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Spectrum … › Postpartum blues › Adjustment disorder with depressed mood › Major Depression › Minor Depression › Dysthymic Disorder (2y) › Anxiety Disorders › Postpartum Psychosis › Bipolar Disorder
Paternal depression Interference with bonding and child
development Marital stress Suicide and infanticide Poor fetal growth (although studying this
is difficult to separate confounding factors)
Possible increased risk of psych disorder for offspring (confounded by genetics)
Characterized by rapid mood swings, anxiety, dec concentration, tearfulness, crying spells, insomnia, irritability
Symptoms peak on 5th pp day and resolve within 2 weeks (if persist beyond 2 weeks=depression)
40-80% of women experience these symptoms
Risk Factors: depressive sx during pregnancy, fam hx depression, PMDD, stress around child care, psychosocial impairment in work, relationships
Minor Depression: Have several symptoms of major depression (2-4) for at least 2 weeks but don’t meet criteria for major depression.
Dysthymic Disorder: depressed mood for at least 2 years.
Adjustment Disorder with Depressed Mood: occurs in response to a stressor. Symptoms do not meet criteria for major depression or dysthymic disorder. Also affects functioning.
Bipolar Disorder: screen for mania
Complicated diagnosis- similar symptoms to postpartum period
Perceived societal expectation of the new mother
Lifetime risk 10-25% Point prevalence 5-9% Risk Factors: marital conflict, stressful life
events, lack of perceived support from community/partner, unplanned pregnancy, no partner, prev SAB, prev psych hx, child care stressors, hyperemesis, congenital malformations in infant, GDMA
DSM-IV includes this as Major Depressive Disorder, not PPD, but rather with ‘postpartum onset specifier’
Differences from normal postpartum: › Unable to sleep when the baby is sleeping › Inability to enjoy taste of food › Profound lack of energy to the point that she
can’t get out of bed › Profound anxiety, anger, guilt, overwhelmed,
inadequacy, feeling as though failure of mother, not bonding to baby, which increases shame and guilt
5 or more of the following symptoms, present most of the day, nearly every day, for a minimum of 2 consecutive weeks (one of which is depressed mood) › Depressed Mood › Loss of interest in most or all activities › Insomnia/hypersomnia › Change in apetite or weight › Psychomotor retardation or agitation › Low energy › Poor concentration › Thoughts of worthlessness or guilt › Recurrent thoughts of death or suicide
Provide an environment of support for our patients, where they feel comfortable discussing these symptoms with us
Increase detection of postpartum depression and psychosis
Ensure that diagnosed patients get help Create a network of counseling referrals Educate patients regarding the mood
changes that can occur in pregnancy, birth and in the postpartum period
Education of staff, physicians, nurses Peripartum Depression Pamphlet Counselor referral network /correlate
with insurance Depression information sheet: coping
skills, counseling referrals, hotline Electronic Medical Record forms:
depression screening, nurse followup, incorporating EPDS into antepartum
Edinburgh Postnatal Depression Scale: 10 item self reported screening questionnaire
Aids in diagnosis of PPD much more than clinical exam alone (35% vs 6%)
Most pediatricians in community use EPDS for moms
Data is best for EPDS (Vs. Beck Depression Inventory, PPD Screening Scale, Center for Epidemiological Studies Depression Scale, PRIME MD scale)
Score equal to 13 or greater (positive screen) HAVING major depressive disorder 57%
Neg screen- 99% did NOT have PPD If mom has positive score, increased risk
for father having positive score.
Given at 28 weeks with EPDS and at all hospital discharges
EPDS given at 24-28w visit EPDS given at 6 w postpartum visit If EPDS over 12…
› Automatically screened for depression › Given depression information sheet › Discussed hotline › Rare referrals to psychiatrist or previous
treating physician › Discussed life stressors, social situation
1756 patients were screened with EPDS at 28 w prenatal visit and/or 6 w pp visit
Note: most studies of preg/pp have sample sizes of 300s…
90% of 28w prenatal visits were screened and recorded (949/1053 patients)
90% of 6w pp visits were screened and recorded. (827/924 patients)
Confounding factors: isolated midwife consults were screened at midwife’s office.
