1. Clinical Assessment: Perinatal Mood Disorders SOUTHERN NEW JERSEY PERINATAL COOPERATIVE

2. OBJECTIVES Recognize the importance of differentiating between ego-dystonic thoughts versus ego-syntonic thoughts in assessing a woman at risk for a perinatal mood disorder. Identify at least three (3) additional assessment parameters that are crucial in providing a comprehensive assessment in a woman at risk for a perinatal mood disorder. Recognize the typical sleeping and/or eating patterns that may present in the woman at risk for a perinatalmood disorder.

3. Background Information Name/Address Date of Birth Phone (home/ work/cell) – Preferred contact number Marital Status Presenting Problem Education History Employment History Spiritual/Cultural Preference

4. Pregnant and Postpartum First pregnancy? If not… Number of pregnancies Number of children If she has had perinatal losses Gestational age in weeks/Trimester How many When

5. Pregnant Postpartum EDC – Due Date Gestational Age Tell me about any complications with the pregnancy How do you feel about being pregnant? Is she going for prenatal care? Where? How often? Has she attended or does she plan to attend childbirth classes? Date of Delivery Gestational age at delivery Full term/Preterm? Tell me about any complications with the pregnancy* Describe how you felt emotionally during your pregnancy* Did you go for prenatal care? Did you attend childbirth classes? If so, were they helpful for you?

6. Postpartum Describe any complications that you had with labor and/or delivery?* How was the pain managed during labor and/or delivery?* Method of delivery Vaginal Cesarean How would you describe your overall labor and delivery experience?*

7. * The answers to these questions may indicate the need for further assessment for signs/symptoms of PTSD after Childbirth

8. PPD Screening Did you take the Edinburgh Postnatal Depression Scale (EPDS) In the hospital after you delivered your baby? In the office/prenatal care center at your postpartum visit? If the baby is less than 6 weeks old, she may not have had a postpartum visit yet

9. Infant Feeding Are you breastfeeding How is it going?* Are you bottle feeding How is it going?* * Assess for mom’s response to any feeding-related difficulties

10. About the Baby……… Did the baby spend time in the Intermediate Care Nursery and/or Neonatal Intensive Care?* How long?* Reason?* How is your baby doing now?* Does she call her baby by his/her name?* Ask her to describe baby’s personality?* * The answers she provides to these questions may indicate potential or actual attachment/bonding issues

11. Medical History Who are her healthcare providers (HCP) OB/GYN Family physician Any medical problems? Is she currently on medications/supplements? Has her HCP ordered laboratory studies to be done? Thyroid function studies may be ordered Thyroid disease may present during the postpartum period and may be contributing to her depression

12. Psycho-Social History Did you experience tearfulness or mood swings in the first two weeks after delivery? (postpartum clients) Did you feel anxious and/or depressed during your pregnancy?* Do you have a history of postpartum depression?(If applicable)* Have you ever been diagnosed with anxiety or depression at any other time in your life?* Have you ever been diagnosed with Bipolar Disorder?* Have you ever been diagnosed with Psychosis?*

13. Psycho-Social History * If she answers “yes” to any of these questions, then ask the following: Onset Duration Treatment Postpartum Psychosis most often presents as a cyclical disorder during the postpartum period, such as Bipolar Disorder or Schizo-Affective Disorder Bipolar Disorder (BPD)can occur for the first time following childbirth, BUT look into her personal history of “mood swings”, sexual abuse and a family history of BPD, depression, and/or substance abuse Explore family history: substance abuse, domestic violence, trauma, sexual abuse along with anxiety, depression*, BPD and psychosis Family HX: depression in a 1st degree relative, especially a mother and/or sister increases her risk of PPD.

14. Psycho-Social History Use of caffeine Use of nicotine Use of alcohol Use of recreational drugs Domestic Violence Trauma Sexual Abuse

15. Social Assessment Where does she live? Who lives with her in her house? Adults – who are they? Children – how many? Their ages? Does she perceive that she has social supports? Who are they? Level of functioning for Activities of Daily Living (ADL)

16. Symptom Assessment Describe your sleep patterns Do you sleep when the baby is sleeping?* At night, can you get to sleep?* Once asleep, can you stay asleep?* How many hours of uninterrupted sleep do you get during the night? Do you feel rested upon awakening in the morning?* Do you take naps during the day? Do you feel fatigued and/or lack energy during the day?*

17. Symptom Assessment Tell me about your eating patterns Do you feel hungry before you eat?* Tell me what you are eating Do you enjoy eating your meals?* * Sleep and/or appetite disturbances are symptoms associated with a clinical depression; however, women with a perinatal mood disorder typically tell us they are unable to sleep and/or eat. It’s important to ask the additional questions related to sleeping and eating patterns!

18. Symptom Assessment Are you crying for no reason? Are you anxious or worried? Do you feel isolated? Do you get irritable? Do you feel overwhelmed? Are you having difficulties in concentrating? Are you having difficulties in making decisions? Are you having difficulties with your memory?

19. Symptom Assessment Do you have feelings of worthlessness? Do you have feelings of shame/ guilt? Do you blame yourself? Are you having any “scary” thoughts about the baby or about yourself? Strange, intrusive thoughts are associated with an Obsessive Compulsive Behavior Disorder, not to be confused with Obsessive Compulsive Personality Disorder or Psychosis

20. Ego-dystonic = “scary” thoughts Women with “scary” thoughts need to be encouraged to reveal them in a safe environment to an experienced clinician. Ego-dystonic thoughts are uncharacteristic of who she thinks that she is and it causes her extreme anxiety. She often avoids objects (knives, scissors) or being with her baby in order to lessen the chance that she may act out on her frightening, tormented thoughts. She is reluctant to verbalize these “scary” thoughts to anyone b/c she fears her baby will be taken away from her. She needs to be encouraged to share these thoughts to a clinician who has expertise in the area of Perinatal Mood Disorders so that proper treatment can be recommended. Furthermore, she should be reassured that her “scary” thoughts IS a symptom of her Perinatal Mood Disorder and that she is NOT Psychotic. The difference between Ego-dystonic thoughts and Ego-syntonic thoughts (that ARE associated with Psychosis) is that she knows that these thoughts are out of character for her, she is scared to death and this is what is causing her extreme anxiety.

21. Symptom Assessment Do you have thoughts about harming yourself? If yes, assess for suicide risk Do you have thoughts about harming the baby? If yes, assess for homicide risk Ego-syntonic thoughts are associated with psychosis Psychotic episodes (MDD with psychotic features/mixed states (BPD) may be associated with infanticide (4%) )especially when delusions include the infant) or suicide (5%) Postpartum Psychosis is rare. The incidence is 1-2/1,000 women

22. Bear in mind………….. With these women, don’t be fooled into believing that what you see is what you get!” These women can present looking well dressed and groomed, but may be seriously ill. Cheryl Tatano Beck, DN.Sc (Professor at the School of Nursing at University of Connecticut, Storrs) describes the psychological disorder that mothers develop following the birth of a child as “chameleon-like” in their complexities and varying presentations. “These disorders take a different form and have a different emotional coloring for each mother. What they is an onset or diagnosis linked to the birth experience.”

23. In the end…….. “This juxtaposition of one of life’s greatest gifts and one of life’s most unkind illnesses is what makes postpartum depression different from depression that is unrelated to childbirth. It’s hard to put into words, but this is what we mean when we say that it’s the same, but it’s very, very different.”(Karen Kleiman writes in Therapy and the Postpartum Woman: Notes on Healing Postpartum Depression for Clinicians and the Women Who Seek Their Help – 2009- p. 52)