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The process of appropriate clinical intervention requires a proper approach to the patient: Listen carefully to what the mother says Talk to the mother about the many factors that could be influencing her emotional state without “ explaining away” her symptoms. Teach some specific strategies that can help the mother deal with her illness or with childcare. Encourage and assist the mother in mobilizing her support systems. This includes not only her family but also offering referrals to people or organizations that can offer long-term support
The effective treatment of postpartum disorders mandates a multidisciplinary approach. Since it encompasses obstetrical, pediatric, psychiatric, psychological, and social/cultural dimensions, a limited scope in treatment approach will often result in failure. The treating clinician must be well aware of his/her abilities and limitations and be ready and willing to use other clinicians as co-managers or referral sources. It is important to remember that in dealing with such complex disorders, we can not do it by ourselves.
Laboratory testing should be considered in women with postpartum mood disorders. Fatigue from anemia, malaise from infection and thyroid problems can all complicate the course and treatment of postpartum mood disorders. Women presenting with postpartum mood disorders should have preliminary blood work including a CBC with differential, a comprehensive metabolic pane, and thyroid function tests including an antimicrosomal antibody titer. Postpartum thyroiditis will usually present with hyperthyroidism during the first three months which will then progress to a hypothyroid state somewhere between 3 to 5 months and will gradually return to normal in 60-75% on mothers by about 1 year postpartum. Clinically, many of these women will require intervention with hormone replacement. If a woman is suffering from a postpartum psychiatric illness as well, the hormonal problem will often affect the presentation. In addition, it is not uncommon for women with an undiagnosed postpartum thyroid illness to have an incomplete response to standard psychiatric treatment. 25-40% of mothers will continue to have problems with their thyroid after he postpartum period. The illness will have a fluctuating course similar to Hashimoto’s Thyroiditis and most women will ultimately become hypothyroid. Referral to an endocrinologist should be considered for treatment during and after the postpartum period.
Considering the adverse consequences of untreated perinatal depression, it is essential to treat PPD rapidly and effectively. It is also important to determines whether the woman can be effectively treated in an outpatient setting or if she needs hospitalization. Current recommendations regarding treatment range from adequate education regarding the illness and possible treatment approaches, psychiatric medications, psychotherapy, and when clinically indicated, referral. Self help groups are available and are an important component of the recovery process.
Psychotherapy is a desirable treatment modality because it can treat mild to severe forms of PPD, it circumvents infant psychotropic exposure and it can address psychosocial precipitants and effects of depression. ITP has efficacy for both acute and maintainence treatment.
ITP is a relevant and effective treatment for women suffering from PPD because it helps assress the many interpersonal stressors that arise during postpartum.
While DBT was designed for Borderline Personality Disorder, it is used for patients with other diagnoses as well, including depression with suicidal or self harm thought-these individuals are emotionally intense and labile – frequently angry, intensely frustrated, depressed, and anxious 2 elements Individual therapy- woman and therapist discuss issues that come up during the week following a treatment target hierarchy, Self injuries and suicidal behaviors take first priority followed by interfering behaviors and quality of life issues. The client and therapist work towards improving skills. Group therapy -usually meets once a week for -2 1/2 hours. Woman uses specific skills are broken down into core mindfulness emotion regulation, interpersonal effectiveness and distress tolerance skills.
This slide presents three compelling studies yielding results clearly emphasizing the ameliorating influence of maternal support groups. In the first study, 45 women scoring above 12 on the Edinburgh Postnatal Depression Scale participated in a brief psychoeducation group for postnatal depression The other group received only routine primary care. Compared with Routine Primary care Group the, the psychoeducation group significantly reduced the level of depressive symptoms. The second study refers to an ongoing program in which the treatment of postnatal depression involves ongoing group therapy in both rural and urban settings. This program has resulted in significant lowering or elimination of depressive episodes with group participation. In the Chabrol study, the largest of the three, a sample of 859 women were selected who scored 9 or above on the Edinburgh Postnatal Depression Scale (indicating probably depression). The women were assigned to either a P group (prevention) group a control group. The P group received only one counseling session integrating supportive, educational and cognitive behavioral components. At 4 – 6 weeks post partum, women in the P group had significant reductions in the frequency of probable depression and in the intensity of depressive symptoms An interesting follow up to this initial counseling session was that both sets of mothers P&C were then offered a program of 5-8 home visits; most of the women who had not had the original counseling session declined to participate while most of those in the P group agreed to the home visits and showed further substantial improvement. It is noteworthy that these results were achieved with only one group session. While the protocols for these studies varied greatly, mega analyses of such studies support the conclusion that post partum support in a group setting clearly has significant beneficial results for women either at risk or diagnosed with post partum depression.
