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Depression in Pregnancy. Angela Bowen, RN PhD (Cand.) Community Health and Epidemiology Assistant Professor, College of Nursing Strategic Training Fellow Community & Population Health Research Program Nazeem Muhajarine, PhD Associate Professor Community Health and Epidemiology

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depression in pregnancy

Depression in Pregnancy

Angela Bowen, RN PhD (Cand.)

Community Health and Epidemiology

Assistant Professor, College of Nursing

Strategic Training Fellow

Community & Population Health Research Program

Nazeem Muhajarine, PhD

Associate Professor

Community Health and Epidemiology

University of Saskatchewan

Funding: CUISR, CPHR-SPHERU, CIHR

slide2

Depression

World Health Organization

  • 2020
    • depression will be 2nd greatest cause of premature death and disability worldwide in both sexes
  • Already
    • number one cause of disease burden in women

Canada

    • Prevalence 7%, lifetime prevalence 12.3%(Stewart, 2003)
slide3
Why mothers die?

Confidential Enquiries into Maternal Deaths (1997-9 UK)

  • 12% of maternal deaths attributed to psychiatric illness(death during pregnancy and in the first year post delivery)
  • 10% suicide
    • #1 cause of death (>deep vein thrombosis etc.)
  • Those with early onset of illness died early
    • others did die later ~ often didn’t appear to be suffering PPD
  • Less associated with low income and other risk factors
  • More violent methods of suicide
    • Few by overdose(Oates, 2003)
depression is depression
Depression is Depression…
  • Major Depressive Disorder
    • Having 5 of these symptoms for 2 or more weeks
  • Minor Depressive Disorder
    • Having 2 of these symptoms for 2 or more weeks
slide5
Depressed mood most of the day
  • Anhedonia (severely diminished interest or pleasure in activities)
  • Weight changes-secondary to appetite changes
  • Insomnia or hypersomnia
  • Psychomotor; restless, agitated, slowed
  • Diminished energy level
  • Feelings of worthlessness or excessive guilt
  • Decreased concentration and increased indecisiveness
  • Recurrent thoughts of death or suicide
women express depression differently
Women express depression differently
  • increased anxiety
  • somatization
    • physical symptoms for no reason
  • feelings of sadness
  • excessive guilt and worthlessness
  • ↑ weight
  • hypersomnia
    • too much sleep
  • anger and hostility
  •  suicidal attempts
postpartum blues
Postpartum Blues

“Normal” transient, emotional response

    • up to 85% of women, peak day 3-5
  • Depressed in the 1st week after delivery
    • 20-40%  major depression in the 1st year pp
    • Significant increase risk for PPD at 4-8weeks(Teissèdre &Chabral, 2004)
  • Present in father (day 1-2)
    • co-morbidity in parents
  • Impaired bonding – associated with “blues”
    • I feel trapped, my baby cries too much, I wish my baby would somehow go away, I feel happy when my baby smiles and laughs, my baby irritates me, I resent my baby, my baby is the most beautiful baby in the world(Edborg, 2005)

awareness, early identification & intervention

postpartum depression ppd
Postpartum Depression-PPD
  • Major depression
    • Psychosis, infanticide, homicide
  • 60% women experience their 1st major depression PP
  • Idealization of birth & motherhood
  • Feeling inadequate, lack of social support, primip>30 (Beck, 2001; Fergerson, 2002)
  • Hormones, thyroid, cholesterol, anemia, stress
slide9
Depression in pregnancy does

not

predict Postpartum depression

in individual women

but

Up to 66% of women depressed in pregnancy go on to have PPD

and

Is a disease unto itself

depression in pregnancy antenatal depression ad
Depression in Pregnancy--Antenatal Depression - AD

“Melancholia” in pregnancy

    • documented in the 1840s
    • as recently as the 1970s pregnancy

thought to be protective for depression

      • Hospitalization rates
      • Hormones
    • less psychosis & suicide (Brockington, 1996)
  • Effects to mother, baby, and family
slide11

longitudinal studies

    • Equal or greater than postpartum
  • more common than medical conditions routinely screened for
      • diabetes(Austin, 2003; Spinelli, 2001)
  • Some protection for suicide but not morbidity
    • 40% of depressed women had suicidal thoughts(Levey, 2004)
    • Pilot study confirmed this
somatic complaints
Somatic complaints

