S.Berg presentation given at the 2012 South Carolina Home Visiting Summit

1. Mood Disorders in
Pregnancy and the
Postpartum
Stephanie Berg, MD
The Women’s Emotional Health Center
At Midlands Psychiatry
Palmetto Health Behavioral Day Program
September 19, 2012

2. Disclaimer
• I have nothing to disclose
• Some discussion of medications is off
label as no medications are FDA in
pregnancy

3. Objectives
• Introduction
• Depression in pregnancy
• Baby blues
• Postpartum depression
• Postpartum psychosis
• Postpartum obsessive-compulsive
disorder

4. The Women’s Emotional
Health Center
at
Midlands Psychiatric Service, LLC
125 Alpine Circle
Columbia, South Carolina
29223
(803) 779 - 3548

5. Palmetto Health Behavioral Day
Program
• Monday through Friday
– Patients sleep at home
• Partial Hospitalization Program
– 9am to 2:45pm
– 5 groups a day
• Intensive Outpatient Program
– 9am to 12:30pm
– 4 groups a day

6. Palmetto Health Behavioral Day
Programs
• Integrative treatment
– Group therapy
• DBT, CBT, ACT
• Nutrition
• Yoga
• Spirituality
• Recreation therapy
• Music therapy, art therapy
– Individual therapy
– Medication management

7. Perinatal Psychiatric Disorders
• Pregnancy Depression
• Postpartum Blues
• Postpartum Depression
• Postpartum Psychosis
• Postpartum Obsessive-Compulsive
Disorder
• Exacerbation of other illness

8. Depression in Pregnancy
Example
• Ms. B has a history of depression. She
stopped taking Prozac when she found
out she was pregnant. At 7 weeks, she
found her energy to be lower, she was
crying more, and was unable to eat
enough. She presented to her
obstetrician unsure if she wanted to
continue the pregnancy.

9. Major Depressive Episode
• At least 2 weeks
– Sad
– Interest
– Guilt
– Energy
– Concentration
– Appetite
– Feeling restless or slowed
– Sleep
– Suicidality

10. Depression in Pregnancy
• 10 – 20% of women
during pregnancy
• Up to 30% in low-
income populations

11. Depression in pregnancy is very
common
First trimester 7%
Second trimester 13 %
Third trimester 12 %

12. Depression in Pregnancy
Risk Factors
• Previous episode of depression
• Family history of depression
• Poor social support
• “Unwanted” pregnancy
• Young age - adolescents

13. Depression in Pregnancy
• Risks of untreated depression
– Preeclampsia
– Placenta abnormalities
– Low birth weight
– Preterm labor
– Fetal distress

14. Depression in Pregnancy
• Risks of untreated depression
– Poor follow up with OB appointments
– Poorer nutrition, less likely to take folate
– More likely to smoke, use alcohol, or other
substances
– Greater likelihood to develop postpartum
depression

15. Postpartum Depression
Previous Condition Risk of PPD
Major depressive disorder 24 %
Depression in pregnancy 35 %
Previous PPD 50 %

16. Antenatal depression goes
untreated
• Less than 1/3 of women receive treatment
for depression during pregnancy
– Who does get treatment?
• History of MDD
• History of psychiatric treatment
• Depression severity

17. Treatment in Pregnancy
• An individual decision
that is made on a case
by case basis

18. Antidepressant medications
• SSRIs
– Fluoxetine (Prozac)
– Sertraline (Zoloft)
– Paroxetine (Paxil)
– Fluvoxamine (Luvox)
– Citalopram (Celexa)
– Escitalopram (Lexapro)
• SNRIs
– Venlafaxine (Effexor)
– Duloxetine (Cymbalta)
– Desvenlafaxine (Pristiq)

19. Antidepressant medications
• Other
– Wellbutrin (Bupropion)
• Norepinephrine and dopamine
– Trazodone
– Mirtazapine (Remeron)
• Tricyclic Antidepressants
– Amitriptyline (Elavil)
– Nortriptyline (Pamelor)
– Imipramine (Tofranil)
– Clomipramine (Anafranil)
• MAOIs
– Phenylzine (Nardil)
– Tranylcypromine (Parnate)

20. Treatment in Pregnancy
• Sertraline (Zoloft) has the most safety data
in pregnancy and with breastfeeding
• Avoid paroxetine (Paxil) if possible
– Risk of heart malformations

21. Treatment in Pregnancy
• SSRI/SNRI risks
– Miscarriage
– Malformations
– Earlier delivery?
– Persistent Pulmonary Hypertension of the
Newborn
– Neonatal Adaptation Syndrome

