postpartum depression: signs, symptoms, and solutions · 2018. 2. 22. · postpartum depression 0...
TRANSCRIPT
Postpartum Depression: Signs, Symptoms, and Solutions
JENNIFER HAHN -HOLBROOK, PHD
DIRECTOR OF THE LATCH LAB
DEPARTMENT OF PSYCHOLOGY
HEALTH SCIENCES RESEARCH INSTITUTE
UNIVERSITY OF CALIFORNIA, MERCED
OverviewDepression in Parents
Consequences for Children and Families if Unaddressed
Signs that Someone is Depressed
What Causes Depression in Parents?
What Can be Done About It?
Visions of New Parenthood
The Postpartum Transition
11
12
Postpartum Depression
• ().
In the US, approximately 13% of women will
experience depressive symptoms within the first 3 months postpartum (O’Hara &
Swain, 1996)
20% of women will experience depressive
symptoms within the first year postpartum
(Gaynes et al., 2005).
13
Postpartum Depression Around the Globe?
14
Hahn-Holbrook, Taylor-Cornwell & Anaya (2018) Frontiers in Psychiatry
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Maternal Mental Health Report Card
16
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Good! Bad!
USA
Chile
Hahn-Holbrook, Taylor-Cornwell & Anaya (2018) Frontiers in Psychiatry
18
Variability in Depression Profiles
19
Key Symptoms
• Having trouble enjoying things that you once enjoyed
• Overwhelming sadness
• Guilt, shame & anxiety that are disproportionate to the situation
• Thoughts of death or harming oneself
20
Why focus on depression in pregnancy and postpartum?
21
Developmental deficits in children (Grace, Evindar, Stewart, 2003)
Disrupt parenting behaviors
(Field, 2010; Paulson, Dauber & Leiferman, 2006)
Raises risk for subsequent depressive episodes
(Cooper & Murray, 1995)
Associated with Marital Discord(Zellowitz & Milet, 1996)
Consequences of Maternal Depression
22
Breastfeeding RecommendationsThe American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life, with continued breastfeeding and complementary foods at least until the child’s first birthday
Breastfeeding Benefits
DepressionLess
Breastfeeding?
25
Study Design
26
Participants: 205 mothers, >18, English-speaking, non-smoking, singleton
pregnancy, absence of medical condition that deregulates neuroendocrine
function, 70% White,15% Latina, 10% Asian
Measures: CES-D in pregnancy, EPDS postpartum; breastfeeding
frequency, breastfeeding vs. breast-pumping
Analyses: Growth Curve Multilevel Modeling
Covariates: Maternal age, income, work outside the home, martial status,
Latina ethnicity, preterm birth, social support
Birth
5x Pregnancy 3 mos 6 mos 1 yr 2 yrs
Hahn-Holbrook, Haselton, Dunkel Schetter, & Glynn (2013) Archives of Women’s Mental Health
Prenatal Depression Predicted Less Likelihood of Breastfeeding at 3 months
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
3 months 6 months 12 months 24 months
Pro
po
rtio
n o
f W
om
en
Bre
astf
ee
din
g
No Prenatal Depression
Prenatal Depression
P < .05*
27Hahn-Holbrook, Haselton, Dunkel Schetter, & Glynn (2013) Archives of Women’s Mental Health
Prenatal depression predicted less
breastfeeding at 3 months postpartum
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Major Risk Factors
• History of Depression
• Stress (chronic stress or major life events)
• Infant health problems
• Poor social support
• Hormonal profiles in pregnancy
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Previous Research onPostpartum Depression
Yim, Tanner, Guardino, Hahn-Holbrook & Dunkel Schetter(2014) Annual Reviews of Clinical Psychology. 32
11 StudiesIncluded both biological and
psychosocial variables
1 StudyIntegrates biological
and psychological predictors
200 StudiesPublished since 2000
Predictors of Postpartum Depression
Poor Social Support (see Beck, 2001; O’Hara, 2009, for
reviews)
Deregulation of the Stress Hormones in Pregnancy
(see Bloch, Daly, & Rubinow, 2003; Hillerer, Neumann, & Slattery, 2012; Zonana & Gorman, for reviews)
Hormonal Withdrawal?
34
Yim et al. (2009) Higher pCRH in Pregnancy predicts Postpartum depression
Yim et al., (2009) Archives of General Psychiatry
Does Social Support Provide
a Buffer?
