Operating Instructions: A Journal of My Son’s First Year” Depression After Delivery 1-800-944-4PPD (http://www.depressionafterdelivery.com )http://www.depressionafterdelivery.com National Women’s Health Information Center (www.4woman.gov) Postpartum Support International 1-805- 967-7636