Post Partum Depression

Vani Ray, MD
Clinical Assistant Professor,
Dept. Of.Psychiatry,UW.Madison
Chief, Dept. Of Psychiatry , ASMC
Director, Consultation & Liaison
Services
Aurora Behavioral Health Services
Facts about Perinatal
Depression
10%-15% of women experience
depression in the perinatal period
and up to 28% of women living in
poverty.

• There were 70,934 births in Wisconsin in

2005.

• That means that (10-15%) over 7,000 to

10,000 women were likely to suffer from
prenatal and postpartum depression (PPD)
• However, 40% of births were paid for by
Medicaid, which is a surrogate measure
for poverty.
• 28% of over 27,000 women, over 7,600
women, were likely to suffer from
prenatal and PPD.
• What do these numbers mean for your
practice?
Approximately 50% of
women with postpartum
depression are untreated.
• Depression
affects how a
woman is able
to relate to
others,
including her
baby.
 Post Partum Depression

• What is the post Partum Depression?

• How is it different from Post partum blues?
• what is the prevalence of Post partum Depression?
• What are the risk factors for Post partum
Depression?
• Who should Screen Post partum Depression?
• Who treats Post partum Depression?
• What is the treatment of Post partum Depression?
 Post Partum Depression
• Tracey is a 27 year old mother brought into my office
as an urgent care appointment. She just had a baby
4 weeks ago after much anticipation. Her husband is
an only child and her in-laws filled the nursery with
toys and clothes for the baby and are very excited.
• She is unable to sleep and eat, extremely doubtful of
her ability to do anything.
• She is preoccupied with the fear that she will harm
the baby and intense guilt of her inability to meet the
expectations of the family.
• She has been thinking that how easy it is kill herself
than to be this worthless.
 Post Partum Blues

• The days and weeks immediately following the birth

of baby can be an emotional roller-coaster. New
mothers can experience elation, wonder, anxiety, and
most have at least a touch of the blues.
• Between 50 and 90 percent of all new mothers
experience a bout of mild depression right after the
birth of their babies.
• It typically lasts 2-10 days some may progress to
Major depression
 Why Screen?

Screening is an easy, affordable

method of identifying those
women whose symptoms are
interfering with function in their
multiple roles.
Screening is effective in
identifying depression.

• You can’t tell by

looking that
someone has
depression.
• How many times do
you screen?
• Do you have a
system of referral?
 Post Partum Depression
• Depressed mood • Guilt
• Tearfulness • Anxiety or
• Sleep or appetite nervousness
disturbances • Irritability
• Weight gain or loss • Low energy
• Hopelessness • Loss of
• Loss of interest & concentration
pleasure • Thoughts of harming
• Feelings of being self or infant
overwhelmed
Mild Severe
• Severe Symptoms:
– Thoughts of dying
– Thoughts of suicide
– Wanting to flee or get away
– Being unable to feel love for the baby
– Thoughts of harming the baby
– Thoughts of not being able to protect the
infant
– Hopelessness
 Psychological Factors that
influence development of PPD
Emotional stability
Attitudes toward femininity.
Relationship with mother and spouse.
Cultural attitudes
Preparation for parenthood
Prior mental illness
Presence or absence of prior children.
Social support
Socio-economic status
Life circumstances
 Risk Factors for Development of Post
Partum Depression
During Pregnancy After Birth

• A young and single • Labor/Birth

mother Complications
• H/O Mental illness or
substance abuse • Low confidence as a
parent
• Financial or relationship
difficulties • Problems with Baby’s
• Previous Pregnancy or Health
postpartum depression • Lack of supports
• Major Life change at
the same time as birth
of the baby
Role of emotional stress on
obstetric outcome

•Prematurity
•Low birth weight
•Increased child morbidity
•Impaired emotional attachment
to fetus and difficulties in
mother-infant relationship
•substance abuse
 Psychological Changes in
Pregnancy
• Increased anxiety is focused on fetus rather than
on the person herself.
• Increased introspection and preoccupation with
pregnancy with decreased emotional investment
in the external world.
• Heightened dependency needs.
• In some, there is a shift toward primary process
thinking and increase in primitive defenses.
 Psycho-neuro-endocrine factors
influencing Depression
• Gonodal hormones i.e. estrogen, progesterone
and cortisol undergo rapid changes during
pregnancy and increase significantly.
• They regulate neurotransmitter, neuro endocrine,
and neuro modulatory systems in the central
nervous system. In turn they influence
monoaminergic pathways that are implicated in
pathogenesis .
• Gonodal hormones also affect diurnal rhythm
changes crucial in pathogenesis of affective
disorders.
 Mood disorders during
pregnancy
• Diagnosis is difficult, as vegetative symptoms are
normative for pregnancy
• Pharmacological interventions pose challenge during
pregnancy.
• Psychotherapy is beneficial for mild to moderate
depression
• Post partum period is turbulent for patients with
Bipolar disorder.
• Treatment is individualized.based on risk vs. benefit
analysis.
 Depression Screening