28wk with EPDS 949 Patients
90% 28wk without EPDS
104 Patients
10%
PPV with EPDS 827 Patients
90% PPV without EPDS
97 Patients
10%
28wk with EPDS 0-12 859 Patients
91% 28wk with EPDS >12
90 Patients
9%
PPV w/ EPDS 0-12 755 Patients
91% PPV with EPDS >12
72 Patients
9%
EPDS > 12 with adjustment disorder
39 Patients
24%
EPDS > 12 with depression 74 Patients
46%
EPDS > 12 were ok, no diagnosis
49 Patients
30%
Depression diagnosis - receiving Meds
59 Patients
80%
Depression diagnosis - not receiving Meds
15 Patients
20%
Depression diagnosis - treated by provider
67 Patients
91%
Depression diagnosis - referred to PCP/Psych
7 Patients
9%
EDPS > 12 given suicide helpline info
158 Patients
98%
EDPS > 12 not given suicide helpline info
4 Patients
2%
EDPS > 12 given depression info sheet
158 Patients
98%
EDPS > 12 not given depression info sheet
4 Patients
2%
Depression disorder with follow up visit
86 Patients
95%
Depression disorder without follow up visit
5 Patients
5%
Depression disorder accepted meds
and/or counseling 71 Patients
73%
Depression disorder declined meds
and/or counseling 20 Patients
27%
Follow up Patients Felt Better 77 Patients
85%
Follow up Patients did not feel better
14 Patients
15%
EDPS > 12 with follow up
86 Patients
95%
EDPS > 12 unreachable for
follow up 5 Patients
5%
10 patients were started on meds or increased dosage of meds on the follow up call.
Several patients noted how grateful they were that someone called them.
5-9% point prevalence cited in literature for peripartum depression
Prior to EPDS screening, it was estimated that 1.8% of peripartum patients were diagnosed with depression. With universal EPDS screening, detection of depression increased to 4.2% depression and 2.2% adjustment disorder with depressed mood. › 1.8% was estimated by a year’s worth of
visits, EMR diagnosis codes
Education was vastly improved. Doctors didn’t just refer patients away for
treatment, on average 25 mins spent with a depressed patient.
Follow up contact improved care and ensured that people got treatment.
27% of people diagnosed with depression declined to go to counseling or start meds. › Intermittent improvement in symptoms › Concern of teratogenicity to fetus or through
breastfeeding
NUMEROUS examples of great care from doctors and nurses from Women’s Care.
Language barrier- materials translated Cultural differences- Asian population
especially If the patient had a severe pregnancy
complication requiring hospitalization (ie. Previa), follow up not documented.
Some follow up not done yet due to 2-4 week delay.
Educational insight into completing EPDS
Support Reassurance Ensure adequate time for sleep and rest Avoid alcohol (exacerbates mood
swings) Exercise- excellent for all mood disorders
“Scary Thoughts” › Women with obsessional thoughts of
harming oneself or the baby › Usually perceived by mother as illogical and
intrusive › Should alert clinician to screen (psych) for pp
psychosis › Occasional thought are not associated with
suicide or infanticide WHEN perceived by mom as illogical.
Interpersonal psychotherapy Cognitive behavioral psychotherapy Group Therapy (www.postpartum.net) Family and Marital Therapy Well Mama Looking Glass Counselor recommendations on the PP
Dep Info sheet
What med has the most data? › Sertraline has been most studied and
appears safest (Zoloft 50 mg qd starting) › Fluoxetine has the longest half life, and rate
of transfer through bf is highest. › Paroxetine has some ?concern over
teratogenicity. (OR 2.2 in some studies, not all, inc CV defects
› All above have increased risk of persistent pulmonary hypertension of newborn. (6-12 affected neonates/1000exposed fetuses.)
Response expected within 2-6 weeks of starting therapy
If suboptimal response, consult psychiatrist
For first episode of depression, treat for 12 months after remission to reduce chance of relapse
Taper meds when discontinuing