By Ricardo J. Fernandez, M.D., DFAPA Councilor, NJ Psychiatric Association

1. Depression Postpartum D. Wolocko, Daily News ByRicardo J. Fernandez, M.D., DFAPACouncilor, NJ Psychiatric Association

2. “Postpartum Depression”Psychiatric Syndromes of the Postpartum Period

3. This presentation is for the exclusive use of the New Jersey Psychiatric Association website and for the purposes of consumer information and education.It may not be otherwise reproduced or presented without the knowledge and consent of Ricardo J. Fernandez, M.D.

4. Women are at serious risk for developing a psychiatric illness after childbirth. D. Wolocko, Daily News

5. Postpartum mothers are at significant risk of developing a psychiatric illness severe enough to require hospitalization as the next slide demonstrates.This increased risk lasts for about two years after childbirth.

6. 70 60 50 40 Admissions/Month 30 20 Pregnancy 10 –2 Years – 1 Year Childbirth +1 Year +2 Years 0 Admissions to a Psychiatric Hospital:2 Years Pre and Post Delivery Kendell RE et al. Br J Psychiatry. 1987;150:662; presented at WMH, Berlin 2001.

7. First, let us discuss the proper terminology for these disorders.

8. “Postpartum Depression” is a general term used in our society to describe any psychiatric illness occurring after childbirth.

9. In reality, Postpartum Depression describes only one of four syndromes that can occur after childbirth.

10. The four syndromes are: • Maternity or Postpartum Blues • Postpartum Psychosis • Adjustment Disorder of the Postpartum Period • Major Depression in the Postpartum (Postpartum Depression)

11. Unfortunately, common reference to all four conditions as “Postpartum Depression” creates confusion and fear. It is important to understand that Postpartum Psychosis, the most severe and dangerous condition, is relatively rare and quite different from Postpartum Depression, as the next slide demonstrates.

12. Spectrum of Postpartum Mood Changes Medical emergency Serious, disabling Transient, nonpathologic Postpartum Blues • risk for Postpartum • Depression Postpartum Depression 50% to 70% 2/3 have onset by 6 wks postpartum Incidence Postpartum Psychosis 70% are affective (Bipolar, Major Depression) 10% 0.01% Cohen LS. Depress Anxiety. 1998:1:18-26.

13. Postpartum Psychosis is often mislabeled in the media as Postpartum Depression, creating much anxiety and fear in women with the less severe postpartum disorders.

14. Now, lets discuss the specific syndromes.

15. Maternity or Postpartum Blues • Is not considered a psychiatric illness and is unrelated to psychiatric history . • Occurs in 26 to 85% of birthing mothers. The exact incidence is unclear. • Present in all cultures studied • Appears unrelated to environmental stressors

16. Maternity or Postpartum Blues “Blues” = heightened reactivity, not clinical depression • Mood swings from weepiness to extreme happiness and heightened reactivity • Occurs 3 to 5 days after childbirth. It is self limiting, resolving in about a week. • If occurs, increases risk for Postpartum Depression.

17. The rest of the syndromes to be described are all considered psychiatric illnesses and benefit from clinical treatment.

18. Postpartum Psychosis • Is relatively rare, occurring one to three cases per 1000 births • Is a severe and life threatening condition for both mother and infant • Develops soon after birth, often within two weeks, usually within a month • Requires intense treatment and hospitalization: A medical emergency • Is usually followed by Postpartum Depression

19. Symptoms of Postpartum Psychosis • Delusions: False beliefs, often of a religious nature and very frequently involving the infant • Perceptual distortions: Seeing or hearing things which are not present • Often, feelings of excessive well being or importance

20. Adjustment Disorder of the Postpartum Period • Occurs in about 20% of birthing mothers but incidence is unclear as many women with this problem do not seek treatment. • Manifests as excessive difficulties adjusting to motherhood. • If emotional symptoms exist, they are not as severe as those seen in Postpartum Depression Bright. Am Fam Physician. 1994; 50: 595. Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.

21. Adjustment Disorder of the Postpartum Period • Can resolve without treatment over time but can cause ongoing difficulties for the mother. • Can develop into Postpartum Depression if more severe and untreated. • Responds well to short term psychotherapy. Bright. Am Fam Physician. 1994; 50: 595. Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.

22. Postpartum Depression • Occurs in 10% of birthing mothers • 20% if the mother has had Maternity Blues. • Occurs usually within 6 weeks of birth but can occur up to a year after birth Bright. Am Fam Physician. 1994; 50: 595. Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.