• Perinatal Visits
• Labor
• Post partum checkups
– immediate and upto one year
• wellbaby Clinics
 Who Could Screen?
• Clinicians & service providers who work with
pregnant & postpartum women
– Advance Practice Nurses–CNMs, and NPs
– Physicians–OB/GYN, Family Practice, Pediatrics
– NICU staff
– Public health, hospital, and parish nurses
– Prenatal care coordinators
– WIC dietitians
– Lactation consultants & home visitors (PH nurse, etc.)
– Social workers
– Doulas
– Others?
 How to introduce screening:
One way to introduce screening to the
woman is to say:

“It is routine for us in this office to check

with all pregnant women (new moms)
about how they’re feeling. We like to
know a little about your emotional
health.”
 Depression Screening Tools
Center for Epidemiological Studies–Depression
(CES-D) Scale

Edinburgh Postnatal Depression Scale (EPDS)

Postpartum Depression Screening Scale

(PDSS)

Depression Scale in Hmong

Edinburgh Post Natal Depression Scale
(EPDS)
 Edinburgh Post Natal Depression Scale (EPDS) -
Guidelines for raters

• According to Warner, Appleby, Whitton, & Faragher (1996), postpartum

depression affects 10% of new mothers, with the range being from
eight to 15%. The Edinburgh Postnatal Depression Scale (EPDS) was
developed in 1987 to act as a specific measurement tool to identify
depression in new mothers. The scale has since been validated, and
evidence from a number of research studies has confirmed the tool to
be both reliable and sensitive in detecting depression.
Response categories are scored 0,1,2, and 3 according to increased
severity of the symptom.
Questions 3,5,6,7,8,9,10 are reverse scored (ie, 3,2,1,0)
Individual items are totalled to give an overall score. A score of 12+
indicates the likelihood of depression, but not its severity. The EPDS
Score is designed to assist, not replace clinical judgement.
Warner, R., Appleby, L., Whitton, A., & Faraghen, B. (1996).
Demographic and obstetric risk factors for postnatal psychiatric
morbidity. British Journal of Psychiatry, 168, 607-611.
 Two simple questions:
• During the past month, have you often
been bothered by feeling down,
depressed, or hopeless?

• During the past month, have you often

been bothered by little interest or pleasure
in doing things?

US Preventive Services Task Force

 When to Screen
The WAPC “Pathways for Accessing Treatment
& Support Services for Women
Experiencing Prenatal and Postpartum
Depression” recommends screening twice
during pregnancy and twice postpartum,
when possible. For example, at:
• First prenatal visit
• The third trimester
• The 6-week postpartum visit
• And one other time during postpartum year
Such a frequency would identify most
women who experience depression
during that period.
 Communicating with women
about screening results…
“Based on what you’ve told me and your score,
I’m concerned that you have some symptoms
of depression. It’s hard to be going through
this when you are pregnant [or ‘when you have
a new baby’]. Remember, depression is partly
due to an imbalance of chemicals in your body
and things that cause stress in your life. There
are things to do to feel better. Let’s talk about
some ideas that might work for you.”
 Consequences of Untreated
Depression
• Woman may not seek prenatal care or follow
through on health care recommendations
• May be less responsive to infant, resulting in
delayed development
• May cause stress in relationships
• Increased risk for future episodes of
depression
• Increased risk of self injury/suicide
• Difficulty or failure in job performance
 Consequences of untreated
depression for the infant
• Poor weight gain
• Feeding problems
• Sleep problems
• Poor emotional attachment
• Behavior problems/hyperactivity
• Depression
• Mother may be less attentive to
hygiene/safety
 Chronicity, rather than
severity of depression has
more long-term effects on
infants and children.
 Barriers to accessing care
• Most don’t seek treatment
• Concerned with confidentiality
• Fear that seeking treatment will affect job,
relationships
• Unsure of health coverage
• Embarrassed or reluctant to talk
• Myths – Personal weakness, “tough it out”
• Stigma
 Postpartum Depression
• It is important to treat women with symptoms of
depression during pregnancy
• The pharmacological treatment during pregnancy
poses several dilemmas
• Decision making when to treat them is complex
• It involves careful consideration of risks versus
benefits of treatment and education
Pharmacological Treatment of
Depression

