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Peripartum Depression

Peripartum Depression. Laura J. Miller, M.D. Women’s Mental Health Program University of Illinois at Chicago. Risks from untreated major depression during pregnancy. Decreased prenatal care Decreased nutrition Increased use of teratogenic addictive substances cigarettes

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Peripartum Depression

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  1. Peripartum Depression Laura J. Miller, M.D. Women’s Mental Health Program University of Illinois at Chicago

  2. Risks from untreated major depression during pregnancy • Decreased prenatal care • Decreased nutrition • Increased use of teratogenic addictive substances • cigarettes • alcoholic beverages

  3. Effects on offspring of untreated depression during pregnancy • Low birth weight (Federenko & Wadhwa 2004) • Preterm birth (Dayan et al. 2002) • Pre-eclampsia (Kurki et al. 2000) • Neonatal irritability (Zuckerman et al. 1990)

  4. Postpartum “blues” • 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

  5. Clinical features of postpartum depression • Mood predominantly depressed, despondent, anhedonic • Sleep disturbance, fatigue, irritability • Loss of appetite • Poor concentration • Feelings of inadequacy • Ego-dystonic thoughts of harming the baby

  6. Characteristics of postpartum depression • Begins within 4 weeks of birth, but clinical presentation peaks 3-6 months after delivery • Present in 7 - 20% of new mothers in U.S.(Joseffson et al. 2001) • Much less prevalent in some cultures(Wile & Arechiga 1999) • Related to psychiatric history(Steiner & Tam 1999) • Related to environmental stressors(Bernazzani et al. 2004)

  7. Consequences of untreated postpartum depression • Disturbed mother-infant relationship (elevated cortisol found in both) • Psychiatric morbidity in children later (depression, conduct disorder, lower IQ) • Family tension • Vulnerability to future depression • Suicide/homicide

  8. Peripartum depression: posited contributory factors • Hormonal flux interacting with stressors • The magnitude of the postpartum drop in hormones correlates with mood changes; absolute hormone levels don’t • The biological mother-infant attachment system may predispose to depression in the context of stress, low social support & limited resources

  9. Peripartum depression: recognition and treatment in primary care settings • Ob/gyn survey (LaRocco-Cockburn et al. 2003): • Only 32% reported they’d been appropriately trained to treat depression • 73% cited time constraints for screening • Pediatrician survey (Wiley et al. 2004): • 49% not educated about PPD • Only 31% felt they’d recognize PPD • Only 7% were familiar with screening tools

  10. Screening for Peripartum Depression with the Edinburgh Postnatal Depression Scale [EDPS] • 10 item scale; maximum score 30; cut-off 10 - 13 • Self report : quick and easy to score • Widely tested • During pregnancy, sensitivity 100%; specificity 87% • Postpartum, sensitivity 78 - 100%; specificity 93 - 100% • Available in over 20 languages; cross-cultural validation • Defines population in need for further assessment • Can be used to monitor treatment progress • IDPA (Medicaid) reimburses for this screening

  11. Assessment of peripartum depression • Conducted by clinician for all women who score above the cut-off score on EPDS • Purposes - to ascertain whether the woman: • has major depression • is suicidal • is at risk of harming her baby • has bipolar disorder

  12. Treating peripartum depression • Antidepressant medication • Interpersonal psychotherapy • Couples therapy • Self help tools & networks • ECT (rTMS) • Hormone therapy • Parenting coaching

  13. Challenges in prescribing antidepressant medications peripartum • FDA categories have limited usefulness (based heavily on animal data) • Wide variation in amount of data for different antidepressants • Optimal dosing changes as pregnancy progresses • Wide variation in amount ingested by breast-feeding babies

  14. Peripartum Depression Disease Management Model • Education (via workshops) • Screening tool • Assessment tool • Treatment guidelines • Self-care tools • Referral networks • Back-up consultation

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