Study Design• Participants: 210 women were recruited from an urban hospital in
Southern California
• Eligibility criteria: > 17 yrs, English or Spanish speaking, < 20 weeks gestation
• Depression: Beck Depression Inventory
• pCRH: Assayed with RIA
• Statistical Methods: Multilevel Modeling
• Covariates: Age, income, education, ethnicity, medical risk, and parity
19 wks 29 wks 37 wks 8 wks
pCRH, Perceived Partner& Family Support
Measured in pregnancy
Postpartum Depression
Birth
Higher pCRH in Pregnancy Predicted Postpartum Depression
0
20
40
60
80
100
120
19 weeks 29 weeks 37 weeks
Low DepressiveSymptoms
High DepressiveSymptoms
** P < .01
** P < .01900
800
700
300
200
20
Overall Interaction: (F(1, 3) = 3.73, p < .05)
pC
RH
(pg
/ml)
Hahn-Holbrook, Dunkel Schetter, Arora & Hobel (2014). Clinical Psychological Science
Prenatal Family Support was Protective Against Increases in pCRH
0
30
60
90
120
150
180
19 weeks 29 weeks 37 weeks
Low Family Support
High Family Support
*** P < .001
** P < .01900
850
800
300
200
20
Overall Interaction: F(1,3) = 4.20, p < .01
pC
RH
(pg
/ml)
Hahn-Holbrook et al. (2014). Clinical Psychological Science
Mediation Model
Path A:b= -9.84***
Path B:b = -.03*
Hahn-Holbrook et al. (2014) Clinical Psychological Science
Today200,000 years
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• vz
Last 100 years200,000 years
41v
Multigenerational Families because “it takes a village”
Nuclear Families
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Dramatic Changes in Many Aspects of Motherhood Predict Postpartum Depression
Less Family Support
Formula Feeding
Omega 3 poor diets
Vitamin D Deficiency
Sedentary Lifestyles
Hahn-Holbrook & Haselton (2014) Current Directions in Psychological Science.
Breastfeeding in Prehistory
• Formula-feeding was not possible for our ancestors
• Species typical age of weaning is estimated to be around 2.5 years (Stuart-Macadam, 1995)
– Isotopes unique to breast milk in skeletal remains (Clayton, Sealy, &
Pfeiffer, 2006).
– Surveys of traditional societies
– Comparisons of adult/weaning weight in other primates
43
BreastfeedingDepression Protection?
44
Breastfeeding frequency at 3 months Predicts Depressive Symptoms
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0
5
10
15
20
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3 months 6 months 1 yr 2 yrs
% w
ith
Dep
ress
ive
Sy
mp
tom
s
Low BreastfeedingFrequency at 3months
High BreastfeedingFrequency at 3months
p p < 0.05NS p <p < 0.05
Hahn-Holbrook, Haselton, Dunkel Schetter, & Glynn (2013) Archives of Women’s Mental Health
Breastfeeding frequency at 3 months Predicts Depressive Symptoms
46
0
5
10
15
20
25
3 months 6 months 1 yr 2 yrs
% w
ith
Dep
ress
ive
Sy
mp
tom
s
Low BreastfeedingFrequency at 3months
High BreastfeedingFrequency at 3months
p p < 0.05NS
p <p < 0.05
Hahn-Holbrook, Haselton, Dunkel Schetter, & Glynn (2013) Archives of Women’s Mental Health
Mode of Breast Milk Expression
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Lower Rates of Depression
1 & 2 years
after Birth
Hahn-Holbrook, Haselton, Dunkel Schetter, & Glynn (2013) Archives of Women’s Mental Health
Bidirectional Relationship
BreastfeedingDepression
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Potential Mediators
• Direct Pathways – Less stress (Mezzacappa, 2004)
– Breastfeeding hormones?– Maternal programming? (Glynn, 2010)
– Maternal bonding– Maternal physical health (see Bernier, Plu-Bureau, Bossard, Ayzac, &
Thalabard, 2000; Rea, 2004, Stuebe & Rich-Edwards, 2009, for reviews)
• Indirect Infant-Mediated Pathways – Breastfeeding improves infant health (see Kramer et al., 2008;
Kramer et al., 2001, for reviews)
– “Easier” infant temperaments? (Jones, McFall, & Diego, 2004)
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Hypothalamus
Suck
ling
Stim
ulu
s
Decreased estradiol & progesterone
Acute hormonal responses to breastfeeding session
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Re
lati
ve h
orm
on
e le
vel
Time course of circulating levels of oxytocin and prolactin from a breastfeeding bout
Oxytocin
Prolactin
feeding bout
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Experimental Study
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Participants: 40 mixed feeding mothers
Measures: Negative affect, PANAS
Analyses: Repeated measures ANCOVA
Covariates: Infant age
Random Assignment
Mixed Feeding Moms
Bottle-FeedBreastfeed
Experimental test of the acute effects of breastfeeding on maternal mood
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Baseline
• Negative affect
Breastfeeding vs.
