post-partum depression - nevada osteopathic medical...
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POST-PARTUM DEPRESSIONDr Rebecca Levy-Gantt
Premier ObGyn Napa Inc2020
OBJECTIVES
➤ To Recognize the scope of postpartum depression
➤ To Have some screening tools to recognize and diagnose women who have postpartum depression
➤ To Become familiar with some possible treatments and what outcomes to expect
➤ To Be able to be sure that all women who need treatment have it available to them
➤ To Become knowledgeable about newer and most recent treatments for postpartum depression
SCOPE AND DEFINITION:
➤ According to the Center for Disease Control and Prevention, 11-20% of women in the postpartum period will have some type of depression
➤ Estimates of the number of women with postpartum depression vary by age/ethnicity/race and state
➤ 60% of women with postpartum depressive symptoms do not receive a clinical diagnosis
➤ 50% of women with a diagnosis do not receive any treatment
➤ These findings underscore the need for universal screening and treatment
Committee on Obstetric Practice:ACOG Committee Opinion #630Screening For Perinatal Depression OBGyn 2015;1268-71
SCOPE AND DEFINITION:
➤ Depression is the most common mood disorder in the United States
➤ Women are affected twice as much as men
➤ Onset peaks during the reproductive years
➤ Perinatal depression: Includes major and minor depressive episodes which occur during pregnancy or in the first 12 months following delivery
➤ Perinatal depression and other mood disorders can have devastating effects on women, infants and families
➤ Maternal suicide exceeds hemorrhage and hypertensive disorders as a source of maternal mortality
Gavin NI, et al-Perinatal Depression; A Systematic Review of Prevalence and Incidence Obstetrics&Gynecology 2005;106:1071-83
WHY IS DEPRESSION UNDIAGNOSED?
➤ Changes in sleep, appetite and libido may be attributable to ‘normal’ pregnancy and postpartum changes
➤ Health care providers may not recognize these symptoms
➤ Women may be reluctant to report changes in their mood
➤ Providers who take care of women and their babies must ask
➤ May be unaware of screening tools
➤ May not have time or resources
➤ May not have referral base
➤ Lack of appointment follow up
HOW CAN WE DO BETTER?
Mandatory depression screening of pregnant and postpartum women is now recommended by an
increasing number of professional organizations:
ACOG, 2015, the American Academy of Pediatrics, 2010, and the American Medical Association,
following the 2016 recommendation from the United States Preventive Services Task Force (2016)
.
ACOG recommended that screening for perinatal mood changes take place at least once during the
perinatal period including pregnancy and 12 months postpartum. This speaks to the evolving research
regarding perinatal mood disorders. In addition to screening with a validated tool, ACOG acknowledges it
is necessary to have a system in place that couples screening with appropriate follow-up and treatment.
Additionally, in January 2016, the U.S. Preventive Services Task Force (USPSTF, 2016) updated its 2009
recommendation related to screening for depression to include pregnant and postpartum women
USPSTF 2016
➤ In 2009, and then updated in 2016, the United States Preventative Services Task Force reviewed the evidence on the benefits and harms of screening for depression in adult populations
➤ They reviewed the accuracy of depression screening instruments
➤ Also reviewed the benefits and harms of treatment for depression in these adult populations
➤ It bases its recommendations on the benefits vs the harms of a service and an assessment of the balance
USPSTF 2016
Summary of Recommendation and Evidence
The USPSTF recommends screening for depression in the general adult population, including
pregnant and postpartum women. Screening should be implemented with adequate systems in place
to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B recommendation)
Detection
The USPSTF found convincing evidence that screening improves the accurate identification of adult
patients with depression in primary care settings, including pregnant and postpartum women.
Benefits of Early Detection and Intervention and Treatment
The USPSTF found adequate evidence that programs combining depression screening with adequate
support systems in place improve clinical outcomes (ie, reduction or remission of depression symptoms) in
adults, including pregnant and postpartum women.
Siu, et al. Screening For Depression In Adults: USPSTF Recommendation Statement JAMA 2016:315:380-7
MAJOR RISK FACTORS:
➤ Depression during pregnancy
➤ Anxiety during pregnancy
➤ Encountering stressful life events during pregnancy or in the early postpartum period
➤ Preterm birth or experiencing infant admission to the neonatal ICU
➤ Low level of social support
➤ Previous history of depression
➤ Problems with breastfeeding
PRESENTING SYMPTOMS AND SIGNS
➤ Feeling sad, hopeless, empty, overwhelmed
➤ Crying more often than usual, for no apparent reason
➤ Worrying and feeling overly anxious
➤ Feeling moody, irritable and restless
➤ Oversleeping or being unable to sleep even when the infant is sleeping
➤ Having trouble concentrating or making decisions
➤ Experiencing anger or rage
➤ Suffering from physical aches and pains, headaches, muscle pains, stomach problems
PRESENTING SYMPTOMS AND SIGNS
➤ Losing interest in activities that are usually enjoyable, including sex
➤ Eating too little or too much
➤ Withdrawing from or avoiding friends and family
➤ Having trouble bonding to or forming an emotional attachment with the infant
➤ Little or no energy
➤ Doubting ability to care for the infant
➤ Thinking about harming herself or the infant
DEPRESSION SCREENING TOOLS
Postpartum Support International (PSI) was founded in 1987 by Jane Honikman in
Santa Barbara, California. The purpose of the organization is to increase awareness
among public and professional communities about the emotional changes that women
experience during pregnancy and postpartum. “When the mental health of the mother
is compromised, it affects the entire family.”
