Postpartum Depression

Postpartum DepressionCapital Region Family Medicine ConferenceBrigid Mack, MDSeptember 7, 2013Postpartum DepressionWhat is it?DefinitionSpectrum of diseaseWho gets it?How to recognize it?How to treat it?Capital Region resourcesPostpartum depressionDSM VNot a separate diagnosis a specifier of depressive disordersWith peripartum onset applied to the current or most recent episode of major depression if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.50% of postpartum depression episodes begin prior to deliveryOften associated with severe anxiety, or panic attacks

PPD ACOGDepression is very common during pregnancy & postpartum periodInsufficient evidence for universal screeningStrongly consider screening given potential benefitPositive assessments require follow-up evaluation & treatment

NYS ACOG tool kitPPD - AAPRecommends screeningNotes prevalence of between 5-25%Broad negative impact

Bright Futures Tool KitPPD - AAFPUnique involvement in peripartum period

Established therapeutic relationship

Often unrecognized, must distinguish between PPD & baby blues (duration & severity)

Symptoms reported different in PPD than other MDD

PPD - AAFPTranslating Research into Practice for Postpartum Depression (TRIPPD) study(annfammed.org), reported in the July/August 2012 Annals of Family MedicineImproved maternal depression outcomes through primary care-based screening, diagnosis and management PPD The SpectrumPPD - The SpectrumBaby bluesUp to 80% of womenAttributed to hormonal shiftsSx: emotional lability, irritability, crying jags, exhaustion, distrupted sleepResolved by 2 weeks postpartumInitially considered benign but may progress to PPD

Postpartum Depression DSM VEst 10-20% of women during peripartum periodMajor Depressive Episode with peripartum onset5 major symptoms lasting 2+wks with depressed mood or loss of interest/pleasureSignificant distress or impairmentNot attributable to a substance or another medical conditionOnset of mood sx occur during pregnancy or 4 weeks following deliveryMood and anxiety sx during pregnancy as well as baby blues increase risk for PP-MDEPostpartum Depression with Psychotic Features1 in 500-1000 deliveriesMore common in first-time moms, but also prior pp mood episodes, prior h/o depression or bipolar d/oRecurrence risk 30-50%Psychiatric EmergencyPPD w Psychotic FeaturesOnly know if ask: Some women have thoughts Do you?Must separate mother and babyInpatient hospitalization not just help at home5% suicide rate, 4% infanticide rateParanoia, Delusions, HallucinationsMay wax and wane

Postpartum Other mental health concernsPTSD Related to birth experienceUp to 3% per ACOG website

Eating disordersAnxiety d/oSchizophrenia

PPD How to screenPPD Screening Tools

Edinburgh Postnatal Dep ScaleQuick (10 questions, less than 5 min)Score >10 = possible depression (max 30)Always review question #10

Available in multiple languages!EPDS

PHQ-9Quick (9 questions, less than 5 min)Score >10 = possible depression (max 27)Always review question #9

May already be available in primary care officeNot specific to PPDAvailable in >30 languages!www.phqscreeners.comMay be preceded by PHQ-2 Postpartum Depression ScreeningBe sure to screen for hx of ManiaHave you ever had four continuous days when you were feeling so good, high, excited, or hyper that other people thought you were not your normal self or you got into trouble?Have you experienced four continuous days when you were so irritable that you found yourself shouting at people or starting fights or arguments?

PPD laboratory evaluationAnemiaThyroid dysfunctionPPD When to ScreenWhen to screenDuring PregnancyEspecially in patients with previous hx of depressionSignificant amount of depression starts prenatal

When to ScreenDuring Postpartum visitBut visit typically not until 6 weeks postpartum

During Well Baby Visits!Ideal very frequent during critical early postpartum periodPPD - TreatmentPPD TreatmentOptions similar to other depressive d/o

PsychotherapyIndividual CounselingGuided Support GroupPeer Support GroupsMedicationSSRIs, othersPsychotherapyCBTInterpersonal

Limitations insurance coverage, referral possibilities, difficulty in connecting patient to resources

Benefits no concern with medication side effects/breastfeedingSupport GroupsBenefitsLess stigmapeers