23. Postpartum Psychiatric Disorders
Disorder Incidence Time Course Clinical
Features
•Tearfulness
Postpartum 70 – 80 % Within first week
→ 14 days •Anxiety
Blues •Insomnia
•Mood Instability
•Depression
Postpartum 10 % Within first month
•Guilt
(technically)
Depression •Anxiety
•Fear of harm to
baby
•Obsessions
•Disorientation
Postpartum 0.1 – 0.2 % Within first month
•Confusion
Psychosis •Delusions
•Hallucinations
•Rapid Mood Cycling

24. Postpartum Blues Case
• Three days after she brought her baby
home from the hospital after an uneventful
pregnancy and delivery, Ms. S started
worrying that she would drop her baby and
found herself become teary while watching
television. She was able to sleep when
her baby slept and was eating normally.
This resolved by the time her baby was
two weeks old.

25. Postpartum Blues
• A.K.A. Baby Blues
• Common
– (70 – 80% of women)

26. Postpartum Blues
• Risk factors
– Low mood during last trimester of pregnancy
– History of bad premenstrual symptoms
– Depression in the past
– Preeclampsia
– Stress
– Not enough support
– Not feeling comfortable with how baby is
nursing

27. Postpartum Blues
• Symptoms
– Mood swings
– Irritability
– Tearfulness
– Confusion
– Feeling tired
– Sensitivity
– Not depression or apathy

28. Postpartum Blues
• Treatment
– Reassurance
– Support
– Education
– Monitoring

29. Postpartum Depression
• Two weeks after Ms. J’s son is born, she
begins to feel sad and have lower
motivation. Even though she is continually
exhausted, she has trouble falling asleep
when her baby sleeps. She has repetitive
thoughts of her baby falling out the
window but these thoughts scare her and
she would never act on them.

30. Postpartum Depression
• Later onset than Postpartum Blues
• Places child at risk down the road
– Lower self-esteem
– More acting out
– Nursing infants gain less weight
– Duration of mother’s episode correlated with
degree of impairment in child

31. Postpartum Depression
• Symptoms
– Depression, crying
– Inability to sleep when the baby sleeps
– Intrusive thoughts
• Thoughts of hurting the baby
• Thoughts of hurting self
– Suicidal thoughts
– Loss of appetite
– Lack of interest in the baby
– Anxiety and panic attacks

32. Postpartum Depression Risk
Factors
• Family history
• Psychosocial Factors
– Social/partner support
• Related to hormonal related depressions
– PMS
– Seasonal
– Perimenopausal
• Multiples
• Difficulty with breastfeeding
– Watch with weaning

33. Postpartum Depression Risk
Factors
• Risk is not reduced with subsequent
children
- may be increased
• Risk of recurrence:
– 1 episode – 50%
– 2 episodes
– 75 – 80%

34. Postpartum Depression
Previous Condition Risk of PPD
Major depressive disorder 24 %
Depression in pregnancy 35 %
Previous PPD 50 %

35. Postpartum Depression
• Consequences
– Inconsistent use of birth control
– Parenting difficulties
– Family and marriage difficulties
– Developmental, behavioral, and
emotional problems in children
– Personal suffering
– Suicide

36. Detection of Postpartum
Depression
• Detection rates for depression in Ob-Gyn
settings 15-30%
• Treatment rates – 75% are untreated

37. Detection of Postpartum
Depression
• Edinburgh Postnatal Depression Scale
(EPDS)
– Can be used during pregnancy and
postpartum
– 10-item, self-administered
– Easy to score
– Score of at least 10-13 indicates depression
– Validated in at least 12 languages

38. EPDS

39. Breastfeeding
• Most medications excreted into breast
milk
• Drug levels in breast milk are less than
what crosses the placenta

40. Medications in breastfeeding
• Avoid long half life or sustained release
medications
• Schedule medication dosing immediately
after feeding or right before long rest
period
• Advise mother to monitor for oversedation,
especially with cosleeping

41. Half Lives of Antidepressants
Fluoxetine 2-3 days
Citalopram 34 hours
Escitalopram 30 hours
Sertraline 29 hours
Paroxetine 24 hours
Bupropion 12 hours
Duloxetine 12 hours
Venlafaxine 5 hours (metabolite = 11
hours)

42. Postpartum Depression Treatment
• Antidepressants
– Low levels in breastmilk of
• Paroxetine (Paxil)
• Sertraline (Zoloft)
• Citalopram (Celexa)