Postpartum Support International (PSI) recommends universal screening
for the presence of prenatal or postpartum mood and anxiety disorders,
using an evidence-based tool such as the Edinburgh Postnatal
Depression Screen (EPDS) or Patient Health Questionnaire (PHQ-9).
postpartum.net/professionals/screening
DEPRESSION SCREENING TOOLS
Both the EPDS and the PHQ-9 are validated for use in the perinatal population.
The benefits are that they are self-administered, translated into many
languages, and easy to complete.
The EPDS addresses the anxiety component as well as depressive symptoms
and suicidal thoughts.
The PHQ-9 does not have the anxiety component but includes suicidal
ideation. The PHQ-9 also incorporates the categories that define depression in
the Diagnostic and Statistical Manual (DSM), which helps with diagnostic
criteria.
DEPRESSION SCREENING TOOLS
➤ PHQ-9: a list of 9 questions, asking:
➤ Over the last 2 weeks, how often have you been bothered by the following? (0=never, 1=some of the days, 2=more than half of the days, 3= every day)
➤ Little interest in doing things
➤ Feeling down, depressed, hopeless
➤ Trouble falling asleep, staying asleep
➤ Feeling tired or having little energy
➤ Eating too much or not eating enough
➤ Feeling bad about yourself, like a failure, letting people down
➤ Trouble concentrating
➤ Moving or speaking slowly, or being fidgety and restless
DEPRESSION SCREENING TOOLS
**The last question of the 9 asks “Do you have thoughts that you would be better off dead, or of harming yourself?”
If the answer to this question is “yes”, practitioner is obligated to have the patient be seen right away.
The rest of the screening is scored and the columns added up.
Total Score Major Depression Severity
1-4 Minimal
5-9 Mild
10-14 Moderate
15-19 Moderately severe
20-27 Severe
PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ® is a trademark of Pfizer Inc.
DEPRESSION SCREENING TOOLS
PHQ-9
There is a question #10:
Since the questionnaire relies on patient self-report, all responses should be verified by the clinician, and a
definitive diagnosis is made on clinical grounds taking into account how well the patient understood the
questionnaire, as well as other relevant information from the patient. Diagnoses of Major Depressive
Disorder or Other Depressive Disorder also require impairment of social, occupational, or other important
areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic Episode
(Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the
depressive symptoms.
# 10—If you checked off any problems, how difficult have all these problems
made it for you to do your work, take care of things at home, or get along with
other people?
1=Not at all; 2= Somewhat 3= Very 4= Extremely
EPDS: EDINBURGH POST-NATAL DEPRESSION SCALE➤ Most commonly used to identify depression in postpartum women
➤ Ten-item questionnaire
➤ Validated in many different patient populations
➤ Available in almost every language
➤ All women should complete it once, preferably twice, in the antenatal period and in the post-natal period
➤ Post-natal screening has traditionally been @ 6-12 weeks, but studies now show earlier screening is helpful, sometimes as early as a week after birth
El-Hachem, et al. BMC Psychiatry 2014;14:242
EPDS
➤ Ten item questionnaire:
➤ Each question scored 0, 1, 2 or 3
➤ Asked to answer each question in terms of the last seven days
➤ Score is calculated by scoring each individual item, then adding the numbers together
➤ Clinical judgement is necessary when interpreting the EPDS score
➤ Total score of 13 or more is considered a flag for the need for follow up of possible depressive symptoms (major depression)
➤ In the antenatal period, a score of 13 or more should be repeated in 2-4 weeks, and if still elevated, referral is appropriate
➤ Post-natal, one score of 13 or more is a flag for referral
EPDS
I have been able to laugh and see the funny side of things
I have looked forward with enjoyment to things
I have blamed myself unnecessarily when things go wrong
I have been anxious or worried for no good reason
I have felt sad or panicky for no good reason
Things have been getting on top of me
I have been so unhappy that I’ve had difficulty sleeping
I have been sad or miserable
I have been so unhappy that I’ve been crying
The thought of harming myself has occurred to me
Ten questions
1
2
3
4
5
6
7
8
9
10
EPDS
➤ Follow up may also be needed if questions 3,4 and 5 suggest symptoms of anxiety
➤ ANY score above zero on question 10 should include an assessment of the safety of the woman and her children, and according to clinical judgement, advice sought or a referral made immediately
➤ Scores may be influenced by the understanding of the language used
➤ Cultural practices and stigmas associated with mental health issues, especially in the postpartum period may influence the performance of the EPDS
EPDS
➤ Maximum score is 30
➤ 10 to 12 = mild depression
➤ 13 or above = major depression
➤ Note that 3 & 5-10 are Reverse scored