Bottle-feeding
• Negative affect
Infant Play Session
• Negative affect
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AH-HA! It’s Biological!
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Nature & Nurture/Genes & Environment
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“plasticity alleles”
• Those genes that are predicted to cause either
increased or decreased sensitivity of an individual to
their environment (Belsky, 2009)
• Do certain allelic differences in DNA predispose
some women to be more sensitive to social factors in
their environment?
Oxytocin: The Love Hormone?
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Oxytocin Receptor Gene
• 7 transmembrane domains
belonging to the family of
G protein coupled receptors
(Carson et al., 2013)
• Encoded by OXTR gene on
chromosome 3p25 in
humans (Saphire-Bernstein
et al., 2011).
• Activates
phosphatidylinositol-
calcium second messenger
system
rs53576
• Silent change in the third intron of the OXTR gene
• AA/AG vs GG
• GG genotypes are more empathetic, feel less lonely,
employ more sensitive parenting techniques compared
to AA/AG genotypes (Saphire-Bernstein et al., 2009)
Methods
• Participants: 224 mothers
• Locations of data collection: Orange County, mainly at farmer’s markets, mommy & me classes, and baby boutiques
• Procedure :
• Saliva samples collected in OraGene 5mL tubes from DNA Genotek
• Sequenced by the Roswell Park Cancer Institute in Buffalo, NY
• Survey testing measures such as Perceived Stress Scale (PSS), Edinburgh Postpartum Depression Scale (EPDS), and social support measures
Are you socially sensitive?
B = -.37, p = .003 B = -.06, p = .79
It’s Not Just Moms
• 1 in 10 Dads will Experience Depression during
Their Partners Pregnancy
• Hormones Change in Dads Too!
• Predictors of Depression in Dads
• Partner who is depressed
• Hormonal changes
• Sleep disturbances
• Stress
It’s Not Just Postpartum
• Major depression is very common
• Times of heightened risk:
• Adolescence
• Transition to parenthood
• Major life changes
• Pregnancy & postpartum
• Menopause
• Parents report more stress than non-parents, especially at the beginning
• Women with more children are more likely to be depressed than women with fewer children
INTERIM SUMMARY
• Postpartum depression is bad for mom, baby and family.
• Loads of factors contribute to postpartum depression risk.
• Biological, social and psychological factors can collide to create a ‘perfect storm’ for some women.
• What can we do about it?
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Screen for Postpartum Depression
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Free & Reliable Tools are Available
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Best Treatments
• Cognitive Behavioral Therapy
• Anti-depressant Medications
• Enhancing Social Connections
• Reducing Stress
• Exercise
• Improving Sleep
• Nutrition
• PREVENTION
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What Can you Do?
• If you work directly with children and parents…
– You are a key member of the Support Network
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What Can you Do?
• Be their confidante.
• Parents need your reassurance.
• They need to feel that you like their children and care about them.
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What to do if you think someone is struggling?
• Ask how they are doing/Check in
• Listen and provide support in response to their fears and anxiety
• Delicately destigmatize depression
• If they say they are struggling, reassure them that they are not alone and help is available if they need it
• Know the resources in your community
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UC Merced Affiliated Families
• Most have good medical coverage for low-cost psychological assessments and treatments
• Most family general practitioners are aware of postpartum depression and can refer mothers to a psychologist or even prescribe anti-depressant medications
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Medi-Cal Families• Figure 4
• Mental health care is an essential service covered by all health plans in the USA
• Primary health Drs. can refer people to mental health care
• People can contact their health plan to find providers in their area
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Empowering Families
• Give families realistic expectations of new parenthood
• Don’t forget about dad, grandma or other key caregivers
• Destigmatize mental illness
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