Physical complaints are considered normal in pregnancy and postpartum

  • Other times in life would be flag for depression
    • Aches and pains-- GI, headache, nausea
    • Sleep
    • Appetite, weight changes

excessive physical complaints can alert to potential depression

Significantly more physical complaints

  • 23% - primary care setting depressed
    • Depression/anxiety most significant predictor of increased somatic complaints
  • 47% of depressed reported more than 6 physical symptoms

(Kelly, 2003)

risk factors general
Risk factors-general
  • Female
  • Single or living with parents
  • Partner discord
  • Lack of social support
  • Stress -- Often precedes first episode
  • Substance Abuse
  • Previous Hx of Depression
  • Moods up/down
  • Low income -- Food security
  • Low education
  • Ethnic minority -- new immigrant Aboriginal
obstetrical
Parity

Age

teen vs. older primip

Complications

Diabetes, Bedrest

Family violence

Often starts in pregnancy

Ambivalence about pregnancy

Attempted abortion

Anxiety about fetus

Infertility

Depression precedes infertility

Discontinuation of Anti-Depressants

Obstetrical
depressed pregnant women
Depressed pregnant women…
  • deteriorating social function, emotional withdrawal
  • worry excessively about pregnancy & ability to parent
  • less likely to attend regular obstetric visits
  • less likely to comply with prenatal advice
  • take prenatal vitamins less often
  • know less about the benefits of folic acid
  • Fetal abuse
    • punch abdomen
    • lack of care
    • substance abuse

*Poor self-care = poorer obstetrical outcomes *

(Bonari, 2004; Kent, 1997; Zuckerman, 1989)

effects on pregnancy mother baby
Effects on Pregnancy, mother, baby

Depression not well studied or understood …

Stress ~ Anxiety ~ Depression

  • Stress- anxiety
    • often considered “normal” in pregnancy
  • Timing of stressor in pregnancy
    • No consensus
      • Earthquake only affected preterm in 1st trimester
    • Early stressor affects organ development
    • 28-32 weeks affects neurobehavioral(Wadwa, 2005)
    • Real or perceived stress
slide18
Depression is associated with higher rates of tobacco, alcohol, and other substance use

Smoking is associated with drinking/drugs

Smoking increases with parity

Quitting smoking can trigger depressive symptoms (Kahn, 2002)

alcohol depression
Alcohol & Depression
  • Chronic alcohol use associated with depression
  • Both are harmful to mother and fetus
  • Exacerbate each other; increased acuity
  • More likely to relapse
  • More resistant to treatment
  • More likely to suicide(Homish et al 2004)
slide20
Fetus

Cortisol “the stress hormone”

  • Fetal and maternal endocrine levels are correlated
    • Hypercortisolaemia affects gluccocorticoid receptors in fetal brain
    •  CHR, ACTH
  • FHR35 wks+
    •  variability  rate / contradicted in one study
    • Habituation and dishabituation decreased, delayed in depressed
  • Uterine irritability
  • resistance in blood vessels to the uterus
  •  blood flow to the baby- IUGR
  •  pre-term delivery

(Austin, 2005; O’keane, 2005;Teixeira,1999; Zuckerman, 1990)

slide21

Stress

Hypothalamic-pituitary-adrenal (HPA) axis

  • Chronic dysregulation affects neural function
  • Estrogen/HPA are intertwined
    • ↑depression ↓fertility

HPA-placental neuroendocrine axis

  • Maternal stress affects fetal development
  • Sustained HPA dysregulation and stress reaction
  • Neuronal death & abnormal development of fetal brain
  • Altered performance on neuromotor tests, ability to cope

monkeys, rats: no reason to expect different in humans(Austin, 2005; O’keane & Scott, 2005; Glover et al, 2002)

effects of depression on mother
Effects of depression on Mother
  • Increases and worsens with parity
  • Increased risk for further depressions
  • Increase in severity if left untreated
  • Complications in the pregnancy
    • Hypertension, Epidural & operative deliveries (Andersson, 2004; Chung, 2001)
  • PPD - emergency c/s vs planned (Kurki, 2000)
mother
mother…