➤ Clinical assessment should always be carried out to confirm the diagnosis
➤ In doubtful cases it may be helpful to repeat this in 2 weeks (number does not match your clinical judgement)
TREATMENT
➤ Untreated, the condition can last months or longer
➤ Barriers to treatment, including stigma, concerns about medication and breastfeeding, and partner concerns
➤ Depressed women have poorer responsiveness to infant cues
➤ Non-pharmacologic, psychotherapeutic, hormonal, pharmacologic, supplement therapy, & light therapy have all been explored as treatments for postpartum depression
TREATMENT
➤ Early initiation of treatment results in a better prognosis
➤ Severity of the illness guides the treatment
➤ Non pharmacologic treatment is indicated for women with mild to moderate depression
➤ Individual or group psychotherapy are effective
➤ Psychoeducational or support groups
➤ Especially attractive to mothers who are nursing and may want to avoid medications
TREATMENT
➤ Pharmacologic therapies are indicated for moderate to severe depressive symptoms that do not respond to non-pharmacologic treatment
➤ Medication can also be used in conjunction with non-pharmacologic therapies
➤ In patient hospitalization is indicated for severe postpartum depression unresponsive to out-patient treatment
TREATMENT: PHARMACOLOGIC THERAPY
➤ Anti-depressants: first line of treatment
➤ Symptoms diminish in 2-4 weeks
➤ 6-12 months of treatment are recommended
➤ If recurrent depression, longer term therapy reconmended
➤ SSRI’s are first line
➤ Prozac 20-60mg/day
➤ Zoloft 50-200mg/day
➤ Paxil 20-60mg/day
➤ Celexa 20-60mg/day
➤ Lexapro 10-20mg/day
TREATMENT
➤ SNRIs
➤ Serotonin/Norepinephrine reuptake inhibitors
➤ Effexor 75-300mg/day
➤ Cymbalta 40-60 mg/day
➤ TCAs
➤ Tricyclic antidepressants
➤ Nortriptyline 50-150mg/day
TREATMENT: SIDE EFFECTS:
➤ SSRI:
➤ Insomnia, jitteriness, appetite suppression, nausea, headaches and sexual dysfunction
➤ SNRI:
➤ All of the above plus sleep disturbances, constipation and abnormal vision
➤ TCA:
➤ Sedation, dry mouth, constipation, weight gain and sexual dysfunction
TREATMENT
➤ March 2019, a new medication received FDA approval for postpartum depression
➤ BREXANOLONE injectable: First medication approved specifically for post Partum depression
➤ Available only through certain programs which require this drub be administered in a certified health care facility
➤ Continuous IV infusion over 60 hours
➤ Patients must be enrolled in a program before receiving the drug
TREATMENT:
➤ Treatment of Postpartum depression with synthetic forms of naturally occurring Estrogen
➤ PPD occurs in the setting of Estrogen withdrawal at delivery
➤ Is PPD a disorder of hormonal mood dysregulation? And if so, can it be treated with Estrogen? Or Progesterone?
➤ Review of the data concluded that use of Estradiol for PPD requires additional data regarding the maternal tolerability, long term safety of Estradiol treatment, and passage into breastmilk is needed before Estradiol can be used as a treatment for Postpartum depression
Eydie L. Moses-Kolko, et al. Transdermal Estradiol Use for PPD: A Promising Treatment Option.Clin Obstet. Gyn.2009 Sept 52(3); 516-529
TREATMENT
➤Brexanolone:
➤Synthetic version of the steroid allopregnanolone
➤Breakdown product of Progesterone
➤Mechanism of action unclear but it is thought to modify the body’s stress response
➤Binds to GABA A receptors
➤Effects of a single infusion can last up to 30 days
➤Adverse reactions: sleepiness, dry mouth, flushing and loss of consciousness
Postpartum PsychosisPostpartum psychosis is the most severe form of postpartum psychiatric illness. The condition is
rare, occurring in approximately 1-2 per 1000 women after childbirth. At highest risk are women
with a personal history of bipolar disorder or a previous episode of postpartum psychosis
Postpartum psychosis has a dramatic onset, emerging as early as the first 48-72 hours after delivery. In
most women, symptoms develop within the first 2 postpartum weeks. The condition resembles a rapidly
evolving manic or mixed episode, with symptoms such as restlessness and insomnia, irritability, rapidly
shifting depressed or elated mood, and disorganized behavior.
The mother may have delusional beliefs that relate to the infant (eg, the baby is defective or dying, the infant
is Satan or God), or she may have auditory hallucinations that instruct her to harm herself or her infant.
The risks for infanticide and suicide are high among women with untreated postpartum psychosis
CONCLUSION:
—Untreated mood disorders place the mother at risk for
recurrent disease.
—Maternal depression is associated with long-term
cognitive, emotional, and behavioral problems in the child.
—One of the most important objectives is to increase
awareness across the spectrum of health-care
professionals who care for women during pregnancy and
the puerperium so that postpartum mood disorders may be
identified early and treated appropriately.
THANK YOU