43. Postpartum Depression –
Treatment
• Check thyroid function
• Increase support
• Psychotherapy
– Interpersonal Psychotherapy
• Phototherapy
• ECT

44. Postpartum Depression in Fathers
• More common than you would think
– 10.4 % overall from 1st trimester to 1 year after
delivery
– 25.6% at 3-6 months
• Biggest correlation is with depression in
the partner
– But also associated with marriage problems

46. Postpartum Psychosis
• Ms. S was hospitalized 3 weeks after her
baby was born. She was feeling that her
neighbors were poisoning her water and
planning to steal her 2 older children from
their school. She heard the neighbors
talking through the walls of her house.
She was feeling that there was no choice
but to kill herself and her children and
made plans to drive them into a tree.

47. Postpartum Psychosis
• Believed to be related to bipolar disorder
– 35% risk postpartum psychosis
– 60 % risk of recurrent affective illness
• Psychiatric Emergency
– HOSPITALIZE

48. Postpartum Psychosis
• Rare
– 1 to 3 cases per 1000 births
• Abrupt onset
– Usually by postpartum day number 3

49. Postpartum Psychosis
• Dangerous
– 4 % risk of infanticide
– 5 % risk of suicide
• HOSPITALIZE

50. Postpartum Psychosis
• Risk factors for infanticide
– Psychosis
– Suicidality
– Depression
– Life stress
– Alcohol use
– Limited social support
– Personal history of abuse

51. Postpartum Psychosis
• Related to bipolar disorder
– 75 % with bipolar disorder
– 12 % with schizophrenia
• Mothers with bipolar disorder have a 100-
fold increase in rate of psychiatric
hospitalization after delivery

52. Postpartum Psychosis
• Symptoms
– Confusion
– Bizarre behavior
– Hallucinations
– Mood lability
– Restlessness
– Agitation

53. Postpartum Psychosis - Treatment
• Treatment
– Hospitalize
– Mood stabilizers
– Antipsychotic medications
– Electroconvulsive Therapy
• Consider prophylactic mood stabilizer treatment
starting at birth with next pregnancy
– Women with Bipolar Disorder should probably
continue treatment through pregnancy

54. Postpartum Obsessive-Compulsive
Disorder
• After delivering her next child, Ms. J
begins to have concerns that she might
throw her newborn daughter out the
window. She avoids picking up her
daughter and keeps all the windows
locked at all times. She does not want to
hurt her daughter and is having difficulty
sleeping because of these thoughts.

55. Postpartum Obsessive-Compulsive
Disorder
• Underappreciated
• 21 % of women with OCD have perinatal
onset
• OCD worsens in pregnancy and the
postpartum
• 60-80% comorbidity with MDD
Brandes 2004

56. Postpartum Obsessive-Compulsive
Disorder
• DSM IV-TR OCD Criteria
– Obsessions or
– Compulsions
– Understands thoughts are excessive or
unreasonable
– Causes distress

57. Postpartum Obsessive-Compulsive
Disorder
• Intrusive thoughts
– May be seen with depression
– Intrusive, ego-dystonic thoughts
– Often violent thoughts of harm to child
• Avoidant behaviors to avoid harm
– Often contamination fears
– Usually not associated with compulsions

58. Postpartum Obsessive-Compulsive
Disorder
• Peak onset 2 weeks
• Screening question
– “It’s not uncommon for new mothers to
experience intrusive, unwanted thoughts that
they might harm their baby. Have any such
thoughts occurred to you?”
• Rule out psychosis or extreme anxiety

59. Postpartum Obsessive-Compulsive
Disorder
• Treatment
– Reassurance
– Cognitive behavioral therapy
– Family therapy
– SSRIs
• No specific data
• Require higher doses

60. Take Home Points
• Depression in pregnancy is common
• Untreated depression in pregnancy carries risks
for both the mother and the child
• No antidepressants are FDA approved in
pregnancy
– But sertraline is generally agreed to be “safest”
• Must weigh risks and benefits with the mother
(and partner) on an individual basis

61. Take Home Points
• SSRIs may be associated with
malformations, PPHN, and a neonatal
syndrome.
• SSRIs are “safe” in breastfeeding
– Sertraline and paroxetine probably safest

62. Take Home Points
• Postpartum psychosis is a true psychiatric
emergency
• Postpartum obsessive compulsive
disorder is often overlooked and marked
by intrusive thoughts

63. Questions?

64. Resources
• www.womensmentalhealth.org
• http://www.postpartumprogress.com/
• Midlands Postpartum Coalition
• Postpartum Support International