↑ physical problems

  • ↑gastric secretions, Irritable Bowel Syndrome (Solmaz, 2003)
  • Nausea, constipation

Sleep problems

  • ↓General wellbeing
  • ↓ Decision making, irritability, perception of events
  • Associated with ↑substance use, $ worries, loneliness, anxiety
  • PP Depression/psychosis (Hiscock, 2001; Sharma, 2004)
slide24
Cortisol
  • prolonged increases can lead to changes in mood
    • cycle continues and worsens

Chronic depression

  • changes in the adult brain
    • shrinking hippocampus
    • memory and cognitive impairment
  • ↑ risk for depressions(MacQueen, 2003)

Less responsive to baby’s cues

    • Attachment problems begin
    • Less attentive to stimulating baby, safety issues (Spinelli, 2001)
effects on newborn
Effects on Newborn
  • ↑ risk of preterm delivery
  • ↑NICU admission
    • Effects of depression and/or antidepressants
  • Lower Apgar scores
  • Lower birth weight/IUGR
    • ↓ weight gain
  • ↓ NBAS
  • Less breastfeeding
    • PPDSG
  • ↑ Failure to thrive
  • Smaller head circumference (Chung, 2001; Murray, 2003)
effects on babies
Effects on babies…
  • Less developed motor tone
    • ↓ activity levels
  • More withdrawn
  • Cry excessively, irritable, less consolable
  • ↓ expressivity and imitative behavior
    • Negative expression
  • ↑ SIDS
  • Effects of lifestyle
    • alcohol ?FASD, smoking, poor diet etc.(Murray, 2003; Zuckerman, 1989)
effects in children
Effects in Children
  • Behavior problems in children
    • anxiety in pregnancy = ↑ADHD in boys
      • Direct effect of antenatal anxiety on fetal brain development
  • ↑ Depression
  • Patterns of stress
  • Withdrawn
  • Social and school difficulties
  • Autism
  • Criminality (Austin, 2005; Maki, 2003; Murray,2003; O’Connor;, 2002; Weinstock, 2005; Wilkerson, 2002)
family
Family
  • Up to 50%↑ paternal depression in PPD
    • No reason to expect it will be any less than for antenatally depressed families (Goodman, 2004)
      • Non-depressed fathers important to child development
  • Intergenerational problems continue
    • Usually magnify if not treated (Murray, 2003)
slide29
Depressed pregnant women

are underdiagnosed

and undertreated

(American Psychiatric Association Meeting, 2004)

slide30
Pregnancy is a time of

increased contact with

health services

Chance for the early identification and intervention of depression

depression screening
Decreases clinical morbidity

British Columbia - 2007

22-26 weeks, postpartum X 2

Calgary

all women 6 weeks postpartum

Edmonton

at immunization visits

Ontario

Healthy Babies Healthy Children

Hamilton

antenatal and postnatal in doctor’s offices

Saskatchewan

Feelings in pregnancy and motherhood Study underway in Saskatoon Health Region

Depression Screening
edinburgh postnatal depression scale epds
Edinburgh PostNatal Depression Scale - EPDS
  • Most widely used perinatal depression screening tool - 1987
  • Takes out physical and emotional symptoms common in the perinatal period
    • Irritability, sleep disturbance, tiredness, bowel, appetite, and weight changes(Cox, 2003)
  • GPs diagnose ~25-50% of ppd (Fergerson, 2002)
    • EPDS and clinical assessment=82% (Buist, 2002)
slide33
EPDS…
  • Reflects the mood over the past 7 days
    • Short - 10 items
    • Self-report
    • Free
    • Easy to complete, score
      • >10 minor depression, population prevalence
      • >13 major depression
    • Acceptable to women and caregivers
    • Valid and Reliable
      • antenatal and postnatal
      • Many languages and dialects
        • Sensitivity 100%, specificity 80% (Cox, 2003)
slide34
EPDS…
  • Opens door for communication
  • Can also pick up anxiety (2 items)
  • Rapid identification of suicidal ideation (item 10)
    • Asking -- prevents not provokes suicide
    • Family drs pick up ~12% of suicidal thoughts (Smith et al, 2004)
  • Screen for depressive symptoms
  • does NOTDiagnose depression
  • Clinical interview needed to confirm depression
slide35
Interventions
  • Psychotherapy
    • Cognitive Behavioral Therapy - CBT
    • Interpersonal Therapy-IT
      • Significantly more than just education (Spinelli, 2003)

