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Pospartum depression
- 1. POSTPARTUM DEPRESSION Adriano Lercara | João Augusto Ribeiro | João Sousa Soares CU Gynecology and Obstetrics, 4th year NOVA Medical School
- 4. 1. Biological Factors 2. Obstetric Factors 3. Clinical and Pshychological Factors 4. Socials and Psycho-Social Factors POSTPARTUM DEPRESSION RISK FACTORS
- 5. 1. Biological Factors Hormonal variations during pregnancy and puerperium 2. Obstetric Factors C-section Unplanned pregnancies POSTPARTUM DEPRESSION RISK FACTORS
- 6. 3. Clinical and Psychological Factors History of previous depression Prenatal anxiety and/or depression POSTPARTUM DEPRESSION RISK FACTORS
- 7. Stress pré- natal Falta de suporte social Falta de suporte conjugal Expectativa/Reali dade de ser mãe Exigências do cuidado do bebé Temperamento do bebé POSTPARTUM DEPRESSION RISK FACTORS – SOCIAL AND PSYCHO-SOCIAL FACTORS POSTPARTUM DEPRESSION RISK FACTORS – SOCIAL AND PSYCHO-SOCIAL FACTORS
- 8. Sintomas • Perda de prazer, energia e motivação • Ansiedade • Irritabilidade, agitação • Alteração dos hábitos alimentares e de sono • Medo de não ser uma boa mãe – culpa • Pensamentos em magoar o bebé ou a si própria
- 9. Trying to mitigate the serious adverse outcomes of PPD already mentioned → EARLY DETECTION! Screening: at 1st postnatal obstetrical visit (usually 4-6 weeks after delivery), FP or pediatric setting Most common: EPDS (Edinburgh Postnatal Depression Scale) (Sensitivity 80-82%, Specificity 78-82%) Other: PDSS (Postpartum Depression Screening Scale) and PHQ-9 (9-item Physician’s Health Questionnaire) Antepartum: APQ (Antepartum Questionnaire) (Sensitivity 80-82%, Specificity 78-82%) POSTPARTUM DEPRESSION SCREENING
- 10. PPD frequently missed by the primary care team (clinical signs not apparent unless screened for) DSM-IV Criteria for MDE (Major Depressive Episode) ↔ PPD Antepartum education on PPD! Postpartum onset of MDE → 4 weeks after delivery … but… 3 months? ≥1 year? Differential psychiatric diagnosis: Postpartum Blues (up to 75% of mothers in the 10 days following delivery) Differential psychiatric diagnosis: Postpartum Psychosis (psychiatric emergency requiring hospitalization) Differential non-psychiatric diagnosis: Transient hypothyroidism, hyperthyroidism, anemia, infection POSTPARTUM DEPRESSION DIAGNOSIS
- 11. Treatment 1st line therapy: non-pharmacological therapy! Psychotherapy → IPT (Interpersonal Therapy) and CBT (Cognitive Behavioral Therapy) IPT – time-limited interpersonally-oriented psychotherapy (depression as a medical illness occurring in a social context) Effectiveness supported by several studies (O’Hara and colleagues, Clark et al) CBT – well studied and effective treatment for MDE (modification of distorted patterns of negative thinking and making behavioral changes that enhance coping and reduce distress) Several trials assessing CBT alone or with other interventions for the treatment of PPD → support CBT interventions as helpful in the treatment of PPD (Appleby et al, Misri et al)
- 12. 1. Postpartum blues: generally self-limited and resolve between 2 weeks and 3 months. Supportive reassurance is sufficient. 2. Postpartum depression: • psychotherapy • pharmacotherapy • diet 3. Postpartum Psychosis, add: • electroconvulsive therapy • hospitalization POSTPARTUM DEPRESSION TREATMENT OPTIONS
- 13. • IPT (InterPersonal Therapy): time-limited (12-20 weeks) treatment based on addressing connection between interpersonal problems and mood. • CBT (Cognitive Behavior Therapy): to help the depressed patient to modify negative thinking and to make behavioral changes in order to reduce distress. • Non-Directive Counseling: with a health visitor to empathically and nonjudgementally listen and support. • Peer and Partner Support: practical and emotional support from partner and friends are essential to recovery for most women. POSTPARTUM DEPRESSION PSYCHOTHERAPY – 1ST LINE TREATMENT
- 14. • Doses and time are similar to the ones for major depression. • Must be continued for 6 to 12 months after childbirth. • If the mother had responded to a specific psychodrug in the past, that medication must be the first one to consider. POSTPARTUM DEPRESSION PHARMACOTHERAPY – 2ND LINE TREATMENT
- 15. • SSRI (Selective Serotonin Recaption Inhibitors): I choice • Sertraline • Paroxetine • Fluoxetine (Prozac®) • TCA (Tricyclic Antidepressant): II choice - Nortriptyline - Imipramine POSTPARTUM DEPRESSION PHARMACOTHERAPY – ANTIDEPRESSANTS
