Depression in Reproduction Flashcards

1. Describe the epidemiology of depression during pregnancy and postpartum (MKS 1f) 2. Discuss risks of antidepressant use during pregnancy (MKS 1e) 3. Review risks of Major Depressive Disorder during pregnancy (MKS 1b) 4. Present data about breastfeeding and antidepressant use (MKS 1e) 5. Be aware of the impact of pregnancy on drug disposition and the need for antidepressant dose changes (MKS 1e) 6. Learn why the FDA categorization (ABCDX) for drugs in pregnancy should not be used to guide

1
Q

What are the gender differences in prevalence of major depression?

A
  • Women are approximately 1.7 times as likely as men to report a lifetime history of MDE
  • Sex difference begins in early adolescence (age 10) and persists through the mid-50s
    • The sharp divergence in the 50’s is based upon a small sample size and not thought to be reliable.
  • Sex difference in depression is most pronounce among early adolescents, with the highest relative hazard of first onset (OR=2.3) in the age range 10-14.
    • This is a consistent finding throughout the world, regardless of how depression is diagnosed
  • Since women are no more likely than men to be chronically depressed or to have ana acute recurrence in the past year – therefore higher prevalence is due to higher risk of 1st onset
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2
Q

What are some factors that affect women in terms of depression during pregnancy?

A
  • 14.5% pregnant women-new episode of depression
  • 14.5% of postpartum women-new episode during the first 3 months after birth; 21.9% in first year
  • Symptoms MDD/Anx=physiological dysregulation
  • Appetite and Nutrition Effects; Overweight/Obesity
  • Cognitive changes; safety; prenatal care compliance
  • Alcohol, drug use, smoking
  • Loss of Interpersonal and Financial Resources
  • Capacity for maternal attachment behaviors
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3
Q

What are some common findings of major depression?

A
  • For two weeks, most of the day nearly every day, 5 of these (one must be mood or interest):
    • Depressed mood
    • Diminished interest/pleasure
    • Weight loss/ gain unrelated to dieting
    • Insomnia/ hypersomnia
    • Psychomotor agitation/ retardation
    • Fatigue or loss of energy
    • Feelings of worthlessness/guilt
    • Diminished ability to concentrate
    • Recurrent thoughts of death
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4
Q

What birth defects that are increased in risk due to maternal stress?

A
  • OR for a 3-unit change in the stress index was 1.45 (95% CI=1.03-2.06) for cleft palate
  • A 3-unit change in stress assoc. with 2.35-fold ↑ risk of anencephaly among women without folic acid (CI =1.47-3.77) and a 1.42-fold increased risk among women with folic acid (CI = 0.89-2.25).
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5
Q

What are the risks for depression in women in pregnancy?

A
  • Recurrence risk for women who either maintained or discontinued antidepressants proximal to conception
  • Significantly more women who discontinued (44/65, 68%) compared to women who maintained (21/82, 26%) antidepressant treatment suffered recurrent major depressive disorder.
  • Recurrences emerged rapidly (50% in the first trimester, and 90% by the end of second trimester).
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6
Q

What are the major outcomes impacted by psychiatric disorders and antidepressants that are being studied?

A
  • Major birth defects (approx 3% in the general population)
  • Growth/Preterm Birth
  • Behavioral Teratogenicity
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7
Q

How do SSRIs affect congenital defects?

A
  • Specific defects have small risk
  • Congenital defects, especially cardiac defects are related to depression and NOT SSRIs
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8
Q

How are SSRIs related to growth and preterm growth?

A
  • Pregnancy duration, Birth weight
    • Small for Gestational Age (SGA) infants inconsistently reported with SSRI exposure
    • PTB associated with SSRI
    • SGA and Preterm Birth associated with MDD
  • However, depression may be the underlying cause, but not enough studies yet
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9
Q

What is the relationship between SSRIs and preterm birth?

A
  • Rates of preterm birth higher in women on SSRIs
  • However, depression throughout pregnancy also gave similar rates
  • Suggests that if there is depression, there is something about the illness that increases the risk of preterm birth
    • Unclear if the medication has a separate mechanism or not
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10
Q

How do SSRIs and MDD affect growth after birth?

