Perinatal and Postpartum Depression Flashcards
1
Q
perinatal depression prevalence
A
- Prevalence of Major Depression in Adults
- Depression is a common, debilitating condition
- The National Comorbidity study documented a lifetime prevalence in individuals between the ages of 15 – 54 at 17.1%
- Depression also documented to be more prevalent in women, and occurring most often between the ages of 18 – 59
- Major depression during pregnancy
- 9.4 – 12.7%
- Major depression postpartum
- 7.1% in first 3 months
- 21.9% in first 12 months
- 25%-30% of women with history of MDD are at risk for postpartum depression
- By comparison:
- 2-10% have gestational diabetes
- 5-8% have hypertension in pregnancy
- According to the Centers for Disease Control, 11 to 20% of women who give birth each year have postpartum depression symptoms. If you settled on an average of 15% of four million live births in the US annually, this would mean approximately 600,000 women get PPD each year in the United States alone.
2
Q
postpartum blues
A
- Features: tearfulness, lability, reactivity
- Predominant mood: happiness
- Peaks 3-5 days after delivery
- Present in 50-80% of women
- Present in all cultures studied
- Unrelated to environmental stressors
- Unrelated to psychiatric history
- Common for women to feel this after their baby’s birth, but for 1 in 7 women this progresses to more serious mood disorder of PPD
- 2018- estimated 85% of women experience some type of mood disturbance in postpartum period, 10-15% will experience more disabling and persistent form of depression, .1-.2% experience PP psychosis
3
Q
hormone withdrawal hypotheses
A
- Estrogen
- Receptors concentrated in the brain
- “Blues” correlate with magnitude of drop
- Progesterone metabolite (allopregnanolone)
- GABA agonists; CNS GABA levels & sensitivity may decrease during pregnancy as an adaptation
- The reduced brain GABA may recover more slowly in women with “blues”
4
Q
oxytocin as a neuropeptide neurotransmitter
A
- Peripheral effects include uterine contraction and milk ejection
- Receptors concentrated in brain
- New receptors are induced by estrogen during pregnancy
- Social attachment/ bonding
- Pair-bonding/ intimacy
- Parental behavior
- Disruption prevents/decreases maternal behavior
5
Q
posited relationships between the “blues” and postpartum depression
A
- A subset of women may be vulnerable to mood disorders at times of hormonal flux (premenstrual, postpartum, perimenopausal) regardless of environmental stress
- The normal heightened emotional responsiveness caused by oxytocin may predispose to depression in the context of high stress and low social support
6
Q
major depression: key symptoms
A
- At least one of the following (by self-report or others’ observations) for 2 weeks
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
7
Q
major depression: associated symptoms
A
- Four or more of the following:
- Changes in weight and appetite
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feeling worthless or guilty
- Impaired concentration, indecisiveness
- Thoughts of death
8
Q
clinical features of postpartum depression
A
- Depressed, despondent and/or emotionally numb
- Sleep disturbance, fatigue, irritability
- Loss of appetite
- Poor concentration
- Feelings of inadequacy
- Ego-dystonic thoughts of harming the baby
9
Q
confounds in diagnosing depression during pregnancy
A
- Overlapping symptoms
- Sleep disturbance
- Increased appetite
- Decreased energy
- Changes in concentration
- Illnesses with similar symptoms
- Anemia
- Thyroid dysfunction
- Gestational diabetes mellitus
10
Q
characteristics of postpartum depression
A
- Begins within 4 weeks of birth
- by DSM-IV definition
- Clinical presentation peaks 3-6 months after delivery
- Postpartum period considered up to 1 year
- Related to environmental stressors
11
Q
cultural context of postpartum depression
A
- Regardless of culture, the risks of postpartum depression are similar
- Previous episodes of depression
- Significant loss or life stress
- Unwanted/ unplanned pregnancy
- Prior fetal loss
- Unexpected birth outcomes
- Marital conflict
- Socioeconomic status
- Low social support
12
Q
postpartum psychoses
A
- Heterogeneous group of disorders
- Bipolar disorder
- Major depression with psychotic features
- Schizophrenia spectrum disorders
- Medical conditions (e.g. thyroid disease, low B12)
- Drugs (e.g. amphetamines, hallucinogens, bromocriptine)
- Prevalence
- 1-2 per 1,000 women giving birth
- About 35% of women with bipolar diathesis
- Onset usually within 3 weeks postpartum
13
Q
postpartum psychoses symptoms
A
- Delusions (e.g. baby is possessed by a demon)
- Hallucinations (e.g. seeing someone else’s face instead of baby’s face)
- Insomnia
- Confusion/disorientation (more than non-postpartum psychoses)
- Rapid mood swings (more than non-postpartum psychoses)