- 16. • Transdermal Estrogen • neural growth • neurotransmitters activity • oxidative stress • Must be avoided if risk of tromboembolism is present • Progesterone (norethisterone nitrate) • Very few studies • No role for synthetic progesterone in treatment • Increases risk of depression After childbirth, we assist to a dramatic drop of maternal levels of estrogen and progesterone that could be the trigger to PPD. POSTPARTUM DEPRESSION PHARMACOTHERAPY – HORMONAL THERAPY
- 17. • Few studies on the effects on infants of exposure to antidepressants through breast milk. • Adverse effects include: sleep changes, gastrointestinal problems, respiratory problems, seizure. • Mostly resolved by interruption of treatment or breastfeeding • SSRI (sertraline, fluoxetine) and TCA (nortriptyilne) have the most data supporting safety during breastfeeding POSTPARTUM DEPRESSION PHARMACOTHERAPY – BREASTFEEDING CONSIDERATIONS
- 18. • Diet • Ω3 fatty acids (3-4 g/die): depletion during pregnancy to build the fetus’s CNS • Proteins • vit. B6 • carbohydrates, caffeine, sugar • Electroconvulsant therapy (ECT) - psychotic symptoms - for non-respondent to antidepressants women • Hospitalization - suicide risk POSTPARTUM DEPRESSION OTHER TREATMENTS
Notas do Editor
- Blues – 50 a 70 por cento de todas as mulheres após o parto. Começa ao 3º/4º dia e termina 2 semanas depois. A mulher sente-se cansada, ansiosa, stressada, solitária. Depressão pós-parto – pode ter os blues, mas acaba por arrastar-se por mais tempo; pode também aparecer mais tarde do que apenas ¾ dias. Psicose – raro – mania, pensamentos psicóticos, depressão severa, e outros tipos de problemas. É uma emergência médica.
- O declínio rápido nos níveis de hormonas reprodutivas que ocorrem após o parto podem estar na origem da PPD. Depois do nacimento, os níveis de progesterona e estrogénio caem rapidamente, retomando aos níveis da pré-gravidez em 3 dias. Há um aumento da prolactina também.
- Stress pré-natal – experiências como a perda de um ente querido, divórcios, perder o emprego, mudar de casa são conhecidas como causadoras de stress e podem desencadear episódios depressivos em indivíduos sem história prévia de depressão (uma vez que as mulheres também passam por momentos de flutuação hormonal) Suporte Social – receber suporte social através de amigos e familiares durante tempos stressantes é um fator protetor contra a depressão e vários estudos evidenciam uma redução da PPD com tal. O isolamento é mau. Emigrantes!!! Childbearing – a mãe tende a fazer a maior parte das tarefas de cuidados. Normalmente, a relação entre os pais tende a sofrer e há menos tempo para socializar. Uma relação de apoio com o pai pode ajudar a mitigar o stress de ser mãe. …
- To try to mitigate the serious adverse outcomes of PPD, early detection is key. This might be complicated by the normal physical and emotional demands of new motherhood (changes in energy and appetite, sleep deprivation, concern for wellbeing of the infant) Experts suggest screening at the 1st postnatal obstetrical visit (usually 4-6 weeks after delivery), or in the family practice or pediatric setting. Most common screening tool Edinburgh Postnatal Depression Scale (EPDS), initially proposed in 1987, a 10 item self-report that emphasizes emotional and functional factors over somatic symptoms. Values ≥ 10 indicate a possible PPD, and a reasonable cut-off for a positive screen is ≥ 13 (out of a possible 30), with a special note to positive responses to item 10 (suicidal ideation). Other common screening tools with evidence of validity in the puerperium: Postpartum Depression Screening Scale (PDSS) (http://www.mededppd.org/pdss.asp - 35-item Likert-type response scale consisting of 7 domains: sleeping/eating disturbances, anxiety/insecurity, emotional lability, cognitive impairment, loss of self, guilt/shame, and contemplating harming oneself) and the 9-item Physician’s Health Questionnaire (PHQ-9) (http://patient.info/doctor/patient-health-questionnaire-phq-9 - PHQ-9 is the depression module, which scores each of the nine DSM-IV criteria as "0" (not at all) to "3" (nearly every day). It has been validated for use in primary care. It is not a screening tool for depression but it is used to monitor the severity of depression and response to treatment. However, it can be used to make a tentative diagnosis of depression in at-risk populations). The Antepartum Questionnaire (APQ) was developed in 1997 and evaluates in 24 questions the past and present-time feelings of the puerperal on a number of subjects. A scoring of ≥ 46 should be considered for psychiatric evaluation and followed closely during the postpartum to detect possible signs of PPD.