LimitationsTimingReliabilityqualityPharmacotherapyMedication optionsSSRIsLow side effect profileRelatively well studiedSNRIsOthers

BenefitsLimitationsPharmacotherapy- SSRIMedAdvantages for MomBaby Adv RxnPreg-nancy ClassBreast-feeding SafetyStarting dosageParoxetinenoneIrritable, sleep disrup, +neon seDpreferred by LactMed (0.1-4%)10mg, incr weeklySertralineWell studied?birth def, agitatCpreferred by LactMed (0.4-2%)25mg , incr weeklyFluoxetineWell studiedIrritable, gi upset,neuroCOK if B>R, More in BM (1-12%)10mg, incr weeklyCitalopramFew med interaxnSleep disrup, wt lossCOK if B>R More in BM (0.7-9%)10-20mg, incr wklyEscitalopramFew med interaxnSleepy disrup, wt loss, nec x1COK if B>R Less in BM than cital10mg, may incr p 1wkPharmacotherapy - OthersMedAdvantages for MomBaby Adv RxnPreg-nancy ClassBreast-feeding SafetyStarting dosageBupropionFew side effSeizure, poor wt gain, irritableBOK if B>R (2%)100-150mg, incr wklyNortriptylineWell studiedNoneD?preferred by LactMed (1.3%)25mg, incr wklyVenlafaxineBalanced Decr wt gain, somnolenceCIn BM (5-7%), not preferred25mg, incr wklyDuloxetineBalanced, painLittle knownCNot pref due to lack of info40mg, incr wklyMirtazapineImprove appetiteLittle knownCNot pref due to lack of info15mg, incr wklyCAMLight therapyHerbal supplementsAcupunctureTCMMassage

PPD EssentialsIdentify

Treat

Follow up!Implementing PPD screeningFamily Medicine officesIdeal setting for both identifying and treating

TRIPPD Tool KitACOG NYS Tool KitPPD Cases in the newsCynthia Wachenheim

Lisa Gibson

Cases18yo G1P1Delivered son by c-section due to fetal bradycardiaFOB not involved since mid-pregnancyLives with her mom, younger brother (10yo)Planning on returning to high school after a few weeks

At PPV mentions that she is sad all the time, crying easily

Next StepCases/QuestionsCapital District ResourcesShades of Light - shadesoflightps.orgMultiple peer support group mtgs throughout greater Capital RegionLinks/Contact info to health providersOn FacebookCommunity CradleCommunitycradle.orgSupport groups, resource libraryNational / NYS ResourcesPostpartum Support InternationalDepression After DeliveryUIC Perinatal Mental Health (800-573-6121)UofR Perinatal Consultation (585) 275-3750www.womensmentalhealth.org 617-724-7792

MedEdPPD.orgSTEP-PPD.comBoth are sites with online training modules on PPDSTEP is aimed at primary care providers MedEd is sponsored by NIMHReferencesDSM VScreening for depression during and after pregnancy. Committee Opinion No. 453. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;115:3945 (Reaffirmed in 2012)Postpartum Major Depression. Am Fam Physician. 2010 Oct 15;82(8):926-933.TRIPPD: A Practice-Based Network Effectiveness Study of Postpartum Depression Screening and Management. Ann Fam Med July/August 2012 vol. 10 no. 4 320-329.

Referenceswww.mededppd.orghttp://www.health.ny.gov/community/pregnancy/health_care/perinatal/maternal_factsheet.htmhttp://www.omh.ny.gov/omhweb/savinglives/Volume2/new_mothers.htmlhttp://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT

ReferencesEdinburgh Postnatal Depression Scale. 1987 The Royal College of Psychiatrists. The Edinbugh Postnatal Depression Scale may be photocopied by individual researchers or clinicians for their own use without seeking permission from the publishers. The scale must be copied in full and all copies must acknowledge the following source: Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782786. Written permission must be obatined from the Royal College of Psychiatrists for copying and distribution to others or for republication (in print, online or by any other medium).Translations of the scale, and guidance as to its use, may be found in Cox JL, Holden J. Perinatal Mental Health: A Guide to the Edinburgh Postnatal Depression Scale. London: Gaskell; 2003. Additional information from reference 16.