- Waxing and waning (can appear and feel normal for stretches of time between psychotic symptoms)
14
Q
factors that may contribute to risks associated with antenatal depression
A
- Indirect effects
- Reduced prenatal care
- Less optimal nutrition
- Poor appetite and weight loss
- Socioeconomic deprivation
- Increased use of cigarettes and alcohol
- Direct effects
- Changes in cortisol & HPA axis development
15
Q
effects of untreated depression on obstetric complications
A
- Low birth weight
- Premature birth
- Pre-eclampsia
16
Q
effects of antenatal depression on offspring
A
- Newborns cry excessively and are more inconsolable
- Babies (up to age 1) have poorer growth and increased risk of infection
- Children (up to age 5) have more difficult temperaments, more distress, sadness, fear, shyness, frustration
17
Q
early consequences of untreated postpartum depression for offspring
A
- Sometimes none
- Disturbed mother-infant relationship
- Cortisol elevation (baby and mother)
- Failure to thrive
- Physical injury/death
18
Q
later consequences of prolonged maternal depression for offspring
A
- Depression
- Behavioral disturbance, including conduct disorder
- Reduced cognitive abilities
- More school problems (truancy, dropping out)
- Role reversal
19
Q
effects of maternal stress and anxiety during pregnancy
A
- Altered fetal hemodynamics and movement
- Lower gestational age
- Lower infant birth weight
- Lower Apgar scores
- Enduring changes in cortisol measures in offspring – so far observed up to age 10
20
Q
potential effects of postpartum depression on relationships
A
- Altered roles within the couple
- Altered roles within the extended family
- Establishing alternate caregiver patterns that become difficult to change later
- Impaired communication
- Psychiatric symptoms in the partner
21
Q
risk of suicide from untreated major depression during pregnancy
A
- Overall risk may be lower than in non-pregnant women
- Risk may be increased when:
- Pregnancy is unwanted, especially when woman wanted an abortion but could not obtain one
- Partner abandoned woman during pregnancy
- Woman has had prior pregnancy loss and/or death of children
22
Q
infanticide due to postaprtum depression
A
- Rare; greater risk with psychotic symptoms
- Rarely has a history of abusing children
- Most often part of a suicide attempt
- No anger toward baby; wish not to abandon baby and/or not to burden others with baby
- Rarely attempt to conceal; often self-report
23
Q
thoughts of harming baby: low risk
A
- Common in non-psychotic PPD – 41% of depressed mothers vs 7% of controls
- Mother doesn’t want to harm baby
- Thoughts are ego-dystonic (obsessive in nature & odd/frightening to mother)
- Mother has taken steps to protect baby
- Mother has no delusions or hallucinations related to harming baby
24
Q
thoughts of harming baby: high risk
A
- Mother has delusional beliefs about the baby
- e.g. that the baby is a demon
- Thoughts of harming baby are ego-syntonic
- mother thinks they are reasonable and/or feels tempted to act on them
- Mother has a history of violence
- Mother has labile mood and/or impulsive behavior
25
Q
potential effects on the mother-infant relationship
A
-
Brain and Central Nervous System Development
- Interplay between genes and experiences
- Early interactions directly affect how the brain is “wired”
- HPA axis – stress response system impact
-
Attachment
- Infants of depressed mothers are at high risk for developing an insecure attachment
- Relational problems between infants and their caregivers are connected to early social, emotional, and behavioral problems for children
26
Q
the importance of early relationships
A
- Transactional model of infant-caregiver relationships
- Both infants and caregivers contribute to the developing relationship based on their own unique characteristics (temperament, neurology, etc.) and the context through mutually interactive transactions
- Attachment Theory: Impact on Development
- Secure attachment = child views the caretaker as loving and responsive, and her/himself worthy of love
- Insecure attachment = child views caretaker as unresponsive (possibly rejecting) and her/himself unworthy of love
- Insecurely attached child at risk for later behavior disorders, mood disorders, and delayed cognitive development
27
Q
transactional model: building a relationship is a two way street
A
- The infant brings to the relationship:
- Readiness to socially interact with others
- Unique constellation of individual characteristics & temperament
- Inherent drive towards mastery
- Resilience
- The parent brings to the relationship:
- The capacity to recognize and respond to the infant’s emotional signals (sensitivity & responsiveness)
- Current mental and physical status
- Social support network
- A history of being in other relationships
- Screening and Assessment
28
Q
detecting perinatal depression: why screen?