23. 60 Severe, needed hospital admission Mild, treated by general practitioner 40 Percentage of Patients 1. Time of Onset of Postpartum Depression in 315 Women 20 Within 3 Months 22% Within 6 Months 18% Within 14 Days 46% Within 6 Weeks 14% 0 Within Two Weeks Six Weeks Six Months Onset of Symptoms in Postpartum DepressionTwo Studies 2. Time of Onset of Postpartum Depression in 413 Patients The more severe, the earlier the onset.

24. Postpartum Depression: Symptom Onset • 40%: After first postnatal visit • At 6 weeks • 20%: Coincided with weaning • 16%: At return of menstruation • At 2 to 3 months if not breast feeding • 14%: Initiation of oral contraceptives

25. Postpartum Depression • Manifests as symptoms of depression, often with marked anxiety/agitation and obsessions about harm coming to the child. • Can develop gradually or abruptly after birth Bright. Am Fam Physician. 1994; 50: 595. Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.

26. What are the symptoms of Depression? • Sadness of mood most of the day, nearly every day • Diminished interest or pleasure in usual activities • Major change in appetite or weight • Not able to sleep or sleeping too much • Agitation or feeling slowed down • Fatigue or loss of energy • Feelings of worthlessness or excessive or inappropriate guilt • Diminished ability to think or concentrate, or indecisiveness • Recurrent thoughts of death, dying, or suicide APA Diagnostic and Statistical Manual. 1994

27. Symptoms Frequently Seen in Postpartum Depression • Marked agitation and anxiety • Mother can not sleep even when the baby is sleeping • Obsessions and compulsions about the baby

28. What are obsessions and compulsions? • An obsession is a repetitive, intrusive and disturbing thought that enters the mind and is out of the individual's control. • A compulsion is a repetitive act that is done in an attempt to be rid of the obsessional thought. • Both cause great anxiety and discomfort in the individual.

29. Postpartum obsessions • Commonly focused on infant • Thoughts(obsessions) of hurting the infant • Dropping infant • Drowning infant • Stabbing infant • Putting infant in oven or microwave • Sexually abusing infant • Thoughts that someone will steal or harm the infant

30. Postpartum compulsions • Commonly follow the obsessions as an attempt to alleviate the thought • Avoid holding baby by staircases, etc • Avoid bathing infant • Hide knives • Avoid kitchen area • Avoid changing diapers or bathing infant • Avoid leaving the house

31. Although the presence of obsessions and compulsions indicates need for treatment, these mothers are rarely dangerous to the infants. They are actually at higher risk to hurt themselves as a result of their fear of possibly hurting the infant.

32. How is Postpartum Depression treated? • Psychiatric medication • Antidepressants: • In particular, those that increase release of serotonin in the brain • Medicines for anxiety and to help with sleep • Individual, couples and family psychotherapy

33. What about breast feeding? The incidence of breast feeding in birthing mothers is increasing as the next slide shows.

34. 80% 67% Incidence of Breast Feeding 1926-2001 61% 52% 49% 37% 28% 20% 1926- 1951- 1966- 1972 1975 1998 2000 2001 1930 1955 1970 Briggs, Freeman, Yafee, Drugs in Pregnancy and Lactation, 1998 Maternity Survey, Parents Express, Phil.,PA., 4/01, 4/02

35. Breast feeding… …a reasonable optionin Postpartum Depression ?

36. Although all medications cross into breast milk, there are a few antidepressants that appear to cross less than others and may be safer in breast feeding. Consult your doctor.

37. There are risk factors that predispose women to postpartum disorders.

38. Risk Factors • First pregnancy • Young age • Psychiatric illness during pregnancy • Prior history of postpartum illness • Prior history of mental illness • Family history of mental illness • Recent stressful life events • Problems in the marriage

39. In addition, there are many societal and cultural factors that may predispose women to postpartum problems including...

40. Isolation… …Diminished extended family Involvement.

41. Distorted and glamorized perceptions of pregnancy…

42. …and of recovery in the postpartum...

43. …frequently promoted in the media.

44. As well as unrealistic expectations of the postpartum mother

45. In summary, postpartum psychiatric illness exists. It can be debilitating and dangerous to both mother and child. Effective treatments are available. Support groups of mothers in recovery are also available in many areas of the country.

46. For more information: • Consult with your doctor • Contact: • Depression-After-Delivery (DAD) • www.DepressionAfterDelivery.com • Depression and Bipolar Support Alliance (DBSA) • Phone: 800-826-3632 • Web:www.DBSAlliance.org • New Jersey Psychiatric Association • Phone: 800-345-0143