1. Depressive Disorders in Obstetrics and Gynecology Sheila Marcus, M.D. Kelsie Thelen, B.A. Maria Muzik, M.D., M.S. Copyright © 2011. World Psychiatric Association

2. Depressive Disorders in Obstetrics and Gynecology Premenstrual Syndrome (PMS) 50%-80% of menstruating women experience mild symptoms; 20% severe 1,2 Premenstrual Dysphoric Disorder (PMDD) 3%-8% of menstruating women meet diagnostic criteria for PMDD 3,4 Symptoms: depressed mood, anxiety, tension, irritability, lethargy, food cravings, physical symptoms (breast tenderness, headaches) 4 Risks: history of depressive disorders, cultural attitudes toward menstruation, cognitive style, neuroticism, personality 5,6 Treatment Options: lifestyle/stress management, cognitive behavioral therapy (CBT), 7 antidepressants (SSRIs improve affective symptoms) 8 Oral Contraceptive Use Possible familial risk of developing depressive disorders during contraceptive use 9 High-dose progestin associated with depressive mood, hypersomnia, weight gain, and gastrointestinal symptoms 10 Pyridoxine (vitamin B6) supplementation and lower dose oral contraceptives may alleviate depressive symptoms associated with contraceptives 11 Copyright © 2011. World Psychiatric Association 1 Deuster et al., Arch Fam Med 1999; 2 Perkonigg et al., J Clin Psychiatry 2004; 3 Wittchen et al., Psychol Med 2002; 4 DSM- IV-TR 2000; 5 Bancroft et al., Psychosom Med 1994; 6 Bancroft et al., Psychol Med 1993; 7 Freeman, Pharmacoeconomics 2005; 8 Halbreich et al., Obstet Gynecol 2002; 9 Kendler et al., J Nerv Ment Dis 1988; 10 Rush et al., Biol Psychiatry 2003; 11 Adams et al., Lancet 1973 2

3. Depressive Disorders in Obstetrics and Gynecology Pregnancy-Related Depression During pregnancy 10% of women experience mood disorders; 1 up to 18% suffer subsyndromal depressive symptoms 2 Risk factors: higher number of previous pregnancies, 3 previous depressive disorders, single marital status or marital conflict, alcohol use during pregnancy, 4 bereavement in 2nd or 3rd trimester 5 Consequences of untreated depression –Pregnancy: difficulty obtaining prenatal care, poor weight gain, increased alcohol and drug use 6 –Birth: lower birth weight, decreased APGAR scores, prematurity, and smaller head circumference in infants 7,8,9 –Infant outcomes: higher cortisol and lower dopamine and serotonin levels; poor performance on neonatal behavioral assessments; 10,11 negative impact on infant sleep, feeding, and crying 12 Copyright © 2011. World Psychiatric Association 1 Cohen et al, Psychosomatics 1989; 2 Marcus et al., J Womens Health 2003; 3 O’Hara, Arch Gen Psychiatry 1986; 4 Marcus et al., Postgrad Obstet Gynecol 2000; 5 Kumar & Robson, Br J Psychiatry 1984; 6 Miller, Psychiatr Med1991; 7 Sandman et al., Ann N Y Acad Sci 1994; 8 Steer et al., J Clin Epidemiol 1992; 9 Zuckerman et al., J Dev Behav Pediatr 1990; 10 Field et al., Int J Neurosci 2004; 11 Lundy et al., Infant Behav Dev 1999; 12 Diego et al., Psychiatry 2004 3