Groups

    • Support, psycho education, self-care
  • Supportive, “listening visits”
    • Prevent PPD -- Unknown in antenatal (Clement, 1995)
  • Educate family
    • Support, help with chores
    • Aware and report worsening symptoms
      • Suspiciousness, social isolation, no improvement despite intervention, sudden lightening of symptoms or elation

Lifetime effects

slide36
Self Care
    • Nutrition - food mood
    • Monitor quit drinking, quit smoking
    • Exercise - walk outside, swimming
  • Electroconvulsive Therapy – ECT (Rabheru K, 2001)
  • Bright Light therapy
    • Pilot studies positive (Epperson et al, 2004)
  • Alternate treatments

Limited information

    • Food and supplements – folic acid, omega 6,
    • Acupuncture
    • Massage(Chui, 2003; Simon et al, 2002; Spinelli, 2001)
9 medication
9.Medication
  • 80% of women who become pregnant
    • 35% are taking psychotropic medications
    • 50% are unplanned
  • 1st month most critical
    • teratogenesis, organogenesis
    • most women don’t know pregnant
  • First thought is to come off
    • up to 50% will relapse (Cohen, 2006)
  • If start medication during pregnancy
    • Not likely to start until after first few weeks which is the time of greatest teratogenocity
slide38
Fluoxetine (Prozac)

1st Line of Treatment (CanMat)

  • longest, most studied SSRI, no evidence of teratogenicity
  • Not all women tolerate Fluoxetine

Citalopram (Celexa) (SSRI)

  • 4-fold increase of neonatal adaptation syndrome requiring adm. to NICU-transient-48hrs, manageable (Sivojelezova, 2005)

Health Canada - advisories

  • 2004 – SSRIs
    • Neonatal withdrawal-transient jitteriness, sleepiness, ↓pain response
  • Dec 2005 - Paroxetine (Paxil)(SSRI)
    • 2-fold risk of cardiac malformations
  • March 2006 - SSRIs
    • PPHN potentially fatal

Venlaflaxine (Effexor) SNRI

  • No known teratogenetic effects or toxicity (Einarson, 2001)
slide39
Dosing
    • Always aim for the lowest dose
      • effective for alleviating symptoms
    • Taper dose close to delivery to lessen the potential withdrawal or toxicity effects to newborn
      • But then must monitor woman closely
    • Depressive symptoms tend to increase as delivery approaches
      • if woman has decreased or discontinued medication
        • closely monitor (Misri, 2005).
slide40
Antidepressants

Neonatal toxicity

transient

Heart malformations

PPHN

0.01% (10% fatal)

UNKNOWNS

No known long term effects to IQ or developmental milestones – SSRIs on market for 25yrs now

Untreated Depression

Operative deliveries

Preterm birth

IUGR

Failure to thrive

SIDS

Poorer prenatal care

Developmental delays

Social, behavioral, psychological difficulties

UNKNOWNS

From what we know at this time…everyday new information

slide41
Challenges
  • Problem occurs in obstetrical clients but the clinical expertise, consultant diagnosis, treatment etc… realm of psychiatry
  • Family Practitioners and Nurses

Good position to monitor throughout

    • Pre-conception counseling to those at risk (prev depressions)
    • Throughout pregnancy
    • Postpartum year
  • Lack of resources, interest, expertise
    • Team of reproductive mental health, psychiatric, obstetrical practitioners available for consultation and treatment
    • Keeping up with research…
  • Lack of public policy for screening and education
  • Research is difficult in pregnant women
    • RCTs, longitudinal, recruitment
slide42
Thank you

Women and Staff…

Healthy Mother Healthy Baby,

Community and Westside Clinic,

Postpartum Depression Support Program,

Saskatoon. SK, Canada

ad