postpartum depression
- 1. POSTPARTUM DEPRESSION BEYOND THE BLUES
- 2. INCIDENCE OF DEPRESSION Each year, 15% to 20% of adults in the United States experience a major depression The incidence among women is twice that of men and peaks between 18 to 44 years of age - the childbearing years
- 3. DEPRESSION IN WOMEN Women are at increased risk of mood disorders during periods of hormonal fluctuation- premenstrual postpartum perimenopausal
- 4. THE RANGE OF POST- DELIVERY MOOD DISORDERS 50% to 80% of women experience transient “baby blues” within the first two weeks following delivery 0.1% to 0.2% of women experience postpartum psychosis usually within the first 4 weeks following delivery
- 5. POSTPARTUM DEPRESSION 6.8% to 16.5% of women experience postpartum depression (PPD) also known as postpartum major depression (PMD) Onset can be as early as 24 hours or as late as several months following delivery
- 6. SYMPTOMS OF POSTPARTUM DEPRESSION Hopelessness Loss of pleasure in activities Helplessness Mood changes Persistent sadness Inability to adjust to role of motherhood Irritability Inability to concentrate Low self-esteem Sleep /appetite disturbances
- 7. RANGE OF SYMPTOMS Symptoms range- from mild dysphoria to suicidal ideation to psychotic depression
- 8. DURATION OF SYMPTOMS Untreated, symptoms can last: several months into the second year postpartum
- 9. THE ETIOLOGY OF POSTPARTUM DEPRESSION Various theories based in physiological changes have been postulated: hormonal excesses or deficiencies of estrogen, progesterone, prolactin, thyroxine, tryptophan, among others
- 10. ETIOLOGY OF POSTPARTUM DEPRESSION Other theories cite numerous psychosocial factors associated with PMD: marital conflict child-care difficulties (feeding, sleeping, health problems) perception by mother of an infant with a difficult temperament history of family or personal depression
- 11. Higher rates of depression were noted among women who: Had less than a high school education Reported being abused before or during pregnancy Were less than 19 years old Had 0 to 1 person as a source of social support Resided in a household with an income <$15,000 Were not married Experienced an unintended pregnancy Reported 6 to 18 stresses during pregnancy (sick family member, divorce, etc.)
- 12. THE IMPACT OF POSTPARTUM DEPRESSION
- 13. LONG TERM CONSEQUENCES OF PMD Negative impact on the infant ‘s social, emotional and cognitive development 2 month old infants of mothers with PMD had decreased cognitive ability and expressed more negative emotions during testing
- 14. LONG TERM CONSEQUENCES OF PMD Babies of mothers with PMD were perceived by their mothers as more difficult to care for and more bothersome.
- 15. POSTPARTUM DEPRESSION & MATERNAL MORTALITY In recent years, there have been two maternal deaths due to suicide by women within one year of giving birth. Neither woman had been screened for postpartum depression
- 16. RISK FACTORS FOR PMD -Family history of mood disorder -Child-care difficulties: feeding, sleeping, health -Client history of mood disorder prior to pregnancy -Marital conflict -Anxiety/depression during pregnancy -Stressful life events -Previous postpartum depression -Poor social support -Baby blues following current delivery
- 18. SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY: Be unable to recognize she is depressed
- 19. SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY: Believe her symptoms are “normal” for new moms
- 20. SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY: Fear being labeled a “bad mother” if she admits her maternal experience does not meet society’s picture of bliss
- 21. SCREEN ALL POSTPARTUM WOMEN FOR PMD BECAUSE A WOMAN MAY: Feel she is going crazy and fears her baby will be taken from her
- 22. WHEN TO SCREEN FOR PMD At preconception visit During prenatal intake & subsequent visits During postpartum exams During infant’s WCC & WIC visits When infant is seen for sick care or in ER At early intervention home visits At family planning visits during the first year postpartum At mother’s visits for routine episodic care
- 23. SCREENING TOOLS There are several tools available: Edinburgh Postnatal Depression Scale (EPDS) The Mills Depression & Anxiety Checklist The Center for Epidemiological Studies Depression Scale (CES-D) Others, often on various websites for mental health
- 24. A WORD ABOUT SCREENING TOOLS! Be familiar with the tool - its validity and limitations Have a referral network available for women screening positive Document the screening and any referrals made Follow-up with your client to assure that she received needed assistance
- 25. EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS) Designed for home or outpatient use Consists of 10 questions Can be completed in approx. 5 minutes Reviews feelings the previous 7 days Scored 0-3 depending on symptom severity Depending on study, cut off is 13 - 9 points
- 26. TREATMENT 1. Educate the woman and her support system regarding the diagnosis of postpartum depression.
- 27. TREATMENT OPTIONS Pharmacological intervention Counseling, individual and/or group Support groups
- 28. PHARMACOLOGICAL INTERVENTION Use of tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) may be indicated for both non- nursing and nursing mothers Have low incidence of infant toxicity and adverse effects during breastfeeding* Decisions regarding use while breastfeeding must be on a case by case basis
- 29. OTHER CONSIDERATIONS: Provider must be familiar with agents and the hepatic function of mother and infant Client must be informed of risks/benefits of treatment Vs. no treatment for herself and her infant unknown impact of long-term use of medications on neurodevelopment of infant
- 30. Other Considerations - Cont. If the woman chooses to breastfeed while on psychotropics, she should work collaboratively with a psychiatrist and her pediatrician If the infant experiences insomnia or other behavior changes, his serum should be assayed for the presence of medication Document all discussions regarding treatment in the client’s chart
- 31. COUNSELING Know referral sources in your locale, especially those that: accept Medicaid utilize a sliding fee will develop a payment plan with the client offer free counseling Be familiar with indigent drug programs available through various pharmaceutical manufacturers
- 32. Counseling - Cont. Any woman with symptoms of psychosis or with serious suicidal/homicidal ideation should be referred for emergency psychiatric evaluation
- 33. SUPPORT GROUPS Numerous postpartum support groups are available. Contact: Local mental health agencies Hospitals Websites