Bright light therapy, acupuncture, omega-3 fatty acids are options that are under investigation for use. Acupuncture -One of the benefits of acupuncture is that there is no contraindication to treatment, and it does not adversely interact with other treatments, such as conventional antidepressive therapy. It also has the benefit of not interfering with lactation. One of the &quot;side effects&quot; of acupuncture treatment is that many people enter a state of deep relaxation during treatments, and some will fall asleep. This deep relaxation could benefit a woman with postpartum depression whose symptoms are often exacerbated by lack of sleep, Research has shown acupuncture to be a safe and effective treatment for psychological problems, including depression, however no research was found on the use of acupuncture in the treatment of postpartum depression in particular. Omego-3 Fatty Acids-research indicated that suggest that O3FA may have efficacy as a treatment for PPD, (especially in conjunction with psychotherapy). The findings are important considering that O3FA offer health benefits to the mother and infant if she is breastfeeding . Bright light therapy- Serotonin Hypothesis-Light-Tryptophan is converted Serotonin. P hase Shift Hypothesis-Research has demonstrated the impact the internal biological clock in the hypothalmus has on mood and overall well being. SAD pts sleep longer in the morning and are phase delayed. When light hits the retina of the eye, impulses are transmitted to the hypothalamic center of the brain. This causes the phase to be advanced, and normalized. Suggests favorable outcomes however no large scale controlled trials published to date, more research needed. Hormonal therapy -dramatic hormonal shifts after delivery- produces a transient hypoactivation of the hypothalamic-pituitary axis-lasts weeks –months. Research indicates that this is increased in women with PPD. May be useful to use Estrogen to blunt hormonal and mood declines in women who suffer with PPD. Progesterone has not been shown to be effective and might even be detrimental. There is a need for additional research to confirm findings and to assess safety of Estrogen as it relates to decreased milk production or thromboemboli. While therapy and medication are key in controlling depression, changes in behavior, i.e physical activity and lifestyle -- can be an effective natural depression treatment used to complement medication and therapy approaches. Exercise - We know through research that physical activity can boost mood. The type of exercise used doesn’t seem to matter, getting out and walking may be enough. Infant massage -Developed by Vimala McClure the founder of the International Association of Infant Massage. Studies indicate a that there may be a significant improvement in mothers that attend infant massage classes.
Comorbidities including substance abuse, eating disorders, severe medical disorders, suicidality, infant safety concerns, lack of psychosocial support and inability to adhere to outpatient therapy may be reasons for inpatient treatment.
Although combined antidepressant and psychotherapy treatment is considered first line treatment for nonpsychotic mild to severe depression, nutritional compromise, severe behavioral withdrawal, psychosis and suicidality are clinical indications for ECT.
If a woman experiencing PPD, or a family member calls the 1-800 postpartum depression line, confidential information will be asked by a trained counselor. The client can expect some of the following questions: *name *age *sex *county of residence Note: Callers are NOT required to answer in order to receive information or referral assistance. Language line services are utilized if the client does not speak English. If a client or family member asks for PPD treatment services, she/he is kept on the phone and is warm line transferred to a clinician at the University Behavioral Health Care (UBHC) Access Center (available 24/7). Bilingual services are available. The UBHC clinician is expected to provide an initial phone screening, assessment and support to callers, as well as referral, if needed. It is anticipated that the client may: be referred to the clinical services provider in the caller's home county, to be seen within 5 days be referred for emergent clinical response to the Screening Center in the county where the client resides not be referred for further clinical services based on screening and assessment or based on client choice. If the client permits, the UBHC clinician will follow up to see if the client has received treatment services. Potential benefit of a referral through the NJDHSS Family Health Line 1-800/UBHC process: The client will be seen in 5 business days A client who is uninsured / underinsured can be covered (up to 12 visits) under this PPD clinical services program A client's primary health insurance will be taken into account when clinical services are being arranged.
This slide lists self help information for the patient and clinical resources for the treating clinician. The PPD Helpline provides 24 hour referral information on crisis centers, general health information on postpartum mood disorders, and referral/treatment options for women suffering with PPD. The remaining sites provide general health information and support groups for women experiencing postpartum mood disorders. CNJMCHC resource directory.
A web site has been developed by the state to assist consumers and health providers dealing with perinatal mood disorders. The site will provide consumer information, referral and self help resources. Clinicians will have a portion of the site specifically addressing the clinical problems that can arise in the treatment of these disorders. Referrals and other helpful resources for clinicians will also be available on the site.