 All psychotropic medications diffuse readily across the

placenta.
 Knowledge of the risks to the fetus of prenatal exposure
to psychotropic medication is incomplete.
 Little is known about potential of long-term behavior
abnormalities in children exposed to psychotropic
medications.
 To date, the U.S. FDA approves NO psychotropic
medication for use during pregnancy
 Facts of Psychotropic drug
use in pregnancy
• Major Birth Defect incidence is 2%to 4%
• Cause of 65% to 70% of these is unknown
• Drug exposure as a cause is not established
• 50% of pregnancies are unplanned.
• To limit exposure to either illness or treatment which path
poses least risk?
• Category labeling of all the medications.
• No decision is risk-free.
 Facts of Psychotropic drug
use in pregnancy
• In humans , fetal brain develops through out the
gestation and is susceptible to med toxicity even after
first trimester is complete
• This is the area of concern about use of CNS active
drugs during the gestation
• Behavioral teratogenicity is poorly understood aspect
of teratology.
 Facts of Psychotropic drug use in
pregnancy
Category Description
A adequate, well-controlled studies in pregnant women have not shown an
increased risk of fetal abnormalities.

B Animal studies have revealed no evidence of harm to the fetus, however, there are no
adequate and well-controlled studies in pregnant women.
or
Animal studies have shown an adverse effect, but adequate and well-
controlled studies in pregnant women have failed to demonstrate a risk to the fetus.
C Animal studies have shown an adverse effect and there are no adequate and well-
controlled studies in pregnant women.
or
No animal studies have been conducted and there are no adequate and well-
controlled studies in pregnant women.
D Studies, adequate well-controlled or observational, in pregnant women have
demonstrated a risk to the fetus. However, the benefits of therapy may
outweigh the potential risk.

X Studies, adequate well-controlled or observational, in animals or pregnant women have

demonstrated positive evidence of fetal abnormalities. The use of the product is
contraindicated in women who are or may become pregnant
 FDA Warning
• Neonates exposed to SSRIs and SNRIs
during the late 3rd trimester have
demonstrated increased complications
– Prolonged hospitalization
– Jitteriness, tremor, apnea
these symptoms are consistent with either toxicity
or withdrawal
Caution - Neonatal work up
 Antidepressants

• Altschuler et al., 1996 TCA (N 437) No abnormalities

• Chambers et al., 1996 TCA &SSRI No abnormalities
• Kulin et al., 1998
• Nulman et al,. 1997

• Einerson et al., 2001 Effexor No abnormalities

• Ericson et al., 1999 TCA&SSRI (N 969) No
abnormalities
Sura Alwin et al, N.Engl J Med 2007 356: 2684-92
 Antidepressants

• Nefazadone
• Mirtazepine
• Bupropion
 Antidepressants

• Tricyclics
Most studied are Nortriptylene and Desipramine.
SSRIS
Most studied. Safe to use.
• MAOIS
Incomplete safety data, not indicated in pregnancy.
• SNRIS
Venlafaxine
Duloxetine
Potential risks to the fetus with
prenatal exposure of
psychotropic Medications
• Teratogenicity (Organ malformations)
• Neonatal toxicity (Perinatal syndromes)
• Neonatal withdrawal syndromes.
• Behavioral Teratology (Postnatal
behavioral sequelae)
Psychological Treatment of Depression

Interpersonal Psychotherapy
Cognitive Behavioral Psycho therapy
Couples therapy
Family therapy

Post Partum Therapy groups

Post Partum Support groups
Non Pharmacological Interventions of
Depression

Exercise
Nutritious and Balanced Meals
Taking some time for yourself
Mobilizing support networks
Mental Health Resources for Young
Mothers
Aurora Behavioral Health Services
Aurora Sinai Medical Center
Aorora women’s Pavillion
414-773-4312
www.auroraheallhcare.org/ABHS
Perinatal Foundation, Inc.
McConnell Hall, 1010 Mound St.
Madison, WI 53715
aeconway@wisc.edu
(608) 267-6200 - phone
(608) 267-6089 - fax
www.perinatalweb.org
Depression is treatable and
may not resolve without
treatment.
Women do recover.
Early identification & treatment by
primary care clinicians or
mental health specialists are
essential.

– Those caring for women & children

from pregnancy through the first year
of life should be alert to the symptoms
of perinatal mood disorders.
 A note about providers who
have frequent contact with
women in the postpartum
period:
• Women usually have one postpartum
obstetrical or midwifery visit.
• Women usually have frequent interactions
with primary care providers such as
pediatricians, family physicians, and nurse
practitioners in the infant’s first year of life.
 When to screen?
• When does your facility screen?
• Do you collaborate with others to
ensure women of your community are
being screened?
• What are the “best practices” of the
region?
 Then what?
• Anyone who screens women should
have a follow-up action plan in place.
Motherhood is not
magical for women
suffering with
postpartum
depression