A

No effect

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11
Q

How do SSRIs and MDD affect neurological development of infants?

A
  • No effect on mental development
  • Longer duration of prenatal SRI exposure insreases risk for lower PDI (motor development) in infants
  • Motor differences gone at 19 months, may be a transient dip at around 52 weeks
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12
Q

Are SSRI-treated womoen really better?

A

Mixed results, one study shows that there is some improvement if treated with SSRIs

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13
Q

What are some important factors in providing optimal treatment for women who are depressed during pregnancy?

A
  • Once the decision is made to use medication, treat optimally to provide the maximal reduction in disease burden
  • Document all exposures (drugs, alcohol, environmental)
  • Document risk-benefit discussion and patient’s reason for decision
  • Use a standard symptom monitoring measure (PHQ-9)
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14
Q

How does drug levels change across pregnancy? How does this impact management?

A
  • Much higher active drug levels during pregnancy despite no changes in dose
  • Means that after delivery, simply increase dose, no need to change drugs
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15
Q

What are some non-drug therapies that have been shown to be effective for pregnant women?

A
  • Psychotherapy, many forms!
  • Bright Light Therapy
  • Seasonal and non-seasonal MDD
  • 30-60 mins commercially available, UV-screened 10,000 lux fluorescent light, within 10 mins of awakening
  • Acupuncture for depression during pregnancy
  • Aerobic Exercise (> 30 minutes of moderate intensity physical exercise, 3 to 5 days per week)
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16
Q

What are some findings of post-partum depression?

A
  • Large drop in hormones
  • Not a clinical disorder - 50% to 80% of new mothers, not usually seen by physicians
  • Anxiety, mood lability, crying spells
  • Transient, no pervasive mood disturbance
  • Peak 3-4 days after delivery
  • Gone by day 10 postpartum! Anything else is not “Baby Blues”!!
  • Differentiate from depression by transience and low-level symptoms; be more suspicious if she has a history of depression
17
Q

Why screen for perinatal depression?

A
  • It affects 1 of 7 new mothers
  • Risk factors: anxiety disorder, prior depression, childhood hysical/sexual abuse, psychosocial adversity
  • Brief, easy to use screening measures are available
  • Treatments are efficacious
  • Women motivated toward improved health behaviors
  • Screening has become law in some states including IL
  • Affects many domains of maternal function negatively as well as infant development
18
Q

What are some findings in babies of depressed mothers?

A
  • All forms of communication (voice, face, touch) affected by depression
  • Infants of depressed mothers
    • Irritable and difficult to console
    • More withdrawn and less responsive
19
Q

When is the most common time for women to present depression symtpoms?

A
  • During pregnancy, N=276 (33.4%)
  • Postpartum (within 4 weeks of birth) N= 331 (40.1%)
  • Prior to pregnancy, N=219 (26.5%)
20
Q

What are the indications for screening for bipolar disorders in post-partum women?

A
  • Unopposed Antidepressant risks agitation/rapid cycling
  • Prevalence=1-1.5% to 5%
  • Males=Females
  • Mania/ hypomania alternate with depressive episodes.
  • Onset in mid to late teens
  • Postpartum onset particularly common
  • “Plugged in” symptoms: grandiosity, less need for sleep but not tired, pressured speech, flight of ideas, distractibility, increased involvement in goal-directed activities, psychomotor agitation, excessive involvement in pleasurable activities with likelihood of painful consequences
21
Q

What are the indications for treating postpartum psychosis?

A
  • 1-2 /1000 births
  • Rapid onset post-birth; bizarre delusions/ hallucinations, cognitive disorganization
  • Bipolar disorder! Mania or psychotic depression; use ECT, mood stabilizers
  • Differentiate from obsessional thoughts
  • Very high risk for recurrence after later births; preventive treatment (lithium) appropriate
22
Q

How do antidepressants affect breast feeding?

A
  • Many risks for development if a baby is not breast fed
  • The benefits of breastfeeding are legion and long-term.
  • Data consist of mother and infant serum levels; some breastmilk
    • Usually below limit of quantifiability in infant serum: sertraline (zoloft), paroxetine (paxil), tricyclic nortriptyline
  • Infant serum level monitoring not recommended for healthy newborns