4. Depressive Disorders in Obstetrics and Gynecology Treatment of Depression in Pregnancy SSRIs: not likely to contribute to major congenital anomalies above baseline risk; 1 may be associated with difficulties in neonatal adaptation, such as irritability and feeding/sleeping problems 2 –First trimester SSRI use may lead to preterm delivery, minor malformations 3 Lithium (for bipolar illness): linked to teratogenicity, especially cardiac malformations; though risk of these anomalies small, it is 10 to 20 times higher than in general population 4,5 Anticonvulsants: substantial risk for major fetal malformations (neural tube defects), pregnancy complications, infant irritability, feeding difficulties and arrhythmia 6,7,8,9,10 Lamotrigine: has been approved for treatment of bipolar, but implicated in risk for cleft anomalies 6,9,10,11 Antipsychotic agents: research has not confirmed the presence/absence of teratogenicity beyond the baseline rate 12 ECT: if patient is severely depressed or has psychotic symptoms; little evidence of adverse effects on fetus or mother but may precipitate premature labor or antepartum hemorrhage Copyright © 2011. World Psychiatric Association 1 Cohen et al., Biol Psychiatry 2000; 2 Nordeng et al., Acta Paediatr 2001; 3 Chambers et al., N Engl J Med 2006; 4 Cohen, J Clin Psychiatry 2007; 5 Pinelli et al., Am J Obstet Gynecol, 2002; 6 Cohen et al., J Clin Psychiatry 2007; 7 Jager-Romen et al., J Pediatr, 2986; 8 Kennedy and Koren, J Psychiatry Neurosci 1999; 9 Viguera et al., J Clin Psychiatry 2007; 10 Worley, 2007; 11 GlaxoSmithKline, 2006; 12 Waldman and Safferman, J Psychiatry 1993 4

5. Depressive Disorders in Obstetrics and Gynecology Postnatal Depressive Symptoms (Baby Blues) 50-75% of women experience minor mood swings in the first week after delivery 1 Postnatal Depressive Disorders 10-15% of childbearing women 2 Clinical Features: similar to other depressive disorders in terms of symptomatology, course, duration, and outcome Effects on infant: difficulties in social and cognitive domains, failure to thrive, attachment difficulties 3 Treatment Options: –Interpersonal Therapy (IPT) and Cognitive-Behavioral Therapy (CBT) have proven effective 4 –Re-establishing the mother’s circadian rhythm, getting more sleep –Transdermal estrogen in severe cases 5 –SSRIs are commonly used by lactating women 6 Sertraline has shown no ill effects Fluoxtine use was found to be associated with infant colic –Lithium should be avoided while breastfeeding 7 Copyright © 2011. World Psychiatric Association 1 Glover et al., Br J Psychiatry 1994; 2 O’Hara and Swain, Int Rev Psychiatry 1996; 3 Murray and Cooper, 1997; 4 O’Hara et al., Arch Gen Psychiatry 2000; 5 Gregoire et al., Lancet 1996; 6 Stowe et al., Am J Psychiatry 2000; 7 Kumar and Robson, Soc Psychiatry Psychiatr Epidemiol 1984 5

6. Depressive Disorders in Obstetrics and Gynecology Postnatal Affective Psychosis 1:500 to 1:1000 births across cultures 1 Women with a personal or family history of bipolar disorder or puerperal psychosis are at higher risk 2 ; biological risk factors are more important than psychosocial 3 Most women require hospital admission 4 but respond well to adequate treatment 5 Menopause Prevalence of depression does not seem to increase during menopause 6 Psychosocial risk factors: history of depression during postpartum/premenstrual phases, stressful life events, lack of social support, low socioeconomic status Conventional treatments are recommended, such as antidepressants and psychotherapy 7 –Hormone Replacement Therapy (HRT) may improve well-being but little evidence to show that HRT improves depressive disorders during menopause 8 Copyright © 2011. World Psychiatric Association 1 Kumar, Soc Psychiatry Psychiatr Epidemiol 1994; 2 Kendell et al., Br J Psychiatry 1989; 3 Brockington et al., 1982; 4 Oates and Gath, Clin Obstet Gynecol 1989; 5 Blehar et al., Psychopharmacol Bull 1998; 6 Hunter, BMJ 1996; 7 Sherwin and Gelfand, Psychoneuroendocrinology 1985; 8 Morrison et al., Biol Psychiatry 2004 6