peripartum depression laura j. miller, m.d. women’s mental health program university of illinois...
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Peripartum Depression
Laura J. Miller, M.D.Laura J. Miller, M.D.
Women’s Mental Health ProgramWomen’s Mental Health Program
University of Illinois at ChicagoUniversity of Illinois at Chicago
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Risks from untreated major depression during pregnancy
Decreased prenatal care Decreased nutrition Increased use of teratogenic addictive substances
– cigarettes– alcoholic beverages
(Halbreich 2004)
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Effects on offspring of untreated depression during pregnancy
Low birth weight (Federenko & Wadhwa 2004)
Preterm birth (Dayan et al. 2002)
Pre-eclampsia (Kurki et al. 2000)
Neonatal irritability (Zuckerman et al. 1990)
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Postpartum “blues”
Features: tearfulness, lability, reactivity Predominant mood: happiness Peaks 3-5 days after delivery Present in 50-80% of women Present in all cultures studied Unrelated to environmental stressors Unrelated to psychiatric history
(Miller & Rukstalis 1999)
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“I started to experience a sick sensation in my stomach; itwas as it a vise were tightening around my chest. Insteadof the nervous anxiety that often accompanies panic, afeeling of devastation overcame me. I hardly moved.Sitting on my bed, I let out a deep, slow, guttural wail. Iwasn’t simply emotional or weepy, like I had been told Imight be. This was something quite different. This wassadness of a shockingly different magnitude. It felt as if itwould never go away.”
-from “Down Came the Rain: My Journey ThroughPostpartum Depression” (Brooke Shields)
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Clinical features of postpartum depression
Mood predominantly depressed, despondent, anhedonic Sleep disturbance, fatigue, irritability Loss of appetite Poor concentration Feelings of inadequacy Ego-dystonic thoughts of harming the baby
(Miller 2002)
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“I sat holding my newborn and could not avoid the imageof her flying through the air and hitting the wall in front ofme. I had no desire to hurt my baby and didn’t see myselfas the one throwing her, thank God, but the wall morphedinto a video game, and in it her little body smacked thesurface and slid down onto the floor. I was horrified, andalthough I knew deep in my soul that I would not harmher, the image all but destroyed me.”
From “Down Came the Rain: My Journey ThroughPostpartum Depression”, Brooke Shields, 2005
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Characteristics of postpartum depression
Begins within 4 weeks of birth, but clinical presentation peaks 3-6 months after delivery
Present in 7 - 20% of new mothers in U.S. (Joseffson
et al. 2001) Much less prevalent in some cultures (Wile &
Arechiga 1999)
Related to psychiatric history (Steiner & Tam 1999)
Related to environmental stressors (Bernazzani et al. 2004)
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Consequences of untreated postpartum depression
Disturbed mother-infant relationship (elevated cortisol found in both) Psychiatric morbidity in children later (depression, conduct disorder, lower IQ)
Family tension Vulnerability to future depression Suicide/homicide
(Lundy et al. 1999; Jacobsen 1999)
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Peripartum depression: posited contributory factors
Hormonal flux interacting with stressors The magnitude of the postpartum drop in
hormones correlates with mood changes; absolute hormone levels don’t
The biological mother-infant attachment system may predispose to depression in the context of stress, low social support & limited resources
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Peripartum depression: recognition and treatment in primary care settings
Ob/gyn survey (LaRocco-Cockburn et al. 2003):– Only 32% reported they’d been appropriately
trained to treat depression– 73% cited time constraints for screening
Pediatrician survey (Wiley et al. 2004):
– 49% not educated about PPD– Only 31% felt they’d recognize PPD– Only 7% were familiar with screening tools
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Screening for Peripartum Depression with the Edinburgh Postnatal Depression Scale
[EDPS] 10 item scale; maximum score 30; cut-off 10 - 13 Self report : quick and easy to score Widely tested
– During pregnancy, sensitivity 100%; specificity 87%– Postpartum, sensitivity 78 - 100%; specificity 93 - 100%– Available in over 20 languages; cross-cultural validation
Defines population in need for further assessment Can be used to monitor treatment progress IDPA (Medicaid) reimburses for this screening
(Cox & Holden 2003)
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Assessment of peripartum depression
Conducted by clinician for all women who score above the cut-off score on EPDS
Purposes - to ascertain whether the woman:– has major depression– is suicidal– is at risk of harming her baby– has bipolar disorder
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Treating peripartum depression
Antidepressant medication Interpersonal psychotherapy Couples therapy Self help tools & networks ECT (rTMS) Hormone therapy Parenting coaching
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Challenges in prescribing antidepressant medications peripartum
FDA categories have limited usefulness (based heavily on animal data)
Wide variation in amount of data for different antidepressants
Optimal dosing changes as pregnancy progresses
Wide variation in amount ingested by breast-feeding babies
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Peripartum Depression Disease Management Model
Education (via workshops) Screening tool Assessment tool Treatment guidelines Self-care tools Referral networks Back-up consultation