A
- High prevalence rate
- Risks of untreated symptoms
- Availability of effective treatments
- Under-detection by routine clinical evaluation
- Availability of validated screening tools
29
Q
screening for peripartum depression
A
-
Edinburgh Postnatal Depression Scale (EPDS)
- 10 item self-report questionnaire
- Advantages:
- Easy to score
- Specifically designed for peripartum use
- Well validated during pregnancy and postpartum
- Cross-culturally validated; available in over 20 languages
- Disadvantages:
- Not linked with DSM-IV diagnostic criteria
- Cannot be used for assessment or treatment tracking
- Patient Health Questionnaire (PHQ-9)
- 9-item self-report questionnaire
- Advantages:
- Easy to score
- Items & scores linked to DSM-IV depression criteria
- Can use to assess & track treatment response
- Can use same tool for non-peripartum patients in clinic
- Disadvantages:
- Not designed for peripartum use (somatic confounds)
- Not as well validated peripartum (2 studies)
30
Q
interpretation of the EPDS
A
- Maximum score: 30
- Always look at item 10 [suicidal thoughts]
- Sensitivity and specificity vary according to the chosen cut-off score
- Validated cut off score of 10-13
- Use an assessment tool to further evaluate women with high scores
- Example: Aiming for a sensitivity of at least 0.8 and a specificity of at least 0.7 in detecting peripartum major depression
- Cut-off scores between 10 and 12 have consistently yielded sensitivity and specificity scores in that range
- Cut-off scores above 12 have not been sensitive enough in some studies
31
Q
PHQ-9 scoring
A
- Total score ranges from 0 – 27
- A score of 5 or above out of 27 is considered positive
- Each numeric value is directly linked to the DSM-IV diagnostic criteria for major depression, including severity criteria
- Subtotal each of the 3 columns and add together to determine the total score
- Score tells whether woman meet DSM-IV criteria for major depressive episode along with severity level
- 0 - 5: does not meet criteria for major depression
- 5 - 9: mild depression
- 10 - 14: moderate depression
- 15 - 19: moderately severe depression
- 20 - 27: severe depression
- Initial treatment response: drop in score of 5 or more from pre-treatment baseline after 4 weeks of treatment
- Adequate treatment response: 50% decrease in score after 8 weeks of treatment
- Remission: post-treatment score < 5
- If response in primary care setting is inadequate, refer for mental health care
32
Q
summary of validated screening tools
A
- EPDS
- Best validated screening for peripartum populations
- PHQ-9
- Best validated for tracking response to treatment
33
Q
other tools sometimes used for perinatal depression screening
A
- Beck Depression Inventory
- 3 postpartum validation studies
- Center for Epidemiologic Studies – Depression
- 1 postpartum validation study
- Postpartum Depression Screening Scale
- 2 postpartum validation studies; longer than other screens
34
Q
treatment options
A
- Psychopharmacology
- Antidepressants
- Anxiolitics
- Antipsychotics
- Psychotherapy
- Interpersonal
- Cognitive-behavioral
- Couples/Family
- Mother-Infant didactic
35
Q
the role of social support
A
- The quality of relationships directly impacts mental health:
- Encouragement – to follow through on self care and other tasks to promote health
- Sense of belonging – increases self-esteem and sense of purpose
- Calming/Soothing – the knowledge that someone is there if needed
- Enjoyment – pleasurable experiences with others (even if temporary)
36
Q
evidence of protective influences of social support
A
- Receiving adequate social support during the early parenting period is associated with:
- Greater satisfaction with the marital relationship
- Better maternal-child interactions
- Decreased incidence of postpartum depression
- Increased rate of maternal education completion
- Less maternal alcohol and drug use
- Higher rates of obtaining timely infant immunizations
- Fewer unintentional infant injuries
- Decreased incidence of child abuse
37
Q
recruiting social support
A
- Examples of places people often find support
- Partner
- Family & Extended family
- Neighbors
- Co-workers
- Religious communities
- Professionals (doulas, lactation consultants, etc)
- Postpartum support groups
- Family community agencies
38
Q
educate about self-care
A
- Social support
- Sleep
- Breaks from baby
- Enjoyable, replenishing activities
- Nutrition (iron, calcium, folate, EFA’s)
- Aerobic exercise
- Break isolation
- Be with friends, partner, and/or other mothers with or without baby
- Take time for yourself (even if only 5 minutes)
- Protect yourself and your energy
- Turn off phones, limit visitors, eat frozen food, etc.