- PPD frequently missed by the primary care team, because the clinical signs are not apparent unless screened for. This is why assessment at every chance is key! Because PPD is classified by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a part of the spectrum of major depression the same criteria can be used when screening for PPD An MDE may be classified as having a postpartum onset if the depressive symptoms begin within the 1st 4 weeks after delivery. But there are studies suggesting that depressive episodes are significantly more common in the 1st 3 months after delivery and an increased vulnerability to psychiatric illness may persist for 1 year or more. It is important to differentiate PPD from other psychiatric and non-psychiatric diagnosis. The postpartum blues or “baby blues” is a transient mood disturbance that affects up to 75% of new mothers in the 10 days following delivery, and consists of crying, irritability, fatigue, anxiety, and emotional lability. Symptoms are generally mild and self-limited, and do not involve total loss of pleasure or interest, persistent low mood, or suicidal ideation. On the other extreme, postpartum psychosis is a psychiatric emergency that requires immediate intervention, and is characterized by the rapid onset of severe mood swings, a waxing and waning sensorium, delusions, hallucinations or disorganized behaviors, and a relatively high incidence of suicidal ideation or homicidal ideation toward the infant. Other non-psychiatric diagnoses might include transient hypothyroidism, which affects 4 to 7% of patients and peaks 4 to 6 months postpartum, thyrotoxicosis, which may present with symptoms suggesting panic disorder, anemia, whose symptoms of fatigue, loss of energy and difficulty sleeping overlap with depression, and infection, whose symptoms of fatigue, loss of energy and mood changes also overlap with depression. Antepartum education on PPD is also a big factor in diagnosis. New mothers may feel ashamed when they’re not overjoyed with the birth of a new child and may not report symptoms or problems to their doctor.
- First line therapy is non-pharmacological therapy! Although relatively few studies have systematically investigated non-pharmacologic treatments for PPD, existing research supports the use of both psychological treatments as well as psychosocial interventions. Two methods of therapy that have been shown to be beneficial are Interpersonal Therapy (IPT) and short-term cognitive behavioral therapy (CBT). The IPT is a time-limited and interpersonally-oriented psychotherapy and may be effective for women with mild depression. It addresses the connection between interpersonal problems and mood, which frames depression as a medical illness occurring in a social context. Over the course of the therapy (typically 12–20 weeks), strategies are pursued to assist patients in modifying problematic approaches to relationships and in building better social supports. Several studies have supported the effectiveness of IPT for treating postpartum depression. In one large-scale randomized controlled trial, to give just one example, 120 women with postpartum depression were randomized to receive 12 weekly 1 hour individual sessions of IPT by a trained therapist versus control condition of a wait-list. The women who received IPT had a significant decrease in their depressive symptomatology (measured by Hamilton Depression Rating Scale and Beck Depression Inventory) as compared to the wait-list group, as well as significant improvement in social adjustment scores. The CBT teaches people to recognize their inaccuracies in thinking and to make behavioral changes that enhance coping and reduce distress. There have been several trials assessing CBT alone or with other interventions for the treatment of PPD. These studies support CBT interventions as helpful in the treatment of PPD, though they do not support an additional benefit to CBT in combination with pharmacotherapy.
- IPT: patient and clinician select focus on one of these treatment areas, role transition, role dispute, grief, interpersonal deficits, in order to build better social support. In this case, the treatment areas are more focused on the relationship mother-infant, mother-partner, transition back to work. NDC: the health visitor is usually a nurse who conducts home visits with pregnant and postpartum women.
- The main concern is about the exposure of the infant to the drug through breastmilk (see slide). Another concern is about the mother’s self-perception as a bad mother since she requires medication. The drug must be prescriped by a specialist after careful clinical considerations.
- It is important to monitor the infant for any behavioral and physical changes/symptoms, with particular care on sleeping, and feeding patterns, sedation, social interaction, irritability. Plasma levels of the drug do not correlate with the adverse effects, so periodic blood tests are currently not recomended.
- Anesthetic agents used in ECT are typically rapidly metabolized, and risk of transmission in breast milk can be minimized by timing